Bypassing traditional health care

 A recent issue of the Journal of the American Medical Association notes that primary care is diminishing. “In 2024, more than 1200 positions in family medicine, nearly 1000 in internal medicine, and more than 500 in pediatrics went unfilled.” At the same time, they add, we now have “an emerging direct-to-consumer health care market that bypasses traditional health care organizations.” One of these organizations—no surprise—is Amazon’s One Medical, which “integrates telehealth, primary care, and pharmacy services into its Prime membership,” as described on their web site. You either pay $9.00 a month, $99 a year with Prime membership, or $199 a year without Prime membership. “Telehealth” is virtual health care. You visit a health care person using your computer or phone. Here's an example of how you'd make an appointment.

A while back, my son mentioned having used this service, so I queried him about it, starting with asking him what prompted him to sign up with Amazon’s service. As he explained, his GP had retired, and he needed someone to refill a prescription. As he wrote, “I searched far and wide for a doctor (GP), and it was very difficult to find one. Appointment times were at least six months out. All I needed was a prescription, so I kept searching. I finally got a provider through Amazon medical. I actually dislike Amazon, but it was very easy to get an appointment with a nurse practitioner. And, she's awesome.” 

This nurse practitioner is now his go-to health care provider. She sent his prescription to his usual pharmacy and, when asked, referred him to a local gastroenterologist for a colonoscopy. Like conventional practices, telehealth companies ask for medical records if they’re needed. Visits are covered by your insurance.

I’m still a little mystified by the whole telehealth business. I searched the internet for such companies. There are plenty to choose from. I’m not sure if they all work like Amazon’s. One company, called Sesame, showed photos of their health care providers along with available appointment times, as shown in this photo. Looks easy!

When my GP retires, I’ll probably turn to a telehealth company.

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Anemia

Anemia is defined as a low number of red blood cells. It shows up on your blood test as low hemoglobin, which is the main protein in your red blood cells that carries oxygen and delivers it throughout your body. If your hemoglobin is low enough, your tissues or organs may not get enough oxygen. Symptoms of anemia include tiredness, weakness, leg cramps, shortness of breath, pale skin, and cold hands and feet.

One study showed that anemia affects 12.5 percent of people over 60, and that the rate rises as you age. Another study, published in the Journal of the American Geriatric Society, showed that about one in five patients was anemic.

A friend of mine was hospitalized more than once with anemia, in her case caused by blood thinners that resulted in gastrointestinal bleeding. Transfusions were required. Other causes include hereditary conditions, vitamin B12 deficiency, lack of iron in your diet, bone marrow disorders, kidney failure, heart disease, and inflammatory bowel disease.

Remedies include over-the counter iron tablets—which often have unpleasant side effects—and intravenous iron infusions, which have been shown to be effective.

The World Health Organization defines 13 grams of hemoglobin per deciliter as normal for men and 12 for nonpregnant women. As luck would have it, I’d had a blood test prior to my spine surgery last year, so I looked up the results. Everything was normal (displayed in green) except my hemoglobin, which was high (displayed in red with warning sign). According to the Cleveland Clinic web site, above 16 is high for women. Mine was 16.1. Dehydration is one cause. That’s probably me. But other causes include kidney cancer and congenital heart disease. At any rate, I’m clearly not anemic and have none of the symptoms.

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Best not to sleep for eight hours

I usually sleep about six or so hours a night, and it’s usually broken sleep. Lying awake for an hour or more in the middle of the night is no fun, but I don’t worry about it. Sometimes it’s even productive. I plan menus or think up book ideas. Sleep experts agree that eight hours of sleep is not optimal. Rather, it’s 6.5 to 7.4 hours. A study of 1.1 million people concluded that those who reported more than eight hours of sleep “experience increased mortality rates.” Scientists who have studied hunter-gatherer tribes in Bolivia, whose lifestyles remain the same as our forebears of two million years ago, found that they average less than 6.5 hours of sleep a night.

Nevertheless, the idea that you need eight hours of sleep persists. In 2024 there were more than 2,500 sleep-disorder centers in the U.S. accredited by the American Academy of Sleep Medicine. Aric Prather, the director of the behavioral-sleep-medicine research program at UC San Francisco says the wait time at his clinic is one year. “We have people coming into our insomnia clinic saying ‘I’m not sleeping eight hours’ when they’re 70 years of age. And the average sleep in that population is less than seven hours.” Making matters worse, fear of losing sleep causes sleep loss.

Thomas Wehr, age 83, once the chief of clinical psychobiology at the National Institute of Mental Health, says that humans aren’t necessarily meant to sleep in one long stretch but rather in two shorter ones. The night awakenings tend to happen as we’re exiting a REM (rapid eye movement) cycle, when our dreams are most intense. He says, “If you know you’re going to fall back asleep, and if you just relax and maybe think about your dreams, that helps a lot.” When I’m awake in the middle of the night, I don’t think about my dreams. I can’t remember them.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Undocumented caregivers

Dr. Louise Aronson, geriatrician and author of Elderhood, says, “Caregiving is hard work. More often than not, it’s tedious, awkwardly intimate, physically exhausting and emotionally challenging. Sometimes it is also dangerous or disgusting. It is women’s work and immigrants' work.” Most old people get care from their children, spouses, other relatives, or non-relatives. The remaining caregivers are paid, but not much. The median hourly wage for all care workers was $16.72 in 2023—lower than the wage for all other jobs with similar or low entry-level requirements.

The New England Journal of Medicine notes that “immigrants are a vital part of the U.S. health care system: at least one in five U.S. health care workers is foreign-born, including 29% of physicians, 17% of nurses, and 24% of direct care workers.” Of the 37% of foreign-born direct care workers who are non-citizens, nearly half may be undocumented. The Journal also reports a shortage of direct care workers, estimating that the shortage will grow to 860,000 by 2032, and that 8.9 million positions will need to be filled over the next decade to meet the demand.

Raids by ICE have made matters worse. As the Journal noted, “Just four days after the inauguration, 25 undocumented Filipino direct care workers were arrested in an ICE raid at a senior care facility in Chicago; at least eight have been deported.” In one case, a cancer patient, living alone at home, had fallen but wasn’t found for days because “his home health aide had stopped coming to work for fear of deportation.”

Non-immigrants are unlikely to fill the void. Direct care workers “are often subject to exploitative work practices, including wage theft. The physically demanding nature of direct care work, combined with low pay and high susceptibility to exploitation, makes these roles unattractive to U.S.-born and highly skilled foreign-born workers.”

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Tamper-proof packaging

You might remember this: In September 1982, seven people—whose ages ranged from 12 to 35—died after consuming Extra-Strength Tylenol capsules laced with potassium cyanide. Subsequently, several more people died because of copycat crimes. Predictably, these events led to nationwide panic and prompted significant changes in product safety regulations.

The incident sparked a massive recall of over 31 million bottles of Tylenol and a halt in production by Johnson & Johnson, the manufacturer. The Tylenol murders inspired the pharmaceutical, food, and consumer product industries to develop tamper-resistant packaging, such as induction seals (photo).

 Moreover, product tampering was made a federal crime, and the FDA established guidelines for tamper-resistant packaging of over-the-counter medications. The changes in packaging together with the new legislation supposedly made pharmaceuticals and food safer for consumers.

I don’t know about you, but I’d rather take my chances at being poisoned than having daily struggles opening things. Sometimes I use my teeth. Sometimes a knife or other tools—plenty of opportunity for injury. Maybe with the new anti-regulatory fervor in Washington something can be done!

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Tweezer “surgery”

I am not making this up. A twenty-something young man went for his regular eye checkup. The ophthalmologist casually mentioned that a stray lash was grazing the man’s eye and suggested that he, the doctor, remove it. The man gave the go-ahead. Using a pair of drugstore tweezers, the doctor plucked the lash.

A few days later, the bill arrived. It said “Revise eyelashes, forceps. Surgical $335.” The young man was responsible for $198.97 of that.

The doctor’s office was in network. The ophthalmologist had billed the man’s insurance for $1,085 for the office visit, and the insurer paid $545.20. But the eyelash pluck was extra. It never occurred to the man that he’d be charged for it. He filed grievances, both with the physician’s billing office and his insurer. Both were denied.

Insurers negotiate rates with their in-network providers. Patients are usually not responsible for the difference between the provider’s full charge and the amount the insurer pays, something called “balance billing.” The insurer had agreed to pay $198 for the eyelash pluck, but since the man’s deductible hadn’t been met, he owed that amount out of pocket.

Taking pity on her son, the man’s mother took on the case. She called the physician’s billing department and was told that the patient should know what’s covered. Nevertheless, the mother dug in and finally prevailed. The doctor’s office rescinded the charge.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Screening for cancer

The information in this post comes from an article in a recent New Yorker magazine written by Dr. Siddhartha Mukherjee, an oncologist and author of the Pulitzer Prize-winning book, The Emperor of All Maladies. It deals with efforts to find satisfactory methods to detect cancers.

Mammography is especially problematic because it “reveals only the shadow of a tumor—it cannot divine the tumor’s nature.” That is, mammography can’t tell whether the tumor is aggressive or has already spread or will remain inert. Added to this ambiguity is the prevalence of false positives—test results that indicate cancer where none exists. Only nine percent of people who test positive actually have cancer. People with false positives are sent for biopsies, “a risky, invasive process—which can involve a punctured lung, bleeding, or other complications—with no benefit.” At the same time, aggressive cancers can be missed because their detectable symptoms don’t appear at the time of a screening. Patients with such cancers can even die between annual tests. The apparent benefit of screening, Mukherjee says, is misleading because it disproportionately detects tumors that are less likely to be lethal in the first place. In contrast to the dubious benefits of mammography, colonoscopies pay off. Studies have proven a fifty percent reduction in deaths from colorectal cancer among those who received colonoscopies.

Now, scientists have found that cancer can be detected with blood tests. Fragments of our DNA circulate in our bloodstreams. Using this fact, researchers have found concrete evidence of tumor-derived DNA in cancer patients’ blood. They’ve developed a multi-cancer early detection blood test—one that can identify more than fifty types of cancer, including pancreatic and ovarian. To determine the value of blood tests as a screening tool, they conducted a major study in the UK, enrolling more than 15,000 participants. One result of the study showed that only six of the 1,254 cancer-free participants received false positives—a remarkably low rate. Unfortunately, the test’s ability to identify Stage I cancers was meager—just above 16 percent. It did better on more advanced cancers. But, of course, the whole point of screening is early detection.

Cancer screening is clearly a work in progress. Mukherjee hopes that “Perhaps, in time, we’ll build tools that can not only detect cancer’s presence but predict its course…that may one day tell us not only where a cancer began but whether it’s likely to pose a threat to health.” Stay tuned.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Your “breath print”

Convincing research has shown that our breathing patterns are so distinctive that they can be used to identify us, just as can be done with our fingerprints. Researchers studied this phenomenon by outfitting study participants with sensors that were fitted with tubes to capture the airflow out of each nostril. Sophisticated software analyzed the information. Researchers found they could identify individuals by their breathing patterns 90 percent of the time.

Each time we inhale, that activity fires sensory neurons and other cells in our brains, a phenomenon that yields information about our brains. What’s more, breathing is intimately tied to many body processes, each of which might be unique to individuals. As one of the researchers said, “We hypothesized, brains are unique, ergo breathing patterns would also be unique.” One person might have a consistent pause before each inhale. Another might pause some of the time and barely at other times. For many people, one nostril might have a greater flow than another at different times of the day. These breathing traits proved consistent over the two years of the study, showing that we have very consistent breathing patterns.

In analyzing the data, the researchers found that they could link the participants’ body mass index with features of their breath patterns. They also found correlations between the participants’ breathing patterns and their answers to questionnaires that assessed traits related to anxiety, depression or autism. For example, people who scored high on depressive traits shared a tendency to exhale very swiftly. Because of the apparent link between breath patterns and health—mental and otherwise—researchers speculate about whether it’s possible to determine which breath patterns indicate illness and whether it might be possible to teach people ways of breathing that might change their biology. I guess you could experiment on yourself.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

A guide to pain-relieving drugs

Advil had long been my go-to pain-reliving drug. It worked well for my arthritis pain, but I learned, too late, that it was the cause of my acid reflux, so I quit taking it, which put an end to that side effect. Anyhow, The New York Times published a useful guide to pain relievers, which I’ll summarize here.

There are two types of pain relievers: acetaminophen (Tylenol), and nonsteroidal anti-inflammatory drugs (NSAIDs), which include Advil, Motrin, Aleve, and aspirin.  NSAIDs help relieve pain by rushing to sites of inflammation throughout the body. They reduce or block two enzymes (COX-1 and COX-2) that are involved in inflammation and pain. Tylenol acts on receptors in the brain and spinal cord, but scientists aren’t sure how it works.

NSAIDs are best at treating inflammation pain anywhere in the body, whether it’s localized, such as a toothache, or spread throughout, such as arthritis. All the NSAIDs work similarly, so you’re advised to choose the one that works best for you. Aleve (naproxen) keeps pain away longer than the others—about 12 hours. The others last for about six hours.

Tylenol is most effective for mild pain, such as body aches or mild arthritis. It won’t treat symptoms of inflammation, such as swelling or redness.

You can take Tylenol and NSAIDs together, either at the same time or by alternating them, a technique that lets you benefit from both mechanisms. However, avoid mixing NSAIDs, such as Advil and Aleve.

Avoid too many NSAIDs at once or for long periods of time. Such usage increases your risk of developing chronic acid reflux, nausea, ulcers or kidney problems. Doing so also increases the risk of heart attack, stroke, and high blood pressure. Tylenol is less likely to cause such side effects, although it can be toxic to your liver when taken at high doses.

I now take a prescription drug called diclofenac, which is an NSAID. It was prescribed at the time of my knee replacements and seems to work well. I only take it a couple of times a week. Tylenol doesn’t do much for me. 

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

The health effects of sunlight: Part II

In my last blog post, I discussed examples of the ways sunlight affects the immune system, especially for those people with autoimmune diseases, such as multiple sclerosis. Research has shown that UV light, whether from the sun or from specialized light boxes, tamps down the inflammatory response that causes such diseases. This post is about skin, as reported in a Scientific American article called “Can Sunlight Cure Disease?” Skin is where the magic happens.

As you may have learned in school, your skin is the largest organ in your body. But you probably didn’t know that your skin is a virtual pharmacopeia. In addition to vitamin D, your skin produces melatonin, serotonin, endorphins, endocannabinoids, cortisol, oxytocin, leptin, nitric oxide, cis-urocanic acid, itaconate, lumisterol, tachysterol, and a dozen other vitamin D-like compounds that don’t even have names yet. To keep you healthy, your skin is in constant conversation with the rest of your body, including your brain. It’s also a major site for the immune system. As such, it is stocked with body-defending T-cells, macrophages, neutrophils, cytokines, antimicrobial peptides, and other key players. Sometimes these “key players” go haywire, as with auto-immune diseases.

UV light stirs up this stew of cells in lots of complicated ways, such as breaking chemical bonds, producing multiple molecules, increasing protein production, flipping atoms to new configurations, producing lipids, and so forth. No one fully understands how all of this works—how all the cells and signals bounce off one another. But they do know that UV light “has a surprising ability to calm an immune system that has bolted out of control.” They know that UV light triggers a cascade of signals that reach every organ in the body, and they’re tracking the way molecules in the skin respond to UV light. They’d like to discover a pill that will tamp down an out-of-control immune system. For now, there’s just sunlight or a light box.

I get plenty of sun and my immune system has kept me healthy. But my skin is a mess.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

The health effects of sunlight: Part I

Scientific American has published an article called “Can Sunlight Cure Disease?” It’s very interesting, but also long and complicated. It’s about how ultraviolet light on skin can calm an out-of-control immune system, which is the cause of autoimmune diseases such as multiple sclerosis (MS). Auto immune diseases occur when our immune systems viciously turn against our own bodies and organs.

I’m going to try to summarize the article’s main points over two blog posts. This one focuses on the fact that many diseases are much more common at higher latitudes where there’s less sunlight and rarer near the sunny equator. This is especially notable with MS, which has prevalence rates close to zero near the equator. But the rate increases by 3.64 cases per 100,000 people for each degree of latitude. In northern Europe and North America, MS cases are well over 100 per 100,000 people and are growing stronger over time. In Australia, which has a wide range of latitudes, researchers found that MS rose from 12 per 100,000 closer to the equator to 76 per 100,000 at higher latitudes.

In general, researchers have found other signs of sunlight’s preventive effect on MS. For example, people with the most sun damage on the backs of their hands (more sun exposure) have just one-third the rate of MS than do people with less sun damage. Kids who spent less than 30 minutes a day outside had five times the risk of MS compared with kids who spent more than an hour outside.

Experiments with special UV-emitting light boxes to treat MS have begun. Patients who have used the boxes have found relief from many of their symptoms, such as fatigue. The boxes might also work for other autoimmune diseases such as type I diabetes, rheumatoid arthritis, Crohn’s disease and colitis—diseases that are more common in people who get very little sun exposure. (For years, it’s been known that exposure to sunlight or sunlamps soothes psoriasis, another autoimmune disease.)

Scientists have yet to uncover the “mysterious molecular pathway through which the skin tells the immune system to relax.” As one researcher noted, “We don’t know what the golden molecule is; we just know it’s not vitamin D.” In fact, they note that vitamin D supplementation “doesn’t help with any of these diseases.”

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Hospital advertisements

I always get incensed when I see hospital advertisements, especially those that are wildly expensive, such as full-page ads in pricey publications. Hospitals shouldn’t be spending money on advertising! I shouldn’t be so naïve. We all know that hospitals are businesses and that businesses advertise.

During the last Super Bowl, NYU Langone Health aired a 30-second advertisement. It cost $8 million. Like me, Representative Greg Murphy, a urologist and Republican congressman from North Carolina, was incensed at this expenditure. He wrote a stern letter to NYU Langone’s chief executive, questioning the hospital’s stewardship of its money, especially given the fact that the hospital receives federal money. The letter also asked about the hospital’s overseas investments and whether the health system was exploiting legal loopholes to maximize profit.

Shortly after the letter was received, a private jet landed at the Greenville, N.C., airport, which is not far from where Murphy lives. The jet was registered to the investment firm founded by Kenneth G. Langone, the billionaire benefactor of NYU Langone and the chairman of the hospital’s board of directors. Langone is also a major Republican donor. Reporters know that someone, either Langone himself or his representative, visited Murphy. They don't know exactly what was said at the meeting, but two days after that visit, Murphy sent a second letter, changing his message from critic to booster, praising NYU Langone’s “world class patient outcomes,” and stating that “America would be much healthier if all hospitals could report these excellent numbers.”

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Grip strength

Alert reader Jocelyn sent me an article about grip strength. According to the article, grip strength is one of the best metrics for determining healthy aging. That’s because it’s “an efficient proxy for total muscle conditioning, which is itself a great proxy for overall nutrition, physical activity, and disease profiles. In other words, it’s a proxy for a proxy.”

Grip strength effectively predicts the decline in muscle conditioning which is associated with aging and mortality. One study found that, among people who’d had their grip strength measured in 1965, the ones who lived to be 100 were 2.5 times more likely to have had grip strength results in the highest third.

Developing grip strength alone won't protect you against disease and early death. It's an indicator of your overall muscle strength and conditioning. Muscle strength helps to defend us against the ravages of age. It  cushions our joints and bones, protects us from falls, and even soaks up excess glucose in the blood to reduce the risk of developing type-2 diabetes or insulin resistance.

The way to measure grip strength is with a dynamometer, pictured here. 

Assuming you don’t have one of these lying around your house, you can also test yourself with a tennis ball (which you probably don’t have either). If you get ahold of one, you should be able to squeeze it hard for 15 to 30 seconds.

As luck would have it, the day after receiving this article I had an appointment with my hand surgeon to arrange another carpal tunnel release surgery. (I’ve had it on my right hand; now I needed it on my left.) I got a measurement of 50. I asked the doctor about my reading. He said it was “decent.” I looked it up on a chart. For my age group, my rating was between normal and strong. I guess that’s the same as decent.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Paying for your BP test

The other day, I had to go to urgent care to have a laceration sewed up. (Freak accident: When opening my car door, I managed to lacerate my lower leg on the door’s sharp edge. Eight stitches.) Anyhow, I was thrilled that Doctors on Duty didn’t take my blood pressure. It’s always sky high in such situations. I usually refuse to have it taken, and hate having to deal with that issue each time I visit a medical practitioner. (Though my BP is a little high, I don’t take meds for it.) Besides, I’m suspicious of this BP-taking routine and think it’s a scam of sorts.

Even though having your BP taken seems inconsequential, the medical practice gets paid for it, and insurance, including Medicare, pays for it. For every procedure you have at a hospital or at the doctor’s office—no matter how insignificant—a code is assigned. It’s how they get their money from insurers. Listen to the heart: code; insert a line: code; take blood pressure: code; and so forth. The more they code, the more money they receive from insurers. The more procedures, the more codes. If you look closely at your medical bills, you can see all those seemingly trivial procedures on the bill. It makes me mad and probably raises my blood pressure.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Biodiversity: Male? Female?

A friend of mine posted the following on Facebook:

“It’s a scientific fact that humans come in two varieties: XX for female, and XY for male. Except:

• You can be born appearing female but have a 5-alpha reductase deficiency and grow a penis at age 12.
• You can be born legally male with an X and a Y chromosome, but your body is insensitive to androgens, and you appear female.
• You can be born legally male with an X and a Y chromosome and have a penis and testes and a uterus and fallopian tubes.
• You can be born legally male with an X and a Y chromosome, but your Y chromosome is missing the SRY gene, which gives you a female body.
• You can be born legally female with two X chromosomes, but one of the Xs has an SRY gene, which gives you a male body.
• You can be born legally female with two X chromosomes, but your adrenal gland doesn’t produce enough cortisol, and your body develops as male.
• You can be born with XX chromosomes and XY chromosomes (chimerism).”

I call this diversity. 

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The Blue Zones debunked

 You may have seen a Netflix documentary called Blue Zones. It’s about those supposedly amazing places—from Okinawa, Japan, to Ikaria, Greece—where a disproportionate number of people live into a very old age. Dr. Saul Newman, a research fellow at the University College London Center for Longitudinal Studies, debunked the blue-zone research with studies of his own. He found undetected errors in every blue zone. As he notes in an interview, “...there’s only one data source for human ages, and that’s documents.”

What he found in his studies was a lack of documentation certifying people’s deaths as well as many cases of age fraud—people claiming to be older than they are. For example, families who didn’t register their relatives’ deaths collected their social security money. In Greece, he found that at least 72 percent of the people who were supposedly over age 100 were collecting their pension checks from “underground”—that is, they were dead and buried. In the United States, he found that at least 17 percent of people purported to be over the age of 100 were, in fact, either clerical errors, missing or dead.

The documentary shows old people in Okinawa happily tending to their gardens. In fact, Okinawans aren’t gardeners. The government of Japan has been measuring life in Okinawa and other prefectures since 1975. Their records indicate that, in the matter of growing gardens, Okinawa is third to last out of 47 prefectures, after Tokyo and Osaka, where everyone lives in a high-rise. Government records also show that Okinawans are third to last in their consumption of root and leafy green vegetables. In fact, according to government data, Okinawa lands at the bottom of the health pile.

Loma Linda, California, is the single U.S. blue zone. It’s known for its high concentration of Seventh-day Adventists, who eat a mostly plant-based diet. Newman says the CDC measured Loma Linda for lifespan and found that “it is completely and utterly unremarkable.”

As Newman reminds us, the core of science is reproducibility. Not only have the blue zone results not been reproduced, but the underlying blue zone data has never been published.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Bandages made from dried placentas

It’s true! Tissue banks pay hospitals to collect placentas and ship them to laboratories where they’re made into paper-thin “skin substitutes” to cover stubborn wounds. Such bandages may help certain types of wounds to heal, but often they’re not needed. That’s because they’re moneymakers. One square inch of skin substitutes costs $5,948 on average. Medicare pays for them. What’s more, because the government categorizes them like donated organs, the manufacturers don’t have to prove that the bandages work.  

More than 100 new skin substitute products have come to market since 2023, and their prices have ballooned. Medicare will reimburse any price that a company sets for brand-new skin substitutes, even if it is far above the market average. Some companies offer doctors a “bulk discount” of up to 45 percent. Taking advantage of the discount, some doctors then collect a Medicare reimbursement for the full price of the product, pocketing the difference. The higher the price, the larger the doctors’ cut.

Here’s how it works: For the first six months of a new product’s life, Medicare will set the reimbursement rate at whatever price a company chooses. After that, Medicare adjusts the reimbursement to reflect the actual price paid by doctors after any discounts. To circumvent the price drop, some companies simply roll out new products. Example: In April 2023, Medicare began reimbursing $6,497 for every square inch of a bandage called Zenith, sold by Legacy Medical Consultants. After six months, the reimbursement fell to $2,746, after which Legacy introduced a new “dual layer” bandage called Impax, reimbursed by Medicare for $6,490.

Private insurance companies rarely pay for skin substitutes, but Medicare routinely covers them. Spending on skin substitutes exceeded $10 billion in 2024. In fact, Medicare now spends more on the bandages than on ambulance rides, anesthesia, or CT scans. For one patient in Nevada, Medicare spent $14 million on skin substitutes over the course of a year.

The Trump administration announced that it would delay a Biden-era plan to restrict Medicare’s coverage of skin substitutes, saying that it was reviewing its policies until at least 2026. It turns out that President Trump’s super PAC had received a $2 million donation from a leading bandage seller. I guess DOGE isn’t looking at that.

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Low dose radiation for aches and pains

In Germany, physicians have been using low dose radiation (LDRT) to treat inflammatory diseases of the joints, such as osteoarthritis, plantar fasciitis, bursitis, and tendonitis. They’ve been doing this for decades and have treated more than 20 thousand patients with this therapy.  I’d never heard of it until recently, when I watched a video of an interview with Dr. Sanjay Mehta, a radiation oncologist with over 20 years of experience at St. Joseph’s Medical Center in Houston, Texas. He’s an impressive guy. According to him, the U.S. is way behind Europe in using this low dose radiation to treat inflammatory diseases.

The therapy has a similar anti-inflammatory effect as you’d get from a cortisone shot, but it lasts longer. Dr. Mehta has found that if the pain is not reduced to zero, it’s at least 60 to 80 percent better than it was pre-treatment. Unlike a cortisone shot, it’s totally non-invasive. Depending on the condition, a typical treatment might include Monday, Wednesday, and Friday treatments for two weeks. Depending on the situation, the treatment might be repeated. It’s not a cure-all. For example, you still might need a knee replacement. But Dr. Mehta has found that many of his patients get immediate relief from pain.

One in seven people in this country are afflicted with such ailments, including me, at times, with osteoarthritis, bursitis, and plantar fasciitis. For many people, non-steroidal anti-inflammatory drugs (NSAIDs) cease to become effective and can have side effects such as gastrointestinal bleeds.

In the medical journals I investigated, one, the International Journal of Molecular Science states, “LDRT has been shown to be a cost-effective, noninvasive treatment with minimal side effects.” The Journal of Radiation Oncology says, “Currently, there are strong data to suggest a benefit of LDRT in plantar fasciitis, with about 80% efficacy in pain reduction. Additionally, there are data to suggest benefits in other musculoskeletal disorders, such as trochanteric bursitis, medial and lateral epicondylitis, tendinopathies of various joints, Dupuytren contracture, Ledderhose disease, heterotopic ossification, and other disorders.” (I checked out Ledderhose disease: lumps in the arches of the feet.)

The treatment is covered by Medicare and private insurance. Nevertheless, good luck in finding someone near you who uses this treatment. Dr. Mehta says that most doctors have negative reactions to the treatment because it’s taking away their specialty. Using Google, I did find a hospital in the Bay Area that uses the technique.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

AI may be writing docs' reports

Do you ever look at the “patient visit” notes that are available on your patient portal—the internet site that displays information about your visits with the medical establishment? Sometimes I do. As I learned from alert reader George—who sent me an article written by a doctor—those notes may be created by AI. A busy doctor may not take the time to review the notes and correct them.

Here’s a (rather extreme) story the doctor recounts about one AI-generated report: A patient came in for a routine visit, which consisted of a recitation of aches and pains and a review of recent blood work and other regular tests. AI created a report stating that the patient was on dialysis; that he had a congenital defect affecting his kidneys; that he had recently been septic; and that he was unable to drive because of cataracts. None of this was true. Had the doctor signed this and had it gone into the patient’s chart, the ramifications could be serious. For example, if the patient applies for anything such as life insurance, his application would be denied.

The AI “time saver” may actually take more time for those conscientious doctors who must dig through the notes looking for mistakes. Furthermore, some of these reports, he writes, can run to five or six pages of “gobbledy gook with important data scattered all over the place.”

In my case, I looked up my “patient visit” notes of a pre-op appointment prior to getting steroid injections to treat a pinched nerve in my spine (which didn’t work). The report says that I complain of “low back and right leg pain. Pain is described as spasms/cramps." I never said I had low back pain and never said the pain is spasms or cramps (I had neither). I recognize that this is small potatoes, but to me it illustrates: 1) that the physician’s assistant wasn’t paying attention and wrote down other people’s complaints; or 2) that the report was generated by AI. Incidentally, I’ve found that these visit notes often begin by saying that I’m “pleasant.” I think they do this so you won’t complain.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Your big toe

I’ve recently seen a few articles about feet, especially the big toe. Is that a new thing?  Dr. Courtney Conley, who specializes in foot and gait mechanics, says that “Toe weakness is the single biggest predictor of falls when we get older.” Really?! Apparently, gripping the floor with your toe flexors is crucial in maintaining balance. (The flexor muscles are those you use to curl your toes down.) One study assessed the feet of 312 men and women aged 60 to 90, looking for bunions and other toe deformities. In 12 months, 107 people had fallen. The fallers showed significantly less strength in their toes and were more likely to have bunions and other deformities.

In addition to balance, we use toe muscles for propulsion when walking. If toe strength is compromised, everything up the chain is more vulnerable—ankle, knee, hip, and spine. Lack of toe flexor strength is implicated in bunions (hallux valgus) and lesser toe deformities, such as hammer toe (raised toe knuckle).

The big toe gets special attention. Your big toe initiates propulsion when we walk. Lack of big-toe extension (pointing the toe up) can cause gait dysfunction and can even be a limiting factor in getting up off the floor unassisted as we age. One expert says that, when pointing your big toe up, the angle should be about 50 degrees (photo). 

You can determine your toe dexterity by trying to lift your big toe while keeping your other toes flat on the ground and vice versa. Being able to move your toes independently, even a small amount, is a sign of healthy feet. One physical therapist says your toes can be agile enough to play the piano. Right.

You can do exercises to strengthen your toes, such as, while sitting, placing all five toes of one foot on a folded towel, then pressing your toes down (don’t grip) and raising your heel.

I have bunions and one hammer toe, but I’m not a faller! I tried a series of toe exercises. They’re probably worth doing, but they’re a drag to do. As to the photo: impressive! I can’t even come close.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Administrative waste in health care

This from The Journal of the American Medical Association: The cost of health care is “the largest sector of the US economy and 29% of net federal outlays.” Here are some more of their points:

• For people with employer-based insurance, health insurance premiums represent 25% of the median family household income before having to pay thousands of dollars more to use their health insurance.
• The US spends almost twice the average on health care and administration than the 37 other countries who belong to the Organization for Economic Co-operation and Development (OECD).
• The US spends approximately 10 times more on administrative expenses than any other OECD country. Two-thirds of these costs are related to transactions or billing costs and insurance-related costs.
•  In the US, a primary care physician spends $20.49 to receive payment for a service that generates approximately $100 in revenue.
•  In medical practices, the time spent trying to get prior authorization from insurance companies is equivalent to the annual working time of 100,000 registered nurses.

The authors want the Trump administration to fix the problem.

Bonus factoid: 29% of doctors in the US weren’t born here.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Earworms

In case you didn’t know, earworms are fragments of songs that stick in your head. I have earworms most of the time and have no idea how my mind chooses certain tunes. Once it was a fragment of a hymn! “Killing Me Softly” is a recent earworm of mine. Why that? It turns out that scientists have actually studied earworms! Psychologists call them “involuntary musical imagery” that can produce some insights into how memory works—how associations with music trigger memories or how mood is associated with memory.

One group of scientists conducted a huge survey by asking radio listeners to call the station and report on their current earworm and why they had it. From this data, the scientists determined the most common triggers for earworms. Unsurprisingly, the most common trigger is having heard the song recently, but other experiences can trigger an earworm, such as seeing a license plate with letters that bring a song to mind. Mood is also a trigger. Sadness, for example, might be associated with a certain song. Earworms are more likely to occur when your mind is wandering—when you’re not focusing on something.

Scientists also discovered that earworm songs tend to be in a certain tempo range—around 124 beats per minute (two beats per second), which is generally faster than non-earworm songs. That tempo, they say, aligns with our body rhythms—the speed at which we like to move or dance. Also, earworm melodies tend to go up and down in a regular pattern, which may help us recall the song more easily.

What if you’re tired of your earworm and want it gone? You can switch to a different song, or you can chew gum vigorously. Because chewing involves the same nerve signals you use to mentally sing the song, gum chewing interferes with your mental singing—provided you’re not chewing to the beat of the music.

I don’t mind my earworms, but now I’m back to my Killing Me Softly earworm, which has become tiresome. Alas, there’s no gum in the house.  

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

RFK Jr. and the F.D.A.

But first, a word about measles: You undoubtedly know about the recent measles outbreak in Texas in which one child died, and that Kennedy, an anti-vaccine activist and newly appointed head of Health and Human Services, noted that the outbreak is “not unusual.” In fact, the outbreak is unusual. Until a few weeks ago, someone hadn’t died of measles in this country since 2015.

According to the CDC, before a vaccine became available in 1963, an estimated 3 to 4 million people in the United States were infected each year. Each year, an estimated 400 to 500 people died; 48,000 were hospitalized; and 1,000 suffered encephalitis (swelling of the brain). Since the arrival of the vaccine, endemic spread of the virus was declared eliminated. Of course, we old people were not vaccinated. As a result of my measles infection, I lost half the hearing in my left ear. (Measles can damage the nerve fibers in the inner ear.)

While scientific experts agree that Kennedy’s wacky ideas could pose a danger to human health, they also contend that the F.D.A. needs to change. (At the same time, they also say that the agency should have more resources and authority—not less—and that the FDA is the most important public health agency we have.) Here are the changes they recommend:  

• Stop relying so much on industry funding. Almost half of the F.D.A.’s budget comes from “user fees” in which pharmaceutical and medical advice companies pay the F.D.A. to review their products—an obvious conflict of interest. (The government should pay.)
• Crack down on employee-industry connections. The F.D.A. commonly hires people employed by drug or device companies and, in reverse, F.D.A. employees leave the agency to go work for these companies. Advisory committee members may also have close ties with the industry. More conflict of interest.
• Close loopholes in the approval process. While experts generally agree that the F.D.A.’s approval process for new drugs and vaccines is rigorous, some worry that such rigorous standards aren’t enforced across other divisions, most notably medical devices, food additives, and supplements.
• Break the F.D.A into two agencies, one focused on food and the other on drugs.

Happily, Dr. Martin Makary, who will head the F.D.A., seems well qualified. As one F.D.A. watcher noted, “It could have been way worse.” Fingers crossed.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Walking

 You’re supposed to engage your glutes (butt muscles) when you walk. As Esther Gokhale, the posture lady, writes, “The buttock and leg muscles contract strongly to propel the body forward, thus getting the exercise they need while the back is spared unnecessary wear and tear.” She says that for us in industrial cultures “walking consists of a series of forward falls blocked abruptly by the forward leg. The gluteal and leg muscles are underused.” This “forward fall” type of walking jams the hip joint and every other weight-bearing joint. Now she tells me.

I’ve found it’s hard to think about contracting my butt muscles to propel me forward. But what’s easier to remember is keeping my back leg straight and the heel on the ground. When you do that, your glute muscles engage.

Here's an illustration showing you (too) many things to think about when you walk. 

Now I'm going to think about "leg externally rotated." Maybe it will keep my hips from caving inward, which is what I think caused my knee problems. 

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Hip mobility and balance

I’ve long been big on maintaining strength in my butt. Your butt muscles (glutes) help keep you upright and propel you up from a seated position. If we don’t use these and other postural muscles enough, they “forget” how to maintain balance. Picture a skeleton standing on its two little feet and how easy it would be to tip it over. Your butt and thigh muscles keep you from tipping over.

I hadn’t given much thought, however, to range of motion in my hip joints. One expert notes that “every sort of function or movement you perform is somehow related to your hips.” Your hip joint can’t function properly if it can’t move through its full range of motion or if your glute and hamstring muscles are weak. If those muscles are weak, other joints and muscles will take over, even if they’re not strong enough to manage the load. Pain and injuries from overuse may result.

Sitting for long periods can be a problem: your glutes are turned off, forcing the smaller hip flexor and lower back to provide support. Those smaller muscles become overworked, which is why they may ache when you stand up.

If the muscles around your hips aren’t working properly, it limits how easily you can move your hips. Full range of motion in your hip means that you can move your leg forward and backward, side to side, and in rotation.  If you struggle to touch your mid-calf without bending your knees, or if you have trouble bringing one ankle over your opposite knee while sitting, it means that your hip joint is limited. If you can't get up from the toilet without using your hands, it means your glutes are weak (my analysis).  

You can find plenty of exercises by Googling “hip mobility exercises.” AI will provide you with a nice list with links to additional information.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

The latest on multivitamin food supplements

According to the Journal of the American Medical Association, one in three U.S. adults take multivitamin supplements. (The Atlantic says three-quarters of Americans take at least one dietary supplement.)  Here’s what the Journal has to say about their value:

• Twenty years of studies that included almost 400,000 participants showed that taking multivitamin supplements was “…not associated with a mortality benefit.” In fact, they write, “…mortality risk was 4% higher among multivitamin users, compared with nonusers.”

• Beta carotene supplements, as well as vitamin C and E and zinc, are associated with slowing the progression of age-related macular degeneration. (Beta carotene is a natural pigment found in many fruits and vegetables, such as carrots, sweet potatoes, spinach, and apricots.)  

• Getting beta carotene from food is associated with reduced cancer risk. For at-risk people, such as smokers, taking beta carotene as a supplement increases the risk of lung cancer.

• In older people, multivitamin supplementation is associated with improved memory and slower cognitive decline.

• Taking iron as a supplement, which adds to the iron consumed in food, increases the risk of iron overload. Iron overload is associated with an increased risk of cardiovascular disease, diabetes, and dementia.

• Calcium and zinc may reduce the absorption of certain antibiotics.

Overall, the article says, “…there is little health rationale for the use of multivitamin supplements. Micronutrients come most healthfully from food sources.”

The dietary-supplement industry was valued at $40 billion in 2020. It is minimally regulated: the FDA doesn't review dietary supplements and manufacturers don't have to reveal their ingredients. 

I don't take supplements. Robert Kennedy Jr. says he takes a "fistful" of vitamins each day. You be the judge.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Re-defining Alzheimer’s disease—maybe

Alzheimer’s disease is characterized by abnormal protein deposits in the brain. It begins with an asymptomatic phase and progresses—if the person lives long enough—to mild cognitive impairment and, eventually, a level of impairment that interferes with the daily process of living.

Researchers have developed two types of tests to diagnose Alzheimer’s before symptoms appear: blood tests that identify biomarkers, and genetic tests that identify the problematic genes. The tests show the full spectrum of the disease, beginning with the seeds of pathology deep inside the brain and ending with dementia.

Biomarker tests. A blood test can detect changes in the brain that predict Alzheimer’s disease up to 15 years before the first symptoms emerge.

Genetic tests: Genetic tests can identify a group of susceptibility genes—APOE—indicating an increased likelihood of developing Alzheimer’s disease by age 85. If you have a single copy of the APOE e4 gene, you are two to three times more likely than the general population to get Alzheimer’s by age 85. If you have two copies, you are 12 times more likely to develop the disease.  

Several groups are working to develop guidelines for diagnosing Alzheimer’s. It’s controversial. The working groups disagree on the word “diagnosis” when referring to the results of the blood test. Some prefer the word “risk,” believing that people should not be diagnosed with the disease based on biomarkers alone.

About drugs and treatment:

• Two drugs have been shown to reduce the disease progression by 27 percent, although their effectiveness in the later stages of the disease or in asymptomatic people, is unproven. The drugs cost $26,000 to $32,000 a year, with side effects that include a risk of swelling and bleeding in the brain.
• There are currently no treatments for those who have the biomarkers but not the symptoms.
• New guidelines discourage routine testing of asymptomatic people except in the context of research. But clinical trials of Alzheimer’s drugs are under way for treating people whose blood tests for the disease are positive. If such drugs prove successful, pre-symptomatic testing may become routine.  

About conflicting evidence:

• A substantial number of the people diagnosed with Alzheimer’s—based on blood and genetic tests—will die without ever having exhibited signs of dementia.
• Postmortem studies have found that up to 30 percent of people who received a clinical diagnosis of Alzheimer’s disease did not have the characteristic plaques and tangles in their brains.
• Many people have the plaques and tangles—as shown in postmortem dissections—but not dementia. In a famous study of 678 nuns, ages 75 to 107, postmortem dissections showed that the brains of many of the nuns had all the plaques and tangles of Alzheimer’s disease, but that their owners had shown no signs of dementia when they were alive. In fact, in 80% of the cases the pathology, as revealed in their brains, did not concur with the symptoms seen during life.

Something else is going on here. 

By the way, 23andMe gives you the choice of not looking at the results of the APOE gene test. I gathered up the courage, looked and got the following message: "Constance, you do not have the ε4 variant we tested." Whew!

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Walking

You’re supposed to engage your glutes (butt muscles) when you walk. As Esther Gokhale, the posture lady, writes, “The buttock and leg muscles contract strongly to propel the body forward, thus getting the exercise they need while the back is spared unnecessary wear and tear.” She says that for us in industrial cultures “walking consists of a series of forward falls blocked abruptly by the forward leg. The gluteal and leg muscles are underused.” This “forward fall” type of walking jams the hip joint and every other weight-bearing joint. Now she tells me.

I’ve found it’s hard to think about contracting my butt muscles to propel me forward. But what’s easier to remember is keeping my back leg straight and the heel on the ground. When you do that, your glute muscles engage.

Here's an illustration showing you (too) many things to think about when you walk. 

Now I'm going to think about "leg externally rotated." Maybe it will keep my hips from caving inward, which is what I think caused my knee problems. 

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

The healing power of nature

A famous study, published in the journal Science, demonstrated that nature can promote healing. Researchers found that people in hospital beds who looked onto trees had shorter stays and took fewer painkillers than those who didn’t. Just looking at nature influenced their health, triggering physiological changes in their bodies.

It turns out that not only the sight of the natural world, but also its smell, sound, and feel slows our breathing and heart rates and lowers our blood pressure and adrenaline. In other words, its effects are calming. Apparently, when out in nature, we breathe in volatile molecules released from plants. The molecules enter our bloodstream and interact with biochemical pathways, triggering beneficial metabolic processes.

Sounds, like birdsong, the wind rustling leaves, and the trickling of a stream have similar benefits. Researchers found that people who were awake during surgery experienced much lower stress levels when listening to such natural sounds than when listening to other types of sounds.  

Japanese researchers have studied the effects of “forest bathing” (walking in the woods) and have found that this activity elevates the walkers' Natural Killer (NK) cells. (Natural Killer cells are white blood cells that fight tumors and infections in your body.) The researchers theorize that inhaling the aerosols emitted from the forest are responsible for the effect. A subsequent study, in which essential oils from cedars were emitted in a hotel room where people slept, also caused a significant spike in NK cells. 

I have a few diffusers in my house that emit the fragrance of fir trees. I like the way they smell. Until now, it never occurred to me that they were beneficial to my health. They’re expensive, but maybe worth it!

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

The vagus nerve and inflammation

More than half of all deaths from disease are tied to inflammation, including heart disease, stroke, asthma, diabetes, and autoimmune and neurodegenerative conditions. About a third of people with major depression also have inflammation. Some inflammation is protective, such as the swelling and redness you get when stung by a wasp. This is your immune system dealing with the venom. In such cases, your spleen releases proinflammatory molecules (cytokines) into your bloodstream to activate your immune response, a complex system that includes regulation by the vagus nerve.

But sometimes the immune system can become overactive and damage tissues. In such cases—often the result of stress, chronic infection, or autoimmune disease—inflammation can cause the proinflammatory molecules to circulate continuously for months or years. Examples of an overactive immune system include Crohn’s disease, Parkinson’s disease and chronic pain.

The vagus nerve controls the inflammatory reflex, which includes the delivery of information about inflammation from your body to your brain. In response, your brain—via the vagus nerve—sends signals to your body to regulate its immune response. In the case of chronic, harmful inflammation, the nerve pathway that carries anti-inflammatory signals from the brain to the body may be impaired.  

As with treatment for treatment-resistant depression, scientists are exploring the use of vagal nerve stimulation (VNS) to treat chronic inflammation. The treatment looks promising, as the Pub Med medical journal stated: “Clinical applications have confirmed the efficacy of VNS in managing specific autoimmune diseases, such as rheumatoid arthritis, and chronic inflammatory conditions like inflammatory bowel disease.” This treatment is in its infancy, but worth exploring if you’ve got chronic inflammation.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

The vagus nerve and depression

The vagus nerve is the longest in your body with fibers in nearly every organ, including your brain. There is one on each side of your body, each with up to 100,000 fibers. Most fibers send messages from your body to your brain, helping to maintain internal equilibrium. The information about the state of the body—such as heart rate—is carried to many of the brain regions implicated in psychiatric illness.

Investigators have long known that activating the vagus nerve with mild electrical pulses can treat epilepsy. A surgically implanted device, called a vagus nerve stimulator (VNS), cuts the frequency of seizures by 45 percent. In pursuing their research, scientists discovered an interesting side effect of the treatment: it made people happier.

A similar surgically implanted device is now being used to treat people with treatment-resistant depression. A 2017 study of 800 people with this condition found that five years of VNS fully cured 43.3 percent of them and halved the symptoms for 67.6 percent. (Depression is complex and variable. Different types of vagus nerve signals might be effective for different people.) VNS treatment strengthens connections between certain parts of the brain, including the parts associated with emotion processing. It also increases the activation of “feel good” hormones.

Now you can get devices that access the vagus nerve from outside the body. They’re called tVNS devices (the t stands for transcutaneous). You can buy these online! They come in two types, as you can see below. But studies show that surgically implanted devices are more effective.

In the interests of brevity, I’ve oversimplified this complex subject. For example, one of the research findings has shown a relationship between the vagus nerve and inflammation. I’ll discuss that topic next.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

What if you hit your head in a fall?

Friends who live in a retirement community tell us that, when residents fall, they are asked if they’ve hit their heads. If the answer is yes, they are taken to the hospital to be checked for possible brain injury. If the injury is severe, the person may have a life-threatening brain hemorrhage. But this is unlikely. If anything, the person might have a concussion. “Concussion” is another word for mild traumatic blunt injury.

My 97-year-old super-ager friend, Donna, who also lives in a retirement community, fell during a middle-of-the-night trip to the bathroom. As she was going down, she tried to fall like a 49er ("drop, roll, get up").  Nevertheless, she hit her head, but she did get up and went back to bed. The next morning she was dizzy and couldn't remember what had happened. After calling Resident Services, she was taken to the ER in an ambulance. She had a concussion.

Hitting your head can transmit a wave of pressure through the brain that can temporarily stun the neurons. Any damage to the brain caused by a concussion cannot be detected by a CAT scan or MRI. That’s because the damage occurs on a microscopic level. For this reason, a diagnosis is based on symptoms: headache, sensitivity to light, dizziness, nausea, vomiting, and amnesia. (With most concussions, there’s no loss of consciousness.) Such symptoms can last anywhere from seconds all the way up to weeks or even months. 

People who have had concussions may also experience memory problems, have trouble concentrating, suffer from drowsiness, and/or become irritable. For old people, concussion symptoms can be subtle and easily mistaken for normal aging.

Treatment for a concussion consists of rest, avoiding physical activities while recovering, and taking medicine for headaches. Donna says she "needed brain therapy." In fact, a series of therapists came to her apartment several times a week, helping her with movement and even speech. She felt "supremely supported and encouraged." She fell in early October. We met for lunch in late December. She says she's still concerned about loss of memory. To me, she seemed like her old self: alert, engaged, good humored, and energetic. She remembered how to get to the restaurant and directed me to it.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Have you fallen?

I got most of the following information from an article in JAMA (Journal of the American Medical Association). It was written by a retired physician, Dr. Bruce Campbell. At a visit to his doctor, he’s asked whether he has fallen in the past six months. He lies and says no. That’s what I do! Like him, I think it doesn’t count if you’ve done something like, in my case, tripping over a garden hose. (I have no trouble getting up.) I learned, in his article, why we’re always asked that question.

In the U.S., falls are reported every year by more than 14 million people over the age of 65 and are associated with about 90 percent of hip fractures. A history of one or more falls in the six months prior to a surgical procedure is associated with postoperative complications, higher levels of post-hospital care, and increased 30-day readmission rates.

The Centers for Medicare and Medicaid Services requires medical personnel to ask if you’ve fallen. It gathers this data to track the proportion of enrollees who have been assessed for their risk of falling.  This information, collected by doctors’ offices, is tied to reimbursement. The greater the proportion of patients queried, the better the reimbursement. (That’s what he wrote!)

As Dr. Campbell notes, admitting to a fall might trigger a cascade of medical tests, such a neuropsychiatric evaluation or stress test. Even his 90-year-old mother, who lived in a senior living apartment, lied about falling. When she fell and couldn’t get up, she called her son instead of the office. (She kept her phone in her pocket.) She was afraid she’d be hauled off to the hospital on a stretcher and subsequently moved to assisted living or a nursing home.

Dr. Campbell continues to lie. As will I.

Next week: What if you hit your head from a fall?

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Doctors versus AI

Researchers conducted a small study to compare diagnoses performed by doctors versus those performed by AI, specifically ChatGPT. After recruiting 50 doctors for the experiment, the researchers divided the experiments into three groups: 1) Doctors not using the chatbot; 2) Doctors using the chatbot; 3) The chatbot by itself. The three groups were given six real-world case histories and told to suggest diagnoses and explain why they favored or ruled them out. The case histories had never been published, so neither the doctors nor ChatGPT would have foreknowledge about them.

Here are the results: Doctors who did not use the chatbot had an average score of 74 percent. Those who did use the chatbot had an average score of 76 percent. The chatbot by itself scored an average of 90 percent, vastly outperforming all the doctors!

[The researchers, in a subsequent interview, said "The results were not what we expected....we thought the doctors who had access to the chatbot were going to do way better than the doctors who only had access to the usual internet—UpToDate, PubMed, Google, whatever."]

The doctors using the chatbots often were not persuaded when the chatbot pointed out something that was at odds with their diagnoses. Instead, they tended to be wedded to their own ideas of the correct diagnoses. In describing how they came up with a diagnosis, doctors would say, “intuition,” or “based on my experience.”

Researchers also found that few doctors knew how to take advantage of the chatbot’s ability to solve complex diagnostic problems. For example, they treated the chatbot like a search engine, asking questions such as “What are the possible diagnoses for eye pain?” Only a few of the doctors figured out that they could copy and paste the entire case history into the chatbot and ask for a comprehensive diagnosis.

Hey! We could try this at home!

P.S. This post marks the tenth anniversary of my weekly blogs. 

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.