Doctors of Pharmacy and Their Role in the Health Care Team

My patient, a mental health professional, was sent for an MRI of her hips and back by her orthopedic surgeon. He was in surgery when she called him for an antianxiety medication to help her get through her claustrophobia in the MRI machine.

She waited seven hours for a response and when a repeat phone call resulted in no response she called me. I asked her if she was driving herself to or from the procedure and she answered no that her husband was taking her. I phoned in a small supply of a longer acting antianxiety medication called lorazepam 0.5 mg one tablet 30 minutes prior to the procedure. It was called in at 4:00 p.m. after we first accessed the in-state narcotic prescribing line Eforsce to make sure our patient was not pill or doctor shopping.

I received a phone call at 9:00 p.m. that evening from the patient who was at the pharmacy saying they didn’t have lorazepam in stock. It was unclear to me why, if they did not have the medication in stock, no one was responsible enough to call me and request an alternative prescription? I called the pharmacy in response to the patient calling me and ordered another product. However, they did not respond to my question “Why didn’t you call me if the medicine I ordered was not available?”

This week a 63 year old woman with three days of painful urination came to my office. Her urine suggested an infection. I called her pharmacy to phone in a prescription for ampicillin until her culture and sensitivity results were known. The pharmacist said she was too busy to take the call and asked me to leave a message. I waited for the beep and left the message. Thirty six hours later I received a fax to my office telling me that they were out of ampicillin and did not offer an alternative. I immediately called the pharmacy, furious at the delay and prescribed an alternative medication. Once again, if they did not have the ampicillin then why did it take them 36 hours to inform the patient or me? Why was this done by facsimile and not a phone call? The potential for complications of an untreated gram negative urine infection is frightening and life threatening. This should never occur. Then again why isn’t a common inexpensive antibiotic available in South Florida?

This is not very different than the blood pressure medicine Valsartan recall due to production induced impurities. When the recall was announced, I searched my computer and contacted my patients taking this medication to discuss options. For those demented and cognitively impaired patients I first called the pharmacy to ask if their supply was part of the recall. Much to my surprise much of it was under recall but the pharmacy had no intention and felt no professional responsibility to inform the customers who they had sold the tainted product to.

Pharmacists continually stress their professionalism as part of the health care team. These are three recent local examples of their need for improvement.

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The Florida Legislature and Florida Medical Association Making Docs the Fall Guys

I wrote and mailed my annual $250 check to the Newborn Injury Compensation Act (NICA) fund today. In 1982-83, when there was a medical malpractice crisis and no physician could get insurance to practice, the Florida Medical Association (FMA) cut a deal with the trial lawyers and our elected officials to form NICA. Every physician, regardless of specialty, is required to pay $250 annually into this fund to cover the cost of injuries to newborns. Obstetricians pay $5,000 annually.

In exchange for making the social problems of the state the responsibility of Florida physicians alone, the legislature passed some changes to the medical malpractice laws which encouraged insurers to return to and start writing policies in Florida. Isn’t it time for the State of Florida and its citizens to assume their responsibility for providing reproductive education and prenatal opportunities to women of child bearing age nearly 40 years later? Why does it remain my responsibility as a physician to continue to fund this entity? The FMA thinks it is still a good deal and will not discuss lobbying for a change.

Recently I attended one of many continuing education courses mandated by the elected officials in Tallahassee. It was on prevention of medical errors. It’s the same course I took two years ago and two years before that. Most of the errors are surgical and do not apply to me. The others are communication issues.

I have proposed over and over to my hospital’s chief medical officer and medical staff that we form a medical staff communication committee to facilitate doctor to doctor, and doctor to staff, communication to improve patient safety and care. Time after time they turn a deaf ear to the suggestion yet they host the medical error meeting yearly.

They also host the Domestic Violence lecture yearly. It too is mandatory for license renewal in Florida. The same message is delivered every year. “If the assault is made with a knife or gun call the police because they can do something. If a weapon is not involved your only option is to recommend counseling and safe shelters.” The Legislature has done nothing to toughen domestic abuse laws but they make us sit through the lecture every two years.

I have the same message for the legislature, the FMA and the Florida Board of Medicine, “You can kiss my grits!”

Wasting Taxpayers Money, Medicare Advantage and the RAC’s

My wife and I try to catch up on TV shows on Thursday evenings. We sit down with a cup of decaffeinated coffee on the couch together petting our dogs and watching mindless entertainment after a day at work. Now that the election is over, almost every commercial in my South Florida market is an advertisement for a Medicare Advantage Health Plan. We are nearing the completion of the “open enrollment” period between October 15 – December 7 when senior citizens can change their Medicare Part D Prescription Plan to one that covers their formulary of medicines and they can choose to leave the Medicare system and join a private health plan for a capitated Medicare Advantage Plan. These plans were initiated by the Center for Medicare Services (CMS) as a way to save money on the health care of seniors. The theory was that if they offered a product with a fixed monthly and yearly cost budgeting would be simpler and at least they would know what they are paying.

These programs are run by private insurance companies such as Humana, Blue Cross Blue Shield, and Aetna. Over the years, research has shown that they now cost the Medicare system more money per year, per patient, than the traditional Medicare system. The private insurers are probably making a great profit on this program because the money and energy spent on advertising to attract patients is relentless. I have been receiving multiple daily promotional letters in the mail for weeks now. Full page ads are run daily in major newspapers and magazines. Prime time television is filled with expensive ads with noteworthy spokespersons like basketball hall of famer Ervin “Magic” Johnson in addition to actors, actresses and former elected officials.

The insurers make their money by rationing and denying care provided by doctors and hospitals which agree to see patients in volume for a discounted fee. Patients have no deductibles; have no out-of-pocket expenses for physician care or generic pharmaceutical products if they stay in network. If they happen to get sick out of the service area, coverage is spotty and varies by program with the advice truly being “buyer beware.”

It seems to me that if these programs are actually more expensive per patient than traditional Medicare then why is CMS continuing them and allowing the millions of dollars spent on advertising to attract patients to continue? The information they need to choose a plan is available on the easy to use http://www.Medicare.gov website at no cost.

I open some non-critical advertisement mail as well. One letter from the Center for Medicare Services addressed to me personally as a patient, not as a physician, was extremely interesting. In December 2014 I was involved in a serious auto accident with my vehicle totally damaged due to the negligence of another driver. I was taken by ambulance to the local emergency room, examined, treated and released. At the time I was 64 years old and several months short of being eligible for Medicare. My auto insurance paid my medical bills. My private insurer Blue Cross Blue Shield was not billed.

The letter from CMS was a form letter saying that a claim from December 2014 had been investigated by them and although no payment was made on this claim, which was paid by Traveler’s Insurance (my auto insurer), they were now referring it to the Recovery and Audit Division for further investigation. The threatening nature of the letter suggested that if I was compensated by Medicare for this claim I would be required to pay back the money with interest and penalties. Considering I was not yet on Medicare, and considering the charges were billed by the local hospital health system, I am not quite sure why the letter was generated and forwarded to me?

Once again a government agency is spending taxpayer money on a frivolous item. How many more of these letters go out yearly at our expense?

The second letter I opened was from Social Security. It said that since I was still working and generating income, my wife and I would be required to each pay an additional fee per month for our Medicare health insurance and for our Medicare Part D prescription drug plan. This is in addition to the tax on my salary that goes directly to Medicare. I have been paying this tax on each paycheck since I started working at age 14 (I am now approaching 69). I read this letter just after hearing one of our elected officials to the Senate refer to Medicare as an “entitlement program.”

My Medicare bills now approach what private insurers charge patients for health insurance. I paid into this system for 51 years before I became eligible to use it. I hardly think the Medicare system is an entitlement.

Statin Related Muscle Pain and Coenzyme Q 10

Statins are used to lower cholesterol levels in an effort to reduce the risk of developing cardiovascular disease. They are used after a patient has exhausted lifestyle changes such as changing their diet to a low cholesterol diet, exercising regularly and losing weight without their cholesterol dropping to levels that are considered acceptable to reduce your risk of vascular events.

Patients starting on statins often complain of muscles aches, pains and slow recovery of muscle pain after exercising. In a few individuals the muscle pain, inflammation and damage becomes severe. One of the known, but little understood, negative side effects of statin medications are the lowering of your Coenzyme Q 10 level. CoQ10 works at the subcellular level in energy producing factories called mitochondria. Statin drugs, which inhibit the enzyme HMG-CoA Reductase lower cholesterol while also lowering CoQ10 levels by 16-54 % based on the study reporting these changes.

The November 16, 2018 edition of the Journal of the American Medical Association published a review article by David Rakel, MD and associates that suggested that supplementing your diet with CoQ 10 would reduce muscle aches and pains while on statin therapy. Twelve studies were reviewed and the use of CoQ10 was associated with less muscle pain, weakness, tiredness and cramps compared to placebo. The studies used daily doses of 100 to 600 mg with 200 mg being the most effective dosage. Finding the correct dosage is important because the product is expensive with forty 200 mg tablets selling for about $25.

Since CoQ10 is fat soluble, you are best purchasing formulations that are combined with fat in a gel to promote absorption. As with all supplements, which are considered foods not drugs , it is best if they are UPS Labs certified to insure the dosage in the product is the same as listed on the label and that it contains no unexpected impurities.

Vitamin D Supplements Do Not Reduce Falls, Fractures or Improve Bone Density

Much has been written about the benefits of supplementing Vitamin D in patients. The World Health Organization sets its normal blood level at 20 while in North America it is listed at over 30. Under normal circumstances when your skin is exposed to sunlight your kidneys produce adequate amounts of Vitamin D.

Over the last few years low vitamin D levels have been associated with acute illness and flare-ups of chronic illness. The Vitamin D level is now the most ordered test in the Medicare system and at extraordinary expense. Supplementing Vitamin D has become a major industry unto itself.

The October 4th edition of the Lancet Diabetes and Endocrinology contained an article written by New Zealand researchers that looked at 81 randomized research trials containing almost 54 thousand participants. “In the pooled analyses, researchers found that Vitamin D Supplementation did not reduce total fracture, hip fracture, or falls – even in trials in which participants took doses greater than 800 IU per day.” Vitamin D supplementation did not improve bone mineral density at any site studied (lumbar spine, hip, femoral neck, forearm or total body).

They concluded that there is little justification for the use of Vitamin D Supplements to maintain or improve musculoskeletal health, and clinical guidelines should reflect these findings.

Sleep and Cardiovascular Health

Several recent publications and presentations of data on the relationship between sleep patterns and vascular disease occurred at the recent meeting of the European Society of Cardiology. The PESA (Progression of Early Subclinical Atherosclerosis) study performed by Dr Fernando Dominguez, MD, of the Spanish National Center for Cardiovascular Research in Madrid talked about the dangers of too little or too much sleep.

The principal researcher, Valentin Fuster, MD PhD, looked at 3,974 middle-aged bank employees known to be free of heart disease and stroke. They wore a monitor to measure sleep and activity. Interestingly, while only about 11% reported sleeping six or fewer hours per night, the monitor showed the true figure was closer to 27%. They found those who slept less than six hours per night had more plaque in their arteries than those people who slept six to eight hours. They additionally looked at people who slept an average of greater than eight hours.

Sleeping longer had little effect on men’s progression of atherosclerosis but had a marked effect of increasing atherosclerosis in women. Researchers then adjusted the data for family history, smoking, hypertension, hyperlipidemia, diabetes and other known cardiovascular risk factors. They found that there was an 11% increase in the risk of diagnosis of fatal or non-fatal cardiovascular disease in people who slept less than six hours per night compared to people who slept 6-8 hours per night. For people who slept an average of greater than eight hours per night they bore a 32% increased risk as compared to persons who slept 6-8 hours on average. Their conclusion was distilled down into this belief: “Sleep well, not too long, nor too short and be active.”

In a related study, Moa Bengtsson, an MD PhD student at the University of Gothenburg in Sweden presented data on 798 men who were 50 years old in 1993 when they were given a physical exam and a lifestyle questionnaire including sleep habits. Twenty one years later 759 of those men were still alive and they were examined and questioned. Those reporting sleeping five hours or less per night were 93% more likely to have suffered an MI by age 71 or had a stroke, cardiac surgery, and admission to a hospital for heart failure or died than those who averaged 7-8 hours per night.

While neither study proved a direct cause and effect between length of sleep and development of vascular disease, there was enough evidence to begin to believe that altering sleep habits may be a way to reduce future cardiovascular disease.

Office Hours, After Hours Phone Calls, E-Mail Communications

For clarity purposes, my office is open at 8:00 a.m. through 5:00 p.m. Monday through Friday with staff present. The practice does not close for lunch. The telephone lines are open from 8:00 a.m. through 4:30 p.m., Monday through Friday.

During normal business hours please call the office phone number rather than my cell phone number. My staff will answer the call and bring it to my attention immediately if it is an emergency, or in-between patients if it is not an emergency. Please know there may be times when a consulting physician or hospital nurse may call the doctor’s cell phone directly during your visit. I recognize this may be an inconvenience and will be as efficient as possible while on the call.

If you call before 8:00 a.m. or after 4:30 p.m. the calls are forwarded to my cell phone number if you choose option #2 when listening to the voice message. There is also an option to leave a message.

When calling my cell phone, I will answer immediately if possible. Otherwise, I will return your call within 30 minutes. If you do not receive a return phone call within 30 minutes please call back. There are areas in hospitals and the community that do not have adequate cell phone service so I may not have received your initial call.

If you are having a medical emergency (e.g., heart attack, stroke, major loss of blood, loss of consciousness, breathing difficulty or intractable pain etc.) call 911 immediately and if possible then notify me.

When feeling ill, sick or there is a change in your condition; please call 561.368.0191 rather than sending an email to inform us of the problem. Email communications do not meet Federal privacy law standards.

If your work hours or personal schedule are such that the normal business hours don’t work for you, please call my office manager, Judi Stanich, so we can make arrangements to accommodate your schedule.

Because I have to visit my hospitalized patients during the early morning, I am typically unable to offer appointments prior to 8:00 a.m.

Although I provide 24×7 direct access, you should use discretion when calling me outside of normal office hours. Generally, after hours calls should be when you have a real health concern or an emergency.