Do You Still Trust Your Physician?

From WebMD: “Comorbidity is a medical term that you may have heard your doctor use. It describes the existence of more than one disease or condition within your body at the same time. Comorbidities are usually long-term, or chronic. They may or may not interact with each other.”

“JC Dodge” posted a thought-provoking article at American Partisan. For example:

Although we are all dealing with COmorVIDities, anyone who has COmorVIDities from the vaccine can place them purely at the feet of the medical community. You might say, “But JC, the government and companies required it of Employees.”. Although this appears true on it’s face, if the medical community had stood up and acted on the, “First do no harm.” oath they took as medical providers, the government and businesses wouldn’t have had anywhere to go but “STOP”.

One of the COmorVIDities I now have, is a fear that anything I am told by any medical provider, whether for my kids or myself, is BS and aimed at padding their pocket. The majority of them have proven they will take kickbacks from the GOV or Big Pharma, over providing quality medical care.

I actually questioned my Child’s Pediatrician, when she was getting a normal childhood vaccine, because it didn’t sound like the ones my other three kids had received over the last 24 years. Why? Because I no longer trust them to do the right thing for their Patients.

Although I know some good Doctors and Nurses, I believe most of them were forced out of what is considered, “The Medical Community”, because they weren’t foolish enough to get the vaccine, or wanted to be able to prescribe “Non-Approved by Big Pharma” treatments. Most of those left are getting their “30 Pieces of Silver” from Big Pharma and the GOV, and couldn’t be happier.

I am a hospitalist. Most of the physicians I know are frontline in-the-trenches doctors taking care of patients and in no position of authority over hospital administrators, business administrators, and public health authorities.

I remember only two things from the first day of medical school, spoken by an Asian professor:

  • “If you’re sitting here today, you probably have an IQ of at least 120.” (So don’t worry, you can handle the workload.)
  • Mention of Sir William Osler’s Aequanimitas essay.
  • “Every day not sunny day.”

Most of medical school, which typically lasts four years, involves memorization of massive amounts of information, which you regurgitate and on a test and have mostly forgotten a month later. It is not fun, to say the least. Medical students have actually done more analytic thinking while acquiring their undergraduate degrees and in high school. After med school, physicians spend at least three to five years in a residency that also requires incredible memorization, but you tend to retain more since it is clinically relevant. Much of the actual thinking of a practicing physician revolves around establishing a diagnosis and formulating a rational treatment plan. Even then, much of the diagnosis is made by high-tech imaging and blood tests, so the doctor has to do less thinking than our predecessors of 40 years ago. Similarly, we have “clinical practice guidelines” that are composed by “authoritative” committees, telling us how to treat specific conditions. If we follow those guidelines, we may be more likely to retain our jobs, earn a salary bonus, and prevail in malpractice lawsuits. Physicians who think and question the guidelines are too often seen as trouble-makers. Unlike 40 years ago, a majority of physicians are not independent, but are employed by large organizations that tend to control them via a paycheck.

My point is: Many practicing physicians don’t have to do much thinking, so they don’t. Sad, but true.

So JC Dodqe is right to question his child’s pediatrician.

Steve Parker, M.D.

PS: One of the reasons for specialization is that there is so much to learn in any given field, there’s just no time or mental capacity to keep up with less pertinent aspects of medicine. An orthopedic surgeon doesn’t need to know much at all about heart failure, diabetes, and anemia. That’s my job.

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Books for Folks With Type 1 Diabetes

Roasted Radishes and Brussels Sprouts. For recipe, use search box.

Diabetes Daily has an article by Julia Flaherty that reviews books regarding type 1 diabetes. Just thought you might be interested. It didn’t review Cheating Destiny: Living with Diabetes, which I am mentioned in.

Steve Parker, M.D.

PS: Here’s another book for people with type 1 or 2 diabetes:

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ADA Promoting Low-Carb Eating

Conquer Diabetes and Prediabetes, Steve Parker MD
A very low-carb meal

Interestingly, the American Diabetes Association (ADA) is selling to healthcare providers Low Carbohydrate and Very Low Carbohydrate Eating Patterns in Adults with Diabetes: A Guide for Health Care Providers

About:

The American Diabetes Association has identified low-carbohydrate (LC) and very low-carbohydrate (VLC) eating patterns as options that can improve outcomes in adults with type 2 diabetes.  This 28-page guide was designed to assist registered dietitians, certified diabetes care & education specialists, and other health care practitioners in assessing the appropriateness of a LC or VLC intervention for their patients.  Additionally, it provides strategies and sample meal plans for implementing a LC or VLC eating pattern as an evidence-based intervention in adult with type 2 diabetes.

In my world, “very low-carbohydrate” means ketogenic.

Steve Parker, M.D.

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Recipe: Low-Carb Zuppa Toscana

Photo by Riccardo Bertolo on Pexels.com

DJ Foodie has come up with a low-carb version of zuppa toscana, my wife’s favorite soup at Olive Garden restaurants. I prefer the pasta e fagioli. We haven’t tried it yet but post a link here for future reference. 9.4 net carbs per 330 calorie serving.

Steve Parker, M.D.

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Dr Hall Reviews Weight-Loss Pill Plenity

Dr Harriet Hall wrote a brief review of the new weight-loss drug Plenity at Science-Based Medicine. Her conclusion:

So far, effectiveness has been shown in only one placebo-controlled trial. Diet and exercise must be continued. It doesn’t work well for everyone: 6 out of 10 users lost at least 5% of their body weight; the other 4 didn’t. It appears to have fewer side effects than other weight loss products. Not a way to achieve ideal weight, but probably worth trying for patients who understand that it is only an aid and not a final solution. I hope they will be encouraged enough by a 22-pound weight loss to continue losing weight with or without Plenity.

Overweight and obese folks with diabetes also tend to lose weight with the new once-weekly injection therapy called tirzepatide, brand name Moujaro. (Where do they get these names?!) And remember that bariatric surgery is often very effective at weight loss and controlling diabetes…if you survive the operation.

Steve Parker, M.D.

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Keto Versus Mediterranean Diet: Which Is Best for T2 Diabetics and Prediabetics?

Use the search box to find the recipe for this LCHF avocado chicken soup

Effect of a Ketogenic Diet versus Mediterranean Diet on HbA1c in Individuals with Prediabetes and Type 2 Diabetes Mellitus: the Interventional Keto-Med Randomized Crossover Trial

Right off the bat, I don’t like that they studied both diabetics and prediabetics. There were only 40 original study participants, with complete data on only 33. Why lump the two together?

Participants followed each diet for 12 weeks then lab data and body weight were assessed.

The researchers conclusions:

HbA1c [a measure of blood sugar control] was not different between diet phases after 12-weeks, but improved from baseline on both diets, likely due to several shared dietary aspects. WFKD [ketogenic diet] was beneficial for greater decrease in triglycerides, but also had potential untoward risks from elevated LDL-C, and lower nutrient intakes from avoiding legumes, fruits, and whole intact grains, as well as being less sustainable.

Triglycerides dropped more on the keto diet, no surprise. Body weight dropped the same for both diets, 7-8%. HDL-cholesterol (the “good cholesterol”) rose 11% on keto and 7% on Mediterranean diet. HgbA1c dropped the same on both diets, about 8% from baseline. Both diets lead to eating ~300 calories less per day than baseline consumption.

Dr Bret Scher addressed the increased LDL-cholesteral (aka “bad cholesterol”) over at DietDoctor.com:

The authors reported that LDL “dangerously” rose 10% on the keto diet. But was it really a dangerous change? Triglycerides went down on the keto diet, as we would expect. And as we saw in 2018 with the Virta Health trial, on average, LDL went up 10%. However, the calculated cardiac risk score went down 12%.

In terms of answering the headline question, Keto Versus Mediterranean Diet: Which Is Best for T2 Diabetics and Prediabetics?, the answer really depends on long-term data concerning longevity and various diseases. This study doesn’t answer the question.

What say you?

Steve Parker, M.D.

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Filed under Health Benefits, ketogenic diet, Mediterranean Diet, Weight Loss

High-Volume Versus High-Value Doctors

In your ideal world, would you prefer your physician’s income reflect:

  • number of patients seen and procedures performed, or
  • high quality of care, reflected in ready accessibility, lowering cost without compromising care, compliance with science-based guidelines, and patient satisfaction/experience, or
  • combination of the above

In other words, do you want your physician incentivized by volume or value?

It doesn’t matter what you want anyway, peon.

A recent study looked at salary arrangements for doctors in system-affiliated physician organizations in four states. The main conclusion:

The study results suggest that despite growth in value-based payment arrangements from payers, health systems currently incentivize physicians to maximize volume, thereby maximizing health system revenues.

This in-depth multimodal cross-sectional assessment of compensation and incentives among health system–affiliated POs [physician organizations] for which there is greater exposure to VBP [value-based payment] and APM [alternative payment model] arrangements compared with independent practices found that volume was the most common form of base compensation by a wide margin, being included by more than 80% and 90% of POs for PCPs [primary care physicians] and specialists, respectively, and representing more than two-thirds of compensation when included. Similarly, actions to increase volume were the most commonly cited means for physicians to increase their compensation. Base compensation incentives for physicians were not dominated by population or value-oriented payments, with only a third of POs reporting inclusion of capitation with PCPs and averaging only about a third of total compensation when included. Performance-based financial incentives for value-oriented goals, such as clinical quality, cost, patient experience, and access, were commonly included in compensation but represented a small fraction of total compensation for PCPs and specialists in health systems, operating at the margins to affect physician behavior. Taken together, these findings suggest that despite growth in APMs and VBP arrangements, these value-based incentives were not commonly translated into health system physician compensation, which was dominated by volume-oriented incentives.

The problem is that it’s a lot easier to measure volume than value. Easy wins.

Steve Parker, M.D.

Ref: Physician Compensation Arrangements and Financial Performance Incentives in US Health Systems in JAMA Network

PS: Avoid the medical-industrial complex as much as is safely possible. Let me help.

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It’s True: Olive Garden Won’t Necessarily Blow Your Ketogenic Diet

Steve Parker MD, low-carb diet, diabetic diet
Olives, olive oil, and vinegar: classic Mediterranean foods

Lisa MarcAurele authored an article about eating at Olive Garden even though you’re on a ketogenic diet:

Whether you are traveling and can’t cook or you are celebrating something special with people you love, Olive Garden has some low-carb options that are simply delicious!

They might be known for their endless breadsticks and overflowing plates of pasta, but there are some keto-friendly choices on the menu, too. You just have to know where to look. 

Olive Garden is also known for its large portions, so you will have to think ahead before eating everything on your plate. 

When you don’t have time to cook or just want to dine out, Olive Garden can be an appealing option for people on a ketogenic diet. Thankfully, there are ways to eat a keto meal at Olive Garden – you just have to be a little creative with a custom order!

Thank you, Lisa.

Steve Parker, M.D.

PS: Conquer Diabetes and Prediabetes includes a ketogenic option.

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Leafy Greens Can Kill You!

Not sure if this is chicken or tuna salad with walnuts and grapes

Periodically there are outbreaks of illness caused by eating contaminated leafy greens. The contaminants are usually bacteria such as E coli and Salmonella. The illness is typically diarrhea, sometimes with belly cramps, nausea, and vomiting. And rare deaths.

Cathe Friedrich published an interesting article about this phenomenon. Here are a few bullet points (I haven’t independently verified):

  • Leafy greens such as lettuce are linked to 22% of food poisoning outbreaks over over the last 10 years
  • The riskiest leafy green is bagged, ready-to-serve lettuce

A few ways to avoid foodborne illness:

  • Avoid pre-packaged leafy greens
  • Avoid sprouts
  • Keep the produce refrigerated and dry
  • Consume before the expiration date

Click for leafy green food safety tips from the Canadian government.

Click for a harrowing story at Consumer Reports about E coli poisoning from romaine lettuce.

Consumer Reports article on the safest ways to eat salad.

Steve Parker, M.D.

h/t Jan at The Low Carb Diabetic

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Stable Chest Pain: CT Angiography Versus Standard Angiography

Heart attacks and chest pains are linked to blocked arteries in the heart

We’re all gonna die of something.

The #1 cause of death in the U.S. is coronary artery disease (CAD), which causes heart attacks, sudden cardiac death, and some cases of congestive heart failure. Folks with diabetes have a higher-than-average risk of CAD. Blockage in the heart arteries typically develops over years and many people are walking around not knowing it’s there. The lucky ones develop warning signs like transient chest pain or shortness of breath on exertion. After consulting a physician, the next step may be a “stress test” or some sort or imaging of the arteries of the heart.

Angiography refers to imaging of arteries or veins. Angiography of the heart arteries is helpful in diagnosing blockage of arteries that may cause heart attacks or sudden cardiac death in the future.

CT stands for computerized tomography: x-rays obtain images that are then manipulated by computer technology to provide more information than plain x-ray technology alone. CT angiography of the heart arteries is done with iodinated contrast injected into the low-pressure venous system of circulation. In contrast, standard arterial angiography involves introduction of a needle (and catheter) into the high-pressure arterial system, usually the femoral artery in the groin or the smaller radial artery in the wrist. Standard arterial angiography is associated with a higher risk of complications such as leakage of blood from the artery. Another potential complication is embolization of arterial plaque or clots downstream from the arterial puncture. Because of the higher complication rate in the arterial system, standard angiography is considered “invasive.”

The study at hand asks which is a better way to image heart arteries in a patient with stable chest pain: CT versus standard arterial angiography. The article abstract doesn’t define “stable” chest pain. I assume the researchers did not include acute myocardial infarctions (heart attacks) and unstable angina.

European researchers concluded that:

Among patients referred for invasive coronary angiography (ICA) because of stable chest pain and intermediate pretest probability of coronary artery disease, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy.

I bet the non-invasive CT is also less expensive than standard arterial angiography.

Steve Parker, M.D.

PS: You now what else help prevent heart attacks and cardiac death? The Mediterranean diet.

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Filed under coronary heart disease, Heart Disease