Taming the hangover

By the time the upcoming weekend is over, a certain percentage of the people reading this post (although a very small percentage, I hope) will probably experience the miserable symptoms of a hangover.

Hangovers can happen all year long, but they’re often more likely around the holidays, when the partying and the eggnog can sometimes flow a little too freely.

What exactly is a hangover? The Mayo Clinic offers this rather understated definition: "A hangover is a group of unpleasant signs and symptoms that can develop after drinking too much alcohol." (The term itself appears to have originated in the 1800s as a descriptor for something unfinished or left over. In the early 1900s it also started to be applied to the after-effects of too much drinking.)

Although the hangover is a common experience, surprisingly few studies have scientifically addressed the mechanisms of hangover or evaluated how to treat it. Here’s what we do know, however:

The symptoms of a hangover – dehydration, headache, grogginess, fatigue, nausea – are the body’s physiological response to alcohol itself, as well as to the body’s efforts to process alcohol and counteract its impact on the central nervous system.

The dry, cottony mouth? That’s due to the diuretic effect of alcohol, which can lead to thirst, dehydration and dizziness. Nausea (or, worse yet, vomiting)? Alcohol can irritate the lining of the stomach and increase stomach acid production; it also delays emptying of the stomach, with predictable consequences. Headache? This is usually due to alcohol-induced dilation of the blood vessels.

Feeling groggy and exhausted is another common symptom. Although having a few drinks can feel stimulating to many people, alcohol is in reality a depressant. Eventually the drinker will feel sleepy, but he or she won’t sleep well, hence the fatigue that often comes after having a few drinks too many. Staying up too late or overdoing it on the dance floor can add to the fatigue.

Several risk factors appear to contribute to the severity of a hangover. The Mayo Clinic explains how this works:

Anyone who drinks alcohol can experience a hangover, but some people are more susceptible to hangover than are others. A genetic variation that affects the way alcohol is metabolized may make some people flush, sweat or become ill after drinking even a small amount of alcohol. Research hasn’t clearly shown whether light drinkers or heavy drinkers are more likely to experience hangovers.

Factors that may make a hangover more likely include: drinking on an empty stomach; using other drugs, such as nicotine, along with alcohol; having a family history of alcoholism; drinking darker colored alcoholic beverages; drinking champagne or alcohol mixed with carbonated beverages.

A study in the Annals of Internal Medicine some years back suggested that extra fluids, vitamin B6 and aspirin or ibuprofen can relieve hangover symptoms. There’s no lack of home remedies for hangovers. Drinking sauerkraut juice (!!) is one I’ve heard; so is black coffee with lemon juice. The only sure cure, however, according to the experts, is time and rest.

An even better remedy: Try to avoid getting hung over in the first place. This means drinking in moderation (or not at all), taking it slowly and not drinking on an empty stomach. In the case of the hangover, it seems prevention is usually the best medicine of all.

Photo: Wikimedia Commons

Curbing unnecessary testing

Dr. Lucy Hornstein, a family practice physician who blogs at Musings of a Dinosaur (and has recently published a book), made an intriguing suggestion this week: If a patient asks for a test the physician deems is medically unnecessary and the test results show nothing out of the ordinary, the patient should pay for it. But if there’s an abnormal result, insurance should pay.

There’s no denying that tests are contributing a significant chunk to the overall cost of medical care in the United States. Some of it, as Dr. Hornstein points out, is defensive medicine on the part of physicians. But there’s more to it than this, she writes:

At issue is what to do when patients request/demand inappropriate testing. This has been driven home to me at least three times just in the last week.

From patients with no family history of anything and perfectly normal blood tests (cholesterol panels, blood sugars) a year ago who “really want it done again” despite the USPSTF recommendation of 3-5 year intervals for these screenings, to women who demand annual paps “just to make sure everything’s OK in there,” I find myself struggling to explain the downside of unnecessary testing. “But the insurance will pay for it,” they respond. “What’s the harm?” Sometimes I do it; sometimes I stand my ground; but the encounters often leave me drained and upset. How much is my inability to explain these things adequately, and how much is it the deeply ingrained American idea of “more is better,” “better safe than sorry,” and so on? There seems to be no way to tell.

She reasons that if insurance companies only pay for medically unnecessary testing when the results are abnormal, “patients have a little more skin in the game by taking on the risk of having to pay for negative tests. As most of them claim to only want the testing for ‘peace of mind,’ it stands to reason that many of them would also be willing to pay.”

It’s true that health insurance tends to insulate most of us from the actual cost of health care. This is becoming less the case as more and more people switch to higher deductibles or health savings accounts, which has increased their out-of-pocket expenses. The idea is that when consumers have to pay for some of their care themselves, they’re more likely to think twice before seeking care that might be unnecessary.

I’m not sure if this same dynamic would play out for medically inappropriate screening, especially when the determination whether to cover it wouldn’t be made until after the fact. Nor is it clear how much money would actually be saved. Regardless of who pays the bill, there’s still a cost to the provider for staffing, supplies, use of equipment and so on. 

What’s unnecessary, of course, might be in the eye of the beholder. What price tag do you put on peace of mind? People don’t always go to the doctor because they want to know what’s wrong with them; oftentimes they go because they want reassurance that something isn’t wrong with them. And as we’ve seen in the case of the U.S. Preventive Services Task Force and its recent new recommendation on mammograms, it can be very hard to sell the public on the concept that testing isn’t always what it’s cracked up to be. 

In any case, Dr. Hornstein has made an interesting proposal, and I’m curious to know what readers think.

Update: When it comes to patient requests for additional testing, are doctors darned if they do and darned if they don’t? Here’s another look at this issue.

Committing medical error: fallible or criminal?

A recent Webcast about Eric Cropp, an Ohio pharmacist who’s serving time in jail, has been making the rounds on the Internet and sparking some intense, impassioned discussion.

Cropp isn’t in jail because he embezzled money from the pharmacy or assaulted a customer. He was the lead pharmacist at a hospital in Cleveland in 2006 when a medication error was made, resulting in the death of a 2-year-old girl who was being treated for cancer. Criminal charges were filed; Cropp pleaded guilty to involuntary manslaughter and was sentenced to six months in jail, followed by six months of house arrest and three years on probation. He also was stripped of his pharmacist’s license. (The hospital settled a civil lawsuit with the child’s family for $7 million.)

The case received a ton of attention, as well it might. It also sent shivers down the spines of practically every health care professional who heard about it and pondered the implications.

Should health care professionals be criminally prosecuted if they harm a patient? It’s extremely rare for a doctor or nurse or anyone else to face criminal charges in connection with injury or death to a patient, which is probably one of the reasons why Eric Cropp’s case made the news. Society has generally judged that most medical errors are unintentional and that health care professionals deserve some leeway, at least as far as the criminal court system is concerned.

Are there instances, however, in which someone’s conduct or risk-taking rises to the level of a crime? It’s a troubling question with no clear answers.

Back in May, when Cropp was convicted, many of the online commenters in the health care world were incredulous. Dr. Jeffrey Parks, an Ohio surgeon who blogs at Buckeye Surgeon, described his reaction:

He wasn’t drunk or impaired. He wasn’t even the one who prepared the mixture.  He was inattentive and lazy and careless, and now he faces the real possibility of serving jail time as a consequence. He’s a pharmacist, not a doctor, but the implication and precedent is clear – health care professionals are not immune to the prospect of a criminal trial.

Dr. Parks’s commenters agreed with him. “This should scare all medical providers,” one person wrote. Someone else wrote, “Criminal act? Are you kidding? He made a mistake. We all do… every day.”

“An injustice has been done,” declared Michael Cohen, president of the Institute of Safe Medication Practices, in an opinion piece he wrote shortly after Cropp was sentenced this past August.

Fast-forward to a couple of weeks ago and the Webcast, sponsored by CareFusion, along with the ISMP’s most recent newsletter, which seems to have raked up the emotions all over again. Dr. Bob Wachter, one of America’s foremost gurus of health care safety and quality, brought some of the most critical questions into the forefront recently on his blog.

His view:

The criminal system should have absolutely no role in dealing with medical errors unless we are talking about cases of sabotage, or of willful and recurrent violation of safety rules when harm was foreseeable. By all reports, Eric’s case met neither of these criteria.

I’ve read differing accounts of what happened. One of the allegations was that the lethal saline mixture was prepared not by Cropp but by a pharmacy technician who was distracted by plans for her upcoming wedding. But according to other versions of the story, the pharmacy tech pointed out to Cropp that the saline solution didn’t look right and he approved it anyway.

There apparently were problems with understaffing, the work load and the pharmacy’s computer system that may have contributed to the fatal error, as an analysis by the Institute for Safe Medication Practices found. There even were accusations that the child’s family had political connections that may have influenced the decision to prosecute. Many of the details are impossible to know because they have either been shielded or simply not publicized.

But there’s a bigger issue here, Dr. Wachter explains. It’s the widening disconnect between the health care world and the public on who’s accountable for medical error. Dr. Wachter writes:

… One can feel the ground shifting – from our initial “It’s all about ‘no blame'” mantra to an environment in which accountability is being increasingly demanded of us. Part of my reason for arguing so strongly that we need to begin enforcing our own safety standards – particularly when we’re dealing with no-brainers like hand hygiene – is that the public is beginning to see our reflexive invocation of “no blame” as in-credible – as evidence of our unwillingness to address performance gaps, even when they are egregious. I worry that the more we appear to be looking the other way, the more likely we are to experience imposed solutions: by regulators, through tort law, or, most troubling, in criminal courts.

I can’t help noticing that in many of the online discussions about this issue, it’s the health care practitioners who usually leap to the staunch defense of their colleagues, and members of the general public who are more skeptical. One commenter at Buckeye Surgeon wrote that “health care professionals have always gotten a free pass” and suggests, “Maybe it’s time to level the playing field.”

At MedCity News, a pharmacist reminded people not to be quick to judge. “If you walked a mile in the pharmacist’s shoes you would understand,” he wrote. But someone else wrote, “Of course there was no intent in this case… the pharmacist didn’t mean to kill the child but his reckless and willful disregard for safety [nonetheless] caused the death… and for that he should be held responsible.”

I don’t think the answers are black and white. In fact I don’t know what the answer should be, because the entire question is clouded with ambivalence. One of the commenters on Dr. Wachter’s blog summed up many of the issues that make health care fallibility vs. criminality so hard to address:

Why exactly are health care personnel exempt from the consequences of their mistakes? The answer I hear from others posting is that if we don’t exempt them then they will not report their mistakes and the systems that caused them will not improve.

Is the hospital involved now staffing the pharmacy more fully? Did they learn from their error enough to now put enough personnel (paying enough to have skilled enough staff) in place to keep this tragedy from happening again? Did they pay enough in their malpractice settlement to teach them that it is wiser to invest their money on the front end by hiring enough people, paying enough for well qualified, skilled individuals? Or, as is more likely the case, does the settlement represent “the cost of doing business”?

… One answer proffered here is that this pharmacist or indeed any other health care provider making a similar mistake has already learned his lesson and living with the knowledge of the consequences of his action is punishment enough, and will make him a better pharmacist. But, in other places I have heard time and again that practitioners make mistakes – that they cannot be expected to be perfect – that it is the nature of the art of medicine.

… It seems that health care practitioners want it all. They want to be allowed to make mistakes, not be subject to censure, prosecution or malpractice (because gosh, mistakes happen, we can’t expect perfection) and not have anyone except a few insiders know about it. You want us to trust you to fix it privately, behind closed doors, protecting everyone involved. You want us to trust you, but you don’t think we’re smart enough to understand the complexities of the system in which you operate. You want to be special. You want to operate above the law with your own set of secret rules.

She concludes, “For the record, I am swayed by the argument offered by Dr. Wachter that the pharmacist did not deserve to be criminally prosecuted. And, I still have all these questions noted above.”

Most people in the health care professions are not “bad apples.” The vast majority of them are bright, hard-working, dedicated and ethical. When things don’t go well for a patient, they are probably harder on themselves than the patient or family would ever be. But it’s naive to think all of them measure up to this standard or that all of them are fit to practice. Maybe most mistakes can be forgiven but some cannot. Health care professionals, no less than the public, are wrestling with this, and it’s an issue that calls for some genuine soul-searching.

Taking care of the boomers

The baby boom generation is the largest age cohort in American history, but it seems they’re underrepresented in the doctor’s office when it comes to preventive services such as adult immunizations and screenings, a new report has found.

The study, part of a collaborative project by the American Medical Association, the American Association of Retired Persons and the U.S. Centers for Disease Control and Prevention, was released last month. It calls on the broader use of clinical preventive services among adults ages 50 to 64.

From the report:

By 2015, one of every five Americans will be between the ages of 50 and 64. As they enter this age group, 70 percent will already be diagnosed with at least one chronic condition and nearly half will have two or more. The resulting disease and disability may seriously compromise their ability to carry out the multiple roles they play at this point in their lives. National experts agree on a set of recommended clinical preventive services that can help detect many of these diseases, delay their onset, or identify them early in their most treatable stages. Despite the cost-effectiveness of many of these services, the percent of adults who are up to date on receiving them is low.

The sheer numbers of the baby-boom generation, defined as those born between 1946 and 1964, make it urgent to address their health needs sooner rather than later. In 2007, the report notes, there were nearly 55 million American adults between the ages of 50 and 64. By 2015, there will be nearly 63 million boomers in middle age, a time when chronic health issues have a way of sneaking up on us.

Health care spending among Americans in their middle years has been growing, according to a survey by the Medical Expenditure Panel of the U.S. Agency for Healthcare Research and Quality. The survey found that adults ages 45 to 64 incurred $370 billion in health care expenses in 2006 – $183 billion higher than in 1996. Average spending per individual also rose, because of both increasing use of services and the higher cost of health care services.

More widespread screening and preventive care could help catch many health issues sooner and lower some of the costs associated with illness and chronic disease, the joint AMA/AARP/CDC report says. The report proposes 14 key indicators on which providers should focus: screening for cholesterol, cervical cancer, breast cancer and colorectal cancer; monitoring the risk for obesity, smoking, high blood pressure, risky alcohol use and moderate depression; vaccinations for pneumonia and influenza; promotion of physical activity; and ensuring men and women ages 50 to 64 are up to date with specific screening and preventive care.

How do the boomers stack up on these measures? They fare pretty well on some of them. For instance, nearly 90 percent of people in the 50-to-64-year-old age group have had a cholesterol screening within the past five years, and 80 percent of women have had a mammogram within the past two years. Only about half, however, have been screened for colorectal cancer, 42 percent have had a flu shot within the past year, and 27 percent report no leisure-time activity within the past month.

It’s interesting to learn that boomers, who are often unfairly perceived as entitled and self-absorbed, aren’t always up to date when it comes to their health care. Then again, this generation has always been far more diverse than they’re given credit for. While some of them were grooving at Woodstock, others were in the jungles of Vietnam. Some lived the flashy young urban professional lifestyle in the 1980s while others held down jobs and raised families.

It’s possible that many middle-aged boomers aren’t aware of what screenings and preventive services they should be receiving. Or maybe they simply don’t see themselves as – perish the thought- getting older.

Reaching out to a population this vast and this diverse isn’t going to be easy, so the report recommends the development of collaborative strategies involving state and national public health practitioners, clinical service providers, policymakers and others to “make effective screening, counseling, vaccinations and other recommended services a routine part of prevention for the nation’s adults.”

There’s a fair amount of debate about the cost-vs.-benefit of screening and prevention among those who are younger and those who are elderly. The consensus seems more clear that among the middle-aged, the benefit generally outweighs the cost and that it’s not too late for this age group to start reaping some of those benefits.

Photo: Jimi Hendrix at the Woodstock Festival, 1969. Associated Press file photo.

Lessons from the veterinary clinic

The patient

The world of human health care could learn a thing or two from veterinary medicine.

I’ve been a veterinary client for many years and can’t help noticing the many areas in which veterinary medicine is such an effective model.

There are the small things: For instance, I’ve never had to wonder when my cat’s vaccinations are due because a reminder postcard arrives in the mail every single year. It’s rarely difficult to get an appointment or to have the veterinarian return a phone call, and test results are reported promptly, often on the same day. Even the parking at veterinary clinics is usually easy – a real convenience when you’re trying to juggle a cat in a carrier or a dog on a leash.

In the bigger picture, veterinary medicine seems better at managing costs, perhaps because pet owners are footing most of the bill themselves. Dr. Patty Khuly, a Florida veterinarian who blogs at Dolittler, gave her perspective on the cost curve in a recent post:

… When vets and clients know how much everything costs, and when everyone’s a stakeholder in the cost conservation game, smarter decisions get made.

Add to this the fact that 17% of our hospitals’ costs don’t need to go to the billing department for arcane code translation and chronic insurance carrier disputes and you’ve got a recipe for an automatically slimmer, less wasteful system.

Nor does the veterinary insurance market operate the same way as health insurance for humans, Dr. Khuly points out:

I’ll also agree that giving consumers a choice in their election of insurance carriers and plans makes a big difference to the viability of the system. Unlike our human system, for which individuals are effectively forced into one company’s plan by their employers, pet health insurance offers multiple carriers with multiple plans any owner can choose based on its merits and their personal level of risk aversion.

There’s none of the cost-shifting that takes place in the human health care world. There’s also a higher degree of transparency about prices, making it easier for clients to shop and compare and to know how much they’re likely to pay, whether it’s for routine vaccination or a complicated surgery .

To be sure, the veterinary world has seen much of the same run-up in technology and specialized services as in human health care (but without the medical arms race that has left some communities with a cardiac catheterization lab on practically every corner). You can get CT, MRI or ultrasound imaging for your pet. There’s oncology for pets, orthopedic surgery for pets and physical therapy for pets. Some veterinary clinics even have adopted electronic health records with an online portal, as Josh Seidman of the Information Therapy Center describes in a blog post about his dog, Molly, and the canine-centered care she receives.

None of this is necessarily a bad thing. It means we now have options for treating diseases and injuries that previously would have been considered untreatable. The only limitations, in fact, are the size of the owner’s bank account and his or her perception of the risks vs. the benefits.

While the money Americans spend on veterinary care is growing at the same rate as our spending on our own health, it doesn’t match the cost of the human health care system, a blogger with the American Enterprise Institute points out:

… We spend hundreds of times more on ourselves than on our pets. The main reason for this is obvious: We value our own lives and those of our families more than we do our pets or other animals. At the same time, however, veterinary care is one of the few areas of health where we are directly confronted with difficult decisions regarding the costs and benefits of additional treatments.

I don’t think we’d want to apply such stark values to our own health care decision-making. After all, pets and people are not the same thing. But we’re often unaware of how much our health care costs, nor do we always make the connection between spending and outcomes- and perhaps we should.

I recently had the chance to see this whole system at work, up close and personal. My cat wasn’t feeling well so we made an appointment at our local veterinary clinic, the equivalent of my cat’s medical home for all her primary care needs. An ultrasound exam was recommended, which meant we’d need a referral to a larger facility.

I researched the options online and chose Metropolitan Veterinary Referral Services in Eden Prairie. I’m very glad I did. It’s a practice that specializes in internal medicine for dogs and cats, with advanced services such as oncology, cardiology, gastroenterology, surgery, and diagnostic imaging and evaluations. They have an intensive care unit staffed 24 hours a day; they also provide around-the-clock emergency care. It sounds high-tech and indeed it was high-tech, yet the place had the atmosphere of a neighborhood clinic. The care was patient- and family-centered, two hallmarks of quality in the world of people care.

When my cat’s ultrasound exam indicated we needed to do a biopsy, I promptly received an itemized estimate of what the whole package was likely to cost:

(The final bill, by the way, fell almost exactly in the middle of this estimate. Try getting cost information this accurate and straightforward from a medical clinic or hospital.) It was a real exercise in the true cost of care and the need to weigh that cost against the likely benefit to the patient.

These are some of the practical lessons to be learned from the veterinary clinic. Other lessons are harder to categorize.

How do we make health care decisions, especially when our decisions are on behalf of someone else? Are we able to separate our emotions from the patient’s best interests? Do we react in knee-jerk fashion or do we try to gather information and see the big picture?

What is the value of kindness and compassion? Providers can’t bill for it, and technically speaking, it has nothing to do with outcomes – yet it matters, especially when the patient is very sick or the prognosis is uncertain.

What do we want for the end of life? Do we want to exhaust all the options in search of a cure or do we believe it’s more important to focus on quality of life? Thinking about it ahead of time, before there’s a crisis, can give us a better chance of clarifying what’s important to us and making good decisions.

Finally, here’s the last lesson: Sometimes the story doesn’t turn out the way we want it to. Some diseases can’t be stopped, no matter how much money or how much treatment we throw at them. When that happens, we have to recognize it and let the patient go, knowing that life is something that’s only borrowed and one day we have to give it back.

Photos by Anne Polta

Whither HCMC?

Hennepin County Medical Center in downtown Minneapolis might seem far away from the rest of Minnesota, but the ripple effects of budget cutbacks at HCMC are likely to be felt across the state.

Exactly what’s at risk is laid out on a recently launched Web site, willyoulose.org. I’ll let the folks at HCMC explain why they are undertaking this campaign:

willyoulose.org is filled with stories about the important role HCMC plays in ensuring a well-trained health care and first responder workforce, emergency readiness programs, high quality trauma, specialty care and access to health care for all. In addition, patients, families and others who have been touched by HCMC are invited to share their stories on the site.

"Minnesotans need to understand what’s at stake if the cost of providing care to more and more uninsured Minnesotans is shifted to hospitals," said Mike Harristhal, vice president of public policy. "Safety net hospitals play a number of other critical roles in the state, and if they face a significant loss of compensation when caring for uninsured patients, other programs and services for all Minnesotans could be in jeopardy."

Willyoulose.org doesn’t tiptoe around the magnitude of what could happen next year if General Assistance Medical Care, a publicly funded program that covers the poorest of the poor, is not restored. A section labeled "the fallout" shows a map of Minnesota with the impact spreading out in concentric circles. There are some eye-catching graphics, especially the Photoshopped sign for Mora, Minn., "Pop. 0 doctors", and the do-it-yourself dental kit consisting of a pliers.

Here’s the tally of the services HCMC provided last year to those of us living in the Seventh Congressional District: 440 emergency department visits, 649 inpatient hospital stays, 1,664 clinic visits and outpatient services, 1,133 uninsured patient visits, $1,256,929 in uninsured charges for care, 12,207 calls to the Poison Center.

I’ve lost track over the years of how many times the West Central Tribune has reported on highway crashes in which severely injured drivers and passengers were taken to HCMC. HCMC is the largest Level 1 trauma center in the state. It also has a critical burn unit and a hyperbaric oxygen chamber for treating carbon monoxide poisoning.

If you look closely at a Willmar Ambulance Service rig, you’ll see that among the logos on the side is one for Hennepin County Medical Center. That’s because the local ambulance service has had a contract with HCMC since 2004, bringing added expertise in training and management to help raise local services to the highest level possible.

And if you were to ask local health care professionals about their training, you would find that many of them honed their skills through residencies, fellowships and other training and education programs at HCMC.

MinnPost reports that the "Will You Lose" campaign is operating on a shoestring budget: $30,000, to be exact. The money is being spent on the Web site, plus some print advertising and billboards. Organizers also are leaning heavily on the social media, i.e. Facebook, Twitter and YouTube, to spread the word.

When a hospital with the stature of HCMC is forced to beg in order to maintain its services and keep the doors open as one of Minnesota’s most important safety-net hospitals, it’s a revealing commentary on the times in which we live. But for an organization whose tagline is "Every life matters," I would expect no less than for HCMC and its supporters to do their best to rise to this enormous challenge.

Photo: HCMC.org