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opinions and musings on topical subjects. let’s clear the air

2018-2019 Flu Vaccine, Prevention and Treatment

2018-2019 Flu Vaccine, Prevention and Treatment

This is my seasonal flu post.  One that I update each year.  Here are current recommendations and controversies regarding influenza vaccinations, prevention and treatment.  I am going to give you a slightly expanded version this year related to last year’s flu vaccine post.  In short, I have never been a proponent of flu vaccinations.  I am middle of road on vaccinations.  You really want polio, measles and mumps and tetanus every 10 years.  For high risk exposures you want Hepatitis B vaccination. But we are over vaccinating our children and even pets.

Influenza is a seasonal epidemic viral syndrome that usually starts in December and lasts until approximately February or March.  In the past, I would begin to see large number of acutely ill patients pouring into my Urgent Care clinics in October and November. I eventually termed this the “pre-flu” syndrome.  Something approximating the flu but not the full-blown symptom complex.  The true flu is manifest as fever, shaking chills, severe achiness (myalgias), and malaise.  You feel really sick.  This is more than a common cold.

Now the problem with flu vaccination recommendations is dependent on who makes the recommendation and for what population.  I am going to make a recommendation for you specifically.  This is in contradistinction to a public health official who epidemiologically makes decisions for large populations.   They are concerned about “herd immunity.”  Higher rates of immunized people decreases the spread.  At least that is the theory.

There is no universal flu vaccine

The challenge has always been how to formulate this year’s flu vaccination.  There is no universal flu vaccination.  That is the basic dilemma.  Influenza A is the more virulent strain mainly affecting adults.  Influenza B affects mainly children.  Influenza mutates by “antigenic drift” from year to year.  It can even mutate during incubation. In most years, there is a “minor antigenic drift.”  In some years there is a “major antigenic drift,” in which case far more people fall ill because they have not never been exposed to the current strain.   And thus it is more virulent. A pandemic.

Flu Strains

Epidemiologists classify influenza with two attributes.  H attribute (hemaglutinin).  And N attribute (neuraminidase).  H1N1 and H3N2 are targeted this year.  So the recommended quadravalent (4 strains) flu vaccine being manufactured this year targets:

  • A/Michigan/H1N1
  • A/Singapore/H3N2
  • B/Colorado 2017 B/Victoria 87
  • B/Phuket 2013 B/Yamagata 88

Because we do not know the precise strain that will prevails this 2018-2019 season, it becomes our best educated guess.  What is the most likely strain based on recent world wide observations.  The selection process may begin in February of the current year.  This gives enough lead time for sufficient vaccination stocks to be replenished each year.  This takes time.  It is all the guess.  Again, the primary dilemma is – there is no universal flu vaccine.  That is the holy grail.  Research scientists are busy trying to develop this.

Vaccine Effectiveness Rates

CDC Seasonal Flu Vaccine effectiveness
Seasonal Influenza Vaccine Effectiveness, 2004-2018

Last year it was said that the flu vaccine was only 10% effective.  In retrospect, the CDC published an average for all age groups of 40%.  Here are the reported rates of effectiveness for the last 14 years [link is no longer available].  A more detailed breakdown by age for 2016-2017 shows even more variability.  All these statistics are somewhat irrelevant.  What is more relevant is the flu vaccination most often less than 40% effective.  So the recommendation is based on, “well, it’s better than nothing.”  I can’t think of hardly any other medication in use today were the rationale is, “well, it’s better than nothing.”  Surely there must be a stronger argument and rationale to the widespread public campaign to “get your flu shot now.”

Recalling my days in Urgent Care once again in the early 1990s, it was common knowledge that “there is no medical treatment for the flu.”  So you must get a flu vaccination.  This always puzzled me because there was indeed a medication that treated the flu.  Symmetrel (Amatidine).  This was discovered by happen stance when so many Parkinson’s patients who were treated with Symmetrel for “the shakes” had a much lower incidence of the flu.  I began using Symmetrel with rewarding success.

Anti-Virals now available

Today, we have a developing stable of anti-influenza virals.  That is Tamiflu, Relenza, Rapivab and the newest Xofluza (Baloxavir).  So you have a choice.  You can have the flu vaccine in various forms.  You can defer any vaccination and be treated with any of a number of antiviral drugs.  Or there is a natural routine that I have developed over the years.  Empirically quite effective.

My recommendation for a natural approach

Miller Anti-Viral Regimen ™

  • Vitamin D 50,000 daily x 5 days
  • Astragalus 1000 mg daily x 5 days
  • Thymic Protein A (TPA) 1-2 packets 3 times daily x 5 days

So what do I recommend?  I have been a proponent of aggressive doses of vitamin D which is known to prevent seasonal flu syndromes.  At the first sign of any viral illness or especially the flu, start taking vitamin D 50,000 units for 5 days.  Yes that is high dose.  Astragalus 1000 mg daily for 5 days and a proprietary product called Thymic Protein A (ProBoost).  One packet 2-3 times daily for 5 days.  This is a highly effective routine.  And most effective when started in the first 48 hours.  Sometimes this routine is so effective that after one or day, you may feel totally resolved and stop the routine.  2 to 3 days later, the virus is even stronger.  So a 5 day routine is highly recommended.

Now let me know your thoughts and experiences.

Philip Lee Miller, MD
Carmel, CA 93923
Nov 2018

Why Your Doctor Is Either Depressed or Retiring

Why Your Doctor Is Either Depressed or Retiring

Why Your Doctor Is Burned Out or Retiring

There is a growing litany of acronyms and alphabet soup organizations and algorithms that are designed to confuse, obfuscate and subordinate physician discretionary thinking. Funneling physician thinking into more pre-defined and standardized patterns. With the notion that these patterns are always superior, more efficient and accurate.  More than traditional physician discretionary thought, observation and formulation of diagnosis and treatment plans.

This dizzying array is one of the many reasons why virtually every physician over the age of 65 is retiring. You are losing an entire generation of extremely well educated and experienced physicians. The ones who cared.  Who were trained to observe.  Who were taught to exhaust all testing means. To use deductive and inductive logic.

We have entered the era of economic zero sum medicine.  Simple agents of health insurance reimbursement schemes. A world in which medicine becomes thoroughly and inexhaustibly politicized. That is what is being played out in Washington today.

Do you care?

  • ACO = Accountable Care Organization
  • MA = Medicare Advantage, original Medicare + choice
  • ACA (aka PPACA, patient protection and affordable care act) – disastrously branded as ObamaCare
  • MSSP = Medicare Shared Savings Programs (built into the ACA).
  • MUHIT = Meaningful Use of health information technology
  • GPRO = Group Practice Reporting Option (CMS provider value modifier, 2010 present
  • MACRA = Medicare Access and CHIP Reauthorization (an acronym within an acronym)
    • MIPS = Merit Incentive Payment Systems (has 4 components)
      • ACI = Advancing care information (replaces MUA’s IT).
      • CPI = Clinical practice improvement activities
      • TCoC = Total cost of care (usually expressed as annual cost per beneficiary)
      • Quality = replaces the PQRS (physician quality reporting system)
    • APM = Alternative payment models
  • SGR = Sustained growth rate physician formula (1997 – 2016)
  • RAF = Risk adjustment factor (adjustment used for and a payments)
  • HCC = Hierarchical condition category (codes that derive the RAF)
  • TIN = Taxpayer identification number
  • CMS = Center for Medicare Services — formerly HCFA (Healthcare Financing Administration)
  • CPC+ = Comprehensive primary care plus (a CMS driven Advance Primary Care Medical Home Model)
  • CPT = Current procedural terminology (procedure or billing codes)
  • ICD-10 = Diagnosis coding module currently used in the United States (supersedes the ICD-9)
  • VM or PVBM = Value Modifier or physicians value-based modifier
  • CAHPS = Consumer assessment of healthcare providers and systems (HCAHPS, CGCAHPS, HHCAHPS, OASCAPS, etc.)
  • HiTECH = Health Information Technology for Economic and Clinical Health Act (HITECH Act)

Makes your head spin.  Doesn’t it?  My mission is and has been the development of a new HealthCare paradigm.  Health and Well Being for the next twenty years.  Enhancing your healthspan. Enhancing cognitive function (smarter brains). You are going to need it in these times.

Statins: A Critical Appraisal

Statins: A Critical Appraisal

You can find a number of well written books with articulate statistical analyses over the years questioning the results of statin therapy.   What is the true value and efficacy of statins (HMG-CoA reductase inhibitors) in treating and preventing heart disease?   The statistics can be overwhelming.   What is the real risk benefit ratio?

Lipids and the Emergence of Statin Therapy

Lipid research actually started sometime in the early 1920’s.   It gained more momentum in the 1950’s with John Gofman at the Laurence Radiation Lab in Berkeley.  Then the interest waned, so the field languished for another few decades. John Gofman turned his energies to examining and warning us of the dangers of constant low level radiation therapy

In the 1950’s and 1960’s the cholesterol theory was gaining more adherents. Anyone over 50-60 remembers well the exhortation to eat less fat. No eggs. Skimmed milk. Substitute margarine for butter. It was much healthier.   Cholesterol was bad. Turns out margarine is literally the bottom of the barrel stuff. Highly hydrogenated oils. Much less healthy. Personally, I never believed the cholesterol theory even in Medical School and was labeled a heretic. “Dummy, everyone believes the cholesterol story.”

One of the most erudite and gentlemanly Professors at UCSD Medical School was Dr. Daniel Steinberg, a prominent lipid researcher. He wrote a wonderful book The Cholesterol Wars which is one of the best historical accounts of the lipid research over the past 80 years.   He even admits “we almost lost the cholesterol debate if it had not been for the emergence of Statins.”

The Framingham Study was a large study begun about 45 years ago in a small town outside of Boston where a majority of the population has been studied annually. It is the best cross sectional study we have.

Interestingly, even the Framingham study proved that cholesterol is a bad predictor of heart disease.   50% of those who suffered heart attacks had totally “normal” cholesterol levels.  By the way, the term “normal” is a moving target and subject to standards committee declarations.   There is no “normal” cholesterol, only declared “acceptable levels.”   A GP, an internist or a cardiologist will have different and increasingly aggressive definitions of “normal.”

Association vs causality is an ancient debate which is not well settled. Aristotle proposed four postulates for causality. Many centuries later, David Hume, the great Scottish Enlightenment philosopher expounded about this in detail.

Cholesterol does not cause heart disease.

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Let’s Revolutionize Prostate Cancer

Let’s Revolutionize Prostate Cancer

A New Approach to Prostate Cancer

It is time.  We need to rationally approach prostate cancer with new tools.  Imaging first — biopsy last.

In 2004 Dr. Thomas Stamey, Chief of Urology at Stanford, published a seminal article, heralding the end of the PSA era.  He was known as the “the father of the PSA.”  This was not greeted with great applause.  He concluded that PSA testing was not an accurate measure of prostate cancer.  In subsequent years, he has admitted the correlation coefficient between PSA testing and prostate cancer is approximately 20 percent.   That is less than even odds that an elevated PSA equals prostate cancer.  (Vigorous sex can raise your PSA up to 40 percent.)

Men are in constant fear of an elevated PSA and its implications.  It’s like watching the Dow.  But the approach has been too slow to evolve.

Let me give you the best example.  Women typically have an annual mammogram — often followed by an ultrasound (it should be the opposite).  If you are diagnosed with a suspicious mass, a wire-guided biopsy is performed.  This is very targeted and limited only to the specific area of interest.   A positive biopsy is now most commonly followed by a lumpectomy.  The story then becomes complicated.

For men, the approach is backwards, and medieval.   A suspicious digital rectal exam, followed by an elevated PSA (greater than 4.0) will inevitably demand a prostate biopsy.  15 years ago this would have been a “4 core” sample.  4 blind stabs.  But over the interval there has been a tendency to increase to 8 cores, then 12 cores and now 16 cores.  Blind stabs through an area that cannot be sterilized.  This can frequently cause infection, bleeding and pain.

It is time for this approach to come to an ignominious end.

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Health Care: The Day After

Health Care: The Day After

It was never about Health.  It was never about universal health care.   Access does not equal care and certainly not quality care.   Yes, one side “won.”   This is not a victory for you.

It is not a left-wing agenda.  It is not socialized medicine.  This is the first time the Federal Government has mandated the purchase of a private party product.  And from the very racketeering group that is the root cause of the problem in the first place.   What a travesty.   Another government subsidy.   Effectively amounts to another “government bailout.”

As Michael Moore wryly said:

The larger picture here is that the private insurance companies are still the ones in charge. They’re still going to call the shots. And if anything, they’ve just been given another big handout by the government by guaranteeing customers. I mean, this is really kind of crazy when you think about it.

This is not the same as a state mandate for auto insurance.

The State of California is unrelenting on this point.  Driving is a privilege!  It is not a right.  If you do not drive, you are not mandated to purchase auto insurance.  Furthermore, the reality is auto insurance does not cost $5000-12,000 annually.

This is the first major landmark piece of legislation in American history that was passed by such a narrow margin without a single Republican vote.   Social Security passed with bipartisan support in 1935 — 81 Republican Congressman and 16 Republican Senators.   In 1965  Medicare passed with bipartisan support —  70 House Republicans and 13 Senate Republicans.  In 2010 there was not one single Republican vote.   And the margin in the House was razor thin — 220 to 212.

It also violates a well-tested political strategy — sell it first to the American people who will then pressure Congress to pass new legislation.  The public is not aboard.   The latest Quinnipiac and Washington Post polls show the public still opposes this landmark Act.

AT&T has already made plans for a $1 billion write-off in advance of cost shifting.   And legal staff is hard at work looking for technical loopholes.  This just in from Robert Peer at the New York Times:

William G. Schiffbauer, a lawyer whose clients include employers and insurance companies, said: “The fine print differs from the larger political message.  If a company sells insurance, it will have to cover pre-existing conditions for children covered by the policy. But it does not have to sell to somebody with a pre-existing condition. And the insurer could increase premiums to cover the additional cost.”

Everyone is giddy about “the win.”   This is only the end of the beginning.

Remember the Telecommunications act of 1996?   It was enacted to guarantee local competition amongst the major carriers.  It never happened.

Now watch this interview with Michael Moore:

Health Reform: PostMortem Coda

Health Reform: PostMortem Coda

My take on why we saw the thrilla in … Massachusetts:

From Inside Washington, Nina Totenberg encapsulated it best.   The economy and job prospects dwarf all other issues.

If we had 5 percent unemployment, he probably would have gotten the plan through.  But you can’t refocus people’s attention on an aspirational goal for a society — I think it’s very difficult to do that — when people are hurting so much in the immediate sense and businesses are going down the tubes, small business on a daily basis.  You just look in any mall, places you’ve gone for years, they’re gone now.  People in every level of life are struggling to even have a job or they’re working part time.  Kids coming out of school can’t find jobs.  This is a very dire situation and he has – I can’t say he’s ignored it, but he hasn’t focused on it in a way he probably should have.

From the Chris Matthews Show, David Brooks always seems to have to most cogent social insights:

Mr. BROOKS: Yeah, if I had to generalize, it used to be in this country people of high school degrees lived the same kind of lives as people with college degrees. That’s no longer true. Divorce rates, attitudes towards society, attitudes towards government, it’s very different. College degree, non college degree.  …  And they look at the people who are running them, most of them are college degrees, Harvard law, on both sides.   …  And they say, `That’s not me. That’s not my life.’   …  `And they’re not listening to me.’

And so the President shifts focus in his annual State of the Union address.  It’s about jobs and the economy.  Then education … our future.

Trying to Please Everyone and No One – part 2

Trying to Please Everyone and No One – part 2

Where is this train wreck headed?  Wending its way through the various Senate and House subcommittees, the health care reform debate of 2009 is approaching a crescendo.    What do we have to show?   The question I posed in a previous post still has yet to be answered – just what is the problem?  Is the problem greater access?  Is the problem escalating insurance premiums?  Is the problem stratospheric and ruinous hospitalization bills?  Is the problem rapidly declining quality of care?  Or is this simply become a matter of whose team wins?  The bill fails — the president sinks.

Andrew Weil concludes:

But what’s missing, tragically, is a diagnosis of the real, far more fundamental problem, which is that what’s even worse than its stratospheric cost is the fact that American health care doesn’t fulfill its prime directive — it does not help people become or stay healthy.

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Healthcare Focus: Quality or Quantity

Healthcare Focus: Quality or Quantity

What is the message?    What do you want?

The World Health Organization definition of health has not changed since 1949.  We were asked this the first day of medical school.  No one answered correctly:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Political strategists play with focus groups to achieve Machiavellian goals.  Issues can be framed positively or negatively.  In a recent series of  soundbites with Republican and Democratic response tracks, Republican strategist, Frank Luntz,  found the political segment that was most effective for both Republican and Democratic viewers was the one that featured a female physician.  She was real, conveying substance and legitimacy.   See Luntz explanation of focus and metaphors.  For an even more revealing look at looking at mind-control watch  The persuaders — one of the most eerie documentaries FrontLine ever produced.

This week the President met with “selected physicians” to shore up his support.

This entire public debate would have had been far more successful with tighter focus and goals — health insurance reform and regulation.  We may be on the verge of another government giveaway.

John Podesta,  President Clinton’s Chief of Staff, was interviewed on the Charlie Rose show last month.  His words were quite prescient.

“We’re very close to finally doing what for 60 years presidents and congresses have been trying to do which is to produce quality, affordable health coverage for every American.”

And therein lies the killer paradox.   Affordability implies universal access.   Universal access implies quantity.   Quality and quantity are mutually exclusive.  You don’t go to Costco or Target or Wal-Mart for quality service.  If you’re lucky, you may find quality merchandise.  But not service.

Health maintenance organizations (HMOs) were heavily promoted by the Nixon administration in 1973 to contain costs — Managed Care.  We physicians had another name for it — “mangled care.”   The largest of all HMO’s today, Kaiser Permanente, demands minimalist, algorithm-based, cost-driven medicine.  Lonnie Bristow, a former President of the AMA, recently called this “a work in progress” at a town hall meeting here in Northern California.  Indeed, a work in progress.

Want to know the simple formula for HMO Medicine?   And by extension the cost-savings approach to medicine?  It is a very simple formula.

Lives x Capitation = Revenue

That’s it.   It’s all a numbers game.  Notice what drops out?   Quality!   Not even factored into the equation.   Using a simple mathematical model you can see that cost-driven medicine (managed-care)  is incompatible with quality of care.  And that is what we all experienced, those of us who have practiced in HMOs in the past.  All of us.

The administration and congress is using the same old arguments proffered over 30 years ago.   We will be saved by the cost-cutting gods.  The Green Visor man.  The guy that eventually wraps up every car deal.   Read Dr. Bernadine Healy.   Then from Kip Sullivan of Labor Notes:

Biemiller went on to say that HMOs ‘can provide better quality medical care at lower cost than the fragmented fee-for-service system’ and that the savings HMOs could achieve were ‘enormous.’  His only significant reservation about Nixon’s HMO bill was that it would have subsidized for-profit HMOs.  But because there is no evidence that managed care is less toxic in the hands of nonprofit than for-profit HMOs, this reservation was of little significance.

Harvard and Stanford trained Dr. Margaret Hansen aired this short segment on KQED radio — the lost art of medicine.   Ancient voices from Andalusian Spain, Maimonides, echo similar sentiments every bit as fresh today as when written in the 12th century.

Medical practice is not knitting and weaving and the labor of the hands, but it must be inspired with the sole filled with understanding and equipped with the gift of keen observation; these together with accurate scientific knowledge are the indispensable requisites for proficient medical practice

The ancient wisdom of the Greeks was lost to Western civilization for 1000 years after the fall of the Roman Empire that had succumbed to endless corruption, incompetence and sybaritic excesses.  Greek culture and knowledge passed to Byzantium and Islam.   I appear as either a dinosaur/curmudgeon like Paul Muni in the Last Angry Man or a messenger from the future.  We were taught the “laying on of the hands” was essential to diagnosis and healing.   Great medicine is the accomplished art, intuition and inductive logic of the physician with the wise use of modern technology. Attributes of the 15th Century Surgeon should still be emulated: the eye of an eagle, the heart of a lion and the hands of a woman, the gentleness of a lamb and the patience of a saint.

Service, expertise and time.   That is the challenge.   Will you receive necessary and deserved time, expertise and personal service or simply a 10 minute expedient and tangential encounter? Is this the face of medicine?

Robotized Doctors
Robotized Doctors

The new medicine awaits — like the Phoenix rising — the paradigm shift.

Political Health Endgame: You Deserve Better Solutions

Political Health Endgame: You Deserve Better Solutions

Post-war Britain, and Londoners in particular, had suffered mightily after two years of punishing aerial bombardment.  The East End of London had been reduced to rubble.

Winston Churchill, arguably the greatest leader and politician of the 20th century, was turned out of office.  A new day dawned.  Anuerin Nye Bevin, a “firebrand” Socialist, was determined to remake the British health care system.  On July 5, 1948 he became the first Minister of Health.   Out of his uncompromising efforts was born the National Health System.  Bevin became known as the father of the NHS.  The pride and joy of Britain today.   Out of crisis comes opportunity.   And so it is today.   With crisis, opportunity comes aknocking.

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change the metaphor

change the metaphor

Joseph Campbell first offered this sage aphorism:

“If you want to change the world, you have to change the metaphor.” – Joseph Campbell

The president subtly changed the metaphor this morning in a major financial address.  Instead of the phrase health care reform he used the phrase health insurance reform.  Ah , now we are framing the right debate. Was this metaphorical or strategic?

We have argued for months now that this is not about health care reform.  Want real health care reform — you change the paradigm.  Read Deepak Chopra’s OpEd this morning in SFGate. Then read all our past and future posts.  The advent of the 21st century is quickly evolving.  Old paradigms, companies, and entire industries are vanishing.

The current debate is about economic reform.  And economic reform is about insurance reform — catastrophic economic reform.

If health care is central and vital to the health and well-being of the nation, then health insurance should be regulated as a utility.   As if Dr. Howard Dean had been following our very advice, just yesterday on Meet the Press, he offered the same prescription:

There’s another way.  There’s two countries in Europe that have universal health care without–and it’s entirely run by insurance companies.  But they treat the insurance companies like regulated utilities.  If the insurance companies would prefer to be treated like regulated utilities, we’d drop the public option in a heartbeat.

— Howard Dean

This graphic from the morning’s news even better.  Shows that the administration may be serious about the fundamentals of a healthy economy first.

financial reform first
financial reform first

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