Thinking around pharmaceutical-oriented medicine
posted 6-19-2014 9:50 p.m.

 
(Note: this post is addressed mainly to health care professionals and to the wonderful nurses on 7West at Advocate Christ Medical Center, but it’s also of interest to patients and consumers. It’s longer, too, because a typical blog post a few paragraphs long wouldn’t adequately describe either the problem or the solution. So bear with me, and all will be revealed. Thanks.)


You never know how good your hospital really is until you need it. Mine’s very good, based on objective criteria. But even an excellent hospital that does all the right things 99.9 percent of the time can still have blinders on about certain ways in which it practices medicine. It’s a question of medical mindset.

It turns out continuing education is failing our health care professionals – and, thereby, patients – when it comes to knowing about nutraceuticals and how the foods and beverages we consume can help or hurt our medical care. Instead, physicians and nurses rely too much on marketing material from Big Pharma. That’s a mistake.

My own recent hospitalization is a good case in point. Having covered health care and health policy in the business press for most of the last 30+ years, I’m a picky customer on criteria that matter (hint: they’re not ‘housekeeping’ issues like whether the food tastes good, or the nurses are polite, or the parking’s convenient). I also didn’t choose this hospital because it was the closest one: convenience isn’t an issue when it comes to my health, and people who rank that factor highly either have the wrong priorities or are without reliable transportation. I’m lucky that this place is only 15 minutes away from my house and that I have a car – but I’d travel an hour to get there if I had to.

So when I suddenly had to be admitted a few months ago, it was automatic that as the staff members were evaluating and treating me, I was naturally evaluating them – and in a more detailed, objective manner than most patients would. I expected good medical performance from them because it’s a teaching hospital connected to the top medical, nursing and allied health schools in Chicago and has a Level I trauma unit that is part of the local trauma network. It’s the number four hospital in the metro area (probably in the state, if we’re being honest) and highly rated nationally, too, according to U.S. News and a few other lists that matter (not all do). Plus, they have the best nurses in town, from what I saw, maybe the best in the state, based on clinical measures and other performance criteria that are independently measured on a regular basis.

While I was there, I had to be given an I.V. antibiotic and painkillers, and that was going to influence my discharge planning. But I’ll get back to those in a moment.

The staff passed my initial scrutiny and helped me effectively. At every point, there was systematic checking that the care and meds I was getting were indeed intended for me and appropriate for my condition. At every point, I was informed about what was being done and why, and my questions were answered promptly and fully. I helped myself, too: I was probably the most compliant, informed patient they’d ever had. Still, there was room for improvement – but only because of the pharmaceutical-oriented mindset that most health care practitioners have in the U.S.

You can blame medical and nursing schools for that, but at some point, it’s the responsibility of individual practitioners to keep up with the state of the art. It’s also a hospital’s responsibility to incorporate all new evidence-based health information and institutionalize best practices, make them systematic. All of that, however, assumes that hospitals and practitioners are willing to expand their mindset.

Here’s the thing: I’m well informed and can figure out how to compensate for some less-than-perfect advice about my medical care, and the moment I saw a problem, I talked to my primary care physician about it. But most people don’t have my background and can’t have that kind of conversation with a doctor. They’re stuck, so practitioners have to anticipate and stay well informed themselves. And on a few points that were important to me in recovering faster, they missed some things – because they were focusing on the drugs for my immediate care instead of taking the broader view.

They didn’t even take into consideration what my diet required before this incident, and they should have: I’m on a blood thinner, so I try to be consistent in what I eat and not overdo foods that will interfere with or exaggerate the effects of the blood thinner. Someone besides me should have thought of that when they were prescribing a hospital diet for me.

I’m sure that the attending physicians, nurses, dietary department, and discharge planner all consulted on my inpatient care and discharge plan. No doubt they all remembered that I’d been given an antibiotic. No doubt that my meds and the vomiting caused by the morphine they gave me at first (which was then switched to a painkiller that didn’t create as much nausea) had something to do with the soft, bland diet I endured while my system recovered. But that one-size-fits-all diet wasn’t working for me even in the hospital. My doctor and I discussed it before I was discharged; she didn’t see a reason for it, either, and we agreed that I should go back to eating what was right for me.

But that alone wouldn’t solve the immediate problem: I still felt lousy. It took a full day at home before the painkiller was out of my system and I had a clear head. Then I realized I’d missed something obvious and so had the hospital staff. Antibiotics – of course! All the flora in my system needed to be replaced before I could digest anything properly. And the staff hadn’t even considered the simple, non-pharmaceutical solution: probiotics, in this case yogurt or kefir with live cultures. I should have been given that the moment they took me off the antibiotic. I immediately bought some and began eating it. It took a day or two, but my guts were back to normal much faster than if I’d just blindly followed their instructions. And I was back to a diet that worked well with my blood thinner.

I’ll bet that these same doctors, nurses, dietitians and discharge planners all know that when they themselves take antibiotics, afterwards they have to replace those beneficial ‘bugs.’ But they didn’t take that knowledge to work with them. Probiotic treatment immediately after antibiotic treatment should be a complete no-brainer, an automatic prescription every single time someone takes antibiotics, whether in the hospital or at home – i.e., a systematic part of treatment and aftercare, if only to ward off unpleasant and unnecessary complications like yeast infections – but it wasn’t in my discharge instructions.

Why not? Probably because it’s not traditional pharmaceutical advice. Or rather, it’s not pharmaceutical advice: it’s nutraceutical advice. Those careful, caring professionals weren’t educated to consider that – and they should be. They also need to be far more focused on tailoring diets more accurately to individual patients.

For example: I don’t have high blood pressure, diabetes, or diverticulitis, but I was given a no-salt, soft, bland diet. Why? If anything, after two days of vomiting and not eating I needed to replace some electrolytes and other nutrients, but the liquid diet I had the third day was no-salt. The soft diet also excluded all seeds, raw fruit and raw vegetables. No need, in my case. Also, I don’t have any trouble eating hot sauce or spicy foods, yet all those were banned. Again: why? I wasn’t recovering from an ulcer or short of bile to digest food – I was just temporarily missing some needed bacteria. The reasoning behind avoiding raw vegetables, beans, onions and garlic was to limit the gas in my guts – but come on, guys, has nobody ever heard of products like Beano or Gas-X?? They control or prevent gas, they’ve been around for years, and they’re over-the-counter products. Like yogurt. It doesn’t take four years of medical school to know any of that.

On the other hand, in the hospital I was routinely prescribed a drug that reduces stomach acid, probably because of the vomiting. I declined to take that drug, and my primary care doctor agreed with me. The two of us had better judgment than the hospitalist who prescribed it, as drugs that limit stomach acid production also interfere with the immune system by lowering one’s natural resistance to infection. I certainly didn’t need that.

Why did the hospitalist prescribe it in such knee-jerk fashion? Probably because the pharmaceutical industry has oversold the value of such acid-lowering drugs. It had to: once it became clear that such drugs were no longer useful in treating ulcers – because we now know that ulcers are caused by the bacterium Helicobacter pylori, not excess stomach acid or spicy foods – the industry was going to lose a lot of money. And it did. So now they’ve inflated the incidence of gastric reflux and marketed the drugs as ones that help prevent esophageal cancer by limiting reflux. Sorry, folks, but there simply aren’t enough cases of that kind of cancer to justify the massive marketing campaign for the antacids, which are now sold over the counter and marketed directly to consumers (who are supposedly easier to fool than doctors). If the hospitalist was worried about excess acid in my stomach, telling me to drink milk or chew a calcium tablet would have done me far more good – and wouldn’t have put money in the drug industry’s pocket. So I refused the drug and drank the milk instead, and my doctor backed me up. Good for her. Too bad the hospitalist wasn’t as well informed as we were.

What the soft, bland diet did have was plenty of simple carbs – white bread, mashed potatoes and pasta – foods that I limit because I need to lose weight, and my primary care doc knows this. It banned caffeine, too, for no good reason (I drink green tea, which is good for me and much lower in caffeine than coffee, but there wasn’t a green tea bag to be had in the entire hospital, for love or money). The soft diet also limited the kinds of cooked vegetables that were allowed, and it didn’t even mention asparagus, avocados or beets, three of my favorite veggies; so, was I to eat those or avoid them? Your guess is as good as mine. When I junked that diet and went back to eating as I had before, I didn’t suffer: I felt normal again. And I got better sooner.

The part about the missing green tea at the hospital confused me. Seriously? All the research done about the benefits of green and white tea, and yet I couldn’t get a bag of green tea to save my life. You’d think that the nurses and dieticians would follow the news about complementary medicine and know about that. Apparently not. Green tea with lemon would have done me a world of good while I was in the hospital and would have been comforting, too. The really vile decaf coffee that they served instead? Not so much. I skipped it.

Sad to say, I’m decades ahead of my health care practitioners when it comes to knowing about nutraceuticals – phytochemicals, bioflavonoids, catechins, and all sorts of other food- and beverage-based helpful chemicals that affect your health and wellness. And these wonderful, talented, highly skilled, very nice professionals who otherwise cared for me so well should be really embarrassed by that. They’re excellent at what they were trained to do, but they haven’t added all this other knowledge yet to how they practice in the hospital. They haven’t expanded their treatment mindset – and I and other patients suffer because of that.

My hospital caregivers and the dietician who participated in my discharge planning either didn’t know or didn’t apply what they know to me as a specific patient. And because they didn’t know or didn’t think about how any foods in or absent from the diet they prescribed would affect my condition or recovery, they gave me bad advice. They didn’t mean to, but they did. Was it malpractice? No, of course not. Did it hurt me? At the very least, it certainly would have delayed my recovery, if I’d followed it.

Luckily for me, my primary care physician was more insightful than any of the hospital staff. “You’re well informed, and you know what you should or shouldn’t eat,” she told me. “Just use your own common sense.”

But other people faced with inappropriate advice might not complain to the right person or might simply take matters into their own hands – without telling their doctors or nurses, possibly setting the stage for avoidable problems. Or, they might follow the instructions to the letter and be miserable for days longer than they had to be. Now which result do you think is more likely? I’m betting on patients doing what they want and not telling anyone because they’ve lost faith in what their doctors and nurses tell them – probably because they’ve all had incidents like mine, where the medical advice given didn’t make sense. Better to just admit that up front and try to prevent it.

Giving people diets that haven’t been adjusted for their individual situations is just asking for trouble. Health care practitioners would do themselves and their patients a big favor if they started incorporating all the solid research about nutraceuticals into their daily practice and got a lot more detailed about tailoring diets. Their patients would feel better and might be less tempted to dismiss medical advice next time. Just saying: the proof is in the result, so try it and see. We all have a lot to lose if you don’t.