good evening med had so good to have you here tonight talking about a healthcare
triage episode one of my favorite YouTube channels if you have not seen
healthcare triage it's it's one of the channels that's a part of the dftba
group of channels that is produced by Hank and John Green the vlog brothers on
YouTube and also who put on VidCon which I attended the last weekend they have a
channel called healthcare triage out of Indianapolis that goes over healthcare
policy in great detail with dr. Aaron Carroll a pediatrician and acted
omission in Indianapolis and I am a fan of it so I thought that would be a great
sort of impetus for us to jump off from to talk about the exact same topic as
the most recent video which was d prescribing so I'm going to jump into
that topic at 2 minutes into this video but between now and then I'm going to be
greeting people as they come in like magnetics hey Doc yeah good to have you
here we're glad to have you join us for talking about D prescribing and we
welcome anybody else coming in go ahead and comment
I may not comment on your comment but please put it in any way and you guys
can actually go back and forth with discussion as we talk about D
prescribing or taken away prescriptions and we also will have super chat
available so that is a way that you can break in if you really need to get
whatever you're saying through you just hit that little dollar sign and put in a
mount and you will get recognized if you do that yes mama 3 monkeys
welcome back good evening to you also Jaime Cooley hi jinny from Virginia and
Claire and Barney dog home and na or your home and sending us and Ann two
rocks good you mean dr. Christina Hartman hi doc I'm Christina Theresa D
evening all even in Christian ISA Cheryl McNutt hey dr. Hicks Cheryl and Maya
farmer hello hello mom and Nana rocks hello everyone so thank you all for
coming and hi Ashley shirt also so I'm going to transition now to talking about
the topic which was health care on health care trash which was deep
prescribing and another term that would go along with that
probably put in the description and in the tax for this video would be poly
pharmacy too many medications now dr. Carroll makes mention of studies in the
last decade but if you go back to decades you can see some work by John
Morley and st. Louis and others on the very issue of polypharmacy where they
would find actual improvement in the VA that they were working at when they
would have a medication reduction clinic this was in the late 1990s so nearly 20
years ago some work was being done that was early in this field compared to some
of the stuff mentioned on healthcare triage but thankfully we have more
information newer information information with a larger power about
the benefit of getting people off the medicine as dr. Carol points out we need
more there's there there's little as far as the big scheme you know compared to
other things that we know about in medicine of the benefit of taking away
medicines but there is definitely data out there to support that there are
places where it's appropriate when a patient is on a lot of medicines and
this is particularly elderly that's why I talked about John Morley at Saint
Louis University at that time he was working in community medicine and in
geriatrics and very much working with elderly patients finding that we could
get them down on medicines he actually had the number for medicines which seems
unbelievable when you have patients coming in at
least a lot of the patients who come in who are over age 65 which is more than
half of what I see on any given day is age 65 and over
even though not more than half of my patients are you 65 or over but as far
as number of visits because they come in more often they have more medical
problems and they get more attention so for medications unbelievable if you
think about a lot of the patients that come in if they have hypertension if
they also have with that diabetes if they have something else going on if if
their hypertension is not controlled with one medicine and and when I talk
about this in the back of my mind I could probably hear some of you guys
thinking and in my oh lucky there we have
we have an appearance by Lee so I know some of you are big fans of Lisa so at
least we're talking about old old patients yeah yeah it's not adolescent
today although you're getting out of adolescence here you're growing up so
her birthday's on Saturday so just turn 18 send all your presents to Lisa the
office address you keep your creepy fan on Dad's Channel it's sorry for the
interruption actually I probably shouldn't say sorry they like seeing you
hey Lia thanks for making an appearance okay
oh she's gonna pass through to its anniversary thank you should we tell the
whole world okay sorry for the interruption yes Thank You Teresa very
kind of you to say that and she is so getting back to to where we were oh I
hope there weren't any super chats while they were passing through I don't think
there were and I know that somebody would tell me if there were okay thank
you what you guys have been talking there but staying on the topic here and
I do encourage you to use the link in the description it's already there
before I started this ID the link to the healthcare triage on D prescribing which
is dr. Erin Carol's a term that he's using for this yes I'll tell her that
you said hi Teresa thank you so here's what's going on he talks a little bit in
his video about the data that shows that the more medications the more potential
for adverse effects it can be interactions it can be with blood
pressure medicines blood pressure getting too low he did point out as I do
quite often benzodiazepines and sleep medications which are on beers credit he
didn't mention beers criteria beers criteria is a list of medications that
people over age 65 to put it broadly should it be on now that's a blanket
statement you probably shouldn't make we try to avoid generalizations but if you
were to make a generalization about medicines that people over 65 shouldn't
be on beers list has that list of medications because it puts them at risk
adverse events like Falls densa die as pains and sleep aids we know do that we
know that having too much medication for controlling blood pressure and that's
why we actually have under something called JNC eight a recommendation to
allow patients blood pressure to be a little bit higher at age 60 and older
then we have for younger than age 60 where we say use medication to get it
down get their blood pressure down under 140 systolic 90 diastolic
at age 60 the JNC 8 which is not universal but it's what our practice is
going but allows that blood pressure to kind of right up to 150 systolic as long
as they don't have a problem like diabetes or kidney disease or you know
very fragile as far as risk for stroke with with hypertension heart disease
often times will have reasons for using beta blockers to try to get their their
blood pressure at lower we are doing that in our office we are looking at
medication lists we are asking the question what can be taken away and
possibly improve the patient's outcome when patients come in from the hospital
we actually have a visit where we look at and reconcile the new medications
they have from that visit with the list we have we don't necessarily have that
for when they go to a specialist though we need to we need to specifically see a
patient when they come back from a specialist with the mindset of the
specialist prescribing medicines according to their professional
societies recommendations for whatever they're treating and that's really just
adding on medications it's our job as family medicine to look at the list as a
total list not just medicines of a special a certain specialty and see if
as a whole maybe the patient benefits from taking away rather than maintaining
that big long list or in some cases considering adding medications that
that's kind of the default when a patient comes in all admit it is they
have something and how can you make them better
oh I can write a prescription well a lot of times there's better things in
writing prescriptions I almost spoke about this when
came into the video and that is for example with blood pressure diabetes
lifestyle changes so many Americans compared to less developed countries do
not have a healthy lifestyle as far as what they're putting in their body and
exercise or fitness and that can take away a lot of problems we do on occasion
have a patient that gets motivated enough that through weight loss through
eating differently and also improving the fitness with exercise they can
actually get rid of a diagnosis of hypertension or diabetes they get cured
it's miraculous you know people are looking for miracles I hear this
conversation I see it when a patient actually gets motivated to eat sensibly
and to get regular exercise and really look that lowers their risk for heart
attack or stroke it's hard to see it as miraculous when they're not having a
heart attack or stroke because you don't see that you see when people do but when
somebody doesn't you don't it doesn't register there it's an absence of
something so many things in medicine are improving people's lives by having an
absence of something that otherwise may occur and you can't know in any one
individual where that's going to happen on a lot of the data that goes behind
recommendations for lifestyle changes and avoiding things Oh Lindsay Antoine's
here problems people looking for an effort pre-miracle
yes Lindsay and white like the patient you said to me just give me a pill Oh
Audrey bunch is here too how can our lifestyle change our blood pressure for
example is a diet activity or both okay Audrey we would direct you to the video
on - da SH Dietary Approaches to stop hypertension and it talks about how we
do that we're not going to do the take up that time here with the details of -
or just Google - and hypertension notice I don't say - diet because dietary is in
the acronym - anyway I won't won't talk about that anymore so we also have our
Moneda de Vries how to reduce stress yes that's another thing - in the middle of
this great discussion do we yes I see your comments about me being offline
that's why I'm back now and you guys didn't miss anything I'm
starting right back yet the reason we are not it's nothing we're withholding
people's notes to get them out of work it's that we're being very specific
because when you take patients out of the work place they are less likely to
end up being able to get back in it and functional than if you keep them there
now that's a generalization and there's patients who generally are genuinely are
completely disabled for a period of time or need to be out of the workplace I'm
not talking about those very few unique situations that apparently a lot of
patients think they're in when they're not but most people what we need to do
is write very specific recommendations for what they can and can't do based on
testing them you know can you lift this much can you walk this long can you sit
this long those sort of questions and there's answers to these questions and a
lot of this comes from thinking okay so if you're not at work what are the
activities you're doing at home we will have employers come to us and tell us
please send the patient back because rather than pay out disability we would
love to pay them their regular pay to have them sit and answer a phone instead
of dig a ditch that's a you know a big very specific example is probably not
going to happen but there are situations like that where they say no there is no
light duty I've had patients tell me no there is no light duty yeah and there
actually is when when it comes around to it and we actually write the
recommendations employers can be very creative when they don't want to pay for
disability and they'd rather actually get some benefit to the company rather
than not I guess I'm a little sympathetic to that as a small business
owner but also with the data that we see with you right for disability get people
out of the work place then it's harder for them to get back and the longer
they're out the less likely they are to get back in so it's actually better for
ability to stay in the workplace in a lot of situations so I'm sorry I've been
reading a lot of the the stream of comments there I certainly will respond
to super chats let's see here Pam says doctor I made it through backs right oh
good it's been eight days and I see oh I'm so sorry in the trolley and arm
Anita is smiling we're all you know doctor I'm from Zil don't speak
English but I love you champ well thank you Marilla and thank you for coming up
away put it in English because I'm not so good with Portuguese okay I just want
to have that discussion about D prescribing I encourage all of you to
use the link and to discover the channel healthcare triage I will say this
sometime it's it's a bit thick with the jargon it really seems to be written it
written for people who and it's written by dr. Carol who have a knowledge
already of medical policy or health care policy I say that because I'm a medical
doctor and have been for decades and when I watch it sometimes the
information is going so fast that I'm not able to keep up with what he's
talking about but it's very important right now to get
physicians interpretation what's going on in healthcare policy with our future
of healthcare currently right this week being worked
on and possibly voted on so that is an excellent source of information I will
try to do my best to digest what he presents and combine it with my own
clinical experience to give you a little lower level discussion because he really
he really talks at the policy level he's an academician he he's reading
those journals and in those conversations where as I'm more working
with patients trying to try to make them behind he is too but at a different
place within the healthcare system as far as policy is concerned so thank you
so much for joining us I do encourage you again to check out healthcare triage
channel one of the scishow channels or the same network that size shows and you
know I like that channel too and do keep watching our videos we have one coming
out at four o'clock tomorrow and I believe it's another ear cleaning for
those of you who really love those until next time this is dr. Markman telling
all of you to stay in good health