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Interviewer: How about the next time you need to see the doctor, you don't have to go into the office, but you can see your physician virtually? We're going to talk about virtual doctor visits next on The Scope.

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Interviewer: Dr. Nathan Bexfield is with University of Utah Health Care at the South Jordan Health Center. A brand new thing, because of technology, is starting to happen called virtual visits and I want to find out more about how I can visit my doctor virtually and what conditions qualify. So thanks for taking time. Tell me more about virtual visits.

Dr. Bexfield: Virtual visits are a very cool thing that we have happening here. You can have a visit with your doctor on your computer, on your iPad, iPhone, on your smartphone and just talk to them about what's going on. And we can even diagnose some disorders and some rashes and illnesses via the technology that we have.

Interviewer: So are you using live video streaming. Is it like I call you on FaceTime?

Dr. Bexfield: Yeah, it's like a FaceTime or a Skype call. It goes through something called True Clinic and we are able to talk to you and interact with you like we would if we were in the office.

Interviewer: All right. So if I have a cold, is that a good thing for Virtual Visit?

Dr. Bexfield: Actually, that one's not.

Interviewer: Okay.

Dr. Bexfield: Because that's one where we actually need to lay hands on you and listen to the heart, listen to the lungs, make sure you don't have any ear infection or anything else going on. So we need you to be in the office for that type of visit.

Interviewer: Yeah. So what virtual visits, what are they good for? What conditions?

Dr. Bexfield: Things that we can see so things like rashes. Sometimes eye things that we can look at and just tell whether or not you have a very simple pink eye or something like that. Other things that it's good for are behavioral health issues like depression, anxiety, ADHD, things like that where we are mostly discussing on how things are going, how medication is working, and things like that.

Interviewer: So a follow-up visit.

Dr. Bexfield: Yes.

Interviewer: And why is that beneficial?

Dr. Bexfield: An initial visit where we diagnose those sort of things requires us to do a physical exam and have a little more interaction face-to-face as opposed to virtually.

Interviewer: Yeah. And then those follow-up visits, why is it advantageous not to have to come into the clinic?

Dr. Bexfield: Well, often those follow-up visits are every 3 to 6 months so while that's not super often, we want to make things as convenient as possible. If you don't have to come in for the visit, and you can just talk to me for 15 or 20 minutes through a call, then we can do that. You can do that on your lunch break at work if you want to.

Interviewer: How do you get on the road to a virtual visit?

Dr. Bexfield: You call and make the appointment through our call center.

Interviewer: Just like I would call to make any appointment.

Dr. Bexfield: Exactly.

Interviewer: Okay.

Dr. Bexfield: And they will send you an email, which will have a link that you just click on and it will take you right to the platform that we use for the actual visit.

Interviewer: Do I have to ask for the virtual visit, or is that something the receptionist will offer based on what I've told them?

Dr. Bexfield: They should offer it to you, depending on what the complaint is. But if they don't, and you're wondering whether or not you can do a virtual visit, then just ask.

Interviewer: Okay. And then after I've made that appointment, how quickly does that turn around?

Dr. Bexfield: Well, it's like any other appointment. If you could be seen in the same day, we could do the virtual visit in the same day.

Interviewer: Gotcha. And if it's a rash you'd just take a look at it and you'd go, "Well, that's an easily identifiable rash. I'll write you a prescription." And bing, bang, boom, done.

Dr. Bexfield: Exactly. If we can diagnose it through the virtual visit, then that's even better. Sometimes, there are going to be cases where we can't really tell for sure whether or not it's something that we can diagnose, or whether or not it's something that we need to see in the office. So if that's the case, we may ask you to come in.

Interviewer: And if you have a physician relationship already, and maybe a reoccurring condition, you just need a refill or something that required an office visit at one point, you might even be able to do that virtually, I suppose.

Dr. Bexfield: That is definitely conceivable.

Interviewer: How is this going to change health care?

Dr. Bexfield: I think it's going to make it easy on the patients. I think if you have trouble with transportation, getting in to the clinic, this is going to make things easy for you to do some stuff at home. We can basically do anything through the Internet these days now, so why not do medicine?

Interviewer: And completely secure and private?

Dr. Bexfield: Yes. And that's why we go through True Clinic, as opposed to a FaceTime or a Skype platform. True Clinic is secure; it keeps everything private.

Interviewer: Anything else that you feel compelled to say that I forgot to ask?

Dr. Bexfield: Virtual visits are going to make things way easier on parents, especially parents who have lots of kids. I think we're going to have parents who really appreciate the fact that they can get into and see their doctor whenever they like, provided we have an appointment available, from the comfort of their own home.

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Interviewer: You're not feeling well. Did you ever consider for a second it could be the medication you're taking to try to feel better that could actually be making you feel worse? We'll discuss that next on The Scope.

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Interviewer: Dr. Mark Supiano is the Executive Director of the University of Utah Center on Aging. Sometimes medications can cause more problems than they can actually fix especially if you have multiple medications, prescription and non-prescription that are interacting badly with each other.

Dr. Supiano, let's talk about multiple medications and some of the things you've seen as far as how that makes you feel worse and what you would recommend.

Dr. Supiano: This is a particular issue in older individuals, because older people tend to have more medical conditions that we now have wonderful evidence basis of the benefits of medications to treat those conditions.

When we start to add up those conditions however, if you start to have three, four, five chronic conditions, and you're on three or five medications for each of those conditions, that multiplier effect increases your risk of having an adverse medical event or a side effect from the interactions between those medications.

So older people that we treat are more likely to be on more medications and are therefore at higher risk for exactly these kinds of problems.

Interviewer: So is it the raw numbers that's causing the problem or is it the actual what's in the medication doesn't like what's in another medication or both?

Dr. Supiano: The literature suggests that it's simply the number of medications that you're on. The magic number is if say you're on more than 12 medications, and as you mentioned earlier that is a combination of both prescription medications as well as any over the counter medications that you may be taking, if that number is above 12, there's almost 100% chance that there will be a drug-drug interaction.

Interviewer: Wow. So we're talking over the counter being any sort of pain killers you might take, cough medicine, what about like herbal?

Dr. Supiano: Sedatives or hypnotics or sleep aids that you might be taking over the counter, all of those.

Scott: What about herbal supplements and things like that?

Dr. Supiano: Absolutely and Utah is a hot bed of herbal supplements. So we are very aware of that and really need to be careful about the potential interactions between some of those supplements and prescription and other medications.

Interviewer: So if you are taking a whole bunch of pills, it might be good idea to have somebody professionally reevaluate. I would think that my pharmacist would know or my doctor would already know. Is that not always the case?

Dr. Supiano: If you're going to a single pharmacy, if they have an accurate record of all your prescription medications, there are systems now to screen for the most offensive drug-drug interactions. Most physicians are likewise aware of that but there are other subtleties that individuals trained in geriatrics are more likely to pick up.

Another component is the geriatrics is a team sport and as part of our medical home for example we have a geriatric Pharm.D who has additional expertise to be able to identify the appropriate medications for older people.

The other reason that your pharmacist or physician, if they lack that geriatrics expertise may not be sensitive to this, is that there are changes in aging in how the body gets rid of medications that can increase your risk of having the side effects. So if you're not adjusting the dose of the medication appropriately for that person's age or their kidney function that there may be toxic levels of the medication that accumulate and cause these side effects.

Interviewer: So you really can't set it and forget it? You've got a kind of reevaluate quite often it sounds like?

Dr. Supiano: So I tell patients if they have been on the same drug for many years and it can't be causing problems, well, if you're 20 years older now your body is metabolizing that medication differently and the levels are going to be higher than they were 20 years ago, so it now maybe causing problems.

Interviewer: What might be an indication to somebody that they are actually having some sort of adverse reactions through medication interaction?

Dr. Supiano: Great question and this is really a challenge and particularly since many of these side effects, someone might think, "Well, I'm just getting older, so of course I feel run down the next day or I'm having this particular symptom," say constipation. They may think this is just part of getting older and may not ascribe it to the medication.

So we're taught to teach our trainees that anytime someone has a new symptom, we need to first ask, "Is this potentially caused by an existing medication?" What we really want to avoid is treating that new symptom with yet another medication, because that adds further to this list of medications.

It becomes a vicious cycle and you just keep adding on more and more medications and you get more and more side effects, and the patient isn't getting any better.

Interviewer: So how big of a difference can it make if you identify that there's some sort of a medication-medication problem?

Dr. Supiano: If we can identify someone with side effects from a different medication and the term for this is Polypharmacy, if we identify what that side effect is and either reducing those medications or eliminate it, stop that medication and the patient gets better, that's a victory.

And I can tell you, Scott that in my career of some decades now I am confident that I've made more people better by stopping the medication that is causing one of the side effects, than I perhaps ever will by starting a medication to treat a chronic condition.

Interviewer: That's a powerful statement and a statement to probably keep in mind that more is not necessarily better.

Dr. Supiano: Particularly if it's causing one of these side effects, it's a very grateful patient if you can identify that offending medication and eliminate it from their medication list and their symptoms improve.

Interviewer: If I feel like I'm having this type of reaction, what will be my next steps?

Dr. Supiano: So a comprehensive evaluation to review those medications by someone trained to identify these problems would be the first step.

Interviewer: So my primary care physician not that person?

Dr. Supiano: It could be. I think the main principles, although we do this routinely, what needs to be is a medication chest biopsy. So this is a geriatric procedure. You need to go in and biopsy the medications and the way we do that is not with the needle but we ask people when they've come in for their initial evaluation to get a grocery bag and fill it up with all the prescription bottles, and it's called the brown bag technique.

And if one grocery bag isn't big enough, you load up two or, three, or four and bring them all in and our Pharm.D will sit down and look at each one of those prescriptions and review them and make sure that they're appropriate by with indication, by way of dose and review for these potential side effects.

Interviewer: As we've talked another podcasts, geriatricians, even if you're younger and you have a lot of multiple medications could help you. You don't have to just be an older person.

Dr. Supiano: Correct, so this syndrome of Polypharmacy is not unique to age and our team including geriatrician providers and our geriatric Pharm.D are skilled to evaluate patients for that potential problem.

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Interviewer: Can you test for the flu and should you ask for it when you go visit your physician if you think you have the flu? We'll examine that next on The Scope.

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Interviewer: So wouldn't it just be easier if you could get a test for the flu to know if you have it or not? Well, we're going to find out right now. Dr. Tom Miller is internal medicine at the University of Utah Healthcare. First of all, is there a test for the flu?

Dr. Miller: There are tests for the flu, yes.

Scott: Okay, I want one.

Dr. Miller: You don't get one.

Interviewer: Why don't I want one or get one?

Dr. Miller: You don't need one. First you don't have flu symptoms, and if you do have flu symptoms and you're not severely ill, we would just treat you empirically. Meaning, if you have symptoms, you have a high fever that starts suddenly, shakes, chills, cough, you basically would have the flu until proven otherwise during the middle of the flu season.

Interviewer: So you're saying that the flu for a physician is a pretty obvious thing to diagnose. You don't need a test.

Dr. Miller: Should be, but everybody loves a test Scott.

Interviewer: Okay.

Dr. Miller: Everybody loves the test.

Interviewer: They like to know for sure.

Dr. Miller: So we've talked before on the program about being treated for the flu. So there is a treatment, an antiviral that you can give, but you should give it within the first 48 hours. So if one obtains a test to prove whether you have the flu or not it might be longer than 48 hours before you get the test results back, while in the meantime you're feeling miserable.

Interviewer: Oh. Yeah, so I come into the doctor and they're like, "I'll give you the flu test, if you want it," and then by then it's too late.

Dr. Miller: The decision is made based on a clinical presentation, so looks like the flu, smells like the flu, it's probably the flu. And we go ahead and treat it. We start the treatment.

Interviewer: What do I do if I'm convinced I have the flu, and you're not?

Dr. Miller: I guess we have a problem.

Interviewer: Do you get that? Do you get people that you say, "Oh I'm sorry you don't have the flu."

Dr. Miller: No, I generally don't. I mean it's pretty clear when people have the flu. They feel awful. Now they might have a cold, just a common cold. And I can usually explain to them that, "No, you don't have a high fever. It didn't start suddenly. I think this is a cold, which is due to a virus, but it's not the influenza virus." And basically when they are without a fever, that's something that they just get over after several days, and we really don't have effective treatment for that anyway.

Interviewer: That's the tell-tale sign, is you might feel completely miserable, but if you don't have a high fever above 101 then you likely don't have the flu.

Dr. Miller: Then if you have shaking, chills and you just feel awful and two hours ago you didn't feel bad, that's pretty much flu. Those are flu-like symptoms, and could be something else. The main thing is you want to get started on the therapy that could actually reduce the severity of the symptoms and turn the thing around, and cut it back by a day or so.

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Dr. Miller: How worried do you need to be when you receive your lab results in the mail or online before your physician's had a chance to talk to you about them? I'm Dr. Tom Miller and we're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: Hi, I'm here with Dr. Jerry Hussong. He is a clinical pathologist and also the Director of ARUP. He's also Medical Director of ARUP and we're going to talk about abnormal lab results that a patient sees and how important those might be and what guidelines a patient might have so they don't worry too much about it before they talk to their physician.

Now, Jerry, I'll have patients call me before I have a chance to talk to them about what I would consider normal lab results, but they will get those lab results and if any of the values, and there are many values that come back with a series of standard lab results, if any of those values are outside the normal range, they're usually marked in red. And sometimes they're barely over the limit. But patients can be very concerned about that and worry that the world is about to end. Do you have any comments about how patients should look at those lab results and think about them?

Dr. Hussong: Sure. I think to start with, it's really important for patients to realize that all laboratory test results are going to come with a reference range attached to them. And basically, really, reference ranges are ranges that we establish by looking at normal patients and we establish the reference range by looking at 95% of the normal population or having that as our criteria. So the range will include 95% of the total normal population and that's really . . .

Dr. Miller: But 5% could be outside that range.

Dr. Hussong: But 5% could be outside the normal reference range.

Dr. Miller: Normal is not always normal.

Dr. Hussong: That's right. And so it's really important to realize that you can be slightly outside that reference range and still not worry or be alarmed. It's important to realize a laboratory test should always be interpreted in the context of the reference range, but also in the context of many other things that are going on with the patient. So we put this in context with the physical examination that you're going to be doing with the patient, other laboratory test results and how far outside the range is that result.

Dr. Miller: That's one of the things the patient can look at if they have the ability to do that, is to look and see if the number's very far outside the reference range. If it's two or three times the outside limit then there may be an issue. But if it's just a little bit outside perhaps not such a big deal.

Dr. Hussong: And it may mean that there absolutely is nothing underlyingly wrong with the patient at all and they just have to realize that. In some context, this is why we're doing the test to see if there's anything abnormal with those laboratory testing results. But often, if it's only slightly out of the range, it may not have any indication that there's an underlying problem.

It's really important to realize though that there are some conditions that can really affect laboratory results. Extreme exercise, for instance, can cause you to have a protein in your urine. For instance, in times of dehydration if you've been out in the sun for long periods of time there may be some changes in your electrolyte results that you see. So you have to put it together with all of the other things that may be going on and other circumstances that may be affecting the patient.

Dr. Miller: One of the things that I've heard is that if you order a lot of tests and get a lot of results back, the chance that you'll have some abnormal results is normally higher anyways. Can you shed some light on that as a clinical pathologist?

Dr. Hussong: Yes. Sure. As you're thinking, the normal range is going to include 95% of the population but 5% of the population will not be included. As you exponentially increase that with a number of laboratory tests that you perform, you can imagine that your odds of being outside the reference range on any one of those tests greatly increases.

Dr. Miller: So basically, if I have 100 test results probably five of those are going to be normal but outside the reference range.

Dr. Hussong: Absolutely. That is a possibility that could happen with that. But, again, to realize that we're doing these tests for a reason and sometimes the abnormal results indicate that there's something abnormal going on with the patient. But if they're just slightly outside the reference range it may not indicate disease or an underlying issue at all.

Dr. Miller: So the key thing is to take a deep breath and make sure you get in touch with your physician so he can interpret the findings and help you understand them. And essentially, if they're not too far outside the reference range not to worry too much but definitely to talk to the physician about an interpretation of the lab results.

Dr. Hussong: I think that's absolutely right.

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Dr. Miller: Do you need standard laboratory screening studies during your examination? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi. I'm here with Dr. Jerry Hussong. He is a clinical pathologist and the Chief Value Officer for ARUP Laboratories here at the University of Utah. Jerry, it's pretty typical for most physicians in primary care to order a set of laboratory studies, a full blood panel, a complete metabolic panel and sometimes a lipid panel and we do this almost routinely, reflexively. And I guess for the patients out there, maybe you could tell us what's the value of getting these tests if you are totally healthy? Do you think they're necessary?

Dr. Hussong: So when we think about some of the common laboratory tests that are offered as part of an annual physical exam or for a specialized sort of inquiry into patient's health, there probably are some that we should think about that really should be done once a year. And these would include the complete blood count or CBC, the chemistry panel, even though it can be a limited chemistry panel or metabolic panel as some people may refer to it, as well as urinalysis or UA. Those are the ones that we probably should be thinking about as just sort of routine annual tests. There may be a number of other tests that the physician may want to order to address a specific problem that the patient may have, but as a part of the screening test those are the ones that we want to be thinking about.

Dr. Miller: What in those laboratory studies do you think that we might be looking for that would be important for the patient?

Dr. Hussong: Sure. So when we're thinking about a complete blood count or CBC, we're really looking at it to see if the patient may have anemia, for one, to see if the red blood cell count is adequate or potentially even decreased or increased. We also might look at the white blood cell count, which may be an indication of infection that may be going on or an indication of possibly a leukemic process that could be going on. Some patients will present with low platelet counts, which could be an indication or reason why they're experiencing increased bruising as they might see.

Other things that we see with the metabolic panel or the chemistry panel is things evaluating kidney function such as the BUN or creatinine. We also will monitor glucose as a screen for diabetes and then a number of the other biochemical electrolyte like things such as sodium and chloride.

Dr. Miller: Certainly important when patients have any of these illnesses, but I think what you're saying is that a person who feels very well may have some of these abnormalities, which could be an indication that there is early disease that they might begin to have treated or respond to in a way that would prevent it from being a bigger problem down the road.

Dr. Hussong: Exactly. And this is really just a small number of tests that we use to screen for some sort of wider range of problems that the patient may be having. It's really sort of a truncated panel of all the different types of tests that the physician could order, but really allows us to get a global sense of the overall health of the patient during their physical examination.

Dr. Miller: Now these time-honored tests, and I've ordered them myself and I continue to do so, basically are not terribly expensive. Is that correct?

Dr. Hussong: The tests that we were talking about just now, they're very inexpensive and I think that's important for the patients to realize. There are lots of specialized, newer tests that are out that can cost up to thousands of dollars, but these are very inexpensive tests that can provide a lot of information to the treating physician.

Dr. Miller: And how about a thyroid test? We sometimes order that if we suspect the patient may have a thyroid disorder if they're fatigued or if there's a sudden gain in weight. Do you think that's a useful screening test or should we just maybe order that when there are indications to do on the clinical exam?

Dr. Hussong: I don't think it's a great screening test just overall if someone doesn't have any signs or symptoms that indicate any thyroid disease. I think if there is worry for that it's important to go through sort of a stepwise process ordering a TSH, for instance, to start with and maybe a T4 but not to go to some of the specialized tests for thyroid function analysis unless you have a real indication and have some of these preliminary test results back first.

Dr. Miller: Great. Now the other thing is patients sometimes forget to ask and physicians sometimes forget to tell them whether they need to be fasting for these tests. What's your opinion on that for the series of screening tests you mentioned, the CBC, the complete metabolic panel or cholesterol panel?

Dr. Hussong: So not for these tests, but there are a number of tests that we do in the pathology laboratory that do have special requirements as you say whether it's fasting or other things that they need to do or certain times of test, times of the day when the blood should be drawn whether it's morning or after a meal and so for these basic tests there is no specific requirements to be thinking about to have these routine tests done.

Dr. Miller: What about the cholesterol panel? Sometimes I'll tell people to fast for the cholesterol panel.

Dr. Hussong: It's probably a good idea. You want to get a real indication as far as where the patient sits in regard to their cholesterol levels but, at the same time, you don't want them to just have had a huge meal that may artificially elevate their cholesterol.

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updated: November 20, 2018
originally published: July 7, 2015

Announcer: Examining the latest research and telling you about the greatest breakthroughs. The Science and Research Show, is on the scope.

Interviewer: Geneticist Dr. Lisa Cannon-Albright, is perhaps best known for finding that the genes BRCA1 and BRCA2 cause breast cancer. Now she's taking a step back and developing tools that can be used by anyone to evaluate their risk for common diseases. Dr. Cannon-Albright, what motivates you to take on this project?

Dr. Cannon-Albright: We've been very successful. We identified BRCA1, and BRCA2, and P16. P16 is a melanoma gene. Those genes don't explain all familial cancers of those types by any means. So to me, the question still arises, what about all the other people who are at risk for these cancers and other diseases, but we haven't found their gene yet that explains their family.
People say someday you'll go to the mall, and give them a drop of blood, and get your profile. I think that's a long way off. So what I see is, let's use family history, which is one of the best indicators of risk for many, many common disorders. Use that to classify people according to risk. So number one, we can do it today. Number two, it doesn't cost you anything. It's your family history. You might have to call your brother and ask him about your mother, etc., but it's available to everybody.

Interviewer: Don't physicians take family histories as it is?

Dr. Cannon-Albright: If you look at the literature, very often people who say they're studying family history have a simple question. "Do you have a family history of colon cancer?" That's not the way to take a family history.
The better studies maybe say, "Do you have any first-degree relatives affected with colon cancer? And what we've discovered, it's not just your first-degree relatives. Your second-degree relatives can affect your risk estimate, and even, to a lesser degree, your third-degree relatives can affect it.

Interviewer: So this is what you're developing, some sort of tool for keeping track?

Dr. Cannon-Albright: Well, you could call the paper a tool. It has quick, easy tables for clinicians or even patients to look at. And we've started on the breast cancer and lung cancer analysis.

Interviewer: Have you done proof of concept? I mean, do you know that this works?

Dr. Cannon-Albright: We're so lucky in Utah, because we have this genealogy, and this it's linked to a tumor registry. And the tumor registry goes back to the early '60s and later. So we can study all the cases of colon cancer, people who have genealogy, which is basically more than half the people in Utah. And so we use that to create our models.
We went back to create our models. We went back in time in the database and just locked the data 20 years ago, and said, "Okay, here's what all these people's risk of colon cancer is today." And then we went forward 20 years in time in the database and said, "So did the people whom we thought would get colon cancer actually get colon cancer?"

It's a population-based tool. It's not going to do that, but it is going to find the people who are at the highest risk, and that's a very small portion of the population. And it can tell those people the correct screening to get. You know, it saves the healthcare system and individuals money, and it saves people time, and it makes sure the people at highest risk get screened with the highest dedication to finding cancer.

Interviewer: I suppose the caveats are not everybody knows what their third-degree relatives health was.

Dr. Cannon-Albright: Yes, lots of caveats. Because first of all, probably only 20-30% of cancers are familial. So an only child of a small family, or people who were adopted, or for whatever reason separated from their family's medical knowledge, wouldn't have that opportunity. You know, but the nice thing is there are normal screening guidelines. So everybody would automatically fall to the baseline, which is, if you need to be screened for colorectal cancer, it starts at age 50.

Interviewer: So what would you recommend to people who might be interested in knowing what their risks are for different diseases?

Dr. Cannon-Albright: I actually got genotyped by 23andMe, which is one of these one of many companies that will give you your kind of personalized genetic picture.

Interviewer: Yeah.

Dr. Cannon-Albright: And I helped them out with a project. They were collecting some data, and so my colleague and I, they just said, "Oh, you can have the test, gee. Just spit in this tube." And so we did it, and we both just kind of laughed at it, because it tells me that I'm at low risk for several pretty serious diseases, breast cancer and stroke, that I've already had! So, hello!
But that's been my feeling all along. We don't have a handle yet on just simply using genetic markers to try to assess risk. It's way too early in the game. I'd say the most important thing would be keep an accurate genealogy and keep an accurate medical history for your family, as far out as you can go. And make sure that your children recognize that that's a part of your legacy, and it stays in a safe, and they're going to take over when you're not here, and in my mind, it's really your duty to carry this around in your head and act on it appropriately. So talk to your doctor about it and be proactive about it.

Interviewer: What is your vision for the future?

Dr. Cannon-Albright: My view is someday a national resource. I mean, how wonderful would it be if you could go to a resource and find yourself, your family, maybe add some genealogy, or add in your medical data, and we'll be able to track and estimate risk. So that's kind of my view, and I'm sort of working on something like that with the VA right now. It's a genealogy of the United States. It's already got 38 million individuals in it. We're going to link it to the VHA patient population. We tried to link 11 million vets, and we linked about 5% of them, half-a-million. But if you have a half-a-million people with medical data that you've linked to a genealogy, already imagine how powerful it is.

Interviewer: So you have this database. So I guess I'm a little unclear on how you intend to use it.

Dr. Cannon-Albright: So for instance, the VA population has some phenotypes that are pretty uncommon in the rest of the population. If I wanted to study Gulf War illness, or post-traumatic stress syndrome, I'd have a really hard time finding high-risk pedigrees. Because that environmental exposure of having been to the gulf or of having had some traumatic event is so rare that you could study giant pedigrees and not have very many events.
So using this resource, I can do it the opposite way. So I find all the veterans without identifying anybody. Just using ID numbers, we can find all the veterans who have, for instance, a diagnosis of Gulf War illness, and them link them to the genealogy and see what clusters we find, clusters meaning pedigrees, sets of related people who have Gulf War illness.

And now, again, we've developed tools to test whether that pedigree has more cases of Gulf War illness among the veterans in that family than you would have expected. And so maybe you take that into account when you decided who you're going to deploy to the Gulf War, or who you're going to put in combat versus not.
And then, hopefully like I say, one day, when we study those families, if we actually find the variance that is responsible, then maybe we'll understand what's happening, and possibly we could develop treatments that would reduce the morbidity.

Interviewer: Could you even use those risk models to find people who might be more likely to commit suicide, or undergo drug abuse, or something like that, which I would think is higher in that population?

Dr. Cannon-Albright: Absolutely. And again, I have this terrible bias of believing that everything has a genetic predisposition. And I'm only calling it a bias to be polite, because in my head, it's the truth. But yeah, so there is no phenotype that I think should be ignored, especially, like you say, pretty significant things like suicide and harmful addictions. Wow, if we could find out there was a predisposition, and we could actually do something about it, how powerful would that be?

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Interviewer: How you were admitted to the hospital may affect how much you owe. Don't be surprised by the bill. I'll tell you what it means and what questions to ask next on The Scope.

Male Voice: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: I'm here today with Dr. Russell Vinik. Dr. Vinik is an internist specializing in hospital care. He's also the head of the utilization review committee. What this committee does is it works between the hospital and doctors to see that patients get the right bill. Russell, tell us about how one is admitted to the hospital and how that can affect how much a patient pays.

Dr. Russell Vinik: When people are admitted to the hospital their doctor has to choose what status to put them in. A lot of people think that if I'm coming in and going to spend the night in the hospital I would be considered an inpatient, but there are actually two different statuses. There's inpatient, and then there's the other status of people expected to have a short stay that are typically billed as outpatient, and that really makes a big difference in how they are billed.

Interviewer: I would think that most people wouldn't even be aware of the differences in these categories. This doesn't make sense.

Dr. Russell Vinik: Yeah, and it doesn't make sense. The way that most insurers, including Medicare, are set up is they have very different payments, and they have bundled payments when people come into the hospital as inpatients. Whereas if they're outpatients Medicare has what we call Part B that does that payment, and it's typically billed as a percent of what's charged. Then, the patient is responsible for a percentage of that copay. If they're put in an outpatient procedure they usually have a higher copay to pay depending on what kind of supplemental insurance they have.

Interviewer: How much higher charges can a patient expect if they're billed under this observation status you're telling us about?

Dr. Russell Vinik: It depends on what procedure or what they're in the hospital for. If it's just for monitoring and they're not having many invasive tests it may be only a few hundred dollars. If they're having a major procedure like a pacemaker or a defibrillator placed, those can be upwards of $50,000 for the procedure, and if their copay is 20% that's a big...

Interviewer: That's a big hit. That's a really big hit. I would bet that most people aren't even aware that they could be responsible for that if they're admitted to the hospital.

Dr. Russell Vinik: They can't, and a lot of patients just don't understand the rules. Medicare has its own set of rules right now which says that inpatients are typically patients expected to require two midnights in the hospital. Every other insurance company has slightly different rules, so it's very important for patients to know what their benefits are, and if they are scheduled for a procedure to know whether it might be an inpatient or an outpatient procedure.

Interviewer: So, buyer beware. They should ask what their benefits are. That's one of the things I'm getting from you. Is this mostly Medicare that we're talking about?

Dr. Russell Vinik: This is mostly Medicare, but every insurance company does make this distinction between inpatients and outpatients. Medicare patients typically have a higher outpatient deductible and copayments than a lot of private insurance plans, and this is where a supplemental plan can help pick up those deductibles.

Interviewer: You mentioned this two midnights rule, and there have been some stories in the press about this new two midnights rule. Can you tell our listeners about that just a little bit more.

Dr. Russell Vinik: Prior to October 1 of this year Medicare and most insurance plans used what we call medical necessity to decide if a patient needed to be inpatient or not. That depended in part on how long they were expected to be in the hospital but in part on how sick they were, how intensive the services that they were getting in the hospital were going to be. You can imagine that's a hard thing to figure out. Medicare tried to simplify it a little bit and said in general patients who stay in the hospital two midnights or more are considered inpatient. They don't want hospitals to just keep everybody two midnights, so you still have to need to be in the hospital for two midnights and be getting care that can only be done in a hospital.

Interviewer: I also understood from some of the articles that I read that patients admitted under this observation status might not be eligible for rehab.

Dr. Russell Vinik: Right.

Interviewer: So, if they came in with a broken hip, and they had that repaired, and somehow they were under observation status they would have to front most of the bill, I would think, for the rehab.

Dr. Russell Vinik: Medicare has a rule that says in order to qualify for skilled nursing facility placement you have to be in the hospital as an inpatient for three midnights. A patient, and we've had this happen, who might fall, didn't really break anything, they're not well enough to go home but not sick enough to need a major operation, they don't often meet that rule. It puts a lot more burden on the patient and their family, because the doctors are forced to comply with these rules. They can't keep a patient for three nights just so that they can get them into a care facility.

Interviewer: What should a patient do to better understand this categorization?

Dr. Russell Vinik: Most important is to know your benefits. There are certainly lots of different insurance plans out there. Know your benefits. Ask your doctor if you're going to be an inpatient or an outpatient. If there's a question you can always appeal if you don't think your doctor is doing the right thing. There are appeal rights for just about every insurance plan as well as Medicare.

Interviewer: Russell, other than knowing your coverage and your status as a patient, is there anything else you can do to sort out whether you belong in inpatient versus observation status?

Dr. Russell Vinik: It's a hard thing. If you're unsure, it's always a good thing to ask your doctor about, and they can help. Unfortunately, doctors are being put in a difficult position by the insurance companies and by Medicare. They have a set of rules they've got to follow. If they don't follow those rules they could be accused of committing fraud, so they really have to follow these rules. Sometimes there's a little bit of gray area where a patient might go one way or the other, and that's where a discussion with your doctor can help. Doctors are being forced by these insurance companies and Medicare to follow their rules.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: So Dr. Madsen, I'm curious, physicians, nurses, doctors, when they get sick they can't necessarily take a day off. Sometimes you have to go in.

Dr. Madsen: Right.

Interviewer: For people that are suffering from colds or whatever right now, what are the things that nurses and doctors do to try to keep going that maybe we could do, or to even get better quicker. Is there anything? Is there a magic bullet that you guys know about that you're not telling us?

Dr. Madsen: See, I think you're trying to get free medical advice from me.

Interviewer: Yes.

Dr. Madsen: Because you're sick right now.

Interviewer: Yes, I am. I am. I'm trying. I've got this cough and this congestion that's been going on for a number of days.

Dr. Madsen: But I'm more than happy to offer the advice here, because I went through the exact same thing a couple weeks ago and it is just a miserable thing. And you're exactly right; I have called in sick for one shift in the last 10 years. That's one day of work. So I do everything I possibly can to get through work. And something I deal with on a regular basis is very severe colds. I'm exposed to a lot of people who are really sick and can make you feel really miserable if you catch what they've got.
So the things I do to get through a shift are, number one, I use Tylenol. Acetaminophen is the generic name. I take that one a regular basis and I alternate it with Ibuprofen. I alternate it back and forth every three hours. So that means you're taking each of those, individually, four times a day. You're not overdosing on either one, but it can help a lot with the body aches, the fever, just that feeling of misery you have. And I stay on top of it. I don't wait until I feel miserable. I take the acetaminophen and then I take the ibuprofen, alternating every three hours.

Interviewer: What kind of dosage?

Dr. Madsen: I usually take just a 500mg tablet. You're okay doing 2 of the 325 for the 650 total. And then the ibuprofen I take 600mg, so over the counter comes in 200mg tablets; you're taking 3 of those. For both of these dosing, you will find instructions on the bottle and precautions to avoid overdosing on either of them.

Interviewer: All right. What else do you do, medical professionals?

Dr. Madsen: So the other thing I do, there's the issue with the congestion and the coughing, and that's what can make you feel really miserable. So, typically I'm also staying on top of things and I take a combination of guaifenesin and dextromethorphan. So guaifenesin is a congestion medicine; dextromethorphan is a cough suppressant. And the brand name of that is Mucinex-DM. Again, you can find that as a generic, and I just usually get the generic because it's the same thing. It's half price. I take that also on a regular basis.
Just staying on top of things, morning and night. I think it's just a twice a day dosing on that. Maybe a little bit more. I'd have to look it up. Maybe four times a day, but I take it on a regular basis so I don't kind of get behind the game where I start feeling miserable and then I take it and wait for an hour to kick in.

Interviewer: Yeah. Anything else?

Dr. Madsen: So the other thing I've found is pseudoephedrine. Also known as Sudafed, but again, pseudoephedrine is the generic name. That's one of these things, if I find that these other things aren't cutting it, I take pseudoephedrine and that really just kind of dries my sinuses up. It helps me a lot with the congestion, runny nose. I don't like to take it a lot because personally, it gives me a little bit of a headache, but I usually kind of have it available during a shift if just nothing else is cutting it.

Interviewer: Would you use that on top of everything else we have talked about?

Dr. Madsen: If I'm in a situation where maybe I have taken the guaifenasin and the dextromethorphan and it's been two or three hours, I'm okay with taking it then.

Interviewer: Is there any concern about taking it all these medications? It sounds like a lot of stuff, or isn't it really?

Dr. Madsen: It is a lot of different stuff, but keep in mind these are all different classes of medication. You know, taking all of them can make you feel a bit jittery sometimes, honestly because they can kind of have that effect. The pseudoephedrine can kind of dry your mouth out and with any cold medicine, it's going to make your head a little cloudy. And it's probably already cloudy from feeling miserable from a cold. But they are different classes of medication, so aren't necessarily going to have a cumulative effect with each other.

Interviewer: So you talk a lot about controlling symptoms. Is there anything you can do to shorten duration?

Dr. Madsen: There is some evidence suggesting that if you start taking zinc early in the course of a cold, say within the first 24 hours, that it actually does have an effect. And for years, maybe even physicians have thought, "Well, it's maybe not scientifically based," but there have been several studies that have come out, including a nice review of all the studies that came out about a year ago, looking at zinc based medications. You may have heard of Zicam; that's the brand name. But if you start taking that early on, it very well may shorten the duration of your cold and the intensity of it.

Interviewer: What about drinking lots of orange juice?

Dr. Madsen: Yeah, high dose vitamin C, I've tried to look some things up on that. Personally, I take it, just because I'm like, "It's not going to hurt me, and it may help me." Evidence is a little mixed on it. I feel that personally, it kind of has an effect. Maybe it's a placebo effect. Maybe it's a real effect. Again, trying to look up some studies, kind of a mixed bag on it.

Interviewer: Sure.

Dr. Madsen: But I don't think there is any harm, and it may help.

Interviewer: So that leads me back to another question: Is there anything you do just kind of on a daily basis to help boost your immune system?

Dr. Madsen: Yeah, so on a daily basis, it's funny that you ask that too, especially with the vitamin C question, I take Vitamin C every day because I figure I am exposed to so much junk and so many different types of viruses and illnesses that I'll do whatever. And maybe it helps; maybe it doesn't. It's cheap, it's easy to do, but I do take vitamin C supplements every day.
And of course, the other thing is trying to get sleep. And that's one thing for me, personally, that's a challenge. Just with working night shifts, I find that when I do that, man, a couple days later, I'm really a set up for a cold. But if you're in a situation where you can sleep on a regular basis, and not interrupt your sleep pattern, that's going to help you to stay healthy. And certainly, just exercising. I personally exercise on a regular basis, but I think doing that keeps your immune system up and helps you to hopefully avoid some of these things.

Interviewer: So do you have any concern when you go . . . because there's a lot of discussion nowadays about when you're sick you should just stay home. It used to be, "Oh, I've never been absent a day in my life." But now there's a chance you might spread it to people. In the medical profession that's not an issue, because you said you've had one sick day in 10 years.

Dr. Madsen: Yeah. I mean, if I tried to call in for work, it's just not that simple.

Interviewer: They're going to be like, "Uh, I don't care. You need to come in to work."

Dr. Madsen: They're going to say, "We need you here." I mean, reality is if I'm sick, I'm going to wear a mask. I don't want to spread it to patients if it's really a concern. Unfortunately, that's a big reason people should avoid the E.R. in general. There are just so many bugs floating around there when you walk in the door.

Interviewer: Yeah.

Dr. Madsen: That's why a big thing I always try and talk about is what you can do to avoid the E.R. But certainly anyone who had any immune system compromiser would be a set up for an infection. I'm wearing a mask in that room if I'm even a little sick.

Announcer: We're your daily dose of science, conversation and medicine. This is The Scope, University of Utah health sciences radio.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Scot: You end up with some stomach pains and it's always hard to know if it's something you ate, or if you're paranoid like I am you assume it's food poisoning, or E. Coli, or something worse like the latest stomach bug that you read about in the news. What I'm looking for is a breakdown, an easy to remember symptoms that can help the average person decide if it's something to worry about or if it will pass. I'm here with Dr. Troy Madsen Emergency Medicine at the University of Utah Hospital. Dude what's wrong with my stomach? How common do you see stomach issues in the ER?

Dr. Troy Madsen: Extremely common. It's a very large number and I expect when I work a shift in the ER I'm going to see at least a handful of people that are there because they're having some abdominal pain.

Scot: How about a breakdown of easy to remember symptoms that can help like the average person like me decide if it's something to worry about, or if it's something that will pass, or if it's something that I can take some Tums for.

Dr. Troy Madsen: You know when people come in the ER that's the question in their mind. Do I really need to be there for this? And we see a lot of people in the ER who probably just have some kind of a stomach virus. You know the number one thing I would say is if you're really concerned come to the ER. I don't want to tell you not to come because your judgment is certainly better that just, than hey this, this, this and this.

Scot: Better safe than sorry.

Dr. Troy Madsen: Yeah, but there are some rules of thumb that can help you to try and decide is this really serious or not. One thing that is a real red flag is if you're in your car, let's say someone's driving you somewhere because you're just kind of feeling nauseated, you're going to the pharmacy to get something, and every bump you hit in your car makes your stomach just hurt like crazy that's a bad sign.

Scot: Okay.

Dr. Troy Madsen: Because then I worry whatever's going on in your abdomen if it's your appendix, or your gall bladder has gotten so inflamed and infected that it's actually infected the lining of your abdomen and that's what causes that really severe pain.

Scot: Okay.

Dr. Troy Madsen: So that's a big reason to come in right there.

Scot: So if bumps are hurting you when you're in the car...

Dr. Troy Madsen: Yeah.

Scot: ...that's a warning sign?

Dr. Troy Madsen: You're hitting the bump your abdomen just hurts like crazy with every bump come in.

Scot: All right, what are some other stomach issues and symptoms?

Dr. Troy Madsen: So some other things are think about the right side of your abdomen. If you're having a lot of pain on the right side, so if you feel it on your right upper side that's your gall bladder, your right lower side that's your appendix, and then people who are otherwise healthy those are the two big things I look for. The left side of the abdomen not a whole lot going on over there. The right side those are the two big things that cause problems. So if you push in that right side of your abdomen and the right upper side hurts, the right lower side and that hurts, that's something you need to come in for. You may have an infection in your gall bladder or your appendix.

Scot: So if the rights not right go to the ER.

Dr. Troy Madsen: That's a good way to remember it.

Scot: Well good. So but the left side it's interesting if you have severe pains on the left side what could that be then?

Dr. Troy Madsen: It can be a number of things, and if it's an older person I worry about an infection in the colon, usually that's more people who are 55 and older. Something called Diverticulitis. If it's down really low and you're a female I worry about the ovaries, maybe an ovarian cyst, or something twisting there, but usually with the ovary it's going to be really severe pain, but if it's just some kind of vague pain over on that left side of your abdomen usually not something to be too concerned about. Again use your judgment to see how you're feeling overall but the right side's the side that really gets me concerned as a doctor.

Scot: How do I know if I've got food poisoning? That's always a big question for me. Is it just upset stomach or food poisoning?

Dr. Troy Madsen: The only real way we can say, "Hey it was food poisoning." Is if there were several people who ate the same thing who were having the same symptoms. There's no real test we do for it. Most cases of food poisoning are going to pass within 12 to 24 hours. You're probably going to feel miserable. If you feel just so miserable that you're not keeping any fluids down, if you're dehydrated that's a reason to come in to the ER because we'll give you IV fluids, get you some nausea medication to try and help you feel better.

Scot: What about cramps, gas bubbles, like your stomach feels rock hard?

Dr. Troy Madsen: Yeah.

Scot: Are those major concerns or is it just gas?

Dr. Troy Madsen: You know most of the time it's just gas. A lot of times it's just some kind of viral infection that's making things feel kind of crumby. You can try some over-the-counter medications see if that helps you out, see if you can wait it out. Again if you're getting those real bad symptoms a lot of pain, just getting dehydrated because vomiting is associated with it, or diarrhea, other reasons to come to the ER, but you know that's a lot of what we see is exactly what you're describing, and you know most cases are probably okay to wait it out a day or two.

Scot: All right one more, so if it's food poisoning usually it will pass 12 to 48 hours you said?

Dr. Troy Madsen: Yeah usually yeah.

Scot: All right, what about if it's something more dangerous, E. coli, is there any sort of difference in the symptoms between the or maybe the latest bug that you hear about in the news that's going around?

Dr. Troy Madsen: Yeah you know those are things that sometimes something will come out in the news people will get really concerned, but E. coli is a very serious thing. It's not a lot that we see it but the big thing that we see with it is that often times bloody diarrhea that's kind of the classic thing we see with the most severe cases of coli.

Scot: With stomach issues what should one do to kind of take care of an issue themselves if they believe it's not a major issue, if it's on the left side, maybe it's gas, what would you recommend?

Dr. Troy Madsen: Yeah again try some over-the-counter stuff, maybe some Pepto Bismol, something like that to help with some of the symptoms, some of the cramping, drink fluids, don't force feed yourself, you know don't make it so you're just drinking so much fluid that you're vomiting it up, which I've seen some people do, try and stay hydrated. And again if things are just getting to a point where it is very dehydrated, you just feel absolutely miserable feel free to come to the ER. We can make sure nothing more serious is going on and get you the treatment you need.

Scot: What's the difference between using an antacid and like a Pepto Bismol?

Dr. Troy Madsen: An antacid is going to be more specific just for acid production in your stomach. So let's say you've got a little bit of a stomach virus that's just causing some irritation in the stomach where Pepto Bismol is going to be a little bit better at controlling things like diarrhea, you know controlling maybe some more nausea, more issues with cramping, where if it's just acid where you feel like kind of a burning feeling kind of going up in your chest you're probably fine just taking an antacid like Maalox, or Tums, or something like that.

Scot: What about a gas bubble?

Dr. Troy Madsen: Gas bubble, you know for that kind of thing where you're having a lot of gas and cramping Pepto Bismol is going to be better. An antacid usually is not going to do a whole lot for that.

Scot: All right dude thank you for telling me what's wrong with my stomach.

Dr. Troy Madsen: My pleasure

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