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Once again, the monthly Ezine edition will be published as scheduled on August 1st. Subscribers will find a copy aready in the archive.

The past two monthly editions have addressed some of the less-well-known problems associated with vaccinations. We much prefer to provide positive material that informs about how to actively maintain wellbeing and, when necessary, solve health-related problems by recommending safe and constructive actions. Sometimes we need to be helpful by being a little negative like when we warn of what not to do or what to avoid.

This month we have again followed the trend established over the past two months with a main article that warns about pharmaceutical drugs. The large and wealthy drug companies complain about costs and pretend to be your friends, while pointing to their "squeaky clean" ethics, scientific methods and powerful political allies. In reality they are simply about big business and they frequently get caught out conning you with deceitful practices and poisoning people with dangerous chemicals. They are right about their powerful allies though and that's why they keep getting away with the harms they perpetrate.

The July 2009 ezine edition of The Health Gazette was published on schedule on July 1. Subscribers would have received a copy in their inbox and the archive copy was also made available.This notice was delayed due to technical difficulties on this site.

This month's main article is Part 2 of our two part series documenting what your doctor won't tell you about vaccination. Last month we noted some significant problems. These included the reasonably high vaccination failure rate, resulting in recipients having a false sense of security. We also discussed the inappropriate immune system impact that vaccinations have and the potential this provides for long-term problems and delayed diseases, quite difficult to "pin" on vaccinations.

The June 2009 edition of the Health Gazette Ezine will be published today, June 1st.

In this month's main article we commence a two part exploration of What Your Doctor Won't Tell You About Vaccination. In Part 1 we explain why activating only half of the normal immune response, as vaccinations do, might set up the conditions for chronic illnesses.

Remember, subscription to the Ezine Edition is free.

The coming tsunami of baby boomers means physicians are destined to see an increase in the number of elderly patients in their offices. Preparing to do well by them could require a change in attitude as well as office furniture.

It won't be business as usual, according to the Institute of Medicine's 2008 report "Retooling for an Aging America: Building the Health Care Workforce."

Only about 7,000 physicians in the nation are certified geriatricians, but 36,000 will be needed to provide care for the aging population by 2030, according to the report. The consensus is -- that's not going to happen.

Instead, what will occur is that more and more elderly people will turn to internists and family physicians for care, and the best course of action for these physicians is to prepare for and embrace the inevitable, say a number of geriatricians who offer a variety of pointers.

For starters, "you need to get a sense from them as to what their goals are," said Rosanne Leipzig, MD, PhD, professor of geriatrics and adult development at Mount Sinai School of Medicine in New York City. She also is an adviser to the American Medical Association on aging issues.

Dr. Leipzig works to help her patients live the life they want . She said this mind-set can lead to approaches that vary widely, because older people are a heterogeneous group. "When you've seen one, you've seen one."

Taking the time upfront to consider level of care will save time in the long run. "Is this someone you are going to think about as a robust elder, or someone who is frail, or someone who is in the last stages of life?" Dr. Leipzig asked.

"Some 85-year-olds you would treat as aggressively as you would a 65-year-old," said Jerome Epplin, MD, a family physician who cares for predominantly older patients in Litchfield, Ill.

David Mehr, MD, a professor of family and community medicine at the University of Missouri School of Medicine, in Columbia, noted that "with an 80-year-old you can have a competing athlete or someone with significant disabilities."

Regardless of the patient's level of ability, the treatment goal remains the same: "Keep them functioning independently and having a good quality of life," said Judah Ronch, PhD, professor at the University of Maryland's Erickson School in Baltimore. The school focuses on improving services for older people.

Rewards and attitudes

Caring for this population is a rewarding way to spend the day, said several physicians who do just that. "Geriatrics is going to be the fastest-growing segment of primary care practice, and this is good, because taking care of older people is one of the most thrilling experiences in medicine," said Bill Thomas, MD, also a professor at the Erickson School.

M. Mayes DuBose, MD, a geriatrician who established the first geriatrics-only medical practice in Sumter, S.C., also revels in his work. "I think I got into it for the right reasons. Otherwise I think I'd be burned out." And the right reasons? "The desire to provide high-quality care to America's older adults. And the desire comes from the recognition that they are such a vulnerable population," Dr. DuBose said.

Only about 7,000 U.S. physicians are certified geriatricians.

Caring for older people is "one area of medicine where you can practice the true art of medicine," Dr. Epplin said. The goal is maintaining a proper balance between treating enough to make a difference without overtreating, he said.

Plus, "you have to have an interest in it," Dr. Epplin said. Developing that interest may require an attitude adjustment. Some physicians may see patients older than 70 and assume they are on a downhill course, he said. A conversation may include: "Your knee hurts? You're old, what do you expect?" The biggest complaint Dr. Epplin hears from his patients is that other physicians dismiss their concerns. "Remember that these are very viable people who have a future as well as a past. Then you look at it in a more positive way."

At the same time, legitimate concerns surround the time commitment necessary to care for these complex patients. The primary care physician who is going to care for a significant number of America's elderly has to be willing to change his or her standard of practice, Dr. DuBose said. "There has to be more time taken, and it has to be a slower process than the typical office visit."

Sharpening communication skills is one way to use limited time effectively, several doctors said. Poor communication can cause the entire medical encounter to fall apart, noted John C. Houchins, MD, assistant professor in the Dept. of Family and Preventive Medicine at the University of Utah School of Medicine, and others in a 2006 article in Family Practice Management.

Their communication tips include avoiding distractions, sitting face-to-face with a patient, maintaining eye contact, listening and sticking to one topic at a time.

Patients also may be unable to hear well, whether because of a hearing loss or the loss of the ability to hear higher frequencies. Women doctors may have to enlist the help of male colleagues with lower-frequency voices to improve a patient's ability to hear them, Dr. Leipzig said.

But Dr. Thomas cautions that not all older patients are hearing-impaired, and physicians shouldn't assume they are. "I like to first speak in a normal voice to all older people."

Doctors also should be aware that their oldest patients may not be forthcoming with information because they don't want to cause the doctor any problems, Ronch said. "They might not be comfortable communicating issues that are important for the physician to know about."

Caution also should be taken to ensure that patients can read the materials they are provided. Use large font sizes and high contrast, so the letters are black and the paper is white and nonglare, Dr. Leipzig said.

The top priorities

Some concerns loom as exceptionally important when caring for older patients, and among them is the elimination of medication errors.

Geriatricians agree that all patients should bring a bag of their medications to each visit. Included should be prescription and over-the-counter items, vitamins and herbal products.

Eliminating medical errors is a top priority when caring for older patients.

Dr. DuBose likes to have patients bring the bottles, rather than a list of medications, so he can write on the bottles if a change is required. "Medication errors are very common," he said. "So a doctor or a nurse needs to make a dedicated effort to review all their medications."

Having a good, online resource to check for dosing information and drug interactions is also invaluable, a number of physicians said.

Another top priority is the ability to diagnose dementia and differentiate between dementia and delirium.

Dementia isn't always obvious at earlier stages, Dr. DuBose said. But once it is diagnosed, doctors can prescribe medications to slow its progress. Financial and health safeguards can be put in place for patients' protection.

A primary care physician doesn't need to be able to deal with every complicated patient with dementia, but they should have a good basic approach to follow if a family member expresses concern about an individual or if a patient comes in and says they are concerned about their memory, Dr. Mehr said.

Preventing falls is another area of importance. "One of the most devastating things you can help prevent is falls and resulting hip fractures," Dr. Leipzig said. An evaluation of gait, balance, vision and use of psychotropic medications is necessary.

A "get up and go test" is a fairly simple way to determine an individual's capability, Dr. Mehr said. "Ask a person to get up from their chair, walk across the room and walk back. You want to see if they use their hands to get up."

Doctors also should be sensitive to incontinence, he said, which is common in older women.

Caring for this population is a team effort. Physicians often enlist office staff to carry out many evaluations, and they should also be aware of community resources so they can help connect their patients with services such as visiting nurses, senior centers and entitlement programs. "You don't need to be a social worker, but you need to refer," Dr. Leipzig said.

Changes to the office layout also can make a difference to older patients. Ease of entry is a help to patients of all ages, Dr. Thomas noted. "People living with disabilities will thank you, as will younger people who have torn their Achilles tendons and are on crutches.

The print version of this content appeared in the May 11, 2009 issue of American Medical News.

Two physician groups are urging the federal government to update policies related to HIV infections, charging that the policies were drafted years ago when infection with the virus equaled a death sentence.

Now, with appropriate treatment, people infected with HIV can live a near-normal life span, noted Michael Saag, MD, chair-elect of the Infectious Diseases Society of America's HIV Medicine Assn. He spoke during an April 17 press briefing to introduce a joint position paper of the American College of Physicians and the HIVMA. The paper was released online April 16 and is to be published in the May 15 Clinical Infectious Diseases.

In their paper, the groups call for earlier identification of those infected with the virus, expanded access to treatment and stronger national leadership to respond to HIV's spread in the United States and abroad.

Gains on HIV diagnosis and treatment have made it more important to identify people carrying the virus as early as possible, the position paper said. Yet recent estimates by the Centers for Disease Control and Prevention say that of the 1.1 million people in the U.S. infected, one in five is unaware of his or her status.

Because of near-universal testing and implementation of effective treatments for infected mothers-to-be, transmission to infants has basically stopped, Dr. Saag said. "Now this same concept needs to be applied to the entire population."

1 in 5 of the 1.1 million people in the U.S. with HIV is unaware he or she has it.

Another reason for rapid identification and treatment is a recent finding that the AIDS virus is now more virulent, and damage to patients' immune systems is occurring earlier.

A paper published May 1 in Clinical Infectious Diseases found that 25% of patients diagnosed with HIV in recent years already had CD4 cell counts of less than 350, which is the threshold for implementing antiretroviral therapy, compared with only 12% of patients in the late 1980s.

"Unfortunately, it may no longer be true that there is a time period of several years between diagnosis and the need for treatment -- instead, this time span is shortening," said study author Nancy Crum-Cianflone, MD, MPH, an infectious diseases specialist at San Diego Naval Medical Center.

Broad screening urged

Although the CDC put out a call in 2006 urging widespread HIV screening, the response has been spotty from the nation's hospitals, clinics and physicians' offices. The AMA also recommends that physicians routinely test adult patients.

Among the changes requested by the ACP and the HIVMA are those allowing reimbursement for the screening of all patients in federal health programs. "Although the Centers for Medicare & Medicaid Services are considering reimbursing the cost for testing high-risk patients, we would recommend they expand this policy to cover all Medicare beneficiaries," said Jeffrey Harris, MD, ACP's immediate past president.

The federal government does not support needle-exchange programs.

The cost of treatment increases dramatically in later stages of infection, he noted. With early treatment, the cost is less than $14,000 per year, but that figure increases to more than $36,000 annually, he said.

The groups also request the expansion of proven prevention strategies. "It's time to support evidence-based transmission prevention efforts such as needle-exchange programs and comprehensive sexual education," said Kathleen Squires, MD, HIVMA vice chair. Despite studies showing the effectiveness of needle-exchange programs, the federal government does not support them, she said.

J. Fred Ralston, MD, president-elect of the ACP said work force issues also must be addressed.

Screening is going to be done by primary care physicians, and that network is "in critical condition as we speak," he said. "It has been shown that the collapse of primary care is going to lead to higher costs, lower quality, diminished access and decreased patient satisfaction, which is certainly not the direction in which we want to head."

The print version of this content appeared in the May 11, 2009 issue of American Medical News.