Longevity Metrics

This episode discusses my OPINIONS regarding Direct Primary Care. It is not intended to provide medical knowledge. Just an interesting discussion!

Summary

Direct Primary Care (DPC) is a new movement in primary care designed to improve the provider patient relationship, accessibility of providers to their patients, and transparency of pricing. At its core, it is defined by patients or their employers paying for primary care directly. This is in opposition to using medical insurance or another third party like the government. This new model is growing and has the potential to disrupt healthcare in an amazing way.

Morbidity and Mortality

United States healthcare is bankrupting people and companies at alarming rates. This is because healthcare costs are out of control. As financial security is a more important driver of health than access to medical care, I question whether the United States healthcare system actually helps more people then it hurts. DPC realigns incentives and seeks to control costs. This puts the breaks on healthcare spending.

Key Points

1.     DPCs often utilize affordable subscription-based care. Patients can often call their providers directly whenever medically needed. 

2.     DPC providers take on about ½ to ¼ of the patients in traditional primary care. This allows them more time with patients and improves care.

3.     DPC offices know the cost of everything they recommend, as such expensive treatments, medications, and diagnostics are appropriately avoided.

4.     DPC doctors practice a broader scope of care than traditional primary care doctors. This prevents communications errors and adds value to consumers as the more providers someone sees the more expensive care gets.

5.     Employers who use DPC save money on total healthcare expenses. One study of 10 clinics found a 20% reduction in total healthcare expenses, 40% less emergency department visits, and 26% less hospitalizations compared to traditional care.

6.     DPC is thriving in spite of medical insurance and healthcare policies that undermine it. Imagine how successful it could be with the support of legislation.

References

-       Personal experience as a primary care physician that has worked in traditional insurance based primary care clinics as well as owns and operates Wander Medicine clinic, a DPC in Boise, ID.

-       Millman Inc. Direct Primary Care: Evaluating a New Model Of Delivery and Financing. 2020. Available at: https://www.soa.org/globalassets/assets/files/resources/research-report/2020/direct-primary-care-eval-model.pdf

Background

United States healthcare costs the most of any country in the world. Unfortunately, the health of our population and quality of care provided does not support the cost. We offer the worst healthcare value in the entire world (Value = Cost/Quality)! This has to change for the sake of ourselves and our children. The changes needed are simple. But, change is difficult because so many people are making so much money off of our toxic system.

This podcast is not meant to provide clinical medical knowledge. It represents the opinions of the author. It is intended to stimulate thought and conversion.

Some of the major problems are:

1.     Lack of Transparency in Pricing

2.     Insurance for Every Part of Medical Care (It should not be called insurance anymore)

3.     Businesspeople that Provide no Additional Value

4.     Regulations that are out of Date, Add Complexity, and Provide No Value

5.     Poor Communication by Design

6.     Drugs and Diagnostics that are Obscenely High Priced

7.     Upside Down Provider Workforce

8.     Fear and Defensive Medicine

Ask yourself everyday as a provider:

Would I make such a recommendation to someone in my own family?

Would I want myself to be my own doctor? 

9.     Upside Down Incentives Regarding Wellness and Disease Prevention

10.  Lack of accessibility of providers when patients need them the most

Some of my solutions are:

1.     Mandate that all healthcare entities make prices fully transparent

2.     Provide medical insurance products that only cover catastrophic care on the individual and group insurance markets. These must be affordable, like 50$ a month or less for young healthy people.

3.     Kick most of the businesspeople (suits) out of healthcare. Keep only those individuals who add value.

4.     Modernize regulations to reduce regulatory burden. 

5.     Mandate that EMRs communicate with each other using a universal API.

6.     Start paying the same prices for diagnostics and therapeutics that the rest of the developed world pays.

7.     Incentivize primary care so that the smartest people enter this field and subsequently practice an extremely broad scope of care.

8.     Stop worrying about being sued and start doing what is right for patients.

9.     Incentivize preventative medicine and public health by paying for them

10.  Develop systems were doctors are available to their patients in times of need. E.g. Direct Primary Care (coming next episode)

Summary

Space is a hostile environment. Microgravity, radiation, temperature extremes, vacuums, isolation, and forces related to takeoff and landing are just a few of the hazards faced by astronauts and other space voyagers. Humans have been capable of leaving planet earth for just 60 years. Since that time, we have learned a lot about how to keep humans safe and healthy in space. However, our knowledge remains primitive. To become multiplanetary, physicians, scientists, engineers, and other disciplines will need to take space medicine to the next level. This will be the greatest preventative medicine challenge ever undertaken.

Morbidity and Mortality

Space can kill you in 1000 different ways. Explosions, lethal radiation doses, and environmental control failures can all result in fatality. Those who spend long amounts of time in space can have long term vision issues, higher rates of cancer, and back problems. Longer space flight missions, and those outside of the earth’s magnetosphere will pose much higher risks to human in space.

Story

Getting things into space is getting cheaper. Adjusted for inflation (to year 2000), the price to put 1 kg into low earth orbit was about $85,000 in 1981. In 2019 that number had fallen to $951/kg or 1% of the cost from 40 years prior. Prices continue to get cheaper and space continues to become more accessible.

Key Points

1. Microgravity has a number of adverse effects including motion sickness, muscle and bone loss, and cardiovascular changes.

2. Ionizing radiation is a huge problem is space that we have no idea how to solve

3. The psychological and human factor components can never be understated, even when picking the best humans available.

4. Humans need to become multiplanetary in order to assure the long-term survival of our species. We also need to bring the rest of life on earth with us. Space medicine is booming as a result of the booming space industry.

References

-       Green et al. Handbood of Aviation and Space Medicine. 2019

-       Hodkinson PD, Anderton RA, Posselt BN, Fong KJ. An overview of space medicine. Br J Anaesth. 2017 

-       Wikipedia- Karman Line, Armstrong limit, Space Medicine, Ionizing Radiation, Geocorona, etc.

-       https://www.nasa.gov/feature/nasa-station-astronaut-record-holders

-       https://www.futuretimeline.net/data-trends/6.htm

-       Belavy et al. Disc herniations in astronauts: What causes them, and what does it tell us about herniation on earth?. Eur Spine J 25, 144–154 (2016)

Summary

Space is a hostile environment. Microgravity, radiation, temperature extremes, vacuums, isolation, and forces related to takeoff and landing are just a few of the hazards faced by astronauts and other space voyagers. Humans have been capable of leaving planet earth for just 60 years. Since that time, we have learned a lot about how to keep humans safe and healthy in space. However, our knowledge remains primitive. To become multi-planetary, physicians, scientists, engineers, and other disciplines will need to take space medicine to the next level. This will be the greatest preventative medicine challenge ever undertaken.

Morbidity and Mortality

Space can kill you in 1000 different ways. Explosions, lethal radiation doses, and environmental control failures can all result in fatality. Those who spend long amounts of time in space can have long term vision issues, higher rates of cancer, and back problems. Longer space flight missions, and those outside of the earth’s magnetosphere will pose much higher risks to human in space.

Story

Getting things into space is getting cheaper. Adjusted for inflation (to year 2000), the price to put 1 kg into low earth orbit was about $85,000 in 1981. In 2019 that number had fallen to $951/kg or 1% of the cost from 40 years prior. Prices continue to get cheaper and space continues to become more accessible.

Key Points

1. Microgravity has a number of adverse effects including motion sickness, muscle and bone loss, and cardiovascular changes.

2. Ionizing radiation is a huge problem is space that we have no idea how to solve

3. The psychological and human factor components can never be understated, even when picking the best humans available.

4. Humans need to become multiplanetary in order to assure the long-term survival of our species. We also need to bring the rest of life on earth with us. Space medicine is booming as a result of the booming space industry.

References

-       Green et al. Handbood of Aviation and Space Medicine. 2019

-       Hodkinson PD, Anderton RA, Posselt BN, Fong KJ. An overview of space medicine. Br J Anaesth. 2017 

-       Wikipedia- Karman Line, Armstrong limit, Space Medicine, Ionizing Radiation, Geocorona, etc.

-       https://www.nasa.gov/feature/nasa-station-astronaut-record-holders

-       https://www.futuretimeline.net/data-trends/6.htm

-       Belavy et al. Disc herniations in astronauts: What causes them, and what does it tell us about herniation on earth?. Eur Spine J 25, 144–154 (2016)

Summary

Drowning is defined as respiratory impairment caused by submersion in a liquid media. There are 3 outcomes; death, death with long term morbidity, and death without long term morbidity. Children are at particularly high risk. Over half of adult drowning involve alcohol. Most drownings are preventable.

Morbidity and Mortality

Drowning victims struggle to stay above water or may just be unconscious. Eventually rising blood CO2 levels trigger a breath. This leads to aspiration.  Eventually hypoxia develops leading to tissue injury. This leads to hypoxic brain injury and finally death if the victim is not rescued. Worldwide, at least 500,000 people die a year from drowning, mostly in developing nations. Drowning is the leading cause of death in children age 1 to 4 years.

Story

When New Zealand was first being settled by European colonizers, so many people died trying to cross rivers that drowning became known as the New Zealand Death. Alcohol, dangerous beaches, and flash floods also contributed to the increased incidence of drowning deaths.

Key Points

1. Children, men, having a low income, being African American, having seizures, being elderly with health problems, inability to swim, and substance use are all risk factors for drowning.

2. learning to swim, being honest about swimming ability, using the buddy system, putting physical barriers around pools, having proper supervision, and using proper flotation devices can all prevent drowning.

3. Rescuers should be careful to not become a second victim. Remembering scene safety as well as the phrase reach, throw, row, go is very important.

4. Resuscitation should start with 2 good rescue breaths followed by high quality CPR. Remove wet clothing and begin warming the drowning victim immediately.

5. BIPAP and intubation are often utilized in the hospital setting for symptomatic drowning victims with significant pulmonary edema. Be sure to drain the stomach with and nasogastric tube to prevent further aspiration. Asymptomatic drowning victims are usually observed for 4 to 8 hours before they are allowed to return home.

References

-       Auerbach’s Wilderness Medicine, 7th Ed. Chapters on Marine Medicine. Ch 69-78 (1530-1794). 2017

-       Schmidt et al. WMS Practice Guidelines for the Prevention and Treatment of Drowning. 27(236-251). 2016.

-       Uptodate.com. Submersion Injuries

-       Wikipedia. drowning, free diving blackouts, etc

-       CDC and WHO websites

-       The New Zealand Death. Available at: https://ricky1871.wordpress.com/2013/06/14/376/

-       Personal Experience as an EMT and physician

Summary

For thousands of years indigenous Americans have used hallucinogenic mushrooms in religious ceremonies as entheogens. These mushrooms are now known to contain psilocybin, a small molecule with profound mind-altering properties. While many cultures have understood the therapeutic potential of psilocybin for thousands of years, most modern countries are only now accepting psilocybin’s potential as medicine.

Morbidity and Mortality

The profound mind-altering effects of psilocybin should not be under-estimated and have led to many fatal accidents. However, psilocybin is very safe from a purely toxicological standpoint. The LD50 (dose at which half of people die) is estimated to be 6g or 1000 times the normal recreational dose. Most all reported psilocybin fatalities have involved significant co-ingestions.

Story

The Aztecs called hallucinogenic mushrooms “tonanacatl” meaning “God’s Flesh”. In 1519 when Spain conquered the Aztec Empire, they banned cultural practices like the use of hallucinogenic mushrooms. Years later, in 1970 the United Nations required all member nations to ban psilocybin. However, this attitude is finally changing. Oregon became the first state to legalize psilocybin in 2020. However, it remains federally illegal.

Key Points

1. Psilocybin is a small molecule found in the fruiting bodies (mushrooms) of hundreds of species of fungi around the world

2. It is very similar to the neurotransmitter serotonin and is an agonist at various serotonin receptors, most importantly 5HT2A.

3. Though it is currently DEA schedule 1, psilocybin has numerous potential health benefits, most notably in the treatment of multiple psychiatric disorders like depression and substance abuse.

4. Those who have ever used psilocybin are probably less likely to commit violent crimes and often report enduring beneficial effects. Feeling of interconnectedness with other people, nature, and the universe are regularly reported by users.

5. Some things I forgot to say in the podcast:
- Make sure you get psilocybin from a trustworthy source. Fake and adulterated products are very common. 
- Calling a friend or loved one can be a great way to get through a "bad trip"
- Everyone has a different metabolism. Some will get profound effects from a small dose while other may need larger doses.
- Micro-dosing (taking about 1/10 a normal dose) is often done on an almost daily basis to help with depression, anxiety, and to improve creativity. Think about it like a daily antidepressant. This is a sub-hallucinogenic dose.

References

-       Johnson, M. W., & Griffiths, R. R. (2017). Potential Therapeutic Effects of Psilocybin. Neurotherapeutics:14(3), 734–740. 

-       Hendricks PS, Crawford MS, Cropsey KL, Copes H, Sweat NW, Walsh Z, Pavela G. The relationships of classic psychedelic use with criminal behavior in the United States adult population. J Psychopharmacol. 2018;32(1):37-48. 

-       Neavyn MJ and Carey JL. Hallucinogens. GoldFrank’s Toxicology. 2019.

-       Wikipedia. Psilocybin, Psilocin, Serotonin, Psilocybin Decriminalization in the United States.

-       https://www.dea.gov/drug-scheduling

-       Mandrake K. The Psilocybin Mushroom Bible: The Definitive Guide and Growing and Using Magic Mushrooms. 2016.

Summary
G Force is a measure of acceleration, or a change in velocity and/or direction. All of us experience 1Gz, while standing on earth. However, military fighter pilots may have to perform under 9Gz. Such large G Forces can lead to loss of consciousness (G LOC) and even death. G Force Tolerance is a measure of how many Gs a person can withstand prior to loosing consciousness.  Many factors can affect a person’s tolerance for Gs.

Morbidity and Mortality
G Forces prevent blood from reaching the brain causing loss of consciousness. If you are flying a fighter jet this can lead to collisions or vulnerability to attack. If G Forces are sustained during G LOC, permanent brain damage, and then death will occur. Humans can handle incredible high G forces for short periods of time.

G Force Tolerance Thresholds for Severe Injury for Short Duration Exposures
 | Axis | G Force
 | +Gz | 25G
 | -Gz | 15G
 | +Gx | 50G
 | -Gx | 45G
 | +- Gy | 12G

Taken from Green’s, Handbook of Aviation and Space Medicine. 2019.

Story
Flight Surgeons and Aerospace Medicine researchers in the first half of the 20th century regularly used themselves as guinea pigs in physiologic tests. US Air Force Col. John Stapp, MD PhD took this idea to the extreme. He made rocket sleds at a New Mexico military base to test human tolerance for G Forces. On Dec. 10, 1954, after several runs (26 on himself), Stapp broke the land speed record traveling 662 mph, sustaining 46.2 Gx. 

Key Points
1. The danger of any G Force depends on the direction of force relative to the body, magnitude of the force, rate of onset, and duration sustained.
2. Subscripts are used to identify the direction of force relative to the body. +Gz travels from head to toe; - Gz travels from toe to head; + Gx travels from chest to back; - Gx travels from back to front; + Gy travels from right to left; - Gy travels from left to right.
3. g is the acceleration due to gravity on earth, equal to 9.8 m/sec/sec. G = acceleration/g. Therefore 10Gs = 98 m/sec/sec.  A person feeling 10Gs would feel 10x heavier and their heart would have to pump blood the equivalent of 10 time the normal distance in order to reach the brain.
4. +Gz Forces cause blood to pool in the legs. This prevents blood from entering the brain. If gradual in onset, G forces will eventually cause vision loss, followed by blackout, and then loss of consciousness (G LOC). Rapid onset G forces may lead straight to blackout.
5. G tolerance, refers to a human’s capacity to sustain G Forces without G LOC. G tolerance is different for everyone. For example, +Gz tolerance ranges from 2.7 to 7.8 (mean 4.7) for most people.
6. Several factors can improve G tolerance. Examples include anti-G straining maneuvers, G suits, reclining the pilots seat, proper hydration, proper nutrition, drugs, physical fitness, and proper training.
7. -G immediately preceding +G will lower G tolerance significant. For instance, push-pull aviation maneuvers (nose diving the plain and then trying to pull up quickly) is particularly dangerous for G-LOC.

References
- Green, Gaydos, Hutchison, Nicol. Handbook of Aviation and Space Medicine. CRC Press. 2019
- Mackowski. Testing the Limits, Aviation Medicine and the Origons of Manned Space Flight. 2006
- Wikipedia. G Force, G Suit, High G Training, AGSM
- Youtube. Multiple videos showing centrifuges, John Stapps Sled, and fighter pilots
- Tesch PA, Hjort H, Balldin UI. Effects of strength training on G tolerance. Aviat Space Environ Med. 1983 Aug;54(8):691-5. PMID: 6626076.

Summary
Mercury is a heavy metal and the 67th most common element in the earth’s crust. Its unique chemical properties have led to its use in a number of industries including laboratory equipment (thermometers), medical equipment (blood pressure cuffs and preservatives), dental amalgams, fluorescent lights, chlorine production, and gold and silver mining.  Burning coal creates the majority of the mercury humans are exposed to.

Mercury has no known physiological role in humans. Exposure to mercury can result in nerve damage, brain damage, problems with walking, hearing, and seeing, skin rashes, kidney disease, and breathing problems. Mercury is particularly detrimental to the developing fetus. Avoiding mercury exposure in the expecting mother and young children are of paramount importance.

Morbidity and Mortality
Inhalation of large amounts of elemental mercury can lead to acute respiratory distress syndrome and death. Large inorganic mercury exposure can cause profound gastrointestinal disturbance, severe dehydration, end stage renal disease, and death (lethal dose 30 to 50 mg/kg). Dimethylmercury is so toxic that only a few drops onto the skin caused the death of Karen Wetterhahn, a chemistry professor. Methylmercury can bioaccumulate to high levels in humans that are continually exposed. Such individuals will develop ataxia, neuropathy, and sensory impairment, which can progress to severely altered mentation, paralysis, coma, and even death. Lower doses of methylmercury during fetal and childhood development can result in substantially lower IQs.

 Story

-       Between 1932 and 1968, the Chisso Corp. released wastewater contaminated with mercury into Minamata Bay, Japan. This accumulated in local marine wildlife. Those who ingested the contaminated seafood often developed a severe neurological illness called Minamata disease. Around 1800 people died from this catastrophe.

-       In 1971 in Iraq around 100,000 tons of grain intented for planting was treated with methylmercury as a fungicide. This grain was then used to bake bread instead. This resulted in thousands of hospitalizations and atleast 400 deaths.

Key Points

1. Mercury has no physiological role in humans. All of its different forms have toxic risks.

2. Elemental, inorganic, and organic mercury compounds have very different pharmacology and toxicological effects. 

3. Organic mercury can readily cross the placenta and blood brain barrier. Compounds like methylmercury can have profound effects on the neurological development of fetuses and children.

4. Methylmercury is accumulating in our water, largely from burning coal. This mercury bio-accumulates up the food chain. Apex predators can develop very high mercury levels as a result.

5. Pregnant women, woman of childbearing age, and young children should avoid the consumption of apex ocean predators. Consumption of other fish should be limited to < 12 oz a week in these at-risk groups.

References

-       Young-Jin Sue. Mercury. Chapter 95. Goldfrank’s Toxicological Emergencies, 11th Ed. 2019

-       Harada M. Minamata disease: methylmercury poisoning in Japan caused by environmental pollution. Crit Rev Toxicol. 1995

-       Mercury and Health. WHO. Available at: https://www.who.int/news-room/fact-sheets/detail/mercury-and-health

-       Minamata Convention on Mercury. Available at: https://www.mercuryconvention.org/

-       Wikipedia. Mercury, Mercury Poisioning, Mad as a hatter, Minamata disease, Minimata convention, Karen Wetterhahn.

Summary

Lead is a dense elemental metal utilized by humans for possibly over 8,500 years. This toxic material has no known biological function in human physiology. It is particularly harmful to the brain, peripheral nervous system, blood, gastrointestinal tract, reproductive organs, mental health, and essentially every other major organ system.

Morbidity and Mortality

At very high exposure levels (usually > 100 ug/dL BLL), lead can cause seizures, coma, and death via cerebral edema. However low levels of lead exposure (> 5 ug/dL BLL) over time are really the bigger concern. Even low levels of lead have been shown to lower IQ and cause behavioral disturbances. 815 million children worldwide are believed to have dangerously high lead levels, 500,000 a which reside in the United States. An estimated 900,000 adults are killed every year from lead poisoning. Worldwide, lead may account for as much as 1% of the global burden of disease.

Story Time

Roman aristocratic society made a sweetener called sapa, a grape syrup simmered in lead containers. Many historians believe that extensive use of sapa, reduced the IQ of the ruling class, likely contributing to the fall of the empire. Before 1976 and 1978, lead was routinely added to gasoline and household paint in the United States. Blood lead levels (BLL) decreased from 12.8 ug/dL to 0.82 ug/dL over the 35 years following federal regulations banning lead additives in individuals age 1 to 74 years. This likely resulted in the average IQ increasing between 7 and 12 points. 

Key Points

1. Children are at greatest risk for lead toxicity as they tend to put things in their mouth. Old houses with chipping lead paint are the greatest risk factor. Though blood lead levels have declined dramatically, the CDC and AAP still recommend routine screening in children.

2. Occupational exposures are the greatest risk factor for lead poisoning in adults. Lead smelters, constructions workers, automotive radiator repairmen, firing range instructions, battery manufacturers, lead abatement workers, and metal workers are at greatest risk.

3. The CDC has steadily decreased their definition of elevated blood levels from < 60 ug/dL to < 5 ug/dL over the past 60 years. There is no safe lead level.

4. Blood lead levels are currently the best screening and diagnostic test for lead poisoning. Most lead is absorbed into the bone and can leach out into the body over decades. In the future, we will likely judge cumulative exposure by looking at bone lead levels.

5. Removing the lead exposure is the most important treatment. At BLL > 45 in children and > 70 in adults, chelation therapy with substances like dimercaptal, CaNa2 EDTA, and succimer are both recommended and efficacious.

References

-       Calello and Henretig. Ch. 93. Lead. Goldfranks Toxicology, 11th Ed. 2019

-       Burki. Report says 815 million children have high blood lead levels. Lancet. 2020.

-       Dignam, Kaufmann, LeStourgeon, & Brown. Control of Lead Sources in the United States, 1970-2017: Public Health Progress and Current Challenges to Eliminating Lead Exposure. Journal of public health management and practice. 2019.

-       Wikipedia: Lead, lead poisoning

-       WHO. Lead, Assessing the Environmental Burden of Disease. Available at: https://www.who.int/quantifying_ehimpacts/publications/9241546107/en/#:~:text=It%20is%20estimated%20that%20lead,exposure%20to%20lead%20is%20required.

Lecture Summary

2020 was a crazy year. I learned so much and hope that every single public official has as well. This episode will be the final post of season 1. Episode 29 represents the authors opinion and will provide no medical knowledge. Join me on this more controversial than normal episode!

Key Points

COVID19 Pandemic Lessons

-       Society must distinguish between war time and peace time in the event of crisis. Wartime rules during peacetime was not well received in 2020.

-       Society is upside down. We invest no money, time, or effort in our youth. We close schools while strip clubs remain open.

-       United States citizens have become profoundly unhealthy, making us more susceptible to the infection.

-       We were/are greatly un-prepared from a disaster standpoint. Planning, training, and communication were all lacking.

-       Pandemics should be handled aggressively and decisively from the onset. The middle ground, which most of the world took, was a bad strategy.

-       More young people in power are needed. Every public official does not need to be 80. Minds this old are just not at the top of their game. I believe that 80-year-olds would make better consultants as opposed to ultimate policy makers.

General Lessons

-       Processed food has taken over the American diet and over half of us are now obese.

-       Hazardous chemicals and pollution represent the greatest modifiable threat to the health and the future of the human species.

-       Social media and artificial intelligence algorithms need regulation urgently.

-       Pharmaceuticals are a second line therapy in many chronic diseases. We need the healthcare industry to start acting this way.

-       Space exploration is exploding and extraterrestrial manufacturing practices may inform earth from a sustainability standpoint in the future.

-       Season 2 of full scope will focus more on travel, occupational, wilderness, and aerospace medicine. Shorter episodes, focused topics, and more stories will be a hallmark.

References

My experience living through the last year.