How do I fix my insomnia?

Insomnia is a common and often frustrating problem. Part of the reason it's frustrating is that, unless an accurate diagnosis of the root cause(s) is made, treatments tend to be temporary band aid solutions and rapidly lose their effectiveness.

Do you have an underlying medical problem?

There are a range of medical condition that can cause insomnia. 

Chronic pain, sleep apnoea or a need to urinate frequently caused by an enlarged prostate gland can all cause insomnia. Diseases like arthritis, cancer, heart failure, lung disease, gastroesophageal reflux disease (GERD), overactive thyroid, Parkinson's disease and Alzheimer's disease have all been implicated. Mental health problems like stress, anxiety and depression can also cause problems.

Many of these issues are amenable to treatment, and by fixing the root cause, sleep patterns can return to normal.

Are your medications to blame?

1. Alpha-blockers
2. Beta-blockers
3. Steroids
4. SSRI antidepressants
5. ACE inhibitors
6. ARBs
7. Cholinesterase inhibitors
8. H1 antagonists
9. Glucosamine/chondroitin
10. Statins

Note that you should consult with your doctor before stopping any prescribed medications.

Are your daily habits contributing?

There are many habits and work patterns that promote poor sleep

• Shift work - this scrambles your body clock (circadian rhythm)
• Eating late in the evening night
• Fluids in the evening
• Excess caffeine, nicotine and other stimulant (ie Red Bull) consumption
• Using stimulants in the afternoon and evening
• and having them earlier rather than late
• Not getting enough exercise
• Too much alcohol - although alcohol is a sedative it prevents entry into deep sleep

Could your sleep hygiene be improved?

If you use your bedroom for other activities than sleep and sex you are missing the opportunity to program your thinking along the lines of go to bed, go to sleep.

You will sleep better if:

• Your bedroom is pitch black
• Your bedroom is quiet
• You bedroom is not too hot, not too cold
• You have a comfortable mattress
• You have a comfortable pillow - not too high or too low, too soft or too firm - get one that's just right (and remember they wear out over time)
• You have enough blankets so you're not too hot when you go to bed, but also don't wake up freezing when it cools off in the early morning

What can my doctor do for me?

For a start, any doctor worth his/her salt can discuss everything with you and look for root causes. It's always best to fix the source(s) of problems.

A simple plan (from Dr Margaret Hardy)

• Work out average amount of actual sleep per night from sleep diary
• Choose a regular wake-up time
• Set a regular bedtime by subtracting average sleeping hours from the planned wake-up time
• Review at weekly intervals and, if tired, increase time in bed by going to bed 30 minutes earlier

Your doctor can also provide medications including:

• Melatonin (which re-sysncs your body clock and is thus really good for shift work and jetlag
• Benzodiazepines (temazepam, zopiclone, zolpidem and many others) which are good for short term (particularly stress related insomnia). Long term you become first tolerant (needing ever increasing doses) and then addicted (needed the medication or you won't be able to sleep)
• Antidepressants like amitriptyline and mirtazipine which are used (usually in low doses) not to treat depression but for their common sedating side effect. Their advantage over benzodiazepines is that tolerance is far less of an issue, so they can be used longer term

Don't despair. Most people can get a far better nights sleep with a few simple changes.

Talk to your doctor, or see one of our expert GPs online from the convenience of home.

Dr James Freeman

Testosterone - should you be taking it?

There's an apocryphal story in medicine that goes like this:

An eminent professor concluded his speech to the graduating class with the following comment:

"Ladies and Gentlemen, 50% of everything we have taught you about medicine is wrong, the trouble is, at the moment, we don't know which 50%. Your job is to work it out"

In medicine we have interesting, and contradictory, positions with respect to hormone replacement. 

In women we recognise a condition called menopause, which happens to women in their 40s and 50s when the levels of the hormones oestrogen and progesterone fall rapidly and the menstrual cycle becomes first erratic, then stops altogether. 

We know that many women get symptomatic relief from symptoms of menopause like hot flushes, night sweats, and mood swings if we give them small doses of these missing hormones.

In men the situation is a little different. Testosterone is the primary male hormone, and levels start falling more or less immediately after sexual maturity is reached in the early 20s.

It has taken medical science a long time to get it's head around thinking that males also experience a form or menopause, which some people call Andropause. Perhaps it's because the decline is so slow, or it's because there is no obvious "change of life", other than the pervasive male middle aged spread?

We are now at the point where it has been found that men with Testosterone levels in the lowest 25% actually have the highest levels of cardiovascular mortality - ie die from strokes and heart attacks 

Furthermore supplemental testosterone is safe for cardiovascular health, according to research presented at a meeting of the American Heart Association in Chicago.

It shows men on supplementation have reduced overall rates of major adverse cardiac events at one and three years after their initial low levels of testosterone were measured compared with men with persistently low levels of testosterone.

The study results coincide with an FDA evaluation of the safety of testosterone supplementation and whether it is a risk to the health of older men.

The researchers say it provides reassurance to doctors who can use testosterone with less concern about its effect on patients' heart health.

"With this study we are getting closer to defining the true associations between testosterone treatment and cardiovascular risks or benefits," says study leader Jeffrey Anderson, a cardiologist at the Intermountain Medical Center Heart Institute.

So if you're a man, battling middle aged spread and loss of libido perhaps you should talk to your doctor about having you testosterone level measured, and if it's low, considering supplementation?

You can talk to a doctor confidentially online at GP2U

GP2U - A Great Resource for the Disabled Community

One of the real rewards of being a doctor is getting this sort of feedback from patients.....

I’ve utilised the GP2U service for a little over two years now and remain impressed by it’s advantages.  Prior to discovering this option, I had come to dislike needing to attend medical appointments. In my area, the key medical centres didn’t make appointments so you never knew whether getting in to see a doctor could take one hour or three (the longest I waited was 3hrs 45mins).  

Then there were the toilets. I can’t manage stairs so looking up at a steep set of roughly 27 stairs to the single available practice toilet, made my heart sink.  On more than one occasion I had to leave the waiting room and actually drive home to use a toilet and then face parking issues a second time.

Sometimes I would drive around for 30 minutes and give up, go home, and try again later in the day. Disability parking in some areas is very limited and there is a high demand for the same. It’s not always helpful to have to pay for parking and then manage a 500m journey to the practice.  Trying to see specialists held similar problems.

Of course, the disabled community isn’t a single mass of individuals all with the same challenges. Some people with motorised vehicles or wheelchairs find aspects of medical appointments easier than those with walkers or walking sticks.  For me, GP2U has offered an improved sense of independence and ease.  The convenience is incredible and the level of service provision very high.

I can attend a specialist pathology centre when necessary and frankly find their equipment more suitable for my physical needs than what is generally available in a general practice.  Lots of positives in telehealth – convenience and dignity at the top of the list.

Sue

Will the future healthcare system still need doctors?

Over on LinkedIn Kim Bellard posed the question Is it possible that in our future health care system we won't need physicians? - which got me to thinking about the answer.....

Of course it's possible, however to make it happen consider the complexity of the AI required. In the course of a usual face to face medical consultation:

The patient arrives, and I give them my standard introduction "Hello <name>, I'm Dr Freeman (or James for a child), how can I help?

I place myself on the same level as the patient. In the ER I pull up a seat so I am not towering over the bed. In my consultation rooms I invite the patient to sit beside me in a chair where they can see my screen.

This construct opens the channels of communication in a very human way. It sets up the framework of patient here seeking help, me next to them offering help, and the notion of us communicating on an equal level.

The patient then begins talking. The average doctor will interrupt after 16 seconds, having more or less formulated an initial working diagnosis. I don't, I shut up and listen. Most patients run out of steam after about 2 minutes, some get to 5 minutes and may get cut off. Often the most salient facts come right at the end with comments like...  "and I've lost 10 kilos in weight, does that matter?"

During this time a vast quantity of both verbal and non-verbal information is communicated.

It's said at least 50% of communication is non verbal and any machine hoping to replicate what I do needs to be just as good at doing it as I am.

Now we move into a question and answer phase where I explore various diagnostic possibilities. Does the patient provide evidence to support my diagnosis, or, am I metaphorically barking up the wrong tree?

At some point I will have either decided on a diagnosis, or the steps required (tests, scans, examination) to establish a diagnosis. Occasionally I'm baffled!

Towards the end of this conversation I will ask the question "What do you think it could be?"

While the everyone's a comedian answer is "You're the doctor, you tell me" I need to know what drove the patient to come to see me. If I don't address that driver i.e. "I think it might be cancer" I might well make the correct diagnosis but will not cure the patient of the fear that brought them to me in the first place.

In medicine we say the essence of the diagnosis is the history and ascribe a number like 70% to that, 20% to examination, and 10% to tests. Depending on the realm, and who is inventing the statistics these numbers vary a bit, but the key thing to understand is that diagnosis hinges on a conversation between two individual humans. 

Up until the point a computer can conduct a natural language conversation it will (outside very specific realms) always be inferior to a physician. Until it exists in robotic form that can go out and experience the nuances of social interaction with humans over a period of years it's really going to struggle with concepts like "I'm tired" or "I'm sad". Humans are not alone in the experience of emotion, but it plays a big part in what the words we say really mean.

We are a very long way from machines that can manage natural language, combine that with understanding of the non verbal, and can be accepted with trust. All these things play a role in patient-physician communication. 

A diagnostic conversation can notionally be reduced to a decision tree but humans are supremely good at integrating diverse sources of input. A pocket calculator can leave us for dead, but we paint, we tell stories, and we intuit patterns far better than any machine in existence.

So for it to happen you need something that passes the Turing test.

I love tech and run GP2U, the largest Telehealth outfit in Australia. It works because video provides both the verbal and non verbal cues I need to formulate (in many but not all cases) an effective diagnosis or diagnostic plan, even in the absence of the ability to conduct a full physical examination. 

What a physician does is as much about art as science. 

When a computer can paint like Leonardo, or make music like Mozart, I'll happily retire. 

Until then I'd rather see an expert person than an expert system.

Why I Consult Dr Google?

I asked one of our patients if we could share her story. Here it is in the words of her son.....

My father, who was about 80 at the time, was prescribed the wrong antibiotic by his GP and by the time the mistake was discovered, he needed to be hospitalised with pneumonia. He managed to pull through and the GP admitted his mistake.

 Later my father, after years of complaining he was tired all the time and numerous visits to the same GP was diagnosed with a thyroid deficiency. So the doctor prescribed T4 and kept on increasing the dose and then informed him that he was on the maximum permitted dose and it still wasn’t working. 

So I did an internet search which was relatively new to me at the time and found he was taking the medication incorrectly with meals and suggested he take it on an empty stomach. On the next visit I found his hair was falling out and he was suffering all the symptoms of an over active thyroid.

Later on I went through his list of medication and doing internet searches found he was taking one medication to lower his blood pressure. This did not make sense as he suffered from low blood pressure. Apparently a specialist had prescribed it after a minor heart operation and the GP was reluctant to change the medication.  

  

My mother, who was 11 years younger than my father, was in relatively good health until she reached 80 and she decided to go on a holiday to Europe.  Her legs kept swelling and she had mentioned it to her GP at the time but he dismissed it. I was concerned about her travelling on long flights and the possibility of suffering DVT,  and as she was leaving in a matter of days,  I suggested that at every opportunity she lie on the floor and put her legs up a wall to drain the fluid out of her legs. I don’t know how effective this was but at least she didn’t suffer any health problems on the flight.

Her GP at the time, who liked to make weekly appointments for all his elderly patients had moved his surgery a further 5 km away from my mother’s house, close to a retirement village, and as a result of this she changed GPs. It is not hard to see why the government wants to introduce co-payments as some GPs could be seen to be abusing the system. 

On returning from Europe she found she was suffering from fluctuating blood pressure. At times her systolic blood pressure would be over 200! She consulted her new GP several times and was assured that her “average” blood pressure was OK. I am a professional engineer and I know what bursts pipes, and it is not average pressure, so I consulted Dr Google and found several stories indicating it was a serious issue. So after a few more visits and a print out of these internet sites the GP referred  her to a heart specialist who placed her in hospital and removed ~ 4 kg of fluid from her.

Well the specialist and hospital did a good job in removing fluid and placing her on new drugs to lower her blood pressure, but they were not the ones recommended by an English professor on Dr Google.

After she was discharged her systolic blood pressure was a little better but the fluctuations were continuing for example 193/60 at 7.15 a.m. and 124/42 at 9 a.m. When her diastolic blood pressure fell into the 40’s she would need to go back to bed.  She also had a fall due to being lightheaded from the low diastolic pressure which did some damage. The article by the English professor stated that the drugs she was on would lower the diastolic blood pressure! Who am I to tell the heart specialist he was wrong.

So my mum visited her new GP and told him her problems. He was reluctant to change the medication prescribed by the specialist – this appears to be a common problem with many GPs, that is, they are reluctant to change medication prescribed by specialist. Also he told her she has the blood pressure of a teenager – that was the last straw – we had had enough!

Honestly, this was no life for her, we had consulted two GPs and a specialist, and to me it appeared she was on the wrong medication, I was at wits end; do I drag her around to another GP?  In desperation to get a second opinion, probably from a specialist and fast,   I went looking for an online solution and found GP2U who was also offering much faster specialist consultations than we can normally expect.

As it turned out the GP online Dr James Freeman was happy to treat her directly and changed her medication to the one recommended by the English Professor.  She has recently found a new GP near home who referred her to another specialist who has carried out more testing and continued the medication prescribed by Dr Google and Dr Freeman from GP2U. Her blood pressures are now within acceptable limits for her age 158/66.

I found the GP2U online service to be very professional and useful especially for obtaining a second opinion, He also seemed more knowledgeable and was willing to share his knowledge via online articles.

I know a lot of GPs don’t like Dr Google but one thing is certain, Dr Google is not going to go away. He is going to have a bigger influence on GPs work, as computer literacy increases in the ageing population.  

I now consult Dr Google to check all prescribed medication to determine if it appropriate for my or my family’s condition and that it is being taken correctly.  

       

Bill Myers

October 2014

If you have a medical problem don't just diagnose yourself online, see a real doctor by video conference and get diagnosed online at GP2U Telehealth.

README

Welcome. Give yourself a pat on the back for actually reading a README!

This blog is going to touch on a whole range of eHealth related topics, so if you're interested in how technology is going to change health care stay tuned.

Now if your not a programmer the notion of a README may be unfamiliar, so I'll digress. On that note, you can expect quite a lot of digression in this blog as we wander the highways and byways of eHealth.

So getting back to the notion of a README.

In the open source world when a programmer writes a big application they usually write a file called, quite literally, README. Yes, it really is all caps!

This file contains things like instructions about how to install/use the application and other frequently asked questions.

Many people don't actually read the README and choose instead to email the developers.

Depending on the patience and mood of the programmer who receives this missive the answer may come back as a curt "RTFM" or the more incisive "There is a README did you READIT?"

Now what, you may ask, does this have to do with this blog?

Not a lot really, unless one day you happen to be walking around a tech event and see someone wearing a RTFM top in which case you will know you've just passed a geek with attitude.