Letters to the Editor is a periodic function. We welcome all feedback and can publish a range. We edit for size and readability and require full names.
On a ‘Woke’ Journalist’s Journey
I discovered Jay Hancock’s piece quite intriguing (“Severe Sleep Apnea Diagnosis Panics Reporter Until He Finds a Simple, No-Cost Solution,” Oct. 3). While I agree that positional remedy is usually neglected as a first-line therapy for obstructive sleep apnea, one has to have a look at this critical, life-threatening well being subject in a bit extra element. First, Mr. Hancock’s prognosis was central sleep apnea, which suggests both a neurologic and/or respiratory management etiology. Sleeping on the aspect might stop airway obstruction, however the underlying trigger has probably not been addressed. Second, the hazard right here is that — a bit like hypertension, with which there are little or no perceived signs — a catastrophic occasion would possibly happen with little or no warning. Third, it seems that the positional remedy on this case alleviated the situation — however as one will get older, the situation will probably worsen.
Bottom line: Why does this specific affected person have this situation and what could be completed to deal with the foundation trigger as an alternative of taking a symptomatic method? My concern is that, left untreated, the sufferers go to sleep with a false sense of safety to by no means get up the following morning.
— Dr. Dave Singh, an adjunct professor in sleep medication at Stanford University, Stanford, California
Not loving the tone right here. For each Jay Hancock, there are what number of lives modified/saved by CPAP remedy? https://t.co/28XDe3JZib
— Liz Beaulieu (@hmeliz) October 4, 2022
— Liz Beaulieu, Yarmouth, Maine
Finally! Jay Hancock uncovered the sleep apnea medical racket. I’ve one other therapy choice: During covid, many inpatients had been intubated within the susceptible place. I used to be interested by that and did some Googling. Not solely does sleeping in your abdomen improve lung capability, the gravity on the throat is a pure therapy for sleep apnea. While troublesome to adapt to, it’s higher than a CPAP. Again, docs don’t point out it. No cash in a easy gravity resolution.
— Peg Keohane, Syracuse, New York
A reminder of how medical suppliers work to drive up prices for therapy leading to lowered pay for working Americans!”Unnecessary care is a giant motive Americans’ insurance coverage prices — premiums, copays, and deductibles — are likely to rise 12 months after 12 months.)”https://t.co/F0zqPfGApS
— Stanley Morrical (@StanMorrical) October 3, 2022
— Stanley Morrical, San Francisco
I wish to thanks for this very well timed article. I’ve suspected there was extra to the query of apnea than was being reported. As said, it’s a large trade that perpetuates the concept everyone seems to be affected.
The reporter’s discovery that side-sleeping is the reply is totally legitimate, as I decided way back. The article ought to be broadly disseminated as it’s of utmost significance to tens of millions who’re falling for the hype!
— Lawrence Dee, Chino Valley, Arizona
Sleep apnea is over-diagnosed, based mostly on pointers set by a corporation funded partly by makers of CPAP machines used to… deal with sleep apnea, @JayHancock1 studies. An different “treatment” is usually neglected: Sleep in your aspect! https://t.co/29lohfjI6i by way of @khnews
— Robert Roy Britt (@RobertRoyBritt) October 4, 2022
— Robert Roy Britt, Phoenix
My mouth dropped open after I learn Jay Hancock’s piece about sleep apnea. You are the harbinger of a tidal wave, my pal. The get together is simply getting began.
Empowered Sleep Apnea is a mission we created to guard particular person sufferers from the “conveyer belt” of the American well being care system, because it’s poised to take care of tens of tens of millions of latest diagnoses of sleep apnea, which is able to quickly be made in major care and dental workplaces throughout our nice land, utilizing automated, wearable know-how. That time is coming inside 18 months.
You suffered as a result of there was insufficient teaching for a very sophisticated illness. Simple as that. All those that shall be subjected to a cloudburst of automated diagnostics could have the identical journey to make. Out of necessity, your resolution was to slog by means of your personal analysis to get your self some sane path. You empowered your self. Good on you.
My resolution was to take my life’s work as a patient-centered sleep medication doctor and switch it into one thing stunning to behold, so that everybody can profit from sane teaching. Our mission hinges on affected person empowerment. Our web site is a pleasant introduction. Our podcast can be a blast that I believe your readers would discover very attention-grabbing.
— Dr. David E. McCarty, proprietor and CEO of Empowered Sleep Apnea, Boulder, Colorado
I’m certain it really works – glorious abstract of messy #sleep #apnea ‘treatments’ and 0 prices resolution for many individuals https://t.co/6Jt09rbtf1
— Art Sedrakyan (@ArtsyTwits) October 6, 2022
— Dr. Art Sedrakyan, New York City
As president of the American Academy of Sleep Medicine (AASM), I write to deal with a number of issues in regards to the current article “Severe Sleep Apnea Diagnosis Panics Reporter Until He Finds a Simple, No-Cost Solution” (Oct. 3). While I commend the creator for in search of medical assist for his daytime drowsiness and loud night breathing, I concern his article might mislead readers in a approach that would jeopardize not solely their very own well being and security however that of others as properly.
The creator is clearly dissatisfied with the care he obtained; nonetheless, utilizing this to counsel that just about everybody identified with sleep apnea ought to merely deal with it on their very own “for free” is harmful. Sleep apnea is a standard and continual medical situation that will increase the dangers for quite a few bodily and psychological well being penalties, diminished high quality of life, motorized vehicle crashes, and untimely demise.
Positional remedy (which generally requires the usage of a tool to take care of a side-sleeping place), although helpful for some sufferers with sleep apnea, is just not the most effective therapy for many sufferers, particularly these with reasonable to extreme sleep apnea. Positive airway stress (PAP) remedy is the best-supported, evidence-based therapy for sleep apnea. The most up-to-date systematic assessment and meta-analysis included 80 randomized managed trials investigating the usage of PAP remedy to enhance outcomes. Millions of sufferers with sleep apnea can attest to the life-changing — and even lifesaving — affect of PAP remedy. Treatment choice is a crucial resolution that ought to be made collectively by a affected person and their treating supplier.
Furthermore, it’s inappropriate for the creator to make use of his expertise as justification to malign our total group and our 12,000 members. AASM strongly refutes the implication that help from trade biases our medical follow pointers and insurance policies. Our pointers are based mostly on a assessment of the newest analysis by a process drive of specialists who decide the power of proof for a given therapy. The AASM additionally ensures conflicts of curiosity are mitigated by means of a stringent medical follow guideline improvement course of. While the creator claims our group “finances its operations” with trade help, that is merely unfaithful. Industry help represents roughly 1% of our annual income and is guided by a transparent coverage that helps guarantee clear interactions to forestall undue affect and help public well being. Likewise, the implication that our members are prescribing PAP remedy as a part of a revenue-generating scheme is fallacious. The overwhelming majority of PAP units are bought by sturdy medical gear suppliers, not by sleep facilities or sleep docs.
I hope that readers struggling to get a superb night time’s sleep will search data from credible sources and discuss with a trusted well being care skilled to find out which therapy greatest addresses their particular conditions.
— Jennifer L. Martin, president of the American Academy of Sleep Medicine, Darien, Illinois
Psst. Sleep apnea is type of a racket. https://t.co/PHepAmgLaz
— Timothy Noah (@TimothyNoah1) October 4, 2022
— Timothy Noah, Washington, D.C.
I simply noticed Jay Hancock’s article on my Google feed and skim it, as I undergo from critical sleep apnea as properly. I’ve obtained tailored mouthguards, so to talk, which seem to work quite properly.
But I’ve additionally been studying books on respiratory, beginning with “Breath, the New Science of a Lost Art” by James Nestor, after which on to “The Oxygen Advantage” by Patrick McKeown. I noticed I used to be a mouth breather and that that contributes to the apnea drawback as properly and have since been attempting to study to breathe by means of my nostril always — to date with blended outcomes, however the topic could be very attention-grabbing because it pertains to much more than simply the right way to get a superb night time’s sleep.
— Dimitri F. Frank, Málaga, Spain
More and extra hospital techniques personal pressing care facilities which have limits on who they deal with — for each monetary causes. Urgent care facilities are a brand new excessive income stream for a well being system to generate quick cash making a pipeline of latest sufferers.https://t.co/GQU1HDQC3T
— James Hughes (@JamesHu29812484) September 30, 2022
— James Hughes, Savannah, Georgia
Treating Trauma — Followed by Billing Trauma
I’m an emergency doctor who additionally works at pressing care. While I respect sufferers attempting to be fiscally accountable with their decisions, the pressing care did exactly the fitting factor on this case (Bill of the Month: “Turned Away From Urgent Care — And Toward a Big ER Bill,” Sept. 29). Urgent care can sometimes handle fender benders or different minor accidents, however somebody whose airbags deployed and whose automobile rolled thrice and wound up “crushed” up right into a tree ought to at all times go to the emergency room. The mechanism of such accidents could be very regarding and sometimes justifies a trauma activation and CT scans to guage for inside accidents. Urgent care is just not geared up to deal with sufferers in the event that they develop life-threatening issues from a extreme damage.
— Dr. William Weber, Harvard Medical School / Beth Israel Deaconess, Boston
More proof that we want an everybody coated for every part, zero copay, federal single payer well being care system financed by truthful taxes. https://t.co/NNhMceezD0
— James Conner (@jrcflatheadmemo) September 29, 2022
— James Conner, Kalispell, Montana
This article is lacking the angle of a medical supplier. I’m a retired board-certified emergency doctor with 33 years within the emergency division and greater than 5 years in pressing care and really feel the necessity to tackle the medical care variations between the ED and pressing care.
I agree with the info of your article and don’t dispute the monetary points, issues, inequities of the damaged system. But there may be extra to the story.
The information, means, talent, and expertise of the supplier are key. The location of care predisposes to the talents of the supplier however doesn’t assure them. You might obtain glorious to below-average care relying on the supplier. I’ve seen folks die from auto accidents that had been despatched house from pressing care after receiving an analysis by a normal practitioner not educated in trauma. Some ED physicians miss issues, however the odds are higher that the ED physician won’t miss crucial circumstances.
Conversely, you would possibly get care from an skilled ED doctor at an pressing care.
Then there are the personnel and assets offered. If it’s a easy “urgent” drawback, no important distinction in final result is more likely to consequence.
There is the dilemma. What is an emergency? This has been argued in Congress: to err on the aspect of not lacking critical issues for which a “prudent layperson” may observe signs. So an emergency is what a “prudent layperson” believes it’s.
Some of the pressing care facilities I labored in turned away “third-party” circumstances however most didn’t — even inside the similar hospital-owned pressing care chain. An choice could be to supply to pay money, asking for the cash-upfront worth. Difficult to be correct in predicting the price forward of time, however an estimate is just not unreasonable. Instead of a low four-figure invoice, the household may need turned out to have a low three-figure invoice if not referred to the hospital after the pressing care analysis.
In my expertise, I’ve by no means seen a affected person despatched from pressing care (owned by or affiliated with a hospital) to the hospital for the only real motive of the hospital billing a second cost. Many sufferers are despatched as a result of they want a better degree of care that isn’t accessible, similar to hospitalization, injectable drugs, specialty care, imaging, and “stat” lab work not accessible.
Sure, the hospital makes use of the pressing care as a feeder website, however the affected person (or the paramedic) will get to decide on which hospital to go to, if they’ve a desire.
Please keep in mind that not all hospitals or pressing cares are the identical. Many smaller hospitals do not have some/many specialists required to again up the emergency division. Some pressing cares use primarily normal practitioners, whereas others use solely board-certified emergency physicians, nurse practitioners, or doctor assistants.
Yes, the system is damaged. Per a current webinar by the California Medical Association: In the previous 50 years, the rise within the variety of physicians was 2%. Administrative well being care personnel elevated greater than 3,000%. (That contains each the supplier and the payer aspect.)
— Dr. Mickey Kolodny, Palos Verdes Peninsula, California
The US healthcare system is so dysfunctional, it nonetheless staggers me at occasions.https://t.co/nU3nZG94rE
— Donald Farmer (@DonaldTreeHive) October 3, 2022
— Donald Farmer, Woodinville, Washington
After 40 years as a board-certified emergency medication doctor, I consider the article by Sam Whitehead could be very deceptive. First of all, the affected person ought to by no means have gone to an pressing care. Had she referred to as 911 as she ought to have, simply due to the mechanism of the crash, she would have been dropped at an emergency room. The ER clearly believed two CT scans had been wanted, which the pressing care wouldn’t have been capable of present. The reporter didn’t dig into the main points of the acute trauma care this affected person wanted — apart from understating her post-accident state of affairs, which was self-defined. The creator writes as whether it is strictly an insurance coverage subject or a approach for the pressing care/hospital system to realize sufferers.
There is not any indication of this occurring on condition that the affected person wanted, by protocol, Advanced Trauma and Life Support (ATLS). By EMS protocol and by malpractice case legislation, this affected person wanted a go to to a trauma middle emergency room. And the invoice is a completely completely different subject. In different phrases, the creator completely missed the medical points to overstate and sensationalize billing points.
— Dr. Anthony F. Graziano, Oconomowoc, Wisconsin
assume twice earlier than heading to an pressing care https://t.co/ixllGV7a1d by way of @khnews
— kendra lee (@kendraedits) October 3, 2022
— Kendra Lee, Woodbridge, Virginia
I listened to your story as retold on NPR a few younger lady who had a excessive invoice for an ER go to after a automobile accident. I felt that the story was editorially biased, because it talked about nothing in regards to the necessities for look after traumatically injured sufferers. It appeared to suggest visiting pressing care facilities as an alternative of emergency rooms. Although cheaper, such services usually shouldn’t look after sufferers with critical accidents. Most hospitals require board-certified emergency medication physicians and have intensive assets whereas an pressing care physician might not have accomplished a residency. The “physician expert” within the story clearly had no expertise within the care of traumatically injured sufferers. Having such perception would lend depth to what I noticed as a superficial have a look at a nuanced subject. Clearly the general public ought to be higher knowledgeable about cost-effective care, however an analysis after a critical automobile crash is inappropriate to be despatched to an pressing care.
— Dr. Christopher Goltz, Flint, Michigan
A Wealth of WISDOM
Nice article (“Genetic Tests Create Treatment Opportunities and Confusion for Breast Cancer Patients,” Sept. 21). With breast most cancers consciousness month upon us, I’d additionally level out the existence of the WISDOM research funded by the National Institutes of Health, which is completely different approaches to utilizing genetic testing to display girls for breast most cancers. Check it out at www.thewisdomstudy.org.
— Dr. Daniel Halevy, New York City
Let the client beware. The reality {that a} marker could be detected doesn’t imply that it’s going to enable you to optimize remedy. #snakeoil #breastcancer@acog @apha_mch @aafphttps://t.co/oyixlxBwRH
— Cee A. Davis,MD,MPH (@cdBRComHealth) September 22, 2022
— Dr. Cee A. Davis, Winchester, Virginia
On the Birth of Obstetrics Emergency Departments
I used to be dissatisfied by your article “Baby, That Bill Is High: Private Equity ‘Gambit’ Squeezes Excessive ER Charges From Routine Births” (Oct. 13). While I acknowledge that medical billing is usually complicated and at occasions even alarming to sufferers, I want to share just a few factors that I really feel had been downplayed or omitted:
- The article gives the look that the obstetrics emergency division, or OBED, is created just by rebranding an current course of inside hospitals. The creator neglects to say that earlier than the OBED, most hospitals didn’t have OB-GYN hospitalists stationed in-house 24/7 to deal with emergencies. Prior to the implementation of the OBED, many expectant moms, involved that one thing is perhaps flawed, weren’t capable of see a doctor after they visited a hospital emergency room. Instead, they had been transferred to the labor and supply division to be evaluated by a nurse taking directions over the telephone from a doctor. If the affected person and her child had been in critical misery, it turned a ready sport, with the danger escalating each minute she waited for medical consideration from her physician — or any physician. Hundreds of hundreds of life-threatening emergencies are managed annually by OB-GYN hospitalists who workers obstetrics emergency departments.
- Reporter Rae Ellen Bichell appears to have a beef with the follow of hospitals charging for an emergency analysis when unscheduled pregnant sufferers arrive on the hospital with medical complaints. Whether we prefer it or not, that’s merely the best way that well being care works in America. If you present up unexpectedly at a hospital for analysis of a well being concern, you can be handled as an emergency — and you’ll probably obtain a big invoice akin to the unscheduled care you obtained.
- The creator works exhausting to ascertain or suggest a causal relationship between the non-public fairness backing of medical staffing firms and the truth that hospitals are billing sufferers for emergency medical providers. However, hospital service suppliers and distributors have completely no management over a hospital’s billing practices. This bit about non-public fairness appears to serve no logical objective on this article besides to make the story seem as a “whodunit,” casting non-public fairness companies within the position of immoral shadow bosses turning a revenue on the expense of unwitting expectant moms, when actually they play no position in establishing the billing insurance policies that Ms. Bichell incorrectly and maybe unfairly characterizes as “moneymaking ‘emergency’ events.”
I’ve devoted my profession to the event and implementation of obstetrics emergency departments in a whole bunch of hospitals throughout the U.S., however I’m unaware of any hospital turning routine births into moneymaking emergency occasions as claimed within the title and deceptive argument of this text. I stand by my assertion — and my honest perception — that having educated docs accessible 24/7 on the labor-and-delivery ground has considerably enhanced the standard of care accessible to expectant moms at among the most difficult and medically consequential hours of their lives.
Thank you for contemplating my viewpoint.
— Dr. Christopher C. Swain, Charleston, South Carolina
Healthcare hyper-capitalism goes simply nicehttps://t.co/oZWmp5EFVL
— Adam W Gaffney (@awgaffney) October 13, 2022
— Adam W. Gaffney, Boston
Shooting Craps?
Online inventory brokerage homes have made all cellphones into “gambling devices” years in the past (“Addiction Experts Fear the Fallout if California Legalizes Sports Betting,” Oct. 5). What a load of crap that California gaming would out of the blue create new circumstances of dependancy. Stop the crap studies.
— Matt McLaughlin, Carpinteria, California
I’m already battling display dependancy with my 13 yr previous boy. final thing i would like is to fret about on-line sports activities betting as he will get older. No approach on #Prop27. Addiction specialists concern the fallout if California voters legalize sports activities betting https://t.co/v9ECIhNn6w
— Kristina Bas Hamilton (@kbashamilton) October 6, 2022
— Kristina Bas Hamilton, Sacramento, California
Measuring Fat: A Gut Check
Julie Appleby offered helpful data on how trendy medication misclassifies sufferers’ well being standing by means of the usage of the physique mass index (“BMI: The Mismeasure of Weight and the Mistreatment of Obesity,” Oct. 12). She included feedback advocating the usage of waist circumference (WC, by tape measure within the standing place) quite than physique weight to point extra particularly the place the metabolic issues could be discovered. She’s heading in the right direction, however her article may need gone additional to discover different, extra centered indicators of extra adiposity.
Anatomically, greater than 90% of human physique fats could be labeled into three important depots: gluteo-femoral (hips, buttocks, and thighs) subcutaneous adipose tissue, belly subcutaneous adipose tissue, and visceral (contained in the stomach) adipose tissue. Of these three, solely the visceral fats is clearly related to cardiac and metabolic issues. Increased gluteo-femoral subcutaneous fats has been proven repeatedly to be related to improved well being outcomes. Abdominal subcutaneous fats tends to have impartial, benign results for most people.
What we want is a straightforward adiposity indicator that may estimate the burden of visceral fats. Three a long time of analysis suggests {that a} easy measure of the supine sagittal belly diameter (SAD, generally referred to as the “abdominal height”) predicts poor well being higher than the standing WC. When individuals are within the supine place, their benign, belly subcutaneous fats falls to the perimeters of the midline. For this motive, variation within the SAD, quite than within the WC, is extra strongly related to the variation in visceral fats quantity. The SAD/top ratio (SADHtR) is arguably even higher than SAD alone. The SADHtR has been proven within the federal National Health and Nutrition Examination Survey (NHANES) to be considerably higher than BMI for figuring out main cardio-metabolic threat elements, i.e., insulin resistance or serum triglycerides.
There is a easy instrument that researchers or clinicians can use to measure the SAD: a low-cost, transportable, sliding-beam caliper. Various calipers can be found, all of that are cheaper than a high-quality scale. And the calipers are simpler to calibrate, too.
Choosing between the adiposity indicators SAD or WC may depend upon the tactic’s simplicity and replicability. Especially amongst individuals with giant bellies, the reliability of the standing WC is challenged by conflicts between minimizing rigidity on the measuring tape and the tape’s tendency to droop unpredictably beneath the horizontal aircraft. For the SAD, each the examinee and the examiner can chill out because the higher arm of the sliding-beam caliper descends simply to the purpose the place it touches the stomach. No additional judgment is required.
— Dr. Henry S. Kahn, Atlanta
Now can we cease speaking about #BMI and begin utilizing metabolic scores as measures of well being? And when you’re not somebody’s private doctor, your opinion is neither wished nor warranted.https://t.co/ep8eYbN4SK
— Morgan Harlan (@baiacou) October 13, 2022
— Morgan Harlan, Washington, D.C.
Revisiting the Homelessness Conundrum
To me, there is just one resolution to serving to our homeless get off the streets and into an surroundings that’s secure, that may present them with meals, medical consideration, and safety, in addition to present them a way to regain the lack of shallowness of so lots of the homeless (“Sobering Lessons in Untying the Knot of a Homeless Crisis,” June 21). Our army bases may present all of the above, in fact, with the permission of the Department of Defense and base commanders. I see so many efforts at attempting to make the most of inns, condominium buildings, and the like, which might be costing our cities, states, and federal authorities a lot cash that actually is only a waste of time. We want to indicate our homeless that our authorities and all of us actually care about them. We want to supply them the chance to settle in on a army base. They have the human assets and monetary assets to essentially do one thing, and in a brief time period. These homeless may even be provided up some duties to do on the bases. Please help this effort. Thank you in your efforts, too. I believe each coronary heart cries once we see this tragic state of affairs on our avenue, and leaves us feeling helpless and hopeless for them.
— Mike Stalsby, La Jolla, California
Fantastic article exploring the intersection of excessive residing prices, drug use, and coverage to clarify the homelessness disaster in Portland. https://t.co/RVg0BwSABsBut how does a lot funding yield such restricted outcomes? $36 million interprets to 1500 mini properties/RVs?
— Arielle Kane (@ariellesophia) June 21, 2022
— Arielle Kane, Washington, D.C.