Saturday, December 18, 2010

Robotic Surgery

There has been a flood of people requesting robotic surgery, especially men with prostate cancer, and I fear that they are not aware of all the pertinent facts. These men seem to think that robotic surgery is superior (i.e. more curative), and therefore have greater disappointment when the cancer returns. I have certain biases against robotic surgery, both medical and economic, and I would like to explain these to you, with reference to both general (open) and laparoscopic ("mini") surgery.

First some background, and an explanation of what robotic surgery really entails. The first surgery, of course, was "regular" surgery, which left a long scar because the surgeon needs adequate exposure to visualize the surgical field and its surroundings, and thereby minimize the chance of transecting the common bile duct during gall bladder surgery, etc. The need for adequate field of view was drilled into the heads of all surgical residents. The result for cholecystectomies was usually a long (8 to 12 inch) scar under and parallel to the lowest right rib, and a 10 day recovery period in the hospital. The surgery was almost always done after a severe gallbladder attack, with the idea of preventing a second severe attack and possible ascending cholangitis.

Laparoscopic surgery  typically involves only four small incisions in the abdomen, each no longer than an inch. Lights and a TV camera are  inserted, and the surgeon then directly manipulates his/her instruments to remove the gall bladder. They have gotten so skilled at this that last year a surgeon removed a gall bladder through the superior vaginal wall (!), leaving no abdominal scar whatsoever. In addition, because of minimal incisional tissue damage, the time in the hospital after a laparoscopic cholecystectomy was reduced from ten to three days, and now it may be as little as two. Therefore there  is less trauma and faster healing than under the old method, and it was thought that with fewer days in the hospital, the nationwide annual cost of cholecystectomies would decrease. Unfortunately, as shown by an article in NEJM 10-15 years ago, this was not the case. The surgery was so "easy" that  satisfied patients informed their friends, and  more and more patients with asymptomatic gall stones elected to have the laparoscopic cholecystectomy. The overall result was that the annual total cost of gall bladder surgery increased in the United States.

Now we come to robotic surgery. It is essential to remember that the FDA does NOT have to clear or approve of any new surgical technique, unless a medical device (artificial hip, heart valve) is implanted. If I wanted to drill a hole in your head to let the "evil humors" escape,, and you were agreeable, then it is a go.
If I wanted to remove your gall bladder through an endoscope, it is also a go. In robotic surgery, several  things are true that are not true for laparoscopic surgery:

(1)  There is an extra $3,000 added to the cost of the surgery,---$1500 for the instruments that have to be disposed, and $1500 to amortize the cost of the equipment. Whether or not Medicare or your HMNO will pay the extra expense is a separate question.

(2) There is no direct tactile feel by the surgeon on your organs. Even with laparoscopic surgery, the instruments are directly moved by his hands, and he can feel resistance, texture, etc. But in robotic surgery, he types in commands to a computer console, and the computer then moves the instruments. It is true that the computer has finer motions than human hands, but it has no "feel", and the patient also has to hope that the program was properly entered, not like the CT scans of the brain or the gamma-ray vs. electron beam treatment of tumors where the wrong button was pushed or the wrong program entered, and the patient's tissues were fried. So the robotic surgeon is deprived of tactile feedback.

(3) Most important of all: There is a sharp learning curve in robotic surgery, precisely because of the lack of tactile feedback. It has been estimated that it takes between 50 to 100 robotic operations on the prostate for the surgeon to become proficient enough so that the results and the time of robotic surgery equals that of non-robotic surgery. Skin-to-skin prostate surgery takes 2 to 2.5 hours, and the first time a surgeon uses the robot it can take 4.5 to 5.0 hours, and the depressive effect of anesthesia on your heart and lungs increases after 2.5 hours. Therefore, the first question you should ask any surgeon who wants to to robotic prostate or heart valve or any other critical surgery on you is : HOW MANY OF THESE ROBOTIC OPERATIONS HAVE YOU DONE? If the answer is fewer than 50, I, for one, would not let him/her touch me. It makes you wonder: Who "volunteered" to be the surgeon's first robotic surgery patient, and did the patient know that he/she was the first? Did the surgeon tell the patient?

Friday, December 10, 2010

Aspirin and Colon Cancer

There have been reports in the news lately about two different articles in medical journals: (1) whether daily aspirin use reduces the incidence of colon cancer, and (2) the expense and morbidity of robotic surgery as opposed to standard laparoscopic ("keyhole" or "mini") surgery. Since I am an internist and neither article will affect my practice or income, I feel  can comment on them without bias (outside my usual inquisitorial examination of the evidence presented in research papers, a habit than has only been intensified by my over 20 years of reviewing articles). This blog will discuss the possible aspirin-colon cancer reduction link, and the next will discuss robotic surgery.

Let us look at the aspirin-colon cancer article first. As some background, let me inform my non-medical readers that it appears that it takes 5 years from the time a polyp first develops in the colon until it becomes cancerous (and I am here excluding any familial cases). Since as the polyps enlarge they tend to put drops of blood into the stool, the first screening for colon cancer that was shown to reduce the death rate from colon cancer was the annual test for blood in the stool. When I started practice in the early 1980"s, it was known that  five year examinations of the distal 25 centimeters of the colon by a rigid proctoscope detected enough cancers to reduce the death rate from colon cancer, and this became a standard practice for me. One curious fact that was noted and unexplained was that even though only a minute part of the distal colon was examined, fatal cancers originating in the proximal colon were also reduced (although not by as much). The proctoscope, or rigid signoidoscopy was soon replaced by the flexible sigmoidoscope, which reached further into the distal colon. This examination, if given every 5 to 10 years, also reduced colon cancer deaths in the proximal as well as the distal colon, but, again the incidence of cancers in the distal colon were much more strongly affected, than that  of cancers in the proximal colon .

A few years ago, a 5 year retrospective study of 5,000 female American nurses was published. The study showed that the frequent use of NSAID's (usually Advil or Alleve) reduced the incidence of and death from colon cancer. (I might here mention that a parallel 5 year study of females placed on a low fat diet showed no reduction in the incidence of either colon or breast cancer, but people still seem to think, without any hard evidence, that animal fat is carcinogenic for humans.)  This study led to the Vioxx study, where Merck hoped that they could show that Vioxx, another NSAID, also reduced the incidence of colon cancer, so they could get FDA approval to market it as such. Unfortunately, the initial data showed an increase in cardiovascular events, so the study  was terminated, as was Vioxx. I leave it to the audience to search the published reports to see which NSAID is the safest and which is the most apt to produce cardiac events. The last time I reviewed the subject (and this may not be true now) prescription Celebrex was the safest anti-inflammatory , and OTC Alleve/Naprosyn had the highest incidence of cardiac events.

So now we come to the latest study, published in Lancet (Vol. 376, Nov. 20, 2010, pp1741-1750). The study found that a dose of 75 mg. of daily aspirin (a baby aspirin has 81 mg) reduced the incidence and mortality of colon cancer, and the benefit was highest for proximal cancers. A few caveats. This article was the result of pooling 5 different studies, and in none of the studies was colon cancer the endpoint. Furthermore, the pooling showed a much greater effect in men than in women.We also think we know that aspirin reduces the incidence of colon polyps by suppressing COX-2, and tumors in the distal colon seem to have greater interaction with COX-2 receptors than do proximal tumors. It also did not compare the use of daily aspirin with q. 5 year colonoscopes with regard to reduction in the incidence of colon cancer.

Now when my patients ask me about  how to apply the results of this study to their own medical lives, I will reply as follows: There is now some evidence that taking a daily 81 mg. (children's) aspirin will reduce your chance of getting colon cancer, but no one has compared the % reduction achieved with aspirin with that achieved by either an annual stool-for-blood test or q. 5-10 years colonoscopy, and daily aspirin use increases your risk of GI bleeding. We also have absolutely no idea if adding daily ASA to the suggested routine of colonoscopy plus stool-for-blood  will have a positive synergistic effect. On the other hand, it is evident that if aspirin does have a preventive effect, it is greater for proximal colon tumors than distal tumors, and proximal tumors are the ones least likely to be detected by either colonoscopy or stool-for-blood. I would also suggest that if they absolutely refuse to ever have a colonoscopy then a daily children's aspirin is probably a good idea.

Sunday, November 28, 2010

The Ethics of Dying

When I started practice 30 years ago,  it was assumed that the family doctor knew his patients well, that he/she had their best interests at heart, and that the patient communicated his/her final wishes about the desired  manner of death to us (no hospital, or no resuscitation, or shock but no intubation and placing on a respirator, or no feeding tube by naso-gastric or PEG, etc.), and we mutually understood what "no heroic measures" meant.

Now, however,  "dying will" laws have been passed, all of which assume a priori, that the doctor and the patient are total strangers to one another, and that the doctor does not have the patient's best interests at heart. The results have only placed family members under extreme emotional burden to make decisions that they were never trained to make, and will probably feel guilty about, either way. There is a reason that doctors should not take care of their families, because of lack of emotional distance, but it is assumed that the spouse and/or the children have enough emotional distance to "pull the plug" with no problems.  And often, after they have made their heart-rending decision about terminating life support, the hospital "ethics committee", with little more training than good will, will often ask them to justify their decisions. It seems to me that if you do not trust your doctor to make an ethical life-and-death decision about your existence in conjunction with you, then it is time to find another doctor.

I would like to tell you about several terminal cases with which I was involved, so that you can compare what happened in the past to what is happening today. I have an office in one state, but admit patients to a hospital in another state where I am a medical attending with teaching and admitting privileges. I am, of course, licensed in both states.

30 years ago, before hospice, I had a number of elderly patients who were irreversibly dying at home,and had no wish to ever enter a hospital again. (This was before the days of hospice). One gentleman had metastatic multiple myeloma as well as COPD, but he had all his faculties and wished to stay in the nursing home and finish his life there. This he did, and was made comfortable by increasing doses of IV morphine, to sedate his anxious breathing. Refusing intubation or hospital admission, he received increasingly higher doses of oxygen and morphine, until he then died peacefully, not agitated or gasping for breath. He had no immediate family.

Another patient had esophageal carcinoma, and a PEG feeding tube into his stomach through which he was given Ensure and other high-protein drinks. When I came, I poured 2 oz. of Johnny Walker Black into the tube, and he swore he could taste and feel it. He also died at home, without a 911 call.

The next patient had hepatocellular (liver) cancer, and recurrent ascites. He also insisted on remaining at home. I came by weekly to tap his abdomen, which interfered with his breathing if it got too filled with fluid (ascites), but since effusive ascites is protein rich, I had to be sure to replace the lost protein.

Another patient had inoperable wide-open mitral regurgitation, and she also was treated at home for a number of months.

Then the laws changed: The nursing homes were fined $5,000/day if they did not report to the state ombundsman any patient that they thought might die without hospital admission. And unless the patient had a Do-Not-Resuscitate form stapled to his forehead, the EMT's always did a "full-court press",  whether the patient wanted it or not. In fact I had had a patient with stage IV breast cancer with bilateral pleural effusions,
 and the family agreed not to call 911 if she passed out (her wishes). A neighbor called 911, and although I told the EMT's on the scene that I had a valid DNR order in my office, I was in one state, they were in another, and unless I could fax them the DNR immediately., they were going to intubate her immediately and transfer her to their hospital. They did so, and she lived to 10 days on a respirator in the ICU, which was not what she wanted.

I had a patient with terminal Parkinson's Disease and Alzheimer's Disease;. The family and I agreed to support him with fluids by clysis. The nursing home filed a report to the state ombundsman who demanded the operative replacement of a PEG tube in the stomach. I admitted the patient to my (only) admitting hospital in another state, where he died peacefully ten days later. The state ombundsman accused me and the patient's son of transferring the patient to another state to avoid his jurisdiction, and I was forced to have the Medical Society's lawyer point out that that was the only hospital (at that time) to which I had admitting privileges.

The worst case of recent memory involved a male patient. He stated quite clearly in his living will that he wanted "no heroic measures", and "not a life as a vegetable". His wife did not agree with his point of view, so he appointed his three children jointly as executors of his medical well. (Of course the son from California, i.e.the one who saw his father the least, had the greatest objections to pulling the plug.) It took the three children 10-14 agonizing (and I do mean agonizing ) days to make the decision to end life support, and then the operating surgeon insisted that this decision be referred to the hospital ethics committee, who finally agreed with the children, all of whom were emotionally wrung out and barely speaking with their mother when the ordeal was over.

So now we are glad to turn all these problems over to the hospitalists, who do not know the patients very well, but they do know the rules of the state, of the federal  government, the ethics committee, and the hospital.

Let me close with a story that does not cast glory on the hospital political system. When open heart surgery was first performed, the heart-lung machine needed 20 units of blood from different donors to have enough volume to work efficiently. At that time, we had not discovered Hepatitis C (which can be fatal through progressive cirrhosis or the induction of hepatocellular cancer). We could test for hepatitis with Anti-A and anti-B antibodies, so when patients got hepatitis after heart surgery, we would call it "non-A, non-B hepatitis", to mask our lack of knowledge.  Lancet published an article demonstrating that if their open-heart patients received massive doses of pooled gamma globulin just before and just after cardiac surgery, it sharply lessened their  chances of  getting non-A, non-B hepatitis.  (Clearly the pooled gamma globulins must have had antibodies against the new hepatitis.) Since I took rigid care of my patients even on the open-heart surgery floor (I admitted them, in order  to maintain some sense of control and feedback)  I decided to give them 2cc's of pooled gamma globulin directly before surgery, and on return to the recovery room. NONE of my patients developed Non-A non-B hepatitis.
But then the head of Infectious Disease called me into his office, saying that no other doctor did this. I explained my rationale, and showed that my patients did better. He said that was beside the point,that it would "not look good" if I was the only doctor doing this, no matter how well my patients did, and that I should stop doing it.  I responded that I saved lives. His only response was to place IV gamma globulin under ID control, so I could not order it for my patients without ID approval which, of course, was never granted for open-heart surgery patients.

If the government would just leave doctors and patients alone, we could take much better care of them.

Thursday, November 18, 2010

Deaths after Chiropractic

I seem to be sending out warnings lately. This latest came to me from Medscape, which quoted an article from the International Journal of Clinical Studies. I had heard of similar studies earlier. Apparently there is a risk that chiropractic manipulation of the neck can lead to acute dissection of the vertebral artery, stroke, and death. The majority of these events occur in patients younger than 40 years.

The link to the abstract of the article (see Medscape for fuller details) can be seen at PubMed:

The danger seems to be in acute rotation of the neck, since this is done without an MRA study of the vertebral arteries.

Wednesday, November 17, 2010

OTC Phenypropylamine---increased stroke risk

A friend of mine forwarded me a brief letter which I feel deserves the widest possible circulation.

There were originally two over-the-counter (vascular) decongestants that were sold for relief of the symptoms of the common cold: phenylpropylamine, and pseudoephedrine. Of the two, phenylpropylamine was observed to cause a more severe vascular constriction in the cerebral circulation, and a statistically significant increase in the incidence of strokes in patients NOT OTHERWISE AT CVA RISK was noted. This was of especial significance in women and children, and so gradually fewer and fewer OTC "cold pills" contained phenylpropylamine. For instance, the popular decongestant Sudafed contained only pseudoephedrine.

Several years ago, the government noted that bathtub chemists were "cooking" psudoephedrine (with acetone, I think) to make methamphetamine, aka "speed" or "crank". The government therefore strongly discouraged the use of OTC pseudoephedrine, and now in some states it is kept behind the drug store's counter, or you have to sign for it, or the amount you can buy is limited.

However, post-marketing studies, as reported in the FDA's surveillance bulletin, have again noticed an increase in strokes associated with the use of phenylpropylamine. Therefore I have send a letter to all of my patients: DISCARD ALL COLD TABLETS CONTAINING PHENYLPROPYLAMINE, and never buy such tablets, either OTC or by prescription. This warning also applies to nasal sprays.

I would hope all my readers follow this advice (and please check with your doctors to notify them of your action and your reason for it).

The FDA link is:

Sunday, November 14, 2010

Dabigatran: a replacement for Coumadin and Lovenox?

The results of the RE-LY study were just published in the New England Journal of Medicine. Since this blog is for both doctors and patients, I will try to split the difference in medical info. The article discussed a brand new anti-coagulant, dabigatran, which will be marketed here in the U.S. under the trade name Pradaxa, and is a pill to be taken twice a day.

The drug blocks the action of thrombin, which takes part in the final step of the clotting cascade. Thrombin converts fibrinogen to insoluble fibrin, which then makes a blood clot solid and tenacious.

The greatest risk factor for forming a clot is relative stasis of the blood flow next to the wall of a blood vessel. This clotting possibility is enhanced by some (unknown ) chemicals secreted by some cancers, especially prostate, as well as prolonged immobility, such as flying across the Atlantic Ocean.

The initial oral anti-coagulant was Coumadin (actually Warfarin, which was developed as a rat-killer by the University of Wisconsin from a chemical component of hay) which prevents blood from clotting, and so the rat bleeds to death internally. When Coumadin is given to humans, weekly blood tests are needed: a PT, as well as a monthly Hct. There is a narrow therapeutic window for Coumadin: too much and the patient can develop a GI or an intracranial bleed, and too little and the patient's blood will clot where it is not supposed to. If the patient finds the bleeding risk psychologically intolerable, oral alternatives are aspirin, and aspirin + dipyrimadole (Aggrenox). Under many circumstances, injectable low molecular weight heparin (e.g. Lovenox) can be used; this requires no blood tests for monitoring, but the patient has to inject him/herself daily.

This particular study compared oral dabigatran to oral Coumadin in patients with non-valvular atrial fibrillation. In this condition, the left atrium quivers like the surface of a bowl of jelly rather than contracting rhythmically. The blood flow against the left atrium wall is relatively static, and clots can form in the left atrium which then break loose and can go up to the brain, causing a stroke. Coumadin has been shown to sharply reduce the risk of this event, and aspirin will also reduce the stroke risk, but less so. The study showed that the risk of stroke as well as the risk of bleeding was lower with dabigatran than with Coumadin, and the FDA has approved the use of this drug for patients with non-valvular atrial fibrillation.

I doubt that this study will ever be repeated, so let us assume (and hope) that the conclusion reached is a correct one. The question then becomes: will dabigatran be used for other medical problems where Coumadin or aspirin is indicated, without going through a formal study? This is called an off-label use, but is neither illegal nor immoral. For instance, once it was found serendipidously that calcium channel blockers (used for hypertension and angina control) also reduced the frequency of migraine headaches, it was frequently prescribed for this purpose.

So now we have an anticoagulant that causes less bleeding than Coumadin in therapeutic doses (I am unaware of any bleeding studies vis-a-vis aspirin), need no weekly blood tests, and can be taken orally. I can think offhand of many medical problems where this drug might be useful.
In no particular order they are:

1) Cross-Atlantic flying----no studies of aspirin have shown reduction in the incidence of deep vein leg thrombosis.

2) Heart valve replacement---instead of Coumadin.

3) Post-op, especially in orthopedic procedures such as total hip or knee replacement

4) Any deep vein thrombosis

5) Any pulmonary embolus

6) Pulmonary hypertension, baggy heart with EF less than 20%, migraine headaches

7) Post-MI to reduce the risk of a second MI, instead of aspirin

8) (Unknown as yet) Patients with the need for anti-coagulation who have relative contra-indications such as erosive esophagitis, gastric ulcers, or duodenal ulcers

9) ? Patients with the lupus anticoagulant

10) Patients with factor V or Leiden problems

11) Patients with polycythemia or polythrombocytosis

12) Patients with TIA or embolic stroke

13)? Patients with any cancer who develop a deep vein thrombosis

etc., etc., etc.

Please feel free to post any other suggestions.

Monday, November 8, 2010

Medical Beliefs and Medical Treatment

There have been many articles recently both in the medical and lay press urging patients to take better care of themselves: lose weight, exercise, eat "healthy" foods, stop smoking, don't drink to excess, etc. The problem with compliance with this or any other medical advice (take your prescribed medicine daily, please get a colonoscopy) is that if the advice does not fit in with the patient's mental model of disease, it won't be followed. I always allow 45 to 60 minutes for the first visit, so I can explore with the patient his/her model of disease.

The problem with patients' following any medical advice is that the human brain is designed to react to immediate problems, and not those predicted to happen 20 years down the road. We also have magical beliefs about our health, and sometimes are too eager to follow the latest health fad without examining the scientific data behind the recommendations. We all have heard of the remark made by a Greek mathematical tutor to Alexander the Great : "There is no royal (i.e. shortcut) road to education", but we do not realize that this applies to taking care of ourselves medically, as well.

Without sounding prejudicial, because I have seen many unpredicted beneficial reactions to many treatments (last month an elderly male patient of mine had his shoulder repaired, and afterwards his problems with his prostate disappeared), I must remind my readers that "alternative" medicine is another way of saying "unproven" medicine, although some alternative treatments do work on some patients.

Vegetarianism is an interesting belief. All animal cells need vitamin B-12 to create the nuclei of new cells, and no vegetable cells do. In fact, if you are a strict vegetarian (meaning no milk, fish or eggs, etc.) then you will die from pernicious anemia in 3 to 5 years from lack of vitamin B-12, and may sustain irreversible damage to your brain cells or peripheral nerves before you die. In addition, there are eight "essential" amino acids, in that unless your food contains all eight, you cannot make new protein. All animal meals contain these eight, of course, but no vegetable does. This is why traditional vegetarian meals must contain two different kinds of vegetables: rice and beans, corn and green peas (aka "succotash), etc. Furthermore, autopsy of the oldest human skeletons, when we were just meat-eaters, shows no evidence of tooth decay. Once we started to farm, and eat more carbohydrates, then dental caries appeared in autopsies.

Some examples of past and present beliefs (again I am only saying that there is no rational evidence in favor of a defined belief, not that it is necessarily incorrect):

Frontal lobotomies to cure schizophrenia, induced insulin shock to cure schizophrenia or epilepsy, bleeding to treat various diseases , purgatives to remove "poisons", high colonic enemas to cleanse oneself out, magnets in your shoes or on your belt to cure an aching back, copper bracelets to cure arthritis, staples in the earlobe to reduce appetite, eye exercises to improve myopia, chewing your food 20-100 times before swallowing it, an hour of sleep before midnight is worth two after midnight, a certain number of bowel movements a day or per week is necessary for good health, if you swallow fruit seeds you will grow bushes in your stomach, brown eggs are healthier than white eggs, raw (un-pasteurized) milk is healthier and safer, intravenous chelation therapy to remove harmful metals, removal of mercury fillings to de-toxify your body, fluoridated water is dangerous to your health,-----.
The way to test any of these beliefs on yourself is to alternately follow the advice and then completely ignore it either for one week or one month at a time. In that way you can determine what makes you feel better.

Other beliefs are more subtle. Yes, we all know we should lose weight, but few people believe that losing weight is beneficial enough to one's health to go through the discomfort of actually doing it. We all generally feel better after exercise ("runner's high") due to the generation of endorphins, but rarely do we make exercise part of our regular ritual. Furthermore, if we abstain for two weeks, there tends to be tremendous inertia against restarting exercise. We all believe that cigarettes are harmful, but no one believes that the one they are smoking at this instant will be fatal. We know that exceeding the speed limit is dangerous, but we do it so often that it becomes meaningless to us.

Many men believe that you are sick only if a doctor tells you that you are sick, so if you never see a doctor, then you are never sick. (This is one reason so many men become depressed after a heart attack---their system of denial has visibly failed.) Everyone believes that the less medicine you take, the less sick you are, so most patients try periodically to taper their medicines, often without checking with the doctor. Many patients absolutely refuse to have a colonoscopy, and some even refuse to do the stool- for- blood test. Some men are anxious to have a cardiac stress test, and some absolutely refuse. Meanwhile, many wives come with their husbands into the consultation room to make sure their husbands tell me the truth, and some even come into the exam room. Often a husband comes in asking for a stress test because his wife asked him to. When you dine in a restaurant if you will often hear wives telling their husbands what to eat, how much to eat, and what not to eat---again the man and his wife have different beliefs about food.

What I am trying to say in all the above is that it is generally fruitless to try to argue a patient out of his/her medical belief system, because it is rarely rational. I can sometimes get a patient to try it my way for one month, and then make an informed decision as to whether or not they feel better, but a spouse's medical advice is generally doomed to failure. Sometimes, a patient knows what the "right" medical thing is to do, but for various subconscious reasons just refuses to do it. They even will admit that they "should" do this or that, but they won't. Just recall how difficult it was to get your two-year-old child to eat spinach, and then extrapolate to the refusal an adult can mount.

Finally, please remember Freud's dictum that the ego cannot conceive of its own non-existence, i.e. of its own death.

Wednesday, October 27, 2010

Medication, Prescribing, and Timing

There is an important variable that arises in pharmacology that is rarely addressed: after the choice of an antibiotic, how often a day should it be given, what time of day should it be given, and how do doctors compensate for the fact most patients stop antibiotics before the prescribed time period is up?

Sometimes we just don't know, sometimes we forget that patients stop almost all Rx's too early, and sometimes published clinical results are not followed because they are not in the PDR. One concrete example is malaria prophylaxis. Many of the drugs have to be continued for one to four weeks after the patient leaves the malarious area, and many patients forget about the fourth week. My practice is to have the pharmacist label the bottle: "Take.........until the bottle is empty", and then I emphasize to the patient the importance of following this advice.

If you prescribe antibiotics to be taken three times a day, you are fooling yourself, because most patients forget the midday dose, and only in the hospital can you depend on this schedule being followed (by the floor nurse, not the patient). Just ask your residents the next time you see them how well they complied the last time they were prescribed antibiotics. That is one reason I rather prescribe Augmentin, which can be overkill, rather than Amoxicillin, because the former is 2x/day, the the latter 3x/day. For the same reason I prefer Ceftin at b.i.d. to Keflex, especially when treating abscesses, where constant penetration at a bactericidal level is critical and, occasionally, once a day Levaquin to twice a day Cipro, even though the latter is available as a generic.

A classic study was done at NY Presbyterian's pediatric clinic about 40 years ago. Mothers were prescribed the classic bottle of liquid (yellow) penicillin suspension, with the instructions to give their child 1 tsp. four times a day, and warned about the strep throat/rheumatic fever connection. When the mothers returned with their bottles in 10 days, only 10% of them had empty bottles. Assuming that none emptied the bottles that AM out of embarrassment, this means that at least 90% of the most vitally interested persons did not follow the instructions. Add to this the belief of most patients that the less medicine they take the less sick they are helps us to understand why intelligent drug companies prescribe an antibiotic for longer than is necessary (e.g. 3 days of Zithromax is generally equipotent to 5 days, because of its persistence in the necessary tissues and cells) in order to be sure of observing a positive effect.

We all are aware that as the blood sugar climbs above 200, blood becomes more of a non-Newtonian fluid with an atypical cross-sectional velocity profile, and an enlarged viscosity-dependent boundary layer, so that Schlichting's classical theory does not apply. Two well-known results from this are (a) reduced diapedesis of white blood cells, thereby lessening resistance to containing infection, and (b) a non-linear increase in the pressure required to drive blood through the circulatory system, thereby increasing the amount of heart failure. But does the level of blood sugar affect the bactericidal effect of antibiotics? This question is not answered for most antibiotics, which is unfortunate, because diabetics have difficulty controlling the fasting and the post-prandial glucose level equally well, and that should therefore determine the optimum time of the day to deliver a once daily or twice daily antibiotic.

As far as I am aware, although some anti-cancer drugs are tested AM vs. PM to look for a diurnal variation effect, no antibiotic has been. We do know that for some antibiotics the peak level is important, for others the trough, and for still others the area under the dose-time curve, but it is difficult to translate these results into concepts the patient can understand. And the question of with food or on an empty stomach is often answered theoretically rather than clinically. For instance, does it really matter if Synthroid is taken before or after breakfast so long as the patient is consistent by taking the medicine at the same time each day, to reduce the variation of the blood free T4 level? Should a daily antibiotic be given in the AM, when the serum cortisol is at a peak, or in the PM, when the serum iron is at its peak? One could make a case for AM dosing, because one way the body apparently fights infection is to lower the serum iron, but I am unaware of any studies on this possible effect.

Another important point is to make sure certain drugs are dispensed only in tablet rather than capsule form. This is especially important when prescribing Doxycycline, since if a capsule with a pH of 12 gets stuck in the esophagus and dissolves there, the resulting chemical burn can take two to three weeks to heal. I also routinely give skiers the sunburn warning, because if snow blindness is of concern, then so is sunburn, especially on the lips.

The problem of generics also should be addressed (and I realize that I am drifting from my main topic). The generic and the brand name drug are usually compounded differently, with different binders and dyes to make up the tablet. I have seen several cases where the allergic reaction of the patient was due to the binders or the drug-carrying vehicle, and not to the parent antibiotic or drug, e.g. in a reaction to an IM steroid given to treat an acute allergic reaction.

We still do not know the optimum length of time to treat acute sinusitis or acute otitis media or acute cystitis or acute prostatitis. ENT physicians seem to add a Medrol Dospak to any infection they treat above the neck, and we internists do not, but I am not aware of any definitive comparative studies on this subject, nor does it appear in the Cochrane Report. We don't know if we should treat sub-acute Lyme disease for 14 or 21 days, but if you are concerned over malpractice, then 21 days always wins out.

And despite our encouragement NOT to treat viral infections, and the awareness of the public of the problem of drug resistance, I can tell you that if my wife gets a URI and she is not treated, the number of friends who tell her to see another doctor (not myself in either case) so she can get "put on an antibiotic and be properly treated" is astronomical.

Let me close with a related anecdotal story. When I was an intern in NYC, I admitted a male alcoholic with pneumonia one freezing December PM. We put him straightaway into the ICU because of trilobar pneumonia (in those days the admitting intern also covered his patients in the ICU with the help of the ICU resident, not the ward resident). The patient died within 12 hours of admission, and I filled out the death certificate: "Cause of Death...Acute Pneumonia". The supervising ward manager called me down to his office, telling me that in NYC if the death certificate did not specify either viral or bacterial pneumonia, then it became a ME case due to health law, and the body could not be released to the family for burial until an autopsy was performed to determine if a virus or a bacterium was responsible for the death. He asked me to insert an adjective for the family's sake, and I did. So much for the accuracy of death certificates---patients and their families can and should take priority over accurate facts under certain conditions.

Friday, October 22, 2010

Medical Malpractice

The topic of medical malpractice and its cost in both premiums and extra medical tests has recently been discussed in various places, including the Op-Ed pages of the NY Times, but usually by non-doctors. As a practicing family MD (internist) who has been sued 5 times, (once as ward attending, once as hospital medical consultant, and three times for office visits) and who has had all three cases dismissed with prejudice (i.e. no trial, and no payment), let me describe to you non-doctors and non-sued doctors what is wrong with the system.

First, being sued does not make a doctor a better doctor. We improve through experience and studying, and not making the same mistake twice. But the ever-present threat of malpractice makes us more careful, in that most doctors ask themselves before any medical action: how will this look to 12 jurymen who are not doctors? And if a scenario similar to that which we were sued for ever re-occurs, even if we were dismissed, we make sure the same procedure is never followed, because who wants to be sued? An example is the fact that although the Virgin Islands has a Good Samaritan law for emergency treatment by physicians, a physician was sued for doing dockside CPR on a patient who eventually died. His case of course was dismissed because of the law, but the existence of the law did NOT protect him from being sued. He told the newspapers he will never offer emergency medical assistance to a stranger again, because he doesn't want to be sued.

As an example, I had a female patient with Hodgkin's disease, who was cured. For years, her gynecologist and I both urged her to get a colonoscopy, because people with one cancer are at higher risk for a second. There were seven years documented in both our charts of her refusal to get a colonoscopy, and she even refused to check annual stools for blood. When she died from metastatic colon cancer, her husband sued both me and the gynecologist for failure to diagnose the cancer. Again, this took a lot of time away from us. Both our cases were dismissed with prejudice. But the result is that I "fire" (i.e. discharge from my practice) any patient who refuses to do an annual stool for blood or a colonoscopy every 5 years, because again, who wants to be sued even if you win the case?

So now in addition to asking myself "what can the patient have that can damage or kill him/her if I do not diagnose it?" I also ask myself "What test can I be sued for not doing?". You see, a doctor is never sued for doing a test, but only for not doing it. So if a patient or spouse or relative asks for any test, I always say yes, which I never used to do, but that is what the system wants me to do. And it does no good to follow the "disease guidelines", because if you have a patient with 5 diseases (high blood pressure, GI reflux, heart failure, osteoporosis, and asthma) then some of the guidelines will conflict with others. In addition, the guidelines are not uniform: the USPHS, AMA, American Urological Association, American Cancer Association, and American College of Physicians, have widely differing guidelines on using the PSA test for prostate cancer, and even if it should be used at all.

I think it would reduce costs tremendously if the malpractice cases were taken out of the tort-contingency fee system, and put instead into the no-fault system, as is auto insurance in the State of New Jersey, where doctor's and lawyer's fees are set by the workmen's compensation fee schedule.

We also cannot practice medicine and keep notes as the lawyers would have us do, in part because we cannot bill for telephone time and making notes. We could certainly sharply reduce malpractice suits by telling every patient to either come into the office or go to the ER, and never renew any medicine or give any advice over the phone, because we can be sued for telephone advice. I also once flabbergasted a lawyer at a deposition; when he said "If you haven't written it down, you haven't done it", I answered "And what makes you think that if I did write it down I did do it?". For instance we all warn patients on sleeping pills to be careful when driving, but none of us forbid it. I know one doctor who photocopies the PDR warnings of every drug he prescribes, and gives one copy to the patient and puts the other in the chart.

Some results of the threat of malpractice: in at least two counties near Miami Fla., no neurosurgeon will cover the ER for automobile accidents; virtually no OB's teach or do forceps delivery, e.g. for a transverse lie, but proceed immediately to a C-section, and in 2 counties in Northern West Virginia there are no pediatricians, because they all moved northward across the river to a state with lower malpractice premiums. I was taught to tap the chest ("thoracentesis). In about 1% of the cases, in the best hands, there is a partial collapse of the lung (pneumothorax). So now all internists have pulmonologists or chest surgeons do it, because they do it more frequently, and therefore can defend against the incidence of pneumothorax more easily (and of course the chest surgeon charges more).

So now the doctor's mantra is not to avoid error, but to avoid being sued. This is not synonomous with practicing the best medicine. I even know some doctors who refuse to treat any lawyers or their families at all, just as many landlords in NYC refuse to rent to lawyers.

Again, every doctor wants to take the best possible care of his patient, but if 1/2500 infants is born with a birth defect, and 5% of aortic aneurysm repair patients die, and if 1% of hip replacements get infected, the doctor seems to get sued for every bad result. Although in theory the plaintiff has to show the doctor did something wrong, in practice the doctor has to show that he did everything right, and if he/she did, why was there a bad result? In American jurisprudience, if anyone has a bad result in anything, it is someone's fault (unless, of course you lose a lawsuit, and then it is never the lawyer's fault).

One final note: In NY State, they started keeping a record of the death rate for open heart surgeons (and later, their hospitals). The immediate result, as you might expect, is that cardiac surgeons took on fewer riskier cases where the patient has an estimated less than 10% chance of survival, no matter how the family pleads, because he doesn't want his death rate to go up. Several years ago there was a piteous Op-Ed piece about this in the NY Times, by a columnist who said it took him 10 days to find a cardiac surgeon willing to risk operating on his mother, and the surgery was not done at a major hospital teaching center.

I guess I should close with a repeat of a previous story. About 10 years ago, a California woman refused a pap smear for several years in a row, and her refusal was well-documented in the chart. When she died from cervical cancer, the husband sued the gynecologist. He convinced the jury that if the doctor had warned the patient properly, then any prudent patient would have agreed to the pap smear and found the cervical cancer. The jury agreed (!), and found against the GYN who now, of course, fires from his practice any woman who refuses an annual pap test or mammogram.

Sunday, October 17, 2010

Rx. Drugs, Pharmacology, and Side Effects Part I

I think it is important for the public to understand how and why drugs are used, the studies that are used to test for efficacy and side effects, and the importance of using drugs properly.

For starters, it is not true that the less of a drug you take, the less sick you are. Rather, since using any drug exposes you to its side-effects, which often are NOT dose-dependent, you should always take enough of the drug to get the maximum benefit, rather than see how little of the drug you can get away with. You certainly should not be like some of my patients who skip asthma inhalers to see if they really "need" it. In fact, if I suspect exercised-induced asthma in a patient, rather than going through pulmonary function tests with methacholine challenge, I would prefer to convince the patient that the inhaler is needed. So I ask the patient to use an anti-inflammatory inhaler one-half hour before heavy exercise every other time for the next 20 exercise sessions, and then ask the patient if he/she noticed an increase in stamina or time to fatigue/dyspnea. In this way the patient sees the need for the inhaler.

Treating high blood pressure is more of a challenge, because a patient (usually) cannot feel high blood pressure. However, after I tell them that the one event treating hypertension has been shown to prevent is a stroke, they all become faithful converts. Most patients seem to fear loss of function more than death or cancer.

Now how does the FDA require that drugs be tested? In the old days, human prisoners were used as guinea pigs, with time off their sentence used as an inducement to participate. Then it was decided that this was immoral, so now we first test on animals, such as white lab rats and guinea pigs, and we first look to see (a) if any organs are damaged (usually the liver), or (b) if tumors/cancers are induced. The problem, of course, is that all animals have different physiology and biochemistry than do humans. For instance only the guinea pig, along with humans, needs exogenous Vitamin C. All other mammals have the enzyme necessary to make Vitamin C. So already the internal milieu will be different. Then we try to figure out, experimentally, the LD50, i.e. the dose (mg/kg) that will kill half the experimental animals. Then we will try massive doses of the drug to make sure that the drug is not carcinogenic to animals. Of course, an increased dose for a short period of time is not physiologically equivalent to a lower dose over a longer period of time, but that is what we do. One problem with massive doses is the pure effect of a large dose: 8 glasses of water a day is fine for humans, but 80 glasses of water a day will quickly lead to death from dilutional hyponatremia and secondary brain swelling.

Now we have to see if the drug works, so we test the drug against a placebo, and look for a positive effect. Of course, if we already have a treatment for the disease or condition in question, which we usually do, then we test the drug against a drug that we know "works". The drug company runs the test to see if their new drug is "not inferior" to the standard drug for the condition. Later on, when they want to corner the market, they will run a different comparison drug to show that their drug is superior to their competitor. Still later, once the FDA approves the drug for conditions specified in the PDR (e.g. beta-blockers for hypertension), the manufacturer will look for a unique "off-label" benefit, i.e. a use not specified in the PDR. This is neither illegal nor immoral. So now physicians will also use beta-blockers to prevent or reduce the incidence of migraine headaches, and also give beta-blockers (under most conditions) to survivors of heart attacks to lessen the chance of a second heart attack.

The FDA requires the drug company to list all observed side-effects in the PDR. The side effects can either have been observed, or included because of the class of drugs. Remember, if the drug company warns you about a possible side effect in the PDR, it is difficult for you to sue them if you get the side effect. Sometimes this is overdone, as in the case of steroid creams which have the same steroid warnings as to high-dose oral medicine. Later published studies may show that the theoretically predicted side effect does not occur, but unless the drug company wants to spend the money to submit new studies to the FDA, this result never appears in the PDR.

BTW, over-the-counter drugs have a much less stringent warning requirement, which is usually to call your doctor after several days or doses. Nowhere on any aspirin bottle, for instance, are you warned that if you have nasal polyps and asthma, a single dose of aspirin can kill you by causing severe allergic bronchospasm. Maybe that's why when Bayer first patented aspirin it was available by prescription only.

Now, what happens after the drug is released by the FDA to be available to the public through a doctor's Rx? All doctors are requested to report any unusual occurrences (lab tests, physical side effects, acute medical attacks) that occur to patients on the drug. The problem is that the drug initially was tested on naive patients, i.e. on patients on no other drug. But the typical patient in his/her sixties is usually on five to seven drugs (diabetes, hypertension, high cholesterol, GI reflux, etc.) so the new drug is added to the chemical mix, and now we have the patient undergoing a new drug test (i.e. 6 drugs plus the newbie) that has never been studied before, and there are certainly no published results dealing with this particular combination. So if the doctor reports an effect, it is initially impossible to know if the effect is due to the drug (if indeed i t is) or to the combination of the new drug with one of the other six. And no one, to my knowledge, when they file an incident report with the FDA include any information on any artificial sweeteners the patient may be ingesting, which is, of course, a 7th drug.

More to come in a later blog, but one caveat of which you may not be aware. NO governmental body tests, clears or approves any new surgical technique. So if a doctor can convince you to be the first patient in the world to undergo robotic prostate or heart surgery, so be it. And no one really tests new drugs on children or pregnant women, for obvious reasons. I personally feel that any parent who volunteers his/her child for any new drug test is guilty of child abuse!

Saturday, October 16, 2010

Stress, Part II

All of us, by being civilized by our parents, our schools and society, become stressed and, usually neurotic. Freud in his "Civilization and Its Discontents" showed that in his opinion, the best we can be after being civilized is a well-adapted neurotic. Huck Finn put it more succinctly when he talked about how he would no longer be the same person after being civilized by soap and water and schooling. Karen Horney discussed the problem at greater length in "The Neurotic Personality in our Time".

I am not going to discuss Rousseau's "noble savage" or the French view of the importance of the school system in instructing its citizens how to think, or even McKinley's bloody, misguided attempt to "Christianize" the Philippines after the Spanish-American War. I guess for McKinley the Philippines' being instructed in Catholic catechism and being converted from paganism didn't count, since he was a Protestant. And that's where we learned the virtues of waterboarding in getting prisoners to talk , only to turn around and try judicially and execute those Japanese POW commandants who waterboarded American POW's.I'll only mention in passing Jacqueline Kennedy's deathbed comment that she wished she had "drunk more champagne", and observe that few if any humans on their death beds
said that they wish they worked harder and did more things that they found emotionally distressing, rather than having more fun and more orgasms. (As an aside, I once had a girlfriend who felt that a night without an orgasm was a wasted night, but that is a different story, and from a different country.)(And no, the "wench" as Marlowe called her, is not dead.) At least we were never as brutally civilized towards a greater good for the greater end as were the Kulaks in Stalinist Russia, the Chinese peasants and intellectuals in the "Great Leap Forward", or anyone who wore glasses and might be an intellectual in the horrifying regime of Pol Pot in Cambodia. The Civil Wars in Africa defy anyone's explanation, except for the trite observation that there, God appears to be dead.

Let us note in passing that the rules in elementary school seem to be created by women for girls,, with its emphasis on neatness, minimal direct confrontation, the importance of group behavior, and the superiority of means over ends (might does NOT make right, unless the teacher in bawling you out). On the other hand,in the business world and the army rules are made by men for men, where the ends justify the means, the only people you may not lie to are close friends, and fellow workers (military, medicine), your word (but not your valuation on the stocks you are selling) is your bond, and cheating is forbidden only at the poker table (but not on the golf course, where many unofficial Mulligans are taken). The same is true of all colleges, where internet-driven plagiarism seems to be the norm, but the lines of battle are not as clearly marked out.

In thirty years, I have found that the more you do that is emotionally conflicting, the angrier you get. Since women are not allowed to show anger directly, this gets converted into depression,, or into anxiety or panic attacks when their subconscious is afraid that the anger will erupt in a socially unacceptable way. Men just grab the nearest M-16 or AK-47 and shoot up their workplace, so that if the flags fly at half-mast at the post office, it means they are hiring again.

But above all, this suppressed anger and depression transforms itself into bodily complaints. The pain threshold in every body organ gets lowered. It becomes an effort to get out of bed, you gain weight, stop exercising, drag yourself to work and back to home. Men nick themselves while shaving, women lose their appetite and sex drive, as do men, and both report (to me , when I ask) even a decrease of romantic/sexual dreams and masturbation. I will admit, however, that female masturbation has increased with good orgasmic results ever since the invention and sales of the Sybian.

Women are trained by society to never think of themselves first, and to feel guilty if they do. The majority cannot turn off their cellphones for one hour, in case an "emergency comes", and they must imagine that 911-EMT is not up to the job. If a daughter gets divorced, the father feels bad for the daughter and the mother feels guilty ("what did I do wrong?). It isn't a coincidence that ever since the Greek habit of capturing barbarians to be slaves died out that Hinduism, Orthodox Judaism, Rigid (Calvinist) Protestantism, and all Orthodox Moslem priests believe that a woman should be subservient to man, a fact that carried over into Napoleonic Law, when married women were not allowed to own property on their own.

If you continue to do what you don't want to do emotionally, you will eventually crash as the brain runs out of the psychic energy it needs to control and repress those "socially unacceptable" thoughts of your anger that you have been reduced to emotional slavery, never doing what you really want to do, and always feeling that YOUR feelings, wants, needs and desires don't count and we become abjectly depressed, which we continues until we feel free again.. And then people around you will ask why you changed, because they didn't. And the more "noes" you give, the happier you will be, and the more energy you will have.

I leave you with three thoughts: (1) "No" is a complete sentence not only where sex is concerned, but in all phases and activities of life, whether you are going away for a college reunion or baby-sitting, and needs no explanation. (2) You are always right, so if the play bores you, leave at intermission and read a book; the play rarely gets better.
(3) If you have an increase in psychic pain, or develop a new muscle spasm or headache or eye twitch or GI distress or--- you truly are under pressure, and need to "get out of Dodge" as rapidly as possible. You can always say you have to go to church or synagogue right now---people may think that is odd, but no one will criticize you. Then you can sit in a pew in quiet, recompose your thoughts, and meditate on how important you really are.

'More to come when I see the comments on this blog topic.

Friday, October 15, 2010

Does Calcium Intake Increase Cardiac Risk?

There was a recent article published in the British Medical Journal whose results suggested that calcium supplements increased heart attack risk. This was a meta-analysis combining 12 different studies with different groups of people, etc. The results of a meta-analysis are ALWAYS suspect, since they are a mathematical construct which may or may not represent the true state of affairs. The concept of combining several studies, none of which reached statistical significance, and re-analyzing them as a group, hoping the "law of large numbers", by combining them, would produce a scientific result was first advanced by Peto in several articles in the Lancet over 10 years ago, and I refer my more mathematically inclined readers to his papers. I was never convinced of the validity of his analysis and conclusions, and feel strongly that the results, if any, of a meta-analysis should be treated as a hypothesis to be tested rigorously by a proper, future medical study.

I discussed my mathematical objections at great length in this blog in my issue of May 30, 2009. The essential point is that the writer chooses which studies to include and chooses which of two methods he will use for analysis as to clinical significance: one depends on randomness (and hence the law of large numbers), and the other does not, and the two methods can easily give opposite results. I refer my interested readers back to the issue entitled"Analysis of Meta-Analysis, at

I feel that it is unfortunate that authors of meta-analyses do not mention at the end of their articles the reasons that their particular analysis may be mathematically and statistically suspect.

Sunday, September 26, 2010

Why (Single) Family Practice is Dying

There have been many articles written by family doctors in medical magazines about the present difficulties in the profession, the "good old days", and reasons for retiring early, but few, if any written for the patients, so they can understand the problem. The following is an attempt to remedy that lack. (And please feel free to forward this blog to your local Congressman, Senator, and legislators in your state's capital.) I was stimulated to write this blog by a friend of mine who has recently retired from the solo practice of internal medicine, because (a) he was spending more time on the phone with insurers and with paperwork than he does on patient care, and (b) because his net income was dropping each year so that his retirement annuity now exceeds his net income, even though he still enjoys the practice of internal/family medicine.

The main problem revolves about the amount of time that he needs to spend in non-patient care, and time is his least fungible resource. For instance, he now has to certify the need for home visits by a nurse weekly rather than monthly, and name stamps or his secretary's signature is not accepted.
This is an additional 23 pieces of paper he had to sign every Monday.

If a deaf MCR patient requires a sign language interpreter, the doctor must pay for it out of his own pocket, which costs more than what MCR pays him for the visit.

The HMO's such as Oxford keep on writing him letters to fulfill their HEDIS requirements to the government asking him why his diabetic patients have not received their yearly eye exam or his female patients their yearly mammogram. He then has to take time to explain to Oxford that the patient saw a non-Oxford ophthalmologist or radiologist, and since he was not the referring doctor he does not have a copy of the report.

He continually has to get permission for a MRI rather than a CT scan (HMO, not MCR), or explain to MCR part D that the generic medicine does not work, and the patient needs the brand name, or explain to the HMO that OTC Claritin does not work in this patient, so he/she needs Rx. Allegra or Xyzal.

He gets paid much more for doing than for thinking: MCR pays more for a 10 minute pulmonary function test than for a 30 minute visit. This is because MCR and HMO's can't measure thinking and diagnosing, but they can ask for a copy of the test.

The hospital now has an electronic order system. It used to take him 5 minutes with pen and paper to admit the patient, and now it takes 25 minutes to go through all the templates, including the birth date of the doctor (and how does that help patient care?) and whether or not his private patient should get a flu shot at discharge. Again, all this takes time, time, and time.

But if he wants to give a Botox or Restalen injection, which HMO's and MCR don't pay for, he needs supply them no proof, get no permission, and charge whatever the local traffic will bear.

A few years ago, MCR asked him why he did more flexible sigmoidoscopies than any other internist in his county. He wrote back to MCR asking them why more internists didn't look for colon cancer in their patients. He never heard from them again. Clearly MCR was more interested in reducing the number of (more expensive) financial outliers than in ensuring the good health of MCR patients.

If I write you a prescription for a sleeping pill, I make it PRN, i.e. take it if you can't fall asleep. That has been an illegal order for any MCR patient in a nursing home since 1996. MCR decided that the nursing home nurses on the night shift would be tempted to drug their patients so the nurses could have a quiet night. So I either have to write for a sleeping pill every night, which is bad medicine, or come in to the nursing home on the same day I want a patient to have a sleeping pill. The answer: I stopped seeing all nursing home patients, and let the assigned nursing home doctor worry about the problem. Once again, I didn't have the extra time.

And if I saw two nursing home patients in a nursing home the same day, I got paid less for the second one, because MCR claimed I was there already, so maybe I didn't really have to see the second patient. This was another reason to stop seeing nursing home patients, because again it took up extra time that I didn't have.

Federal MCR rules require that the rear doors of nursing homes be locked during the night, so demented patients can't wander off, but state laws forbid the locking or rear fire escape doors at any time while the building is occupied.

HMO's have their preferred list of brand name drugs, and it takes a lot of arguing with them to convince them that Prevacid works and Prilosec does not in my particular patient, or that I want my diabetic hypertensive patient to have Coreg as a beta-blocker because it is the only beta-blocker that has been shown to reduce microalbuminuria in these patients.

If I had my way, no insurance company, HMO, or MCR outfit would be allowed to challenge any Rx, Xray or blood test ordered by a doctor, and we would really save a lot of time.

The government is pushing computerized EMR's and drug ordering systems, which is another recipe for wasting time. There are a lot of (sometimes theoretical) drug conflicts listed in the PDR, and the computerized order system mindlessly follows them. The fact that the warning has been superceded by more recent research never makes it into the PDR, because it would cost the drug companies too much money. For instance, it is NOT true that beta-blockers cause depression (see, for instance, NEJM article from 3 years ago), but every time I try to add a beta-blocker to a patient on an antidepressant, my hospital's computer flashes an alert, and I have to manually put in an override command. I even got flashed for putting a young patient on a calcium channel blocker, with the warning that there were more efficient anti-hypertensives. In fact, I was using the Ca++ blocker for the well-recognized off-label use of reducing esophageal spasm, and again this explanation/override took time. And don't even think of using a tricyclic anti-depressant for stomach acid suppression----no computer has ever heard of such a use!

Unlike lawyers, doctors cannot charge for telephone advice, but we can be sued for it.

And we don't need tort reform so much as we need removal of the contingency fee from medical malpractice cases. Let it all be no-fault, similar to some states' mandatory automobile insurance policies, and let the workman's compensation fee schedule prevail for doctors and lawyers. And no, the threat of being sued for malpractice doesn't make a doctor a more careful physician. No doctor wants to harm a patient, either by omission or commission. But the threat of malpractice suits makes us order many more Xrays and specialty consults than we think the patient really needs, and in some counties (e.g. in Florida) no neurosurgeon covers the emergency room, because all automobile accident injuries end up in court. Similarly, no OB attending trains his residents in the use of forceps, because of the risk of a malpractice suit when the doctor is asked:"if there was a problem, why didn't you do a C-section?" That is why the number of C-sections has increased.

I still think that medicine is the most wonderful and rewarding profession in the world, and I also feel that internists have the most enjoyable specialty because we get to be real family physicians and take care of three generations of the same family. But all my children are educated and married, my mortgage is paid off, and I don't need that much income. I don't know if I would choose this specialty if I were starting off today.

I wish all doctors had time enough to spend more time with each patient, but I have no idea how to achieve this.

Tuesday, September 14, 2010

Basic Care by Doctors for Patients

There have been articles (and even books) written about what a patient should expect from a doctor, but I have found none of them to be of practical use. Let me tell you about the basic behavior I expect from my medical residents. Some if it is what I call "good housekeeping", some of it is common sense, and some of it is based on over 25 years of experience of taking care of ward and office patients. This list is not complete, and it is not a check list of what the doctor should do, because check lists are mechanical, and are not insightful for the doctor. Rather, if your doctor does NOT do several of my suggested actions, it may be time to find a "luckier" doctor for you, i.e. one who is more thorough with his/her patients.

Every patient should be asked about past transfusions (most usually occur during childbirth, so ask specifically). If any transfusions before 1985, do blood test for Hepatitis C antibodies, and, if positive, for Hep. C. RNA.

Ask about blood donations (immediate check for Hepatitis A,B,C, syphilis, West Nile disease, etc.).

In the appropriate neighborhood or background, skin test for TB on high risk patients. Always skin test on admission to a hospital, rehab center, assisted living, or nursing home. Patients from the Caribbean, especially the DR, have usually had BCG vaccine to protect against bovine TB, but the PPD should still be planted. Ask about prior TB skin tests, + or -.

Check on last Tetanus booster (at least one every 10 years), and Pneumovax and cervical herpes vaccine if appropriate. Offer flu vaccine.

Ask about any foreign travel in the past 5 years, and any illnesses while traveling or shortly after return home. Ask if took malaria prophylaxis, if appropriate.

Over age 50, one test for Vitamin B-12, as well as 25-OH Vitamin D. Also test for Vitamin D and Calcium after any bone fracture.

ANY patient put on steroids for longer than one month should be placed on Fosamax or its equivalent to help prevent steroid-induced bone loss.

If patient requests Viagra or its equivalent, check free and total testosterone level as swell as prolactin level. If either testosterone test is low, check the pituitary FSH/LH.

In irritable bowel disease, always check for lactose intolerance and celiac disease/malabsorption. Both can occur at any age.

There are only two acceptable reasons for not doing a rectal exam at the annual physical: no rectum, and no finger.

If no mammogram in the past year, examine breasts.

In hospital visit, always SIT DOWN. The patient should not feel rushed. You should always at least take the patient's pulse for physical contact and reassurance.

Ask about allergies, and request copies of written Xray reports and all past operative reports.

Ask about any veneral diseases, specifically herpes.

Last ophthalmology, dental and GYN visit, and any abnormalities. Can the patient read street signs at night when he/she drives?

Birth control used, sexual satisfaction with partner, and sex of partner.

Any stresses in life. Children or parents with mental or physical problems. Do you like your job?
When was your last vacation? Do you exercise regularly? Do you fall asleep easily? Any pets at home?

Check blood pressure in both arms. If over 50 (or 40 with certain medical conditions such as diabetes), listen for murmurs in the carotid arteries in the neck.

Do NOT tell the patient your own problems. You are wasting their time, because you are there to help them with their problems.

Keep a shadow chart in code of embarrassing facts the patient does not want released, and NEVER copy the shadow chart (OK to verbally give info to treating doctors with secrecy caution): e.g.; adultery, uses cocaine, prior pregnancy and surrender for adoption or abortion, bisexual, hole in nasal septum, lax anal sphincter.

Only try to diagnose treatable diseases (e.g. atrial fibrillation due to hyperthyroidism, and not atrial fibrillation secondary to cardiac amyloid).

The test may not be the patient's, so always repeat any abnormal blood test before you alarm the patient.

If the patient has syphilis and you suspect neurosyphilis, send the spinal fluid only for a VDRL, and never for an FTA, because no one knows what to do with a positive CSF FTA. Remember that Lyme disease is also caused by a spirochete, and is the cause of many false positive VDRL/RPR screens for syphilis.

Ask about orgasms. Ask about suicidal thoughts or attempts or plans. If sex drive low or sex with partner infrequent, ask about masturbation.

Undiagnosed Addison's disease can kill, and you won't make the diagnosis if you don't think of it.

If you have been on prednisone or other oral steroid in the past year, ask the doctor about stress doses of steroids if admitted to the hospital with an acute illness or infection, or for surgery.

If there is a dog in the house, the dog should get the monthly drop on the neck to keep Lyme ticks off.

If the patients says 2 drinks/day, ask how big the drinks are. (In some groups "two beers" means "two six-packs".)

Last menstrual period, and consider pregnancy test (must be done on every hospital admission.).

Ask the patient (1) what he/she thinks is medically wrong, and (2) if there are any other questions.

Most important: try to deduce the patient's model of disease, because any prescribed treatment that is in conflict with this model will not be properly applied.

(Trivial) if patient is low in serum potassium, check urine potassium, and serum magnesium; serum PTH usually not needed.

If kidney stone, 24 hour urine collection for Ca++, urate, and Ox-- so can treat to prevent further recurrences (if untreated, 50% have recurrent attack in 5 years).

Ask about unprotected sex (there is always some), and berate patient appropriately.

ALWAYS skin test for TB (and strongoloides as well?) when immunosuppressing with steroids, imuran, etc.

You may not be worried about lung cancer, but if you are a smoker your doctor should tell you that you are 100% guaranteed to develop emphysema, and spend the end of your life on an oxygen tank if you live long enough.

Why does the dentist go into the other room when taking dental Xrays if they are so safe?

Your doctor should never complain to you about his/her personal problems, but bitching about Medicare, HMO's and Electronic Medical Records is perfectly appropriate.

Never be afraid to leave a doctor because you don't want to "hurt his/her feelings". You should always find a doctor with whom you are gemutlich. I always tell my patients that my ego is not on the line: I give them my best professional advice, and they take it or not.

50% of our current medical knowledge will be obsolete in 5 years, but we don't know which 50%.
Leeches for high blood pressure, anyone?: (They did work , which makes it all the more surprising that the Red Cross will not let anyone with high blood pressure donate blood!)

And finally, do you feel "good" about your doctor?

Wednesday, August 25, 2010

How to Minimize Arguments with your Teenagers, Part 1

My wife and I raised 3 children so we were always outnumbered. Nevertheless, I think we minimized our battles with our children. Without pontificating, I think it is a matter of being reasonable, drawing clear lines about safety, requiring respect for one another, and realizing that not all children have the same drive (or ability) to do well in school. Our children all went on to college, got married with no divorces yet, and seem to be reasonably happy in their jobs.

Of course the first two things we all do when we become parents is to stop smoking grass (or at least hide it very well), and start attending a church or synagogue. So immediately we are telling our children (even before they know it) to "do as I say, and not as I did". This should not be a problem until the child reaches high school or bar mitzvah or confirmation age and starts to ask embarrassing questions about drugs, sex, and religion, but that is off in the future for new parents. But you should start to think about how you will convince your children to do as you say, and not as you did, and what to say when they ask you if you ever drank alcohol under age, let alone used marijuana.

"Because I said so", and "because it doesn't feel right to me" are both perfectly valid veto messages to your children (e.g. your child from Bergen County, N.J. wants to drive to Provincetown, Cape Cod on the night of her senior prom and stay over there with some friends).

It is "obvious" to most teenagers that older people deliberately discriminate against them and not "for their (sic) own good". The most egregious example is the 55 years old and older housing developments in Arizona and Florida. If the development's founding compact stated that Blacks or Jews could never buy there, and only live there for two weeks out of 52, there would be an immediate outcry, and the courts would rule it was a 14th amendment violation, or somesuch. But if the discriminated against group is under 18 (for living) or under 55 (for buying), the courts have upheld it. I guess older people and builders have a lot of voting clout, or donate more money to politicians than do younger people.

Please make sure your teenage daughter sees her own gynecologist before she goes off to college, and do NOT go in to the consulting room with her, or ask her what she discussed with the doctor. If your daughter wants you to know, she will tell you. It is reasonable as a responsible parent to ask her if she has any questions, but also to reassure her that the doctor is forbidden to discuss or reveal anything your daughter said in private.

Since no records are ever kept totally secret, tell your teenagers that if they are asked to fill out a form as to whether they ever drank under age, drove drunk, used illegal drugs, etc., the answer is always never. The penalty to the releaser of privileged information is never as great as the embarrassment or job prejudice that a teenager would suffer from such release. And be sure to remind them that ANY electronic information they send or receive, such as e-mails, voice mails, twitter, smart-phone photos, etc., can and probably will be viewed by someone else. Most teenagers are relatively innocent, naive and trusting, and they think that if they are upright and honest, then anyone they meet will also have these traits. This was somewhat true in the days of personal introductions, but certainly not over the internet.

In the same vein, too many teenagers and young college adults have sex without protection (and one is really too many). I tell all my patients of either sex never to have the first sexual contact with a new partner take place without a condom. Rather than warn them about accidental pregnancy or AIDS, I have found it much more useful to talk about herpes and venereal warts and how they are spread by direct contact by people who may not even know that they are infected or are carriers. And, as I have said before, if they are starting a new relationship and want to be tested for AIDS, I suggest instead their donating a unit of blood to the Red Cross, who will test the blood for many STD's.

The real problem, of course, is that for most children, teeenager seems to be a time of natural rebellion "all me friends are doing in" They are simultaneously pulling away from you and scurrying back for safety. In the mall. they don't want to walk next to you (not "cool"), but they do want to know where you are (!).

To most male teenagers, school is a form of jail. (And on a little reflection, I am sure you will agree that school is run for the females, and the business world is run for the males (topic of a future blog). I think you have to admit this, and point out to your (usually male teenager), that in the real world they will have to shovel an awful lot of crap, so they better learn about how to do it now. (My teacher insisted on a script "Q" rather than a printed "q". They both conveyed the same meaning, but she was the boss. Explain to your teenager that work rules make even less sense, but he/she has no chloice but to follow them.

Saturday, August 21, 2010

Medical Myths and Magical Thinking

Everyone has a certain degree of belief, aka myths, about medicine, their body health, and illness. If we all took a course in human physiology as seniors in high school, we would understand our bodies better, but since a recent poll showed that 75% of Americans believe in the existence of angels, we still would have beliefs as well as facts controlling our reaction to illness and doctors. I recall my parents' friends all ate a lot of wheat germ because they listened to a weekly radio program by Carleton Fredericks, and Dr. Jarvis' book on Vermont country medicine and the beneficial uses of apple vinegar is certainly well written and convincing.

It is of vital importance for a doctor to talk to his/her patient in enough depth to understand the patient's belief system, and I do not mean Catholic vs. Protestant, or Jehovah's Witnesses, or Christian Scientists, but rather how much medicine is acceptable to the patient, both in words and prescriptions. All beliefs about medicine are true beliefs, in the sense that the patient is committed to them, the recitation of facts and research will not sway them, and they will feel stressed if forced by circumstances to act against them. For instance, I can usually convince a committed vegetarian to take 1 mg/day of Vitamin B-12, which is needed to make animal DNA but not vegetable DNA, but it is not easy.

I have tried, with some success, to convince the medical residents under my direction that a patient's refusal to take a medicine is not grounds for an immediate psych consult. The last study of pharmacology behavior (or " pharmacological autonomy" if you want to be politically correct) showed that 25% of patients who leave the doctor's office with a prescription never fill it, 25% of those who fill it never take it, and 25% of those who take it stop before the indicated date, or rarely take it 3 times a day when so prescribed. Medical residents are guilty of the same behavior. At the same time, the most frequently committed federal or state felony is taking one of your relatives' or friends' controlled substances for pain, to sleep or to relieve anxiety, but no one seems to get reported or arrested for this.

I have male diabetic patients who refuse to take insulin:They believe that if they take insulin, then they are admitting that have diabetes, but if they just take pills, then they only have a "sugar problem". I have patients whose blood pressure is normalized with medicine asking me if they can stop their medicine now that their blood pressure is under control, or stop taking their statin now that their cholesterol is below 200. 25% of female high school seniors in the upscale, medically knowledgeable area in which I practice have never seen a gynecologist; I don't know if their parents think that seeing a gynecologist = approval of sex, but a girl should have her first pelvic done by an experienced gynecologist, who has time to ask questions and make the patient feel at ease, and not some GP in a college clinic who is just looking for vaginitis and STD's (and I apologize to those college physicians who are true gynecologists).

I have thousands of wives telling their husbands what to eat, not realizing that eating cholesterol (egg yolks) does not raise your cholesterol as much as eating animal fat does. For that matter, french fries and potato chips, both of which contain no cholesterol, contain enough fat to raise your cholesterol, and when Frito-Lay wanted to advertised their potato chips as having absolutely no cholesterol (which is a true statement for any vegetable product), the FTC made them pull the ad, because they were afraid that the public would equate "no cholesterol" with " "no fat".

I don't believe there is any such thing as "junk food" or "useless calories", but rather eating too much or to little. I don't care what you eat so long as you gain no weight, and have a daily multivitamin to cover whatever you may be missing. One of my children lived for a year on peanut butter and fluff,(and Poly-Vi-Flor vitamins) with no apparent ill effects, since he made the Little Leagued All-Star team as a pitcher. Exercising for 30 minutes non-stop every other day helps as well. White potatoes (and French fries, of course) have the highest glycemic index of any of the common foods, and therefore put the most stress on the glucose-insulin-fat system, so if you are on a diet, white potatoes are absolutely verboten.

It is not true that if you make love standing up you will not get pregnant. And you can't possibly douche soon enough to keep rapid swimmers out of the uterus. And if you follow astrology, what counts is the configuration of the planets at the moment of insemination, because a sperm is easier to direct than is a whole embryo. So you must know the planetary configuration at the moment of insemination (even better is at the moment that the father's sperm entered the cervical os, or the Fallopian tubes).

It is not true that a bowel movement a day is necessary for good health. Some of my patients average three movements a day, some three a week, and some three a month. In my human physiology class we were told that the longest time between movements was recorded as a year and a day, but since they had to then operate on the patient and use a hammer and chisel, perhaps that is a bit too long.

Too many mothers overemphasize their effect in the nature-nurture result. His mother did not give Derek Jeter the ability to hit major league pitching, or Frank Sinatra the ability to sing. I'm not sure what Midori's mother ate on the night of her creation, or if she listened to Mozart while she was pregnant with her.

Some patients will always see the glass as half full, and others as half empty. (And I see the glass as too large, but I generally think "out of the box".)Some are born salesman, and some are born daydreamers. We should also remember that the result of all tests are effort-dependent: hearing, PSAT, GMAT, 4th grade arithmetic, stress tests, and pulmonary function tests. Many students do not give the test 100% effort, but this is impossible to determine. In fact, some free-thinking students realize that since the state-wide test results do not affect their grade then they are guinea pigs, and put down "(a)" or whatever suits their fancy for every answer; why should they study hard and work on a test that is promised not to affect their grade.? In fact, if they do poorly, their school district can get even more money for supplies, so perhaps they are really helping. I myself never rewrote any humanities term paper in college, because (a) I was a physics major, and (b) the required effort to rewrite a B+ into an A- paper wasn't worth it to me. The one exception was a paper on Zoroastrianism in my course on Oriental Religions, because I was really interested in the subject.

Patients also think that the less medicine they take, the less sick they are. So when 40mg of Zocor was replaced with the equipotent dose of 10mg of Lipitor, they were very happy, and even happier with 5mg of Crestor. And Vytorin is one pill, not two, which is also good. They also think that the less asthma medicine they can take, the less serious their asthma is, and they are forever skipping doses of inhaler and believing that their breathing is not affected. On the other hand, 50 mg of Viagra must be better than 10 mg of Levitra, because the Viagra pill is bigger, has a great blue color, and is a larger dose.

Along with the above, the most surprised patients are those who survive a heart attack and go home on five new medicines. These many medicines do not mean that you are very ill, but rather that physicians know from experimental studies that each of these five medicines will reduce your chance of a second heart attack (and remember that the single greatest risk for having a heart attack is already having had one). The medicines are: a platelet blocker (aspirin, Plavix, or Coumadin), a beta-blocker, a statin to lower your cholesterol and stabilize any atheromatous plaques in your coronary arteries, an ACE inhibitor or an ARB, and, if you are in any heart failure at all, spironalactone. Again, these are all to reduce your chance of having a second heart attack, and should be taken exactly as prescribed.

If your doctor and you have a clash of opinions that is too strong for you to feel comfortable with him/her, then you should find another doctor. Never feel guilty about this, because it is your body and mind, and therefore your privilege to see or stop seeing whomever you want to. Speaking for myself, I do not want my patients to feel guilty about calling me after hours or when I am not in the office; when I am on call, I expect to be called. Your "job" is to tell me your symptoms, and mine is to worry about them and interpret them. We are both partners in your physical and mental well-being.

Added note: If your doctor spends more time talking about his/her problems than listening to yours, it is definitely time to find another doctor!

Medical Information and Mis-information (Part 1)

I have always been struck by the number of medical "facts" that my patients "know" that just aren't so (e.g. there is no evidence that an hour of sleep before midnight is equal to two hours of sleep after midnight), so I thought I would devote this blog to a discussion of such "facts".

I first must explain the difference between correlation and causation. Often medical epidemiologists will examine a homogenous group of patients with disease X, to see what , if any, their life styles have in common compared to patients without disease X. However there will always be some accidental correlation: if you shoot at a tree you are bound to hit a leaf, but unless you specify in advance what leaf you plan to hit, this information is of no use. Similarly, in a given state, some county will have the highest prevalence of breast cancer, and another will have the lowest, but I wouldn't recommend rushing to move to the county with the lowest incidence. So although it appears epidemiologically that females who have pet cats or kittens under the age of 16, or who live north of the Tropic of Capricorn or south of the Tropic of Cancer (i.e. not in the tropics) until age 16 have an increased risk for developing multiple sclerosis, we should treat this correlation as a hypothesis to be proved. Now we have to do the forward experiment, and see the effect of giving or not giving kittens to matched young girls (which is, of course, not ethical). Similarly, there was a great hooraw in the news when it was found that coffee drinkers had a greatly increased risk of getting a heart attack compared with non-drinkers, until it was realized that many more coffee drinkers smoked cigarettes than did non-smokers. Also, although low fat diets seem to be epidemiologically connected to lower breast and colon cancer rates, a five-year forward study of females placed on a low-fat diet showed no diminution of cancer incidence. As I tell all my patients ALWAYS WAIT FOR THE SECOND AND CONFIRMING STUDY.

Some of you may not agree with my statements, but again I must emphasize that if you think my statement is incorrect, you should find a published refereed research paper (you can check through PubMed) that disagrees with my statements. In fact this is the trouble with all newspaper stories, that they quote from and interpret the research study, but never include a link where you can read the original research and decide for yourself. You should also beware of all statements made at scientific meetings, since until they are published they have never been reviewed for accuracy.

1) The recommended maximum pulse rate for efficient exercise is a fiction. The study group was young healthy men, and the 80% was pulled from God knows where. When Bjorn Borg won the French Open, his resting pulse was 34 (similar to many marathoners). If he ever tried to get his heart rate up to 0.8x(220-age), he would have either failed or died trying.

2) Where is the evidence for waiting one hour after eating to go swimming?

3) What is the scientific basis upon which the government specifies the minimum amount of square feet an egg-laying hen should have? Dr. Kandel was fortunate that when he did his Nobel prize-winning memory experiments on Aplysia, the government didn't care how many snails he kept in a box, or how often or what he fed them.

4) For any children reading this, it is not true that if you swallow watermelon seeds you will grow a plant in your stomach.

5) Barry Bonds was indicted for perjury for denying using performance-enhancing drugs. Steroids may bulk you up, but I know of no medical article that demonstrated that taking steroids improves your baseball performance. It shouldn't matter what we think, what the government thinks, or what Mr. Bonds thought. If you deny an impossibility, I don't see how it is perjury. (When I went to college my performance-enhancing drugs were a cup of Choc-Full-O-Nuts coffee and two of their brownies.)

6) For years, heavyweight fighters and other athletes were told not to have sex the night before a crucial game. But Joe Namath, Mickey Mantle, and other top athletes have told us that this is not true either (at least it wasn't for them) and beer helped Bobby Lane, the former Detroit Lions' quarterback. Maybe that's why Tiger Woods is having trouble winning now.

7) Radiation can be used to kill virtually ALL germs, eggs and insects. We could safely sterilize our food supply and avoid disasters such as the egg-borne salmonella epidemic, the hamburgers that carried E. Coli, and the lettuce that carried hepatitis. But there is such an ingrained fear of the effects of radiation that even though it is only the food that is irradiated, and there is no residual radioactivity in the food, public opinion prevents Congress from permitting this, let alone requiring it.

8) There is no evidence that colonoscopy reduces the incidence of colon cancer more than rigid sigmoidoscopy does, but since it seemed "obvious" that examining the whole large bowel would produce better cancer prevention than a partial examination, a comparison study of the two was never done. But if colonoscopy were a drug, the FDA would have required a comparative study with cancer or pre-cancerous polyps as an endpoint.

9) Lately, dermatologists have been telling my patients that the growth they removed is "pre-cancerous". That is a ridiculous statement. Your whole body, including your skin, is "pre-cancerous". The medically correct term for such a growth is "not cancer".

10) How often should you have a mammogram, stool for blood, pap smear, etc. No one knows!
Cancer has occurred between annual screening tests. We doctors sort of pull numbers out of the air, modified by what the insurance companies will pay for. If Medicare only pays for cholesterol profiles every 4 months, then that is what we recommend. But maybe you should have a mammogram every six months, or every three. Maybe men over 50 should have a stress-thallium test of their heart every three months, or maybe an echocardiogram every month.

11) Medicare usually does not pay for screening tests. So if a doctor thinks you have a thyroid problem, and he/she puts down "possible thyroid problem", then MCR will not pay for it, and you will probably refuse to have the test done, not wanting to pay for it yourself. So we put down 244.9, which is a thyroid condition, to have MCR pay for the test. Similarly 780.79, "general fatigue", is an acceptable diagnosis to test for anemia with a CBC. On occasion, doctors have even used 799.99, "unknown disease", because we all have at least one of them (which is generally found at autopsy). So we tell all our MCR patients to ignore any diagnoses, and that we put down "Brain tumor" to get their MRI of the brain paid for by MCR or their HMO.

12) How does anyone know what babies want or need? You can't ask the babies, and no eighteen-year comparative studies are done. Right now playpens are out of favor, and we still have no agreement on how long a baby should be left to cry until being picked up. We still argue whether babies' food allergies are reduced or increased by early exposure to proteins. Despite the existence of cat-scratch fever and toxoplasmosis, we still permit kittens and cats to be around pregnant women and new-born babies. I might also mention that dander (cat saliva applied by licking to cat fur) helps induce bronchospasm and possible asthma in humans of all ages, and some states still permit children to keep turtles as pets despite the fact that they are known carriers of salmonella.

13) Medicine can be counter-intuitive: one way of reducing the incidence of calcium kidney stones is by INcreasing the amount of calcium in the diet (and thereby complexing oxalate in the gut and keeping it out of the urine).

14) Speed kills. During the Carter administration, with a maximum highway speed limit of 55 mph, traffic fatalities per mile traveled decreased, only to increase when 65 mph was reinstated. Because of kinetic energy, the amount of damage in an automobile accident goes up with the square of the velocity.I am not aware of any auto driver or passenger fatalities occurring as speeds under 35 mph, but we don't want to sacrifice that much time. (We also don't know why in most states when seatbelts were introduced the rate of pedestrian fatalities increased.) You should protect yourself by driving the heaviest car you can, like an SUV, since if you are unfortunate enough to be in an accident, you want the other vehicle to bounce off you, and not to crush you.

15) If you don"t "believe" in sleeping pills, then if you are a woman try OTC Benadryl 25 or 50 mg at bedtime. It is so safe that we give it to pregnant women. A future blog will address medical belief systems. And if you husband doesn't believe in them, hide them from him. It's your body.

16) There has been no study to show that if you post the number of calories next to food that people will lose weight.

17) The FDA does not have the authority to clear or license any new surgical procedure, including robotic surgery. Any surgeon can do any surgical procedure if he/she can convince the patient to permit it. I have read articles that it takes 150 to 250 operations to become proficient, for instance, in robotic prostate surgery. So don't be the first human on whom your surgeon is doing a new procedure.

18) The only way to find out who is a good surgeon, or the ability of any other doctor is to do as I did, and ask the residents who work with them. The residents see it all: in the operating room, post-op care, medical diagnosis and treatment, etc. If you ask your friends, all you get is their opinion. Even the published ratings are a joke, as any doctor will tell you. And hospitals can improve their open heart surgical death rate by not operating on the sickest people. (As I recall, there was an Op-Ed piece in the NY Times about 10 years ago by a columnist who had a very difficult time trying to find a cardiac surgeon who would operate on his mother for this very reason.)