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.)