Saturday, December 31, 2011

Dangers of taking Prednisone (Anti-inflammatory Steroid)

     Prednisone and other anti-inflammatory steroids (not to be confused with testosterone and the other anabolic steroids that athletes use) have an indicated medical use. Prednisone suppresses the immune reaction of the body, and is used when the immune reaction causes the immune system to attack healthy cells and organs. So it is used, for instance, in asthma, multiple sclerosis, poison ivy, polymyalgia rheumatica, swollen nerves, rheumatoid arthritis, systemic lupus, and a host of other diseases.

     However, just as  aspirin  goes throughout the body to suppress the formation of prostaglandins everywhere, anti-inflammatory steroids also go everywhere throughout the body to suppress the immune reaction in every organ, beginning with inhibiting the diapedesis of white blood cells through capillary walls to attack infected tissues and the reduction of immune surveillance of any fungi or other chronic infection that the body's immune system is keeping in check. It is of vital importance to be aware of the multiple possible effects of steroids and to protect the patient against these  putative negative effects. Otherwise, like Eleanor Roosevelt, the careless overuse of steroids can cause death from overwhelming tuberculosis and adrenal failure.

     I am therefore going to list some ordinary precautions that a physician should take before prescribing anti-inflammatory steroids for his/her patient. This list is neither exhaustive nor all-inclusive, but merely covers the fundamentals of good medical care. I firmly believe that doctors can do untold good or harm by the proper use or improper misuse of prescription drugs, which is why I have always read as much as I could about pharmacology and I subscribe to  the FDA drug-warning e-mail emergency list.

     Many patients have been infected with tuberculosis (TB) without being aware of it. If you have a robust immune system, you generally can confine live TB germs  to your lungs. But if you take enough prednisone for enough days, then the body's immune surveillance of the live TB germs in your body is suppressed, the TB germs multiply, and they can spread throughout your body and kill you. This occurrence has been well documented. Therefore, BEFORE your doctor starts you on an oral steroid, he/she should skin test you for TB, and treat you with isoniazid (INH) if your skin test is positive for as long as you are taking the steroid. (The precise dose and length of treatment with INH should be discussed with a pulmonary or infectious disease specialist).
And having received BCG vaccine against TB does not mean that a positive PPD (TB skin test) can be ignored.

     Second, there is a rather common intestinal parasite called strongyloides stercoralis. This nematode inhabits and is fastened to your distal colon, and its reproduction and spreading is also kept in check by your immune system. When the first kidney transplant patients were immunosuppressed, a number of them died from overwhelming strongyloides auto-infection. Therefore before your doctor starts you on oral or IV steroids, you should have a stool exam for evidence of intestinal parasites, especially strongyloides. Again, like ignoring a possible TB infection, omission can prove fatal.

     Third, and in the same vein, steroids also attack the part of the immune system that keeps live viruses under active suppressive surveillance. So if you have received a live virus vaccine (mumps, rubella, oral polio, yellow fever) or have a herpes infection in your eye, the prednisone should be deferred until one month after the vaccine or until the eye infection has been cleared. On theoretical grounds, you should also probably defer any steroid treatment if you have a bacterial abscess, such as acute diverticulitis.

     I should mention  here that your body's natural production of prednisone is approximately 7.5 mg/day, with a diurnal variation, so the peak levels are in the morning. The secretion of prednisone is controlled by a feedback loop to your pituitary gland, which secretes ACTH to stimulate the production and secretion of prednisone by cells in your adrenal gland.  If you take enough prednisone for a long enough period of time (and this amount and time should be determined by testing by an endocrinoligist), then the pituitary gland gets so suppressed that when you stop taking the exogenous steroid, the pituitary gland has lost its ability to manufacture ACTH, so the first time your body is stressed by an infection, your adrenal gland  will be unable  to make "stress doses" of prednisone and you will die in adrenal crisis.

     Now, for completeness, let me list some of the documented conditions  that the chronic use of steroids can create in your body, which, while damaging, are rarely fatal, although they can be permanent:

high blood pressure
congestive heart failure
salt and water retention
bleeding stomach ulcer
insulin-dependent diabetes
ocular cataracts
insatiable appetite
clotting problems
tendon rupture
pseudotumor cerebri

     Needless to say, not all of these side effects happen to all users of steroids, but it is probably prudent to start any patient, male or female, on a drug such as Fosamax that can prevent osteoporosis when steroids arfe started, so long as there is no concomitant esophagitis or gastritis.

     But of course, if the steroid treatment is necessary for your continued good health, such as reversal of an asthmatic attack, treatment of kidney failure caused by lupus, certain bullous dermatoses, then the above risks should not stop you from taking the medicine.



Wednesday, December 28, 2011

Anger Part II--Anger grows out of Frustration

     Anger seems to be amplified frustration, so the questions are (a) what makes us frustrated, and (b) what amplifies it? It seems that frustration is created by the loss of an object, either property or a person, either a real  loss or a fancied or predicted/feared-for loss. We get frustrated and angry in a traffic jam because we are deprived of freedom of movement. We even honk at the "slowpoke" driving in front of us because we are frustrated at our inability  to drive faster. Righteous anger is a special category because then we justify our anger by saying that it is directed at a sinner or a breaker of society's laws or mores who therefore deserves both scorn and anger, which may be amplified by our own  frustration and anger at never having participated in "sex, drugs, and rock and roll" as the hippies of the '60s did.

     It seems that frustration is caused by loss plus the inability to do anything about the loss. (It is notable that in classical psychodynamic theory depression is also caused by a loss. Could the strictures of society then explain why more women  than men get depressed, and more men  than women get homicidal with rage?) This immediately harkens back to a baby's instant anger when deprived of his/her rattle. Society may have taught us how to channel and not act on the rage we feel from being frustrated, but we have never learned how not to feel frustrated. Giving trophies to all the members of all the little league teams' players rather than just to the winners does not prevent adult feelings of frustration in later life; it just makes the sensation rarer and therefore more difficult to deal with.

     So unlike what all mental health practitioners tell us, it is the reaction and negative feeling of frustration that is inborn, and not anger. We must therefore ask what tools our family and society has given us to help us prevent our frustration from exploding into anger, and why, under certain circumstances, our feelings of frustration are relieved by exploding into anger. Of course society accepts our getting furious at ourselves if we drop and break something---we are instantly angry at our loss, and everyone empathizes with us. In a somewhat similar way society understands our getting angry when our favorite team loses, although what it is about the loss that led to  our frustration is less clear since  in that  case nothing tangible was taken from us.

     Therefore the thrust of anger management courses should be to teach us how to prevent frustration from escalating into anger, rather than assuming we will get angry and then teaching us how to control it. You should't  deal with an alcoholic by teaching  him/her how to behave when drunk.  By the time we get angry we are already near a dangerous flash point. And it is much more common than we think----boredom, for instance is low-level anger. We are frustrated that we are wasting our time doing whatever it is that is boring us, and then angry at ourselves or others  for our not getting up and doing something else. We know deep down that the only thing we have to spend that is uniquely ours is our time, and the time we spend  doing something we do not want to do (schoolwork, housework, visiting with inlaws) generates resentment, frustration and eventually anger.

     The surest recipe for frustration-amplification-anger is the knowledge that the loss cannot be reversed, thereby adding a feeling of impotence to our frustration. It is all well and good for Omar Khayyam to have written "The moving finger writes.......", but the reality of the irreversibility of time can be a very bitter pill to swallow. Thus when a loved one commits suicide, we become angry because (a) the loved one left us without warning us or seeking permission and (b) it is totally irreversible. Similarly, in a divorce, the children tend to be angriest at the spouse who leaves, no matter what the justification, since it is the act of leaving that certifies the divorce-to-be. In the same vein, when one of a divorced couple gets married, the other spouse and children often get angry all over again because a re-marriage demonstrates to one and all that the marriage is really over.

Monday, December 26, 2011

Anger Part I

     I decided to write a blog about anger, because it is a condition for which there is no reliable drug treatment  and which is also not classified as a psychiatric disease. There are anger management courses offered, but a recent article in a German newspaper reported that the leader of an anger management course stabbed one of the attendees three times. Even Freud did not write a monograph on the psychiatric cause(s) of anger, probably because it is such a primary response that its origin is  inborn. He did talk about eros and thanatos, which can be thought of (very loosely) as the need for love and the death wish, and treated them as innate,, because he could find no convincing explanation for the existence of war, let alone torture. It clearly must have something to do with thinking, because man is the only animal who tortures, one of the few animals who kills his own kind, and the only animal that commits suicide.

     All babies have an inborn need for love and for human contact, and have the capacity for immediate anger which is usually shown by yelling and getting red in the face. When very young, they usually can be soothed at once by nursing at the mother's breast. No one yet understands what makes a baby colicky, and a noted female pediatric psychiatrist wrote an article about how when her baby became  colicky she was almost driven crazy, even though she knew full well that she had not caused the condition nor was there any successful way to treat it.

     I would like to approach the problem of anger from a different viewpoint: Isn't it more difficult for a totally satisfied person to really  get angry and lose his/her temper? When we are satisfied, anger is furthest from our mind  because we are pre-occupied with the happiness of our state. Whether it is achieved by being in love, or being high  on life or drugs or jogging  or  anything else that gets our  mental endorphins flowing, there is no room for anger. No one knows what chemicals in the brain get increased or decreased  when anger surges; we only know the chemical result which is an outpouring of adrenalin, etc.

     By the same token, we do not understand what really triggers and escalates  anger. It is obvious that it is usually displaced from the real object of  our anger to a surrogate at whom it is emotionally safe or acceptable to display the anger. The trivial example is that your boss yells at you so when you get home you kick the dog. A more subtle displacement is the phenomenon of road rage, with or without gunshots. What is the real source of your anger that is discharged by "losing it" at the driver who cut you off on the freeway? What is the real source of anger when you yell at your spouse or children? Who or what are you angry at when you punch a hole in the wall? The question is what the other person's actions symbolize to you or threaten that is of vital concern to you, and whether or not the anger is generated by your frustration at being unable to address the cause of your anger directly. As an aside,  what damage has been done to your psyche when your parents have suppressed your  need for anger so completely that you "never get angry"?

     All mental health workers agree that the emotion of anger is a normal and natural one and only becomes a problem when it escalates  out of your control, driving you to an action that you would never have done in a "normal" state. That is, in a state of anger, actions that would normally be egodystonic to you become temporarily egosyntonic, as if you are temporarily not the person you recognize as yourself ( "Dr Jekyll, let me introduce you to Mr. Hyde".) And why are there people who walk around in a state of chronic anger?
We often feel ashamed or embarrassed after such actions when we "cool down", and vow never to let such a thing happen to us again, much as an alcoholic vows to stop drinking after his/her first  blackout or arrest for drunken driving, or really severe hangover.

     It is as though we become temporarily insane, in that we lose conscious rational control of our behavior. We rant and rave and yell and strike at people or things both emotionally and physically. Who doesn't recall, for instance, the TV picture of Paul O'Neill, the all-star right fielder of the New York Yankees, kicking the water cooler or slamming his hat or bat down in the dougout whenever he made out? Was that due to his nature or his nurturing or a combination of the two?

     If anger is a state of temporary insanity, to use that word loosely, is it that we slip  the bonds of  "civilized" behavior, or is it that there is a parallel being inside of us who is irrational and can erupt by escaping our control under certain emotional stimuli? There is no good evidence for either explanation. And we certainly have no idea why certain thoughts or ideas or concepts infuriate certain people and make them "see red". Very often our anger response is greatly out of proportion to the triggering incident. This is a sure sign that what/who we vented our anger at is not the true focus of our anger.

To Be Continued.....







Monday, November 14, 2011

Why There are and Will be Fewer and Fewer Primary Care Doctors

     Of necessity, because "man is an economic animal" the different providers of medical care will have different opinions of any payment plan. Internists, psychiatrists, plastic surgeons, anesthesiologists, dermatologists, general surgeons, heart surgeons, orthopods, urologists, oncologists, interventional radiologists, just to name a few of the divisions of medical specialties. We should also add the question of solo or group practice (many fewer solo practitioners today), and practice as private entities or as  employees of a hospital. The happiest doctors, of course, are the plastic surgeons and the dermatologists who do plastic dermatology (Botox injections, Restalen injections, etc.). They are not covered by any insurance plan, so they bill the patient directly,  have  no insurance forms to fill out, and they are free to charge whatever the traffic will bear.

     The internist, who does no procedures (except for the occasional EKG) can only charge for his time, much as psychiatrists and pediatricians do. Medicare pays me three times as much for a rigid sigmoidoscope which takes only 5 minutes (and I could teach you to do in two days) than it does  for a 15 minute office visit where a lot of diagnosis but no procedures are done. This is precisely why we are graduating fewer and fewer primary care physicians-----not only do they get paid less, but they also spend a lot of un-reimbursed time requesting permission for MRI's, or for a different drug, etc. Even if an internist drops out of all HMO's, Medicare and medical insurance plans, he/she will still be bombarded with requests to change brand name drugs to generics, or have to call up to find out why payment was refused for the drug he/she prescribed for the patient, or for the dosage.

     Every month I am offered a  chance to "increase your bottom line" by taking a weekend course in Botox injections and later, collagen injections. The Botox injections have to be repeated every 3 months, because otherwise the neuroparalysis wears off and the face sags, so you have an annuity from this patient of $300 to $500/every 3 months. I am also invited to take weekend courses to learn how to use a laser in my office to remove/reduce leg spider veius. Again, this makes a lot of money but does nothing to increase the amount or quality of primary care.

     A colleague of mine was lecturing to a group of 100 new physicians, all under the age of 35 about the intricacies of electronic billing systems. He asked for a show of hands of those in primary care. NO ONE'S hand was raised. This is terrible. Of course, if you want to make money and have a life then you don't want a specialty with night and weekend call and telephone calls at home and (sometimes) uncontrollable hours. Today about 50% of medical students are female. Following the above guidelines, if they want to be able to schedule their time and also have the time and a clear head to raise a family, their favorite specialties are (and I am NOT being misogynistic, just reporting the facts):
     1) Dermatology (Botox, Restalen injections, Moh's surgery, face peelings, etc.)
     2) Psychiatry---definitely pick your own hours.
     3) Anesthesiology---no calls at home, and you are usually home before 3PM so you can welcome your children home from school.
     4) Radiology---again few if any emergencies, no calls at home, no Sunday hours
     5) Pathology-----dead bodies and chemical tests will never call  you after hours, very low malpractice premiums, almost no weekend hours, no night hours at all.
     6) Emergency Room----can be exciting and challenging, but well-defined 8 or 12 hour shifts, and  when you leave you leave with no worries and no one calls you back.
     7) Allergist---almost no emergencies, charge for all office tests and injections, virtually no phone calls at night and only occasional Saturday AM office hours if you so desire.
     8) Geneticist----just counsel parents and prospective parents about disease linkages and inheritance and penetrance probabilities, again few night calls and no emergencies or weekend hours.
     9) Plastic Surgeon for beautification----again tons of money and few if any night calls or  weekend hours.

There was a book published about one year ago by an author who followed Dr. Craig Smith, the Chief of Cardiac Surgery at Columbia-Presbyterian Medical Center around for six months, and described his days, his work, etc. (Dr. Smith operated on President Bill Clinton, among others.) At the end of the book the author stated that Dr. Smith grossed $2 million, but the top grossing dermatologist at CPMC grossed $3.5 million. We all see where the goose that lays the most golden eggs is, and it is most definitely not in the field of primary care. So unless you are totally in love with the field, the odds are you will not enter it. I might also add that I raised three children and put them through college on my income as a solo internist. I do not net enough today to do that, so I cannot in good faith advise medical students to go into primary care unless they are independently wealthy, and that is a shame and a pity.

Sunday, November 6, 2011

Why Evidence-Based Medicine and Government Guidelines are Impractical

     There have been many articles written recently about how the application of the results of "evidence-based" medicine to patients will both save money and make them healthier. We are also bombarded with many guidelines from the government as well as from various national medical groups as to how to diagnose and/or treat various diseases. I will not discuss the obvious problem that arises when different medical groups produce opposing guidelines (viz. the AMA, American Urological Assn., American College of Physicians, National Public Health Service, American Cancer Society) as to the proper timing of or the utility of PSA testing, or mammograms, or colonoscopies, or-------.

     One problem that the public does not appreciate is the impact these "suggestions" and "guidelines" have on the work time of physicians. Time is our least fungible resource. But every time you deviate (for good reason) from a recommended HMO or government guideline, you end up having to explain yourself in writing, either  in the chart, or in response to a letter from an HMO or Medicare, and this takes up time. Also, sometimes it is necessary to deviate from the guidelines to shield  you from a malpractice suit or to reduce your chances of losing one. The fact that a test you did not do was not indicated in the guidelines will not help you if a malpractice lawyer can convince a jury that application of the possible results of the test might have prevented permanent harm to your patient. And please remember that a doctor much prefers to avoid being sued than to be "right" and win the suit, because defending a suit takes time, energy, and time away from the office.

     When we look at evidence-based results, the first question a doctor asks is if his/her current patient fits the characteristics of the study group as to age, sex, race, economic standard of living and geography. For instance a recent article published in the New England Journal of Medicine on the use of cytisine for smoking cessation did have an equal number of men and women, and married and unmarried. However, all the participants were white, lived in Europe, were between 40 and 60 years of age, and smoked between 10 and 30 cigarettes a day, and your patient is a 25  year old Mexican immigrant who smokes 40 cigarettes a day, and wants to stop smoking. You don't even know the proper dosing regimen because you don't have any data on how rapidly or slowly Mexicans clear cytisine from their blood compared to white Europeans.

     A recent study in Lancet showed that treatment with Augmentin was "not inferior" to surgery for uncomplicated acute appendicitis. The study group was equally divided between men and women and covered ages 18 to 68.  But all were white, all lived in Europe, no mention is made of marital status or use of cigarettes, or even the other medicines they were taking, no one was obese, and no mention is made of prior abdominal surgery.

     Let us say you have a new patient with reflux esophagitis. There are very clear guidelines about treatment and the sequence of adding more drugs for control and which tests and procedures to do. (Although there is no mention of urecholine, probably because it has been generic for so long that no one even thinks about it.) But your patient is also on medicines for heart failure, diabetes, and hypertension, and no one in the GERD treatment group was on these medicines. So some of the GERD medicines may be absolutely contra-indicated in your patient, but it will take time to explain this. Some doctors just write in the office or hospital chart: "This patient refuses to take the following medicines and tests" if the doctor does not think that those particular medicines or tests are either not indicated or might be harmful. This saves him/her from having to answer many letters, and no one from the HMO is permitted to question the patient about this because to do so would violate HIPAA rules. I might also note that the American Assn of Family Practice, the American College of Physicians, and the American Gastroenterological Assn. all have different recommendations about which procedural (i.e. invasively performed by a gastroenterologist) tests should be done to diagnose and follow GERD.

     There are also other possible developments. A new study might be done after the guidelines were published which either introduced a new and better drug for an old problem (Singulair for asthma, dabigatran for anti-coagulation) which can either add an intermediate step to the treatment step-ladder (Singulair before oral steroids) or are safer than an older drug (dabigatran  instead of Coumadin). Sometimes a guideline has an unintended result: Many years ago Medicare decided that no one needed to be transfused just one unit of blood. They started to sanction doctors who did so. Immediately many patients who a doctor thought should have one unit of blood was transfused  two units, thereby doubling the patient's risk of a reaction to the transfusion, e.g. an infection with a disease not screened  for in the transfused blood, such as Chagas' Disease.

     Then we have the problem when the government recommendations directly contradict the clinical evidence. What comes immediately to mind are the many studies that have shown that the antibodies induced by the flu vaccine are useful defensively for only about 6 months. There was even a recent study published in the New England Journal of Medicine that showed that an injection of 4 times the usual dose of flu vaccine provided useful antibody levels for 12 months. It would therefore follow, from elementary pharmacology, that the cheapest way to provide year-round flu coverage would be to immunize every patient with a single dose every 6 months. Yet no insurance plan, HMO, or Medicare will pay for this. Why not? Doesn't the government believe the results of its own clinical tests? Don't they want to keep people as healthy as possible?

     The real problem is that each and every patient is unique, not only in his/her DNA, drug clearance ability, level of hormones, etc. but that each patient has different underlying diseases, is on different drugs, and takes different over-the-counter supplements. They may be smokers or vegetarians. They may be fat or thin. They may be very old or very young. They may be male or female. They may be pregnant or have the possibility of becoming so. They may be on birth control pills (patients on BCP's are never in a study group to test a new drug). They may be  black or brown or yellow or white. They may be on cancer chemotherapy or on medicines to treat heart failure. They may not want to be on "too many" drugs. Outside of a blood transfusion for severe anemia and supplemental oxygen for hypoxia (and be very careful with the amount of oxygen given to premature babies!) there are few treatment recommendations that can be applied uniformly, especially when it comes to prescription drugs.

     Finally, almost all guidelines apply to a patient with a given disease or symptom. None of them takes into account that a patient may already have four other diseases/conditions  for which he/she is being treated, and that the guidelines to treat this fifth disease will almost certainly conflict with some of the requirements of other guidelines. The typical 60 year-old patient is on 6 or more prescription drugs, and NO guideline has studied a group of patients on the patient's particular group of drugs.

     So it comes down to medicine being an art as well as a science, but you cannot subjugate art to check boxes on a computer's template, or note the reaction of a patient to a question, or tell the computer that the spouse insisted on being  in the room with the patient and that  therefore all the answers may not be true, or that the patient requested that certain answers not be entered into the office chart.











Sunday, October 30, 2011

Why Patients Don't Follow Doctors' Orders.

     We often say in a "PC" way  that a patient who refuses to take medicines as  precribed by a doctor is "Pharmacologically Autonomous", but that does not get to the heart of the problem of restoring him/her to health. It is often stated that if patients were better educated about the nature of their (chronic) disease, or their treatment, then compliance would increase, and we would have a healthier society. Nothing that I have seen in over 35 years of practice substantiates that belief:

     1) When I am attending and I poll the medical students and residents, fewer than 50% of them have consistently taken the full course of antibiotics (e.g. 10 days for a strep throat) that was prescribed for them. If patients who are in the medical system and presumably have the most complete understanding of their disease and treatment are not compliant, why should be expect that non-doctors would react any differently? (I won't even mention the large numbers of chest surgeons who operated on lung cancer patients and still smoked cigarettes.)

     2) Most patients believe, either consciously or subconsciously,  that the less medicine they take the less sick they are. That is precisely why although we know than penicillin will cure a strep throat in 7 days we prescribe a 10 day course of the antibiotic. Many patients will stop as soon as they feel better. In fact, a study done about 20 years ago at Columbia's Vanderbilt Clinic demonstrated, by having the mothers bring in the bottle of penicillin at the next clinic visit, that fewer than 80% of them completed the indicated course for their children.

     3) Over the years I have told many diabetic patients that if they lose a certain # of pounds they can recover their normal insulin-glucose axis, and no longer be diabetic. The believe it, but even with support, going to a nutritionist, or going weekly to a diabetic clinic, none of them can achieve and sustain a weight loss. The only method demonstrated to cause sustained weight loss and thus  reverse diabetes is stomach banding or stomach bypass surgery. This is at least 90% successful. And remember that stomach banding does not permanently change a patient's eating habits, but only the amount that can be consumed at a single sitting and within one hour's time. Occasionally, when stomach bypass surgery had to be reversed because of developing liver failure, the patient would put back on the 50 or 100 pounds that was lost.

     4) The only patients who consistently lose weight (besides anorectics, bulemics and purgers) are some overweight men after their first heart attack. This makes instant believers of them of the health benefits of weight loss. Many of them eat so much fish that I have to check their blood mercury levels every six month.

     5) It isn't that patients don't KNOW about healthier actions, they just don't act on their knowledge. Some of this may be wishful thinking, some may be people's refusal to acknowledge their own mortality (Freud stated that it is impossible for the ego to envision its own non-existence), and some is due to the fact that we evolved by reacting to immediate dangers, and not to those postulated to be off in the distant future. Many if not all smokers know that smoking is dangerous (when we were teen-agers we called them "coffin nails") but no one believes that the cigarette they are smoking at this present moment will kill them.

     6) People know from experience how much better they feel after exercising, no matter how tired they thought they were, yet once they get out of the habit, it is very difficult for them to get back into the exercise rhythm. I woke up one day in my dorm room and said to myself "I'm not smoking any more cigarettes", and to this day I have no idea why I stopped. People know they should use seat belts when driving, but the knowledge alone was not sufficient----but when the state started giving out tickets for non-compliance the rate of seat-belting went up sharply.

     7) Some overweight people decide one morning to go on a diet, start eating less, and lose weight. But none of them (usually) can tell you why they made the decision that particular A.M. rather than one week or one month or one year previously. The first time a man goes from a size 36 to size 38 belt, or a woman from a size 6 to a size 8 dress, it is obvious to each and every one of them that they have gained at least 10 pounds, but almost none of them decides immediately to lose the weight. We know from various experiments in big-city schools that if you offer students money to improve their grades, many of them will get higher grades. Perhaps the state should give every citizen $10 for each pound that is taken off and kept off for one year. I bet we would see a lot of weight loss!

     8) And let us not forget individual health belief systems. Some people feel that vaccines are dangerous and unnecessary, some people refuse to get  mammograms or colonoscopies, some people have unprotected sex,
some people don't believe in sleeping pills, some don't believe in anti-depressants, some believe a daily bowel movement is necessary for good health, and so on. Some patients may be covered by their spouse's drug plan, but  need to be on a drug that the spouse does not "believe" in, so they purchase the prescription with their own money and hide the bottle.  Some of my diabetic patients will only take pills for their elevated glucose and absolutely refuse to take insulin-----so long as they don't take insulin they can tell themselves that they are not truly diabetics, but only have a "sugar problem".

     9) In summary, many people know what is "good" for them, so to speak, but refuse to act on their knowledge. Thus we have dead jaywalkers, drunken driving accidents, people who drown while swimming alone, campers who get mauled by a bear while trying to feed it, and people who get severely hung over more than once or twice. No one likes being told what to do, even if it is "for their own good". So all recommendations of prescriptions, actions and tests by a doctor to his/her patients is really a series of negotiations, because you first have to talk to the patient long enough to understand his/her model of disease and treatment, or else none of your recommendations will be followed.



Sunday, October 16, 2011

Dietary Supplements (Vitamins and Minerals): Killers or Life Extenders?

     This blog was triggered by an article in a medical journal and the subsequent media coverage. The article is "Dietary Supplements and Mortality Rate in Older Women, in Archives of Internal Medicine, Vol 171, (#18), Oct 10, 2011, pp 1625-1633. I also refer my readers to a blog I published in 2009 entitled "Nutrition".

     Let us begin with some basic definitions. A vitamin is a molecule that is necessary/essential for human life, but which our body cannot synthesize. For instance, neither humans nor guinea pigs have the enzymes necessary to synthesize ascorbic acid, aka Vitamin C, but all other animals can synthesize it. So only we and the guinea pig can get scurvy. The vitamins we need are present in our food if we eat a "well-balanced" diet, by definition, This includes Vitamins A, the whole B complex (1,2,6,12), Vitamin C,D, E, and folic acid.,  There are also eight amino acids essential for the synthesis of human protein, three essential fatty acids, and a host of elements (iron, iodine, calcium, cobalt, magnesium,copper, zinc, selenium,...) that we must ingest. If we ingest too little of the vitamin we get ill (scurvy, night blindness, pernicious anemia, iron-deficiency anemia, ...). The question is if too much of a vitamin or a supplement is injurious to our health. Very few studies have addressed this question, and our beliefs are not a substitute for clinical studies. Also, it would not be ethical to deliberately overdose human subjects, so we are left with experiments of nature, or retrospective diet histories.

     We do know that an excess of the fat-soluble vitamins (A,D, and E) is injurious to our health.Cod liver oil contains vitamin D and a daily spoonful is probably OK, but eating a polar bear's liver has given Eskimos vitamin D toxicity and even caused death. We also cannot generalize from animal studies: chromium and selenium can help control a lab rat's sugar level but there is no evidence than these elements can be used to treat or prevent diabetes in humans. We must always remember that ALL chemical substances are poisonous; it is only a matter of dose (digitalis, opium, water, salt, iodine, etc.).

     Let me first remind my readers that only animal cells contain Vitamin B-12 (cyanocobalamin) because only animal DNA requires Vitamin B-12 as a cofactor (along with folic acid) for its enzymatic synthesis. Vegetable DNA does not require Vitamin B-12 for its synthesis, and therefore no vegetable cells contain this vitamin. In other words, if you ate only vegetables (and this excludes fish) you would die from Vitamin B-12 deficiency after first suffering irreversible brain and peripheral nervous system damage. Vegetarians must take B-12 supplements, which may be synthesized in a lab, since the human body's enzymes have no way of determining the source of the Vitamin B-12 that it needs and uses.

     We also know from "experiments of nature", i.e. genetic/enzymatic defects that prevent the normal clearing of minerals, that an accumulation of certain elements can cause disease and death. For instance:  excess iron (hemochromatosis), excess copper (Wilson's Disease), etc. The question that remains is whether  an excessive intake of water-soluble vitamins, which are excreted unchanged in our urine, is beneficial or detrimental to human health. By excess, I mean a daily dose much greater than that needed to prevent vitamin-deficient disease. Based  on the problems caused by too much iron or too much copper or too much iodine (affects the thyroid gland) it is probably true that an excess of any mineral element in the diet can be injurious (lead being the most notable, especially for the developing nervous system in children).

     It is difficult to find any study that conclusively demonstrates than a dietary excess of any vitamin is either beneficial or injurious. We do know that it gives the user the most expensive urine in the world. The reason for the lack of good studies is that the human generation cycle is 25 years, and there are no good 25-year vitamin studies (not counting Framingham and beta-carotene) with a good control (i.e. no excess vitamin intake) group. But it seems to me that if you want to make a change in the human diet, it is up to the proposer of the change to demonstrate that no harm will come from adopting the change. Too often we assume that any intervention that is not obviously immediately dangerous will prove to be beneficial in the long run. In my opinion (and I emphasize opinion) everything  we ingest is potentially poisonous, so we should probably never eat the same meal two days in a row (and certainly not eat tuna fish more than twice a week) so as to distribute and minimize the effect of any dietary poisons. And except for a daily aspirin in some people, and a daily glass of wine in everyone, it is probably incorrect to assume that any substantial change in our diet will prove to be beneficial and overcome the result of millions of years of evolutionary pressure on our body's chemistry.

     And let's remember again that the theory that oxidative stress contributed to the shortening of life and the induction of cancers was tested by giving the anti-oxidants  Vitamin E to many American heart disease patients and giving beta-carotene to male Finnish smokers (who have the highest rates of heart attacks and lung cancer in the world). The patients given daily high doses of Vitamin E had an increased rate of heart attacks. The Finnish smokers given beta carotene had a higher rate of lung cancer. And let's not forget taht the Japanese, with their "healthy" fish and vegetable diet have such a high rate of stomach cancer that just as we recommend colonoscopies at age  50 to screen for colon cancer, the Japanese start upper endoscopies at age 40 to look for stomach cancer.






Tuesday, October 11, 2011

To PSA or Not To PSA, That is the Question

     In view of the recent hooraw over whether or not testing for and treating prostate cancer saves lives, I feel I should re-visit this subject, which I first discussed in my blog of May 15, 2009. I want to begin by emphasizing once again, speaking as a trained scientist, that in any given field what counts is what we can show to be true by experiment, and not what we can deduce or think  should be true (with Einstein's Theory of General Relativity being a notable exception, but even that theory was based upon an experimental result, namely the equivalence of inertial and gravitational mess, as first shown by Galileo). It also doesn't matter what we would like to be true, because Mother Nature's rules are independent of our beliefs.

     Some of the examples of medical facts and treatments that we thought should be true or benefit patients but were shown to be false or harmful or not proven when subjected to clinical testing are:

1) If a patient has calcium oxalate kidney stones then the proper treatment is toDEcrease the amount of calcium in the diet.

2) Beta-blockers should never be used in a patient who is in heart failure.

3) Everyone needs 8 glasses of water or fluid a day for good health.

4) Everyone needs at least one bowel movement a day.

5) If a patient is ill, bleeding with leeches will generally make him/her better.

6) An hour of sleep before midnight is worth two hours after.

7) If you go swimming right after eating you will develop an abdominal cramp and drown.

8) Vitamin E, because of its anti-oxidant properties, prevents heart attacks.

9) Beta-carotene, because of its anti-oxidant properties, protects smokers from lung cancer.

10) Mammograms taken between the ages of 40 and 50 saves lives.

11) The optimum time interval between complete physical exams is one year.

12) The optimum time interval between colonoscopies is 10 years.

13) The optimum time interval between mammograms is one year.

14) A drink of alcohol a day cannot possibly be good for you.

15) Daily doses of saw palmetto help treat an enlarged prostsate.

16) Daily doses of gingko balboa help prevent Alzheimer's Disease.

     I could easily add another 10 to 20 pseudofacts to the above list. Now let us look at the question of PSA testing as well as the treatment of prostate cancer. Before asking whether or not measuring the PSA saves lives, we first have to determine if treating prostate cancer saves lives. As of today, there is absolutely no evidence that it does. It may seem counterintuitive that this is so, but the fact is that the majority of men die WITH prostate cancer, and not OF prostate cancer. Roughly speaking, the percentage of men who have prostate cancer at autopsy is equal to their age at death: 70% of men at age 70 have microfoci of prostate cancer, etc. Much as we would like to believe that detecting prostate cancer early and treating it will save lives, there is absolutely no evidence that this is so.

     There have been many review articles coming to this conclusion, and you can check PubMed, the abstract archive of the National Institutes of Health for references. So why do people do the PSA, or take treatment if a prostate biopsy shows prostate cancer? The answers are many and varied, and all are ultimately the result of individual decisions by individual patients. Some of the reasons are:

1) Some people cannot tolerate the thought of having cancer within their bodies.

2) Some wives cannot tolerate the thought that their husband is walking around with cancer.

3) Some men believe that treatment of prostate cancer will save their lives.

     Very few men are told that most prostate cancers detected on biopsy will not spread and kill them. Very few men are told of the possible lingering (6 months to 2 years) or permanent symptoms of radiation proctitis that can result (chronic bloody or non-bloody diarrhea). Many men don't fully understand the implications of the fact that 30% of treated men will develop urinary incontinence (and need to wear a diaper) or be unable to mount or maintain and erection (even with the help of Viagra), or both.

     Since a physician's first duty to his/her patient is to "do no harm", I lay out all the above info to my patients, and if asked, I tell them that I never have taken a PSA test and would never treat prostate cancer in myself. However, if a patient decides on treatment, I urge him to consult with both a urologic surgeon and a radiation oncologist to listen to the pros and cons of each procedure, and then to consult with a medical oncologist for an overall view. I also suggest that he not discuss his decision with any friends who have been treated in order to avoid impassioned but not dispassionate arguments and lectures. And then I remind him that it is his body, that he is the patient and must make the final decision, and not to do any treatment or non-treatment that he does not fully agree with.

Sunday, October 9, 2011

Why You Can't Get The Medicines You Need, Especially Generics at a Reasonable Price

     The capitalist profit system usually works, except in a few cases. The courts have held, for instance, that you cannot charge an outrageous price for a drink of water for a man dying of thirst or for a crust of bread for a starving man. Similarly, there are laws against ticket scalping, and no matter what the underlying economic theory (communist, capitalist, libertarian) there are always subsidies given to farmers to avoid a famine, which subsidies are NEVER provided for or explained in the original theory, but is rather based upon thousands of years of experience with farmers, food crops and famines. That is probably why there has never been a killing famine in a democracy---the voters would never stand for it.

     When it comes to drug prices, however, the economic and politico-legal landscape becomes murkier. About 10 years ago, Lilly and Lederle got so tired of being sued by parents who claimed that their children were permanently damaged by the MMR (measles, mumps, rubella)  vaccine, that Lilly threatened to institute the default position that only Lederle of Canada would manufacture the MMR vaccine, and it would never be sold in the USA so as to avoid tort claims of damage in the US courts. The US government, faced with this possibility, passed a law that the government would reimburse any parents who sued and could prove a case.

     Similarly, the morning sickness of pregnancy with horrendous vomiting and secondary severe dehydration can prove fatal, as it did to the novelist Charlotte Bronte, sister of Emily. Merrill-Dow had a drug that treated and reduced the severity of morning sickness, called Bendectin. Now historically one out of 2500 children born has some sort of birth defect. One year, seven of the parents of such children sued Merrill-Dow, claiming that the Bendectin the pregnant mothers had taken had caused the birth defect. Merrill-Dow won all seven cases, but the legal fees far exceeded their profit from making Bendectin, so they ceased production. Their final words on the subject were: "If you are pregnant and suffer from morning sickness, call a malpractice lawyer".

     Now we come to generic drugs. When a new drug is patented, there are virtually no limits on the price that the manufacturing pharmaceutical company can charge, and it is impossible to calculate what a "fair" price should be, after you try to amortize the years of studies needed to produce the drug as well as those drugs that were tested and never made it to market. It's somewhat similar to the fact that most movies never show a "net" profit, so a smart actor/producer takes a percentage of the gross, which is readily measured. If I am not mistaken, the film company that produced "The Producers" claimed that there was no net profit, and Mel Brooks had to sue them for his share of the net profits. (Caveat: if it was not "The Producers", it was a similarly successful film that generated huge grosses.) In order to encourage the production of a generic substitute, the US government will grant a six month exclusive license to the first generic company to bring a generic product to market when the patent on the brand name wears off.

     Now what do the brand name drug manufacturers do when the patent for the parent, patented drug nears an end? The simplest practice was done by Roche, who put a hollow "v" in their brand name Valium, so patients could complain to their doctors that the generic valium tablet looked different, which it had to, by law. Similarly, the makers of Ativan converted the basic shape to a pentagon, again uniquely and memorably different in appearance from the generic lorazepam. Another solution is to take Prilosec, which is a mixture of right-handed and left-handed molecules (and there IS a difference in their chemical action) and start to make only (purple) Nexium, which is the isolated right-handed form of the basic patent and therefore is entitled to a new patent. Similarly Floxin is the brand name for ofloxacin, which is also a 50-50 mixture of right and left-handed molecules, and the company went on to patent and market only the L-form , called Levaquin, heavily and successfully. A final chemical "trick" was done with the anti-histamine Seldane, which was patented as the first non-sedating anti-histamine. This pro-drug was converted into its active form Allegra, in the liver. As Seldane neared the end of its patent life, the company merely stopped producing it and started to produce the newly patented and tested Allegra. None of these practices is illegal or dangerous to the patient. It just increases the cost of medicine to the patient and the profits of the drug company.

     Now, however, things get a little murkier. Let us say that the generic maker "first on the scene" stands to make a profit of $200,000,000 in the first 6 months of sole production of the generic drug. The brand name producer makes $4,000,000,000  in the same six months, or 20 times the profit. The brand name company simply offers the generic company $400,000,000 free and clear,if the generic company does NOT make the generic drug, i.e. buys up their six-month rights,  so the generic company makes double the profit without tying up their production lines, and the brand name company makes an additional $4B, and the consumers pay more. Just good old free enterprise in action. Or, the brand name company can (and this has happened) buy up all the basic chemical from which Xanax is made, so the generic manufacturers have to buy their base
product from them.

    But the most egregious, albeit legal events have occurred in generic drugs that  treat breast and other common cancers such as the drug  adriamycin. Generic drugs yield the least profit, so few companies want to manufacture them or devote a lot of their production line to them, For this reason there has been a severe shortage of many cancer-treating drugs, and many  patients have to wait to start  their treatment. A few even had to halt their weekly treatment in the middle. A weekly bulletin of the drug shortages can be found at the FDA web site. There is at present absolutely no legal method whereby the federal government can compel any generic manufacturer to make any drug, whether the drug is used to treat cancer, heart failure, or warts, and there seem no solutions on the horizon.

Monday, October 3, 2011

New Medical Device = Guinea Pig Patient

     By now almost all of my readers have probably read about the horrific results that have developed and will  continue to develop in some patients whose artificial hip is the new one of metal-on-metal rather than the old one of metal-on-plastic.The old artificial hip used a metal rod with an attached metal ball to replace the upper half of the femur, and installed a plastic cup into the acetabulum, or that part of the pelvis with  which the femoral head fitted and subsequently pivoted, rotated and articulated , just as in the old hip joint. The new artificial hip used a metal cup instead of plastic so there was constant grinding of metal-on-metal.

     Unbeknownst to anyone, this constant grinding of metal on metal created thousands if not millions of tiny metal splinters and released them around the joint space. The white blood cells engulfed and tried to destroy them as if they were foreign invaders (which is why an unattended splinter in your finger turns red and the surrounding area gets tender). The subsequent release of inflammatory chemicals generated by the white blood cells apparently caused chronic pain and also damaged some of the leg muscles around the joint, necessitating the replacement of the new metal-on-metal joint with the older metal-on-plastic one.

     I mention this not to criticize the inventor of the new artificial joint, but to illustrate the dangers inherent in replacing a " tried-and-true" device with a new one that has theoretical advantages. There is no experimental way to mimic the effect of inserting a medical device into a human being for five minutes, let alone five years. In my opinion unless a medical device immediately provides a tangible benefit that no previous device did, you should let someone else be the guinea pig and have it inserted in them for the first six months to five years of the release of the new device. BTW, did you know that the salesman for the new orthopedic device often accompanies the surgeon into the OR to verbally instruct in  the insertion of the device? You certainly have the right to (a) ask the surgeon how many of these devices he/she has personally installed, and (b) ask that only doctors, nurses, etc. be allowed into the OR while they are operating on you, or that you be told who besides the surgeon will be present.

     The FDA clearance of a device does not imply verification of its "duty cycle" This is an engineering term. A light switch has a (tested) duty cycle of, say 10,000, meaning that it can be turned on and off at least 10,000 times before it fails to work., A light bulb has a defined duty cycle based on how often it is turned on and off, and for how long it is kept lit each time. A soldier's rifle has a tested duty cycle, as does your car's ignition and  your electric garage door opener. (For a wonderful movie  about the vibration duty cycle of the tail of an airplane, I heartily recommend "No Island in the Sky", based on the novel of the same name by Nevil Shute, and starring James Stewart as the airplane designer and co-starring Marlene Dietrich and Glynis Johns.) But the duty cycle of any device inserted into a human being is NEVER tested under true operating conditions. Thus we have had some  heart valves that shattered, or some that  clotted in an unacceptable way. We have had new materials inserted into human bodies that were subsequently rejected by the body and had to be removed. If any doctor wants to insert a new material into you (and to me "new" means being on the market for less than 5 years), I would think carefully before agreeing. The same would apply, for different reasons, if a new drug has been out for less than six months, unless no other drug does what it does, e.g. oral Dabigatgran. And remember also that you may be able to tolerate a brand-name drug, but be allergic to the products that are use to constitute the tablet that contains the generic drug.

     What this means is that any new product implanted in your body is a potential time bomb, similar to the cardiac (heart) permanent pacemaker wires that broke inside the body after months of use, or the use of Xrays to treat childhood acne which  greatly increased their risk of developing thyroid cancer, or the rush of men to treat their prostate cancer with external beam radiation rather than surgery in the belief that this treatment lessened their chance of becoming impotent which has been shown not to be the case. When it comes to surgery, newer is not necessarily better, and we should not confuse the French work "neuf" with the French word "nouveau".Remember that the purpose of all advertising, including the advertising of medical services and products, is an effort to convince you to buy or insist on using the advertiser's product, just as in the 1920's tapeworm eggs were advertised and sold to women as a guaranteed method of weight loss.

     Finally, remember that the government always has its own agenda, and you might not know what it is truly looking for. To mention some of the more egregious government-sanctioned medical "experiments" on unwitting human guinea pigs (and Wikipedia can give you further information on each indicent) we have had (1) The Tuskegee experiment where Negro men in the USA were infected with syphilis without  being told what was being done, and with treatment then being withheld so the doctors could study the "natural" course of the disease, (2) The infecting of Guatemalan natives with gonorrhea, again without telling them what was being done to them, or offering any treatment (3) the testing of the efficacy of Birth Control Pills on females in Puerto Rico who were told that they were getting a free pill to prevent pregnancy, but  50% of the women received sugar placebos instead without being told of the substitution. I won't even mention the escape of nerve gas from the U.S.Army Proving Ground in Dugway, Utah that killed over 6,000 sheep, or the CIA putting LSD into the drinks of unsuspecting drinkers at bars in the 60's to study the effects of LSD on unsuspecting users.

     And be very careful about announcing that the (government) agent is wearing no clothes. In 1947 or so, a noted atomic physicist, Lewis Branscomb, was appointed head of the National Bureau of Standards, In the course of his government-directed studies, he conclusively demonstrated that an advertised additive did not extend the useful life of a car battery. He was subsequently hounded and persecuted by the Senator from the state in which the additive was manufactured.


Sunday, September 18, 2011

What I Covered in a Patient's Medical History by Dr. Robin Motz

     I am continually surprised at the lack of depth and detail in many medical histories that I read that were in the charts of new patients. Of course I was trained at Columbia Presbyterian Medical Center in the late 1970's, and we were taught to allow at least a full hour for the complete history and physical of a new patient. I also have to mention that the last medical patient I admitted as an intern in June 1976 to ward 9W was a 19 year old female with new onset diabetes presenting as DKA secondary to an unknown infection. I examined her down in the ER, brought her up to the ward, and broke her DKA  20 minutes after I extracted a tampon I found on pelvic exam that  she had forgotten  she had inserted the previous month and was the source of her infection.

     We were also taught to come out and greet the patient in the waiting room and escort the patient back to our consulting room, rather than have the PA put the patient directly into the exam room.

     I would like to list here some of the questions that I find are often not asked of a patient on the initial exam by the new physician. This of course pertains to the office exam, and not to the ER exam. In the ER as I would tell my residents, the two main considerations are: (1) does this patient need a hospital admission, and (2) what disease or process can the patient have than can kill him/her before I come in to make my morning attending rounds  (and, in the case of females, ALWAYS do a pregnancy test). The following list is not exhaustive, but I believe that if the questions are not asked, the patient is not going to get the best possible medical treatment.

The order of the questions is usually unimportant, and their place on the list need not correspond to their importance.

1) Are you allergic to any prescription drugs? What was the reaction? (Important)

2) Are you allergic to any over-the-counter-drugs or vitamins or health foods?  What was the reaction?

3) Were you ever hospitalized for any allergic reaction and did you have to be intubated?

4) What prescription drugs do you take and what are their doses? What was the last one added?

5) Are you on birth control pills (many women do not think of this as a prescription)?

6) What daily vitamin and food supplements do you take?----dosage and frequency. ?Daily aspirin dose?

7) Have you ever donated blood? To the blood bank or prophylactally pre-surgery.

8) Have you ever received a blood transfusion? After an accident? or surgery? or childbirth?

9) Do you still have your gallbladder, appendix and tonsils? Any recovery problems or excessive bleeding?

10) Last TB skin test and AIDS test.

11) Last tetanus, pneumonia , and flu vaccine. .Vaccinated against hepatitis A,B; or HPV? MMR? one or two?

12) Have you ever had unprotected sex? More than once? What were the circumstances?

13) When you were a child, did an adult of either sex ever make inappropriate advances to you?

14) Any broken bones, or damages in a motor vehicle accident?

15) Any surgeries or transplants. If yes, any anesthesia reaction?

16) Date of last mammogram, pap smear, colonoscopy, chest x-ray, EKG, stress-test, bone density test.

17) Date of last eye exam. Can you read street signs at night? Are you fearful of night driving?

18) Where were you born, where did you live and go to elementary school, high school, and any college or further education. Any serious illnesses or fractures or sprains while growing up?

19) Have you ever been pregnant? How many times and how many births? Medical pregnancy problems---elevated sugar, elevated blood pressure, C-section. Current method of birth control.

20) How many siblings.

21) Illnesses that run in family. Causes of death and ages at death of parents and any first degree relatives.

22) Excessive bleeding after dental work or tooth extraction or minor surgical procedure.

23) Do you look forward to your S.O. coming home, or to coming home to your S.O.?

24) When was your last vacation?

25) Do you look forward to going to work?

26) Do you have ongoing problems with your parents or inlaws?

27) With your children?

28) If dog in the house, does dog get monthly protective  treatment against Lyme ticks? What other pets, and are they sick?

29) When was the last time you had sex with your S.O.,? Did you both enjoy it? When was the last time before that?

30) Do you have trouble falling asleep or staying asleep?

31) Have you ever consulted a psychiatrist or other mental health worker? Any prescriptions given?

32) Have you ever thought of committing suicide? If yes, have you ever actually made plans.?

33) If you have a health care proxy, who is the named person? If not your S.O., what is the difference of opinion that caused that?

34) Where do you see yourself 5 years from now? 10 years from now?

35) Is there anything you would like to tell me that I haven't covered, or ask me?

36) Have you ever traveled outside the continental U.S. If yes, did you get sick on your travels? If you traveled to a malarious area did you take the prescribed anti-malaria medicine and for how long?

37) Have you ever fainted or passed out? What tests were done if you did?

38) How many times a week do you exercise?

39) What was your weight at high school graduation? College graduation? Before first pregnancy?

40) Do you think you drink too much?

Saturday, September 17, 2011

Dr. George Thomas is pen name for Dr. Robin O. Motz

Hello All,

     Because I started this blog when I was actively practicing internal medicine, I used the pen name of Dr. George Thomas. All case reports and stories of my training and attending are true. I attended Columbia University College of Physicians and Surgeons from 1971-1975, graduating as valedictorian, and was a resident in internal medicine at Columbia-Presbyterian Medical Center from 1975-1978. Upon finishing training I was immediately offered the position of Assistant Professor of Clinical Medicine at Columbia University as well as Assistant Attending in Medicine at Columbia-Presbyterian Medical Center. I am now retired from the direct practice of medicine, and am an Emeritus Assistant Professor at Columbia University.

     My home page, which contains my CV, is at

     I am now engaged in Stress Reduction,Life Coaching, Tutoring in Math and Physics, and dealing with Relationship Problems, as well as doing volunteer work at Gilda's Club of Northern New Jersey, which exists to help those patients who have cancer as well as their families, and is staffed almost entirely by volunteers. I also write a monthly column on medicine for Inner Realm, and am the Director of the Stress Reduction Center of New Jersey, LLC.

You can reach me at:
200 Grand Ave., Suite 201
Englewood, N.J. 07631-4363
Tel: 201-569-0040
Fax 201-569-3244

Robin O. Motz, M.S., M.D., Ph.D. (Physics)

Monday, September 5, 2011

The Death of Professionalism in (Internal) Medicine

     I have been in the practice of internal medicine for 30 years, starting with my internal medicine residency for 3 years  in a big city medical school hospital and then 27 years of the solo practice of internal medicine. I was taught to go into the waiting room to greet each individual patient, escort him/her into my office to discuss the presenting problem(s), then take the patient into the exam room and have the chaperone help the patient into an exam gown. During the exam, I would ask additional questions. I would then tell the patient to get dressed and come back into my consulting room so we could discuss my diagnosis and possible treatments. During all of my training and practice I was always aware that medicine was a mixture of art and science, as well as a gestalt of the patient's medical belief system. One develops a "feel" for illnesses of various types, for the presence of stress, for histories that don't quite match the physical, for the inconsistencies in the way that the patient answers certain questions, and how to recognize when the patient resists (consciously or unconsciously) when  I steered the post-exam conversation in the direction of certain diagnoses and treatments. All of this and more is contained in the professional practice of medicine, which is a mixture of medical knowledge, science, art, psychology, and empathy.

     The concept of professionalism encompasses respect for your patients, respect for yourself, a desire for the respect of your peers, a feeling of collegiality with your fellow physicians, and, I personally believe, always placing the patient's needs first, without appearing shocked at anything the patient says. Too often we doctors forget that we define what is "normal" for the patient. (The old saying that an alcoholic is any patient who has two drinks a day more than the doctor does still holds.) You should also feel personal disappointment if you do not give the patient as much time as the patient needs (within reason), or if you ever make the same mistake twice.
You should also be able to spend the majority of your time in direct patient contact and care, rather than filling out forms, calling HMO's  and drug plans, and writing letters to Medicare. And if you find that you are getting angry during your work day or telling your personal or professional problems to your patients, you should either take a vacation or change your profession.

     When I started practice I felt proud of my practice and my professionalism. I charged more than most physicians in exchange for which I gave my patients much more  time than they did,  and all my patients were happy with this arrangement. I also treated poor people for free in my office(I allowed an hour for the initial visit, and didn't charge extra  if more time was needed), I ordered the blood tests and Xrays that  I determined that the patient needed and also made  referrals to other doctors that I thought was indicated. I also made house calls and charged my patients my usual fee for the time I spend at their house, plus $25 for making the house call,. I generally was following 8 to 10 patients at home, who I saw at intervals varying from weekly to monthly. I also had patients in 2 different nursing homes.

     Then along came Medicare, and managed care (HMO's) and drug payment plans. Suddenly I could no longer take the best possible care of my patients. Medicare began by not permitting me the $25 house call surcharge to patients, so I stopped house calls and explained why. Then I had the problem of an Oxford patient needing shoulder surgery when the best shoulder surgeon I knew was part of Cigna. Then one of my two admitting hospitals had a payment argument with Blue Cross so that my BC patients could not be admitted to that hospital. Then I had to spend time explaining to a drug plan that although Nexium was their preferred PPI to suppress stomach acid, Nexium did not work on my patient and only Prevacid did. Then Medicare asked me why I did more of a certain procedure to test for cancer than other internists did. When I wrote them back asking why more internists didn't look for cancer, I never heard from them again on that subject. The final straw was when Medicare D, which pays for drugs, decided it would only pay for generic and not brand name drugs. In some of my patients, generic Ativan, or Prozac or Wellbutrin, for instance do not work. I have now dropped all HMO's and insurance plans as well as Medicare. I still have to argue with drug plans, but that is all. It is a problem for my HMO patients, because they had to find another primary care doctor for referral to specialists, but I also got tired of telling patients that I could not recommend any surgeon in their HMO. As a final note, if I saw two Medicare patients the same day in a nursing home then Medicare paid  me less for seeing the second patient and even less for the third, so I stopped seeing nursing home patients.

     I could no longer take care of my patients in the manner in which I was trained, and so I was forced to switch to an all cash billing system. This had immediate advantages. Since I no longer submitted any bills except to the patients, I did not need an electronic billing system. And one of my staff no longer had to spend half of her workday on the telephone with drug companies and HMO's.

     But to return to the problem of the death of professionalism in medicine. The insurance companies feel that all doctors are fungible and interchangeable. Anyone would agree that the best doctor (plumber, lawyer accountant) should be allowed to charge more, but no one knows how to measure them. All admissions to hospitals have to match a computer diagnosis, so I can no longer say:"This patient looks so sick that immediate hospital admission is needed". Medicare patients whom I see still have Medicare paying for their  lab tests. I cannot say that " in my experience I think this patient needs a particular blood test",  but rather I have to invent a diagnosis to justify ordering the test. The Joint Hospital Committee invented a rule that all patients with pneumonia in the ER must get antibiotics within 4 hours of ER admission or else the hospital would be sanctioned. I got used to writing in the ER chart that the patient refused antibiotics at the 4 hour mark  after I told the patient that I was unsure of the proper antibiotic at that time. I resented the fact that I had to "game" the system to obtain what I thought was the best possible care for my patients.

     In line with the anti-professionalism trend I know of two large internal medicine practices which have installed a 900 number for after-hours and weekend telephone calls. The recorded message tells callers to either go directly to the ER, or to stay on the line where they will receive a bill for each minute they spend on the phone. This has generated some additional income and cut down a lot on after-hours  phone calls.

     I cannot help but feel that patients are not as well served if doctors cannot afford to spend a lot of time with them, even if there is not a negative result in the mortality statistics. It takes much less time to order a test when a patient has a complaint than to take the time to take a proper history, but the doctor makes more money the former way. And I detest the practice of the PA going into the exam room to obtain a history and take the blood pressure.

     There is something wrong with the practice of medicine when the most competitive residency is dermatology, since  dermatologists can charge whatever the practice will bear since neither insurance companies nor Medicare pays for cosmetic dermatology. At a typical teaching hospital, the top grossing dermatologist takes in almost twice the fees that the top cardiac surgeon does. Plus we have the old saying that one advantage of dermatology is that (barring cancer) "the patient never dies, never gets well, and never calls you in the middle of the night".

Wednesday, August 24, 2011

Medical Economics

     All the talk about the overall cost of medicine is really Macroeconomics. But man is an economic animal, or so the capitalists believe, so an individual doctor's behavior must be considered from a Microeconomic point of view. Of course, in addition to making money, a doctor practices altruism, works for the good of his individual patient (which does not necessarily correspond to the good of society), spends a lot of uncompensated time (ever try arguing with an insurance company about drug coverage?), values the respect of his peers, values himself as an ethical professional, and wants to avoid being sued for malpractice (which is not the same as practicing responsible medicine---see my previous blog on how doctors can avoid malpractice suits). Then we have the insurance company and government interference when both groups say they will only pay for "indicated and necessary" tests and procedures, and then ,make doctors jump through all sorts of hoops to justify the tests and procedures (which again may not benefit the patient), but which they think will save money. Rather than writing a discursive article, I will just list the many circumstances, events, and laws, some of which are based on flawed and/;or unproven assumptions, that circumscribe the actions of doctors. Some of it may be unbelievable, but I can assure you it is all true, as even a cursory search of the internet will show.

1) Medicare (henceforth MCR) decreed that in order to save money, if a dermatologist biopsied two lesions at the same visit, he would be paid less for the second biopsy, since the patient was there already. Dermatologists immediately started telling their patients to come back in two weeks for the second biopsy, so they could collect a full fee for the second biopsy.

2) I used to have four to six of my patients in a nursing home at any one time, following them there after hospital discharge, until they were well enough to go home. I would see these patients every week, two weeks, or four weeks, as I thought the medical situation warranted. (And the state requires that the admitting doctor see each nursing home patient at least once in every 30 day period, which is very reasonable.) If I saw three patients in a nursing home the same day, then MCR paid me less for the second and third patient, saying that I was already there to see the first. Strangely enough they do not apply this payment process when I have three patients in the hospital and see them all the same day. So I have to make six visits to the nursing home in one month to see my six patients which is a grossly inefficient use of my time. Then if I see a patient more often than once every 30 days, if I do not have them sign a statement saying that they acknowledge that MCR might  not pay for a doctor's visit more than once every 30 days, then I can't bill the patient or MCR. I finally stopped seeing any nursing home patients. They were not medically abandoned, since by law every nursing home must have an attached doctor who will admit and follow medically any patient who does not have a personal admitting doctor.

3) An orthopedic surgeon is paid a fee for surgery that includes all the follow-up visits and care in the hospital. He does NOT get paid extra money for a patient's extra days in the hospital. MCR rules were that a patient could go home when he/she could walk 100 feet unaided. Now 65 year old Mr. Jones was much stronger than 95 year old Mrs. Smith, and recovered faster. So the surgeon would send Mr. Jones home at the 100 foot mark, but would tell the physical therapist not to record Mrs. Smith's walking 100 unaided feet until two weeks after the surgery.

4) NY State started keeping a report card of the patient death rates of hospitals and individual cardiac surgeons. The immediate result is that cardiac surgeons stopped doing difficult cardiac cases where the estimated mortality was greater than 20%. As a result fewer open heart procedures were done in NYC teaching hospitals than were done before the report cards were issued.

5) The most competitive residency is dermatology, because of the enormous amount of elective plastic surgery that they do, such as Botox and Restalen injections. In NYC, one Botox injection costs the patient about $500, and has to be repeated every 3 months. Doctors can charge whatever the traffic will bear: since neither MCR nor insurance companies pay for the procedure, their fees are uncapped.

6) All doctors memorize the diagnosis codes necessary so MCR will pay for a blood test that is "indicated" for the diagnosed condition. If a patient looks pale and has orthostatic drops in blood pressure as well as a rapid pulse,
there is no computer code for "in my experience, this patient is anemic". But if I ask him if he/she has ever been tired in the past 20 years, and I get a "yes" answer, then the code 780.79 (fatigue) will let MCR pay for the blood count (CBC). We do this all the time, since there is no fuzzy logic in computer diagnoses, any more than I can say "this patient looks sick and needs hospital admission".

In the same vein, hyperthyroidism is one of the treatable causes of high blood pressure. Until a few years ago, a diagnosis of 401.9, hypertension, was a justifiable diagnosis for MCR to pay for a thyroid test. Then they stopped allowing this diagnosis. Thank God at every autopsy every patient has at least one minute thyroid nodule, so we can put down "goiter" as a diagnosis in order to measure the thyroid hormone of a newly hypertensive patient without breaking the law.

7) All hospitals are paid for an admission by DRG's, or Diagnosis Related Groups. That is if I admit a 65 year old male insulin-dependent diabetic with an anterior wall heart attack, then the insurance company or MCR  will pay for X days of hospital treatment. If the patient is sent home before X days, the hospital makes extra money on the admission. If the patient stays longer than X days, then the hospital loses money. The hospital puts pressure on the ward attendings who pressure the residents who pressure the interns into discharging their patients home as rapidly as possible. Every patient has a "problem list",or a list of his/her medical problems in descending order of importance: (1) heart attack, (2) insulin-dependent diabetes, (3) non-suicidal depression secondary to #1, etc. Now the common saying is: "Problem #1---discharge plans".

8) As an aside, there is a perfectly good reason why doctors are not supposed to treat their families: insufficient emotional distance, and a chance of making a medical decision for partly non-medical reasons. But now all the states require family members to decide when to "pull the plug" on a family member, a decision they are neither emotionally equipped to do nor have any emotional distance from. So according to the state, it is right and proper for a person to end the life of a family member, but not proper for a doctor to write a prescription for a family member. And let's not forget that the doctor probably knows his/her patients true feelings about death and life better than does the family, We all have families in our practice  where the spouse is not given this decision-making power because the children are trusted to make the patient;s wishes come true, and not the spouse.

9) Until recently, MCR said that a patient needed two units of blood or no transfusion at all, and sanctioned doctors who gave only one unit. Guess what the doctors started doing with all their MCR patients if they felt they needed a transfusion of one unit of blood?

10) Medicare is going to reward doctors who prescribe electronically and financially penalize doctors who do not, without any pilot study showing that electronic prescribing either saves money or is safer for the patient. The same Johns Hopkins pediatric hospital that showed the numerous errors resulting from in-hospital written orders instituted an electronic ordering system. A follow-up 2-year study showed no decrease (and a statistically insignificant increase) in medication errors.

11) Finally MCR pays non-linearly. A lawyer or plumber charges a fixed amount per hour, broken down into 10 minute segments or whatever. But MCR will pay me much more to see 2 patients in 20 minutes than 1 patient in 20 minutes, even if the single patient gets better care and a more precise diagnosis from the extra 10 minutes of my . So if a doctor wants to make more money, he will see one patient every 10 minutes and order a test and tell the patient to come back, rather than one every 20 minutes. And let's not forget that psychiatrists get paid 2/3 of what an internist gets paid for the same amount of time, probably because the government feels that if you are a little crazy it won't kill you!

Monday, July 25, 2011

Depression Rx: Psychotherapy w/wout Anti-Depressant Medicines

     There have been several opposing articles written recently in the medical journals as to whether or not "antidepressants" (i.e. drugs) really help treat depressed patients, as opposed to classical psychotherapy and/or placebo. It seems to me that the anti-articles are tilting at windmills. I will discuss here how to (usually) diagnose depression, and who determines  whether or not  the antidepressant treatment ( psychotherapy, drugs, drugs plus psychotherapy, electric shock treatment) really "helps", and what the direct and surrogate markers are used to reach the conclusion that "this treatment helps depression" (better than placebo does).

     To begin with, depression is usually thought of as an affective disease, in  that an interviewer often feels sad after interviewing a depressed person. Freud likened the affect of depression to that of prolonged melancholia, or grief over the loss of a loved one. Depression normally creates some degree of insomnia while it simultaneously  reduces the patient's interest in or ability to enjoy pleasures of any kind: food, sex, entertainment, etc. It is extreme anhedonia (to paraphrase Woody Allen).

     As a family internist, the most common manifestation I see of depression is irritable bowel syndrome, with random abdominal cramps relieved by urgent diarrhea, often  alternating with constipation, where the stool is usually  covered with mucus. The patient is generally totally unaware of this manifestation of depression, but since our entire peristaltic digestive system, from the posterior oropharynx to the proximal rectum is under autonomic control of the spinal cord efferent motor nerves which are in turn controlled by nerve connections to the brain, the relationship  is obvious. (This was first shown by a French-Canadian surgeon who treated a patient with an accidentally self-inflicted shotgun wound to his stomach, and who could then lift an abdominal skin flap to determine how the stomach and digestion responded to extreme emotions.)   And as I treat such patients their attacks, from globus hystericus on downward slowly improve. I should also mention that depression lowers the body-wide threshold to all pains and discomforts, including headaches, and concomitant  lack of sleep further degrades executive ego functions and increases irritability.

    Now what do we mean by "successfully treat"? From the patient's point of view, we have treated him/her successfully if his/her distressing symptoms are reduced or vanish. I leave it to the extreme Freudians to worry about a "flight to sanity", or that  the patient doesn't realize that the depression is persisting, much as Marxists would insist that any worker who didn't feel exploited was brainwashed. So if the patient feels "better" after initiating anti-depressant therapy, is sleeping better or feels less "down", do we consider the treatment to be successful? The problem is that when medical journal articles are written, it is the treating doctors who decide if the treatment "works", and not the treated patient. And there is also political input: the cities of Berkeley, California and Cambridge, Mass. have both decided that electro-shock therapy is useless, and have passed laws banning this treatment of depression within their city limits. I can tell you from personal observation that in some elderly depressed females, where no drug helps, electro-shock therapy definitely relieves many of their symptoms of depression and enables them to resume  the activities of daily living.

     Part of the problem is that while classically depression is thought of as a reaction to a real or imagined loss, I have found that it most often is related to suppressed anger, and there is no pill that treats anger directly. Since most women have been taught by their families and/or society  to suppress or ignore  their anger and not let it show, more women are depressed than are men. Some of the anger results from women resenting the fact that acting as society wants/expects them to act does not invariably bring happiness.I have found that allowing a depressed female patient to acknowledge her anger and not treat it as an unwanted alien often helps to alleviate their depression. Anger is a normal human emotional reaction dating from infancy, and it delegitimizes the ego to tell the child that she "should not" feel angry. It is therefore truly surprising when some of my female patients insist that they "don't have an angry bone in my body". At the same time, there is little or no social disapproval of men who display their anger. Few if any women would openly state at Leo Durocher the baseball manager famously did that "nice guys finish last".One of the most common examples of depression-inducing anger can be seen in an only daughter who is taking care of her mother in a nursing home and who  also has mixed feelings about her mother.

     I personally agree with a famous physician who stated that a doctor's role is "to cure sometimes and to comfort always". If any interaction, procedure or medicine can relieve the psychically and/or physically painful symptoms of depression, then the patient has been helped by the treatment, even if the case is an "n-of-one". I have several elderly patients in my practice who say that an aspirin tablet at bedtime is a wonderful sleeping pill for them. It would benefit no one if I told them that there is no medical evidence that aspirin has soporofic properties. So in my opinion many of the articles pro and con treatment of many psychiatric ailments are not helpful to the average practitoner or patient, and we should use our experience guided by intelligent reading of the literature. And we should ignore the unsubstantiated statement in the PDR at the end of every set of  warnings that the use of beta-blockers (Inderal, Toprol, etc.) makes depression worse. There is no medical evidence for this, and, in fact, several years ago the New England Journal of Medicine published an article showing that beta blockers did not exacerbate any of the symptoms of depression.

Monday, July 11, 2011

Addiction # 2

     There was an article published recently in the NY Times saying that some doctors are treating (alcohol and drug) addiction as a physical and not a mental problem, claiming, among other statements, that MRI's have shown permanent changes in the brains of addicts. They state that therefore treating addiction is a life-long treatment, much as treating diabetes mellitus is. They completely ignore the fact that any almost any part of the brain can be changed by behavioral modification, the environment, or by drugs. If the brain moved from state A to state B under the influence, say, of heroin, why do they assume that the change is a one-way process? There is no evidence that the system cannot reverse itself, with outside help, and move back to state A from state B. How do they explain the fact that some heavy cigarette smokers awake one day and decide to smoke no more? And do their brains show similar MRI changes?

     I had written a previous blog on addiction, and I refer the reader to that one for background. I would also like to mention that the line between addiction and habit is poorly drawn. Is there a permanent change in the brain of a chronic fingernail biter? Are there similarities in the MRIs of the brains of addicts and those who are persistently happy? And in what way is obsessive-compulsive behavior different from an addiction, and what do the MRI's of their brains look like? Are an addict if you enjoy using a legal drug as opposed to an illegal drug?

     All babies desire instant gratification, and cry and yell if they do not get it. The process of civilization, of being raised in a family, of going to school, and growing into "normal" adulthood is largely a process of learning to defer present pleasure for future gain. The problem, of course, is that most addictions give  instant gratification, and how do we modify the brain so that the ego does not seek this? Again, I note the curious exception of nicotine and tobacco: we cough heavily when we inhale our first cigarette, which would seem to be a  negative reinforcement,   but we persist until it feels "good". (Some people would say the same about the taste of beer.) And most drugs are either uppers or downers, in that we engage more heavily with the world, or draw into ourselves. However, pharmacology is not a prediction of social effect: alcohol is a CNS sedative, but people become much more garrulous and interactive under its effect, while heroin, also a CNS sedative, helps you to withdraw from the world and, some addicts add, achieve Nirvana (which is also sought by Buddhists).

     It would seem that almost all pleasurable activities either increase the amount of CNS endorphins ("runner's high") or transport us or insulate us from the present world. I would go so far as to say that ALL pleasurable activities (except for sex between two people who love each other) is an escape: opera, reading, movies, museums, playing Gameboy, fishing, golfing, kayaking, skiing,  bicycle riding, amusement park rides, sniffing glue,nursing your baby, doing your job if you love it, watching your child graduate, seeing your child being born,  or (Jeter's father) seeing your child get his 3000th hit in baseball with a home run, or completing the iron man marathon. I will defer  a discussion of the joys of sex (including masturbation) to a future blog.

     Freud stated that although conforming to the norms and rules of civilization and of your family are bound to make you neurotic, so  long as you possess the ability to work, to love, and to play, you are relatively normal and high-functioning. He had little to say about the use of drugs, and he himself used cocaine frequently. For that matter Halsted, the father of American surgery at Johns Hopkins, was dependent upon daily injections of morphine, but that did not prevent him from being one of America's most brilliant surgeons. I also don't know if the patients of mine who use cocaine only on weekends and whose work does not apparently suffer from this use are true addicts, and how to characterize the may patients and couples in my practice who get stoned nightly on marijuana.

     Then of course, we come to the question of other addictions : food, gambling, sex, etc. In each case, the person prefers the immediate gratification of that action to deferment of pleasure. Even Jackie Kennedy on her deathbed said that she wished she drank more champagne, and very few businessmen on their deathbeds say they wished they worked longer hours at the office. I note in passing that Tiger Woods was denoted a "sex addict" because he slept with 20 to 30 women while married, while Wilt Chamberlain, who openly boasted about having sex with over 13,500 women was not labeled a sex addict because he was not married (!?). I have one patient who feels that a night without an orgasm is a wasted night, but that is her philosophy.

     What it all boils down to is that the pleasure-pain principle rules a large part of our life: some get pleasure by deferring future pleasure, some get pleasure from their families, some get pleasure from their physical complaints (we call them "hypochondriacs), some get pleasure from other people's misfortune (we call them "sadists"), and some get pleasure from immediate escape. In fact, as a doctor, I have come to the conclusion that if an overweight diabetic does not want to lose weight, then some pleasure is derived from this lack of action. This is precisely why gastric bypass surgery is the most efficient and productive way to treat overweight diabetics.

     Since our teenagers' minds are not yet fully formed nor  capable of easily deferring immediate gratification, we fight as hard as we can to keep them from acquaintance with drugs, alcohol and sex.The problem is that their experienced high school colleagues will try to induct/indoctrinate them into this realm,so they are subject to both peer pressure and the tantalizing possibility that something unknown may make them feel better and happier. This is why I would like to reduce the drinking age to 16, especially for non-drivers, so they can learn to drink "responsibly" because they have to come home to mom and dad, rather than have their first drinking experience as an unsupervised 18-year-old college freshman. And state college campuses are even more dangerous: they tend to be strictly dry, even at the fraternity houses on campus, so the students  go off campus to drink and drive back drunk. I don't think that is an improvement.

     As an aside about sex: I tell all of my teenage female patients to always carry a condom in their purse, to never tell the boy if you are on the pill, and to tell him "if he doesn't put it on, he doesn't put it in". I find I have to be direct with the modern teenager, so there is no misunderstanding of my message. I give the boys the same message, but is is less critical for them from an STD point of view, and some of them know it. And as I've said before, if a young adult comes to me and asks for an AIDS and STD test, either because they had unprotected sex or their future sex partner requests it, I tell them to go to their local Red Cross office or hospital and donate a unit of blood, and they will be tested for AIDS, syphilis, West Nile Virus Hepatitis A,B,C, and some other diseases such as Chagas'.