medicine: facts and fictions

Test Blog # 3

2012-01-23T08:48:00.000-08:00

"When a man marries a woman, he hopes she will never change,and she plans to change him, and both attempts are doomed to failure."---Albert Einstein, Nobel Laureate in Physics

Medical Tests for Patients

2012-01-22T12:47:00.000-08:00

This blog is a follow-up to a previous blog on medical testing. Here I will discuss the philosophy that underlies most, but not all medical testing. As you will learn, many tests have no clinical evidence of their usefulness, but that may not stop a doctor from ordering it or a patient from requesting it.

Firstly, I never worry about whether or not a test is "cost-efficient". My moral commitment is to my patient, and not to the amount of money his/her medical care may cost. That is not my decision to make. In other words, I am making a medical decision for one person and not for the 300,000,000 people who dwell within our borders, and I am sure you would want your personal doctor to think and act in the same manner.

Secondly, even if I think a test is not needed, and am fairly certain that the test will be negative, if the patient wants it I generally order it. To me, the fact that the patient will be relieved when the test comes back negative is generally sufficient reason to order it. Often the test is requested because a spouse suggested it, or a best friend came down with a particular disease, or it was discussed on TV or read about on the internet. For instance, for a while the magnesium content of red blood cells was thought to be related to chronic fatigue syndrome, so patients wanted this measured. I do, however, refuse to do tests suggested by The National Enquirer.

As I have mentioned in a previous blog, if a patient comes in requesting an HIV/AIDS test because he/she is starting a new sexual encounter, I refer them to the Red Cross or their nearest hospital. I explain that not only will the blood bank test the blood for AIDS for free (as well as for hepatitis and a host of other blood-borne diseases) but that they will also be helping their fellow citizens by their donation of a unit of blood. I also suggest that their future partner do the same.

Although there is absolutely no evidence that a vaginal ultrasound or the blood test CA-125 can detect ovarian cancer early enough to save lives, I will never deny a woman's request for these tests, because a negative test sharply reduces their worry/concern about having this dread disease.

I have a moral antipathy to the traveling ultrasound trucks that pull up to a nursing home and offer to test the residents for narrowing of their carotid or femoral arteries or an abdominal aortic aneurysm They tell the residents that they are giving them a half-price special because Medicare does not pay for these screening tests. But then they give the results to the patient and tell them to consult with their personal doctor about any abnormal results. To me, this is equivalent to abandoning the patient, and should be outlawed. Any doctor who orders or performs a test on a patient is morally (and should be legally) required to do all the necessary clinical follow-up of any abnormal results.

The same holds true for the total body CT scan that looks for calcium in your brain, your lungs, your coronary arteries and your abdomen. Again the patients are offered a "discount" and are told to follow-up with either their personal physician, or a physician at the hospital where the CT was done. The patient is never informed about the percentage of false positive tests, or if detecting calcium in a particular organ does indeed lead to an intervention that saves lives.

No comment is necessary about the PSA blood test for putative prostate cancer.

Patients should be made aware that the "normal" range for a given blood test is usually the average value of same sex adults plus or minus two standard deviations. This means, assuming the values of the blood tests are scattered "normally" (i.e. in a Gaussian distribution) throughout the test population, then for almost any blood test 5% of those tested will have an "abnormal" lab test, i.e. a value outside the "normal" range WITHOUT having a medical disease.
It is trivial to show that it then follows that in a panel of 25 blood tests, the average patient has a 50% chance (one out of two patients) of having an abnormal blood test. I have not even mentioned that there are racial differences in blood tests as well. For instance, without any disease, the average white blood cell count of white American adult women is 4.5, while the average white blood cell count of black American adult women is 3.5, just as the normal hemoglobin count for adult women is lower than that for adult men, and the normal ESR (sedimentation rate) is higher for women than for men, and teenagers have a "higher than normal" alkaline phosphatase because their bones are still growing. To repeat: you can have an "abnormal" blood test without having any illness at all, much in the same way that any plain Xray of the neck or lumbar spine of every adult 40 years old or older will always show "arthritis", even when the patient is pain-free.

The public is also blissfully unaware that the cutoff value for certain blood tests is determined (and not unanimously) by a group of doctors in Washington, D.C. much as one year the American Psychiatric Association voted that homosexuality should no longer be considered as evidence of a mental disease.
When I was in medical school, the upper value of "normal" fasting glucose was set at 140. It has since been lowered to 120, then 110, and most recently 100, with patients between the "normal" level and a glucose of 200 have been labeled "pre-diabetic". This label has increased their life insurance and long-term care insurance premiums without any demonstrated improvement in their health.

I will close by mentioning that not all clinical laboratories are equally skilled in measuring all lab tests (e.g. N-terminal parathormone), that some "normal" values for the same test are different for different labs, and that the first thing that should almost always be done with any abnormal blood test is to repeat it, rather than to automatically assume that the patient is ill.

Patients' Denials, Lies, and Forgetfulness

2012-01-14T21:58:00.000-08:00

This blog is not intended to be critical of patients, but to point out the various ways in which patients mislead their doctors, either consciously or subconsciously. Lawyers have told me that they have a similar problem in that many of their clients do not tell them all the facts of the case. The people who lie the least to doctors are the parents of sick children (barring Munchausen by proxy or child abuse). I always tell my students and interns before I examine a new ward admission in front of them not to feel surprised or embarrassed if I elicit different answers to the same questions that they asked. The patient may have been under more stress, or heard the question differently, or the spouse was present, or I phrased it differently, or they are no longer as anxious as they were in the ER, or feel better, or didn't like the admitting doctor, or trust me more because I am the same sex or the opposite sex or the same race or the same age or older or taller or they like my smile better or my voice better or whatever. There is also a psychological transference that takes place subconsciously in that the patient will, to a greater or lesser degree, involuntarily relate to me in a manner similar to his/her relationships with previous authority figures such as doctors, parents, teachers, supervisors at work, ministers, spouse, older siblings, or whoever, and in addition the admitting intern may have reminded the patient of someone the patient disliked intensely or had a negative interaction with.

Many "lies" are memory lapses or a misinterpretation/misprocessing of the question. For instance, some men may recall that they had a hernia operation as a child, but forget on which side. I myself broke my fifth metatarsal when I was 14 years old playing football, and I think but am not absolutely sure that it was on the right side. OTOH I am certain that I had a greenstick fracture of my right forearm because I vividly recall my inability to twirl spaghetti on my fork with my left hand when my right arm was in a sling. Many patients know that one eye is weaker than the other, but never remember which one, and often do not recall that their eyeglasses also correct for their astigmatism, or if they were ever tested for color-blindness.

A patient will answer "none" when asked if he/she had any operations, and then when you ask about a surgical scar on their abdomen they will say "Oh, I forgot". A female patient will answer "no" when asked if she takes any prescription medicine, but then answer "yes" when asked if she takes birth control pills, because she associates medicine with treatment of an illness, and not the prevention of pregnancy. Patients will tell you they had open heart surgery as a child but have absolutely no recollection of what sort of surgery it was, or what condition it treated. Very few patients travel with a complete list of their medicines and their dosages,
and virtually no one recalls the date of their last tetanus shot, or if they ever had a skin test for tuberculosis unless the test was mandated because of work.

Patients want to appear to be healthy and moral to their doctor, and this is where deliberate misconceptions come into play. They tend to minimize or forget to mention actions that they think the doctor will consider immature or unwise or immoral, not realizing that we have probably heard it all before. A wise and good family doctor will not appear to be a censuring moralist, lest the patient suppress uncomfortable truths. It is sometimes helpful to tell the patient (and mean it) that you will not write down anything the patient does not want you to record in the medical chart for all the world (including the internet, the spouse, the employer and the medical insurance company) to see. I always do this----I keep a separate list of the patient's true medical problems that are not in the chart---(has a lover, had an abortion, uses cocaine) and I forward this information only verbally to the next treating doctor.

Men deny many more symptoms than do women. The only symptom that I have seen to cause a man to come running to his doctor is when he urinates or ejaculates blood. Any other symptom, including rectal bleeding, coughing up blood, or chest pain usually has to recur at least two to three times before the doctor is notified (unless the wife is aware of the symptom). Patients who take their own blood pressure or measure their own blood sugar level at home usually do so two to four times at a single sitting, and write down the best numbers to give to the doctor at the next visit.

As a final note, you can take it for granted that if the wife accompanies her husband into your consulting room and listens as you obtain his medical history, he will rarely tell you the whole truth. He will only tell you symptoms and worries that (a) he is willing to have evaluated, and that (b) he does not mind his wife telling him what to do about. If the wife mentions a symptom, the husband usually promptly minimizes it. And if you interview the husband alone and the wife later calls you to ask you what you told the patient to do about his chest pain/erectile dysfunction/cigarette smoking/shortness of breath/overweight, you are ethically bound to answer that you discussed the problem fully with your patient and that she is free to ask him about your answers, even if she has told you of a symptom that the patient did not mention to you. It is a general observation of mine that wives worry more and show a greater concern about their husbands' health than the husbands themselves do. This seems to be a gender issue, in that husbands often do not want to have symptoms investigated if they think (a) they will not like the result or (b) they will not like the suggested intervention and treatment. I share space with a sleep-study lab, and I cannot begin to tell you how many men, when they come back to discuss their positive results, emphatically state that "If I had known that I would have to wear this d**mned mask every night, I would never have taken the d**mned test!".

Medical Mis-knowledge

2012-01-13T11:07:00.000-08:00

This blog was triggered by a recent summary of the Cochrane reports, as published by the British Medical Journal. The Cochrane Reports evaluates all recommended medical practices to determine if there is any valid (experimental and clinical) reason for them. Usually there is not.

Test blog # 2. Please ignore the above. Bugs almost all out of system.

Male-Female Attraction: The Thunderbolt and others

2012-01-13T10:09:00.000-08:00

This is only a test of the e-mail sending system of my blog.

Anger Part III----Anger: One Cause of "Acting-Out"

2012-01-12T19:20:00.000-08:00

There are probably other causes of acting-out, and certainly there are other self-destructive manifestations of anger, but the following comments are derived from my tutoring of and therefore also life-coaching schoolboys from the 7th, 8th, 9th and 10th grades. In most cases, their acting-out in school was first officially commented on in or near the 4th grade, when they were 10 years old; i.e. still pre-pubertal. They were generally given a diagnosis of ADD/ADHD, and referred to a psychologist for behavior modification and to a psychiatrist for medication, usually a CNS stimulant such as Ritalin or Adderall. They also usually developed insomnia at about the same time.

Their parents referred the boys to me because they knew that I had been a professor of physics, and that I also used to teach in the science honors program given for bright junior high school and high school students Saturday mornings at Columbia University. I was nominally supposed to tutor them in math and science, but of course it evolved into life-coaching since their societal attitudes had to be adjusted by the students themselves, with some input from me. Remember that all of these boys had gone through nursery school in Bergen County, where they had learned to color within the lines, line up, be polite, follow orders, ask for permission, sit in their seats unless given permission to leave, etc. They also were in private school K-8 or 9-12, and the private school would never allow a boy who was obviously acting out in the interview, etc, to be admitted, so we know that they knew how to "behave"; it was just a matter of what they felt like doing in school and why. By the 7th grade it was obvious to everyone that the students were performing way below their abilities, as evidenced by the downward deviation from their previous scholastic levels, and I was asked to tutor/educate/motivate them. They were still being followed by psychiatrists or other therapists.

One common manifestation of their anger/acting-out was their handing in homework late, or incomplete, or not at all. The usual cognitive tricks such as asking the student to place the finished homework by the front door, or giving the parents a copy of the homework assignment never worked, because like the act of doing the homework itself, it required the active cooperation of the student. You know you can't make a two-year-old eat spinach if he is unalterably opposed to it and you also can't push on a rope. Either analogy will do. I had to help the students to understand that this negative behavior, although it made them feel better by "rebelling" only hurt them because they would be labeled as unreliable and undependable.

Another manifestation was that of doing poorly in tests, either by running out of time and not finishing the test, or leaving questions blank and unanswered. Like underperforming their homework assignments, they felt that they had demonstrated something by their actions. Again, I had to point out that all the teacher would note was (a) poor test results and (b) underperforming, and that this "rebellion" served little purpose since no one would understand or applaud their martyrdom.

All of these actions are, of course, examples of passive aggression, taken to the extreme. They all affected "la belle indifference" as a response to all the negative comments about their actions, as though they were above it all, and that it all was of little consequence in the long run and could not possibly affect their lives as grownups. The problem could not be solved by addressing their anger directly, because the anger was disconnected from their self-picture of reality.

Each student had to be convinced that the world at large didn't care if he was angry or unhappy, but was only interested in the results of his actions. They had to understand that actions or lack thereof did have consequences, and if a teacher labeled them as "unreliable", it would make their future lives quite difficult. They finally understood that their first recommendations come from their high school teachers, and that in these days of electronic records, once a comment was entered about their behavior or performance, be it good or bad, it would follow them for the rest of their lives, sort of like a scholastic Facebook.

I have come to the conclusion that parents have to explain to their pre-adolescents that actions and society's opinions of their actions do have long-term consequences. Yelling at the boys to do their homework or make their beds or pick up after themselves usually has little effect. Boys seem to enjoy whatever rebellion against society they can get away with , especially if it also draws attention to themselves. Of course now with cellphones, the boys all talk with each other and give each other advice as to how to "handle" their parents or school. It's not as serious as the website that teaches anorectic girls how to hide their anorexia, but there is always a subculture and a background current of which parents are (blissfully?) unaware.

Dangers of taking Prednisone (Anti-inflammatory Steroid)

2011-12-31T13:15:00.000-08:00

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
seizures
mania
insomnia
ocular cataracts
insatiable appetite
osteoporosis
clotting problems
myopathy
tendon rupture
pseudotumor cerebri
glaucoma
pancreatitis

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.

Anger Part II--Anger grows out of Frustration

2011-12-28T10:42:00.000-08:00

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.

Anger Part I

2011-12-26T10:30:00.000-08:00

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.....

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

2011-11-14T11:51:00.000-08:00

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.

Why Evidence-Based Medicine and Government Guidelines are Impractical

2011-11-06T11:20:00.000-08:00

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.

Why Patients Don't Follow Doctors' Orders.

2011-10-30T19:20:00.000-07:00

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.

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

2011-10-16T20:12:00.000-07:00

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.

To PSA or Not To PSA, That is the Question

2011-10-11T19:35:00.000-07:00

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.

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

2011-10-09T12:06:00.000-07:00

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.

New Medical Device = Guinea Pig Patient

2011-10-03T07:46:00.000-07:00

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.

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

2011-09-18T09:33:00.000-07:00

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?

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

2011-09-17T10:59:00.000-07:00

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 www.DrRMotz.com

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
rom1@columbia.edu

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

The Death of Professionalism in (Internal) Medicine

2011-09-05T17:16:00.000-07:00

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".

Medical Economics

2011-08-24T20:08:00.000-07:00

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!

Depression Rx: Psychotherapy w/wout Anti-Depressant Medicines

2011-07-25T11:03:00.000-07:00

     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.

Addiction # 2

2011-07-11T21:09:00.000-07:00

     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'.

Some of My Medical Observations and Thoughts

2011-06-14T19:13:00.000-07:00

     1) A bowel movement a day is not necessary for good health, nor are coffee enemas.

   2) No one knows how many glasses of fluid the human body requires in a 24 hour period. We do know that if we ingest 0.5 L of water a day we can clear all the byproducts of our metabolism if we have normal kidneys.

   3) For men, as a rule, if your urine is darker than light yellow, you are relatively dehydrated.

     4) Whether your stools float or sink has nothing to do with your health or wellness.

     5) We don't know how many hours of sleep an adult needs, but we do know that different people have different needs. One way to test yourself is to see how much later you sleep on Saturday or Sunday morning when you don't have to get up.

   6) Eating salt will not cause you to have high blood pressure any more than eating sugar will give you diabetes. (But being severely overweight puts you at risk for both of these disorders.) And we don't understand why some patients lose weight easily on the Ornish diet, while others lose weight more easily with the Atkins diet.

     7) It is probably true that the reason many women and almost no men need bunion surgery is that high heels shift the force of your weight forward on to your big toe, and by Wolff's Law, pressure and/or weight-bearing on a bone causes the bone to grow and enlarge just where the force is applied (i.e. the big toe).

   8) An alcoholic is defined as anyone who has two or more drinks a day than his/her doctor does.

   9) There are no eye exercises to improve myopia (near-sightedness), and wearing glasses does not make your eyes weaker. There is some evidence that ultraviolet rays may contribute to the formation of cataracts; if this is so then wearing sunglasses should help to forestall the development of cataracts.

   10) No doctor ever got sued for doing a test, but only for not doing one (And the jury will never agree with the doctor's reason for not doing the test if the patient got injured or died.)

   11) An hour of sleep before midnight is not worth two hours after midnight.

   12) Caffeine improves mental performance on written tests, and shortens your reflex time in hand-eye coordination sports. (No-Doz worked!)

13) The majority of women dream in color, and the majority of men dream in black and white.

14) No one knows how may meals we should eat a day for optimum health, nor do we know whether the biggest meal should be in the AM, at noon, in the PM or in the evening.

15) We don't know why in the Far East adults with the higher BMI   (body weight) have a lower rate of heart attacks.

16) We don't know the optimum interval for a complete physical: 6, 12, 18 , or 24 months or whatever. The same is true for the frequency of eye exams, mammograms, pap smears, colonoscopies or ANY periodic medical exam or medical blood test or Xray, even if the doctor is following a disease you have.

17) Only we and the guinea pig need Vitamin C as part of our diet to prevent scurvy. All other animals possess the gene necessary to synthesize it. And your body only sees the chemical we call "Vitamin C", AKA ascorbic acid, and it cannot tell where it came from, whether "natural" or man-made, since any chemical process depends on the structure of the chemicals, and not their origin.

    18 An alcoholic drink a day (beer, wine, or whiskey) seems to help prevent death from heart disease, but the US Government refuses to recommend it.

19) Vegetables do not need Vitamin B-12 to make their DNA, so vegetables contain no DNA. All animal cells contain DNA, including eggs and fish. So if you have a purely vegan diet, you will develop a Vitamin B-12 deficiency which in turn will lead to pernicious anemia and/or irreversible damage to your peripheral motor and sensory nerves as well as to your brain.

   20) Patients always lie to doctors, so as to put themselves in the best possible light. They don't realize that we have seen it and much more many times before.

   21) We don't know in America if tall people live longer than do short people, or if righties live longer than lefties. We do know that the lower your social-econonomic station in life, the greater is the risk of disease and early death.

    22)Men are possessive of their women, and the double standard still applies.When a married man asks me for an AIDS test because he is about to start an affair, , and I ask him could his wife also be having an affair, the answer in always a resounding "Impossible".

    23 Most abdominal pains feel worse in the late afternoon and evening, and any abdominal pain in an adult that lasts for 6 or more hours may represent a surgical condition, and should be evaluated in an Emergency Room.

    24) If a doctor spends more time talking about his/her problems than listening to your problems, it is time to find a new doctor, especially if the doctor cries while doing so.

    25) If the spouse wants your patient to have a test, it is almost impossible to avoid ordering the test. Many such patients will eventually ask for the test, even after reassurance by the doctor that the test is not necessary, just to "keep peace in the house".

26) It's your body, and it is the doctor's privilege to be allowed to attend to it, so NEVER feel guilty about leaving a doctor you feel uncomfortable with, or telling the referring doctor why you don't like the specialist to whom you were referred. I never took it personally if a patient left me, since my ego is not on the line, and I feel that the patient is (almost) always right.

    27) After you have given your spouse your medical opinion for the second time, you have been heard, and anything further is nagging. Many patients can't put into words why they don't follow their doctor's advice, let alone their spouses'. For instance, all smokers know that smoking is unhealthy.

28) I practice in an upscale community, and generally see teenagers for the first time at their pre-college physical. As a rule approximately 25% of female high school seniors have never seen a gynecologist. I refuse to sign off on their physical until they do so, because I firmly believe that a woman's first pelvic should be done by an experienced gynecologist, and not by whoever happens to be serving as one at the college health clinic.

29) We could avoid many vegetable-based epidemics, such as the recent E.Coli outbreak in Germany, if we irradiated all food in the warehouse to kill all possible germs (and parasites), but the public fear of radiation will never permit the politicians to pass such a law.

30) You may or may not get lung cancer if you smoke cigarettes, but I can guarantee that 100% of smokers will develop symptomatic emphysema and end their lives attached to an oxygen tank if they live long enough.

31) Question: Should the better (and I leave the definition of and determination of such) doctor be allowed to charge more for his/her services? Neither Medicare nor the HMO's seem to think so, which is contrary to classical economic theory. Lawyers have absolutely no problem with the "better" lawyers (define them how you will) charging higher hourly fees, and this does follow classical American economic theory that the man with a better mousetrap should be allowed charge more for his services.

Cholesterol, HDL Cholesterol, and Heart Disease

2011-05-28T06:40:00.000-07:00

     I am sure that many if not all of you read or heard about the front page story in today's (Friday, May 27) NY Times that using Niacin to raise the level of HDL (the "good") cholesterol did NOT lower the incidence of heart disease. The false expectation of a benefit from raising HDL came from the common confusion (and wishful thinking, because doctors are always looking for ways to help their patients) between correlation and causation. Remember that just because taller people (on the average) weigh more than do short people, it does not therefore follow that the way to increase a person's weight is to increase his/her height.

   We doctors have many suggestions to make to our patients about primary prevention of heart attacks . By primary, I mean prevention of the first heart attack. Since the biggest risk of having a heart attack resides in those who have already had one, we have been very aggressive and successful in finding ways to prevent a second heart attack (hence the phrase "secondary" prevention). This is why a patient who has been on no medicine at all and who enters the hospital with a heart attack usually goes home on five medicines, since each of them has been shown to greatly reduce the risk of having a second heart attack.

   However, despite all our theories, and all our observations about commonalities in patients who have a first heart attack versus those "similar" patients who have not, very few interventions have been shown to reduce the risk of a first heart attack, and of these, stopping smoking leads the list. We also have over 30 years of strong evidence (but only in comparative studies) that mild intake of alcohol of any origin (beer, red or white wine, scotch, slivovits, etc.) reduces the relative and absolute risk of a first heart attack. Unfortunately, we have absolutely no idea how the C2H5OH molecule does this, and it certainly has not been linked to a reduction in cholesterol, but at autopsy mild alcohol ingesters have larger lumens (= less blockage) in their coronary arteries than do tee-totalers.We also have no strong evidence for the benefits of daily aspirin, and we certainly cannot explain the results of a 30 year epidemiological study published in Lancet as to why in the Far East patients with a higher BMI (i.e. heavier patients) had a reduced risk of heart attacks, nor can we explain the studies that demonstrate that patients who are somewhat overweight (BMI between 26 and 29) have the greatest survival rate if they have a heart attack. It is trivial to note that stopping smoking does not affect your total cholesterol, LDL cholesterol, or fasting glucose (except insofar as most ex-smokers gain 10 to 15 pounds the first year).

     In approximate numbers, survivors of a first heart attack have at least a 10% chance of a repeat heart attack in the following two years, so the results of a pharmacological intervention are readily seen. But patients with a high cholesterol who have never had a heart attack have a comparative increased risk of a heart attack in the next TEN years of 10%, so the results of an intervention have to be stronger or longer to show a statistical benefit, which is why it is difficult to show the benefits of any primary prevention in any forward double-blind study. In fact, the first double blind study of cholesterol lowering, done on male smokers in Finland with gemfibrizol, showed no benefit of reducing heart attacks until the statistical method of analysis was altered. I do not have the space here that is necessary to demonstrate why it is statistically unsound to vary your method of statistical analysis if you don't like the result of the first analysis.

     We are left with the result that elevated cholesterol, elevated LDL cholesterol and lowered HDL cholesterol are all statistically associated with an increased risk of a heart attack, but only lowering the LDL has been shown to lower the risk of heart attacks consistently. The Zetia study showed that Zetia lowered total cholesterol, but did not decrease the heart attack risk. (Which only means that this first Zetia study failed to show a benefit, and a second and possibly a third study would be needed to validate this result as a clinical conclusion.) It may well be that the real value in the use of statins to lower cholesterol lies in their anti-inflammatory properties. We now have a study that shows that raising HDL did not reduce the risk of heart attacks. We have also known for years that elevated triglycerides are a statistical risk factor for heart attacks, but no study as yet has shown that lowering the TGL level lowers the heart attack risk. (Some doctors empirically lower the TGL of all their diabetic patients because diabetics have an increased risk of heart attacks, and a relative insulin deficiency causes a rise in TGL, but there is no cause-and-effect proof yet.) We also definitely do not understand why many patients, especially females, can have total cholesterols of over 280 with no evidence of an increased heart attack risk in them or their mothers, and have very patent coronary arteries at autopsy, if one is done. We also don't know why (but we think we do) females have a lower risk for heart disease than do men, any more than we understand why lupus and anorexia are more common among women than men.

     Again, we must be very careful of assuming that any and every statistical relationship is cause-and-effect, and that if elevated "A" is associated with disease "B" then pharmacologically lowering the value of "A" will lessen the incidence of disease "B". In other words, altering a statistical risk factor is not guaranteed to affect the incidence of the disease. Very few facts are "obvious" in medicine: just recall the universal advice to patients with calcium oxalate kidney stones to lower the amount of calcium in their diet to prevent a recurrence, until a physician at UTexas, Galveston showed conclusively that INcreasing the amount of calcium in the diet DEcreased the recurrence rate of calcium oxide kidney stones. It was also thought that anti-oxidants had a protective effect against cancer, but when 50% of a matched group of Finnish cigarette smokers were given daily doses of anti-oxidants, it was found that those who took daily anti-oxidants had an INcreased incidence of lung cancer, a result to which the American Cancer Society has not given proper importance.

     Finally, we also have the Law of Unintended Consequences: When mothers throughout America gave their children pure bottled water to drink, there was an increase in the incidence of dental caries in children, until it was realized that bottled water contained no fluoride, so now they have returned to giving their children fluoride as prescription Poly-Vi-Flor fluoridated vitamins (or their equivalent), just as I did. And since they have lost the business of children with cavities, dentists are now pushing orthodontia and night guards in Medicare patients(!). In most states, when the mandatory drivers' seatbelt law was passed, the death rate for pedestrians INcreased in the first few years, and we still don't know why. And many, many doctors were guilty of prescribing combination estrogen-progesterone tablets for their post-menopausal female patients in an attempt to reduce their risk of a heart attack until the increased incidence of cancer was noted. When we advised patients to take daily Vitamin E (400 Units) on theoretical grounds to lower their heart attack risk, the first decent statistical analysis showed that daily pharmacological doses of Vitamin E INcreased the risk of having a heart attack. Similarly, when men with prostate cancer were given estrogen to decrease the effect of any androgen on the prostate, an increase in cerebral strokes was soon noted. And at the present, only God knows the effect of daily doses of CoEnzyme-Q, or the proper dosage if there is a benefit, or how many times a day it should be taken, if at all, and if so on an empty or a full stomach.

   "Life is short, art long, opportunity fugitive, experimenting dangerous, reasoning difficult....."--- Hippocrates

The Problem With Medical Clinical "Studies"

2011-05-14T06:37:00.000-07:00

     I know that many readers are confused by or why one medical study refutes or contradicts a previous one,
or by how vehemently the purported results of a study are attacked by both physicians and patients who disagree with it. I will try to give some perspective and understanding about this, including why it happens. The practice of medicine is not a precise science, but rather a mixture of scientific principles, knowledge, art, intuition, luck,and a certain je ne sais quoi. In addition, you are dealing with people, all of whom have a tremendous number of "hidden variables", as Einstein would have put it.

     In a well-designed scientific experiment, the scientist keeps all the (known) variables fixed except one, and then he/she systematically varies the one, and looks to see how the system changes. He is seeking data, or verification of a scientific law or principle, but he/she should also be aware of the possible existence of the unexpected, and be prepared to recognize it when it happens, as did Rutherford when some of the alpha particles he shot at a gold foil were deflected/reflected sharply, and he thereby inferred that the atom had a hard nucleus surrounded by a shell of atoms. When Galileo used the first telescope to examine the skies, he immediately detected the moons of Jupiter, whose existence was hitherto unexpected. When Jenner observed that farm girls who became infected with cowpox (which scarified but was not fatal) never developed smallpox, he hit upon the idea of vaccination, and showed that deliberate inoculation with the fluid from the pustules of patients with cowpox prevented the recipients from infection with smallpox. (Of course, this was done years before Institutional Review Boards and the doctrine of Informed Consent had taken hold.)

     No one argues about the correct value for the speed of light, or Planck's Constant, or the diameter of the Earth, or the distance from the earth to the sun or that the core of the earth is liquid, or that the earth is round. (Actually there is a Flat Earth Society headquartered in London, but they have yet to construct a viable model of a flat earth than explains all modern observations.) What I am saying is that if there is vigorous, heated argument about a "fact", then either the data supporting the "fact" is not conclusive, or that some people have a strong vested interest or personal or political belief that makes the existence of the "fact" inconvenient for their belief system or is psychologically stressful. The concept that "ye shall know the truth and the truth shall make ye free" has been replaced by the concept that either the truth is not for all people (hence censorship), or that the truth might lead your thought patterns into dangerous realms (hence the insistence in the Middle Ages that the Earth was at the center of the universe, or the execution of Socrates by the democratic city of Athens for "leading the youth away from the true gods", or the removal of all mention of Trotsky from the Soviet Encyclopedia by Stalin). I would briefly note the vociferous reaction to the announcement by one research group that according to their studies, annual mammograms of women between the ages of 40 to 49 did not seem to save lives from breast cancer as well as the present arguments for and against lowering the amount of salt in the diet. In medicine we still have the ongoing argument between Alcoholics Anonymous who insist that the only treatment for alcoholism is total abstinence, and other drug counselors who say that it is safe to reduce alcoholics to one or two drinks a day. Committees keep on lowering the "normal"value of fasting glucose, although no one has demonstrated any benefit in either reduced morbidity or reduced mortality by so doing.

     Now in physics we worked with inanimate objects, which we could construct as being identical and had no free will or volition. In medicine, we work with humans of all ages, sexes, color, heights and weights, with free will and various cultural and religious beliefs as well as various degrees of compliance with advice and/or medications, who may be taking some unknown herbal medicine or vitamin supplement, so the definition of "identical" is quite different. (And remember that vitamins are a huge variable: they are not under FDA jurisdiction, and the labeled dose may well be incorrect. Several years ago The Medical Letter chemically measured the amount of Vitamin E in gelcaps labeled "Vitamin E 400 Units". They found the amount of vitamin E in caps from different manufacturers varied from zero to 1200 Units.) I will not discuss Hume's famous analysis of the fallacies inherent in the inductive method of reasoning, but I will note that retrospective studies generate inductive "laws" or suggestions, while double-blind studies, assuming the model is correct, are essentially generating deductive solutions. And overall, both types of studies must deal with the question of their statistical accuracy, so I always tell my patients to wait for the second clinical study, which very often contradicts the first. I have discussed the problems with and limitations of meta-analyses in two previous blogs, so I will not discuss that here, except to reiterate that IMHO the results of any meta-analysis should be used to suggest a future double-blind experiment, and not to suggest a medical treatment.

   I will not discuss the proper application of statistics to clinical studies, since that would make this blog much too long. The most common error that retrospective and case control studies make is to mistake correlation for causation. The studies may show that patients with disease X have diet Y or do activity Z, but very often when we then do a controlled study and take a group of (hopefully) identical patients, and have half of them adopt diet Y or activity Z we find that this intervention does not affect the incidence of disease X. For instance, no forward study has ever demonstrated that a low fat diet reduces the incidence of cancer (which of course has not prevented the American Cancer Society from advocating a low fat diet as a cancer preventative). Similarly, no one has demonstrated that a low salt diet prevents high blood pressure or heart failure or heart attacks in healthy individuals. And we still don't know if the optimum diet is one, two, three, four or more meals a day, and whether or not the largest meal should be eaten in the AM, at noon, or in the PM. And once a recommendation attains the force of law, it is rarely rescinded. For instance many studies have shown that a pregnant woman can safely have one drink a day without adverse effects on the fetus, but the Surgeon General's warning remains on every bottle of alcohol sold in the U.S. We also have been told that reducing cholesterol reduces the rate of heart attacks, but cannot explain why Zetia, which reduced cholesterol, did not appear to provide this benefit.

     One example of the interpretation of treatment or intervention is the history of tuberculosis in the 20th century. The incidence and death rate from TB started to decrease in the 1920's in the USA, even though we had no antibiotics that worked at that time. Some social reformers claimed that it was due to the reduction in crowding and filth secondary to the elimination of many tenements, but of course this could neither be proved nor disproved with the available data. Dr. Waksman discovered injectable streptomycin, which was the first anti-TB drug that worked. It had the unfortunate side effect of causing irreversable damage to the 8th cranial nerve, leading to severe deafness in the patients so treated. Then INH, or isoniazid was developed in the laboratory. One of the largest groups of patients treated were veterans in the Manhattan VA hospital with TB: 50% received streptomycin and 50% received INH. INH was shown to be superior to streptomycin with the added advantage of not causing deafness. The old-time medicine cabinets had a slot in the rear for the disposal of disposable razor blades. When they tore down the old VA hospital, thousands of INH tablets were found behind the medicine cabinets, so the INH was probably more effective than anyone dreamed.

   The problem of course with all medical studies is that in successive studies the groups are never identical, so that for instance in a double blind study of any treatment of children in the 50's we had one group of children, while the identical study done in the 70's would be done on children who had received fluoride to prevent tooth decay. Therefore there is no reason to expect a priori that successive medical intervention studies should show the same result, or that a study in London should give the same result as a study in San Francisco. The laws of physics are invariant under a Galilean transformation, but people are not. The same study done in an equatorial country and in a northern European country may disagree for the same reason that children who grow up in the equatorial zones have a significantly different incidence of multiple sclerosis than do children who grow up in temperate zones (as do females who did and did not have a cat as a pet before the age of 16). For all we know, we should do historical genetic testing on DNA from cheek swabs because patients whose distant ancestors came from Asia Minor may have a different response to disease and treatment than those whose ancestors came from the steppes of Russia. Or perhaps nearsighted people and farsighted people also have different disease coping mechanisms or immune responses because of linkage on the same chromosome, and no one allows for that.No two people are identical biologically, genetically, or in their immune defenses or in their propensity to develop diabetes, or heart disease or cancer. We even have the false belief that a teacher can teach a group of 35 first graders as well as she can teach a class of 15.

   Finally the placebo effect which has been shown to be as high as 30% is nowhere accounted for in either the control group or the treated group, and the kappa statistic is an unreliable method for detecting the effect of random coincidence, since the effect can sometimes calculate out as being greater than one, which violates its basic statistical assumption.

   In the words of Ralph Waldo Emerson: "No facts to me are sacred, none are profane. I simply experiment and observe......No truth is so sublime that it may not become trivial tomorrow in the light of new thoughts and facts".

The Cost of Medical Care

2011-04-21T20:02:00.000-07:00

     I have read about various plans and schemes to pay for the present or for expanded medical care, and they all will involve rationing by available money, time, doctors, or equipment. While you are reading this blog, try to imagine how you yourself would design a medical care plan, with the proviso that you must operate behind the "veil of ignorance" that John Rawls popularized in his book "A Theory of Justice". That is, you must design a medical plan that would seem fair to you before you know your position in this self-designed society. Will you be an affluent white male living in an expensive suburb, or will you be a poor pregnant non-white teenage girl with a single mother?

     Right now, although many Americans declaim against "Socialized Medicine", I know of no Medicare patient who would not like Medicare to continue. (And why not, since they get back much more in medical services than they paid in Medicare premiums.) In addition, their middle-class children want Medicare to continue as well, so they can use their own savings to pay for their own children's college education rather than for their own parents' medical expenses. The tobacco companies briefly had an ad showing how cigarette smoking benefited the country on the bottom line: If a smoker dies before age 65, the government pockets all his/her Medicare premiums and pays out not one dime.

     BTW former president Bush was economically unsound when he said that the Emergency Room was always available to patients without doctors. By law, the ER's must accept all comers, regardless of their insurance status. Now if you tell your family doctor you have a headache, he will make several suggestions and then tell you to come in one or two days if you are not feeling better. This all involves little expense. But if an unknown patient comes to the ER with a headache, he will usually get a set of blood tests, an EKG, a pregnancy test if female, a CT scan of the brain, possible a carotid Doppler study of his carotid arteries, and then a consult with a neurologist who in turn may order or do a brain MRI and/or a spinal tap. The ER does not know you the way your family doctor does, including facts not usually written in the medical record: are you an alarmist, a hypochondriac, a stoic, a cocaine user, etc. The fact remains that NO DOCTOR EVER GOT SUED FOR DOING A TEST or ordering a specialty consult, but only for not doing the test. So the best way for an ER doctor to minimize the chances of a malpractice suit is to do as many tests as can be thought of (including a temporal artery biopsy). An article in Archives in Internal Medicine several months ago which evaluated the cost of working up dizziness in the ER was over $20,000, and the cost in the family doctor's office was only a fraction of that. The jury doesn't ever want to hear the defense that the result of a test was unlikely to be useful if the patient died or was seriously damaged.

   Let me give you some examples of the rationing of medical care in this and other countries. Medicare only pays psychiatrists 2/3 of the fee for an internist for the same amount of time in a visit---I guess they feel that if you are only a little crazy it doesn't count. Your friendly drug management company has a "preferred" list of drugs for various maladies, because they do bundle deals with the manufacturers, so one company may say that Nexium is the preferred stomach-acid blocking drug, while the other prefers Aciphex and a third prefers Prevacid. All three drugs have the same end point, but it is highly unlikely that the same patient will benefit equally well from all three. So the doctor has to spend a lot of time (= non-reimbursed monetary expense) explaining that in this patient Allegra works as an anti-histamine,and Claritin does not. The company either agrees (surprise and hooray!), or disagrees, whereupon the patient has to decide to pay the lesser price for the drug that does not work so well, or the higher price for the drug that does. Medicare also rations the number of visits to a physical therapist per month for a given musculoskeletal condition.

   I have a good friend in Vancouver, Canada. He developed angina and needed CABG, or cardiac bypass surgery. Unfortunately, the hospital his doctor admitted to had an allotted ration of 150 open-heart surgeries per month. He had to wait from mid-January to Mid March for his open heart surgery. Fortunately he survived to have it. One year Canada decided to cap the annual salary (calculated by the number of patient visits) of all general practitioners. The result was that all GP's stopped practice by early or mid-November, because why should they work for free?

      In England, the National Health Service does not pay for kidney transplants, or for chronic dialysis over the age of 55. So if you have kidney failure, you may end up flying to India to buy a kidney (for about $10,000) to be transplanted into you by an English-trained doctor. The National Health Service also does not admit certain legal drugs to be sold in the country, including some made by British firms, because they do not want to pay for it (such as the inhaled anti-viral that shortened the course of the flu).

     In Germany, each doctor has a panel of patients, and is paid every three months for the number of patients plus the number of their visits. The state also pays for all drugs. But if the doctor's patients average drug cost is too high in one calendar quarter, the doctor's salary is cut the next quarter!

     We are hard up against the fact that the demand for medical care can never be saturated, and that the technical cost of medical care is driving costs through the roof, not the doctor's fees. An artificial hip can cost $8500, before the surgeon's fee, the OR fee, the hospital room fee, etc. Technology costs money, but it works and saves lives. It also extends the useful working life of patients, but no economists calculates that if open-heart surgery cost $40,000, but the patient lived another 15 years and contributed $750,000 in income taxes the country gained. OTOH, try to flip the argument, and say that we could save $2B/year by banning open-heart surgery, and I don't think there would be any takers.

   First we had Xrays, which saved lives, at a cost of approx. $100 each. Then we developed CT scans, which sees much more than Xrays and saves more lives, but because of all the computers involved costs approx. $250/scan. Now we have MRI's, which save even more lives again, but which costs approx. $750 because of the huge magnets involved. No one would want to do without these wonderful devices, but no one really wants to pay for them.

     Until 10 years ago premature babies born with weights of less than 4 pounds generally did not survive. Now with neonatal intensive care units, etc, we can save babies weighing as little as one pound. They may spend three months in the NeoICU at a cost of $1M, but they survive.

   Finally medical economists and budget planners think that we could save a ton of money if we got patients with chronic diseases to take better care of themselves. The problem is that 50% of these chronic diseases were caused by or made worse by the patients precisely because they don't care that much to take care of themselves. I have never, with all the backup help and clinics in the world, ever gotten a ,male diabetic to lose weight to improve his sugar control. People don't exercise as much as they should. (The exception to better diet and more exercise is any male who has a heart attack----they become rapid believers in healthy living.) Very few humans are willing to anticipate what may happen to their bodies more than 10 seconds in the future, so we don't worry about the current cigarette, or the unprotected sex, or driving without seatbelts, because none of these actions will cause a foreseeable problem in the next 10 seconds. Insofar as dietary changes are concerned, if you cannot get your two year old to eat spinach or your teen-age anorectic to eat at all, how do we get anyone to eat properly? Videos of children playing volleyball in camp show that overweight campers move less on the court than others, but we don't know which came first, the overweight or the decreased athletic activity. I am certain that each and every one of my readers can recall several unhealthy (if not illegal) activities that they themselves did.

     So what is the answer? No one knows. What is the ideal percentage of our GNP that should be spent on medical care? No one knows. But everyone is certain that when it comes to their own health care or that of their families, then no expense is too great, and so once again we have the conflict of microbehavior vs. macrobehavior, which is precisely the problem with containing medical costs. (Recall that after the 2008 bank crashes, the government's desired microbehavior was for individuals to save, while the governments desired macrobehavior was for the country to spend its way out of the recession.) As a physician my professional commitment is 100% to my patient, and not to overall economic expense (even if malpractice suits did not exist). And expect no real help from Congress or your State Legislatures: They have voted themselves the finest medical plans that exist, all of which are cost-free to them in Congress and in most states (as are their pensions as well).

MMWR Recommendations for Adult Vaccinations in 2011

2011-04-10T23:05:00.000-07:00

http://www.cdc.gov,
/mmwr/preview/mmwr.html/mm6004a10.htm

Radiation, Radiation Poisoning, and Radiation Sickness

2011-04-03T09:49:00.000-07:00

     Two years ago I wrote a blog on some of the medical effects of radiation. In view of the recent problems with nuclear reactors in Japan, I thought I should add several comments, including a discussion of the lethality of different kinds of radiation, the half-life of a radioactive element, and possible means of protection. This blog will therefore discuss the chemistry, physics and medical effects of radioactivity. I have had some direct experience with this, since in the past I have worked at Oak Ridge National Labs as well as Columbia's Nevis Cyclotron, and I have done medical research for two summers in the radiation physics department of a teaching hospital. I also have had experience with patients exposed to radiation, but I am still not permitted to talk about it.

     Let's begin with a few simple facts: Every atom is composed of a nucleus containing neutrons and protons, surrounded by concentric shells of electrons. The chemistry of an atom depends on the number of electrons, and the physics of the atom depends on the number of neutrons and protons in the nucleus. In free space, a neutron will decay in less than 15 minutes into a proton, an electron, and an anti-neutrino, but inside the nucleus quantum rules often forbid this. The atomic number of an element is equal to the number of protons in the nucleus (and hence the number of external electrons), and the atomic weight is approximately equal to the number of protons plus the number of neutrons. An element, which by definition has a defined number of protons in the nucleus, can have various numbers of neutrons. The different nuclei with the same number of protons but differing numbers of neutrons are called isotopes of each other.

     Some isotopes of elements are naturally radioactive, such as Carbon-14, or Oxygen 17. But since Carbon-12 (which comprises over 99.9% of natural carbon) and Carbon-14 both have the same number of electrons, they appear chemically identical to living biochemical systems and are chemically incorporated into their cells and tissues. Therefore every living animal with carbon has some natural radioactivity. We know the natural C14/C12 ratio in the world, and this, coupled with the known half-life of Carbon-14 of 5600 years, allows us to carbon-date ancient bones and tools. We can apply the same principles to date the age of rocks and the earth, using uranium/lead ratios, since all uranium eventually decays into lead. However, ALL isotopes of the elements above a certain atomic number are naturally radioactive, so that there is no harmless form of thorium,radium,uranium, plutonium, radon, etc., and if you are in close enough proximity to one of these elements for a sufficient length of time, it will be fatal.

   Ordinary water contains two atoms of hydrogen, and one of oxygen: H2O. Heavy water contains two atoms of deuterium (a hydrogen isotope with one proton and one neutron in the nucleus) and one of oxygen: D2O. Although they are similar chemically, if you drink enough heavy water you will die, since water passes through cell membranes by a process called diffusion, which is physical, and not chemical. Because heavy water absorbs neutrons more efficiently than ordinary water, it is often used in a nuclear reactor.

     There are three types of radiation that can harm you. The first is free electrons, also called beta rays (for historical reasons). Electrons have very little penetrating power because they are charged, and interact rapidly with your skin. Therefore usually the worst that beta rays can do to you is to give you a burn, and simple clothing will generally stop them. However, your thyroid gland takes up iodine avidly and rapidly, to make thyroid hormone. Most reactors will, if breached release radioactive iodine (I-131) into the atmosphere, such as happened at Chernobyl as well as Japan. Unfortunately, if I-131 falls on food and you ingest it, it will be concentrated in your thyroid gland. Although I-131 is a low-energy beta ray emitter, you can easily swallow enough to make you gradually hypothyroid, or, especially in children, cause the development of cancer of the thyroid in a few years. This is why we recommend daily doses of KI, or potassium iodide, to children who are exposed to such radioactivity, to block the uptake of I-131. (We first realized the danger of radiation to children's thyroid glands when children and adolescents who received radiation with gamma rays to treat their acne developed thyroid cancer 10 to 20 years later.) Similarly, breached reactors release radioactive strontium, which is chemically similar to calcium in that they are both divalent cations. Therefore, if there is radioactive strontium on the grass, and the cows eat it, it will chemically replace some of the calcium in the cow's milk, and when you drink this milk the radioactive strontium will be taken up and concentrated in your bones, and then it can damage your bone marrow, and/or cause leukemia.

     The second "radiation" that can cause damage is generally not thought of as radiation, but it is released in large numbers and high energies in runaway reactors, and that is neutrons. They are electrically neutral, so they have incredible penetrating power. They are preferentially absorbed and give up their energy to hydrogen atoms, which is why water is a doubly useful substance for cooling reactors. Cadmium is also an excellent neutron absorber, and cadmium rods can be used to SCRAM a runaway reactor. Unfortunately, over 60% of our body is water, and our brains are especially sensitive. There is no portable way to measure neutrons, (such as a Geiger counter for gamma rays), and there is no way to measure or detect how much damage the neutrons have done to your body, or what your total neutron exposure was. When I worked at the cyclotron lab, we all had radiation badges to measure our monthly exposure to gamma rays. But there was only a long string of yellow plastic rope stretching from one side of the cyclotron to the lab wall, with a floor sign underneath:"Do Not Approach Closer Than 10 Feet When the Cyclotron is in Operation".We all respected that sign.

     The third radiation, and usually the most lethal, is gamma rays. These are photons, or "pieces of light". Their individual energy has a huge range, and the shorter the wavelength, the greater the energy. Thus radiowaves with wavelengths of kilometers are harmless, microwaves can be used to heat water, infrared waves can be used to heat rooms, ultraviolet rays will give you a sunburn or worse, and shorter wavelength rays such as X-rays can be lethal or give you radiation poisoning (which is probably why the dentist or hospital X-ray technician goes into the other room when he/she takes your x-rays---they don't want the exposure), and you aren't even given a radiation badge to measure the exposure to gamma rays you just received.

     We have no way to measure the amount of radiation your body absorbed, or how much energy particular tissues (heart, brain, bone marrow) absorbed. We can only guess, since we just don't know. We think we know the safety limits for hospital radiation treatment of cancer, and we know that the old treatment of polycythemia vera with oral radioactive phosphorus caused bone marrow cancers and leukemias later, but we don't know precise doses. We really don't even know if radiation exposure increases your risk of getting cancer linearly, in that each exposure adds to the risk of the previous one, or of there is a threshold dose of radiation below which there is no risk. We do know that in acute radiation exposure you can die in 48 hours or 48 weeks. We do know that the most rapidly dividing cells are preferentially killed by gamma rays, so that the bone marrow and the lining of your gut are especially sensitive. We do know that there can be delayed burn-scar tissue results, such as fibrosis of the lungs, or constrictive pericarditis (of the heart).We know that radiation sickness can affect every organ system of the body, but we can't reverse or treat it, except to support the patient's vital signs, and hope that death from overwhelming infection or cancer does not ensue. We also know that developing embryos are exquisitely sensitive to the damaging effects of radiation.

     Now as to radioactivity and reactors themselves. The natural radioactivity of the trans-thorium elements provides the heat in the earth that keeps the core liquid and the earth's surface warm. Without natural radioactivity, the energy from sunlight would not be enough to keep us from freezing to death. Now since uranium emits heat when it radioactively decays, it needs to be constantly cooled in a reactor, which is why the naked exposure of uranium-embedded zirconium rods created so much heat that it boiled the surrounding water, energized the freeing of hydrogen from water, and then exploded the free hydrogen which then burned in the presence of the free oxygen also liberated. So a naked core is an extreme heat emergency, as well as a radioactive one.

     You can design a nuclear reactor that can never go critical. This is the type that is installed in nuclear subs. In a reactor, free neutrons are allowed to bombard uranium atoms. These then fission,. releasing on the average 2.5 neutrons per uranium atoms struck. If each neutron then splits a uranium atom, then two more atoms are split, and 5 more neutrons released. If this happens rapidly enough, it is a self-sustaining generator of energy (and then converted to heat via giant water boilers)., and we say that the reactor has "gone critical", and we have a chain reaction. We adjust the depth of cadmium rods in the reactor to control the rate of reaction, and if the reaction goes supercritical, we rapidly lower the cadmium rods into the rector to dampen it. I should mention that this reaction occurred naturally at least once in the past, about 2,000,000,000 years ago in Oklo, Gabon, West Africa, where the uranium isotope ratios demonstrate that there was a critical mass of uranium that started to run away, and was stopped only by its own production of radioactive xenon, which is a excellent neutron absorber.

     The half-life of a radioactive isotope is the amount of time it takes half of a given number of radioactive isotopes to decay (and, hopefully into a non-radioactive product, which is the case for Carbon-14, but not for Uranium-235, Uranium -238, or Plutonium-239). I should mention that radioactive cesium, which has a very long half life and is used in hospitals as a source of radiation, as also produced by runaway reactors. The half-life is not related to the radiation danger of the isotope, but the number of radioactive daughter products certainly is, like the production of the radioactive gas radon from the decay of uranium. BTW, did you know that all marble is naturally slightly radioactive?

     I think that you can see that the only safe act is total avoidance, and perhaps the carrying of personal radiation badges, to be checked once a month.If you suspect a radioactive fallout, get rid of your clothes, and shower immediately, and carefully wash all food before eating. I would assume that all government warnings minimize the danger, just as they told the terminal cancer patients in 1947 in whom they injected radioactive phosphorous and other substances that it would cause them no danger (since they were dying anyway, and then the government autopsied their bodies to find out what it could about the deposition in and effects of radiation on the body). Or when they permitted sailors to stand on the decks of their ships and have radioactive debris be showered on them after the H-bomb test at Bikini and Einewetok atolls.

BTW, a reactor is scrammed by releasing the clamps holding cadmium rods out of the nuclear core of the reactor, and let gravity pull the rods in as rapidly as possible. For one midwest reactor, the blueprints were distributed upside down, and because of atomic secrecy, the workmen knew very little of the ultimate purpose of their construction. Luckily, before the reactor was run up to full power to test the SCRAM operation, someone noticed that the cadmium rods were inserted from the bottom!

     But at least we are avoiding 4 stupidities caused by insufficient knowledge of the dangers of radiation:
a) we no longer handle radioactive samples with our bare hands
b) we no longer use radioactive thorium salts to remove hair in the armpits
c) we no longer paint the numbers on watches that glow in the dark with radium-based paint, and have the painters moisten and sharpen the brush tips with their lips and thereby deposit radium salts into their mouths
d) we no longer rush over as children to the shoe store fluoroscope to stand and put our feet in the xray-fluoroscope to see how well our feet fit into our shoes

   How much natural or man-made radioactive exposure is safe? No one really knows. We can sometimes, for a given energy level of gamma rays, estimate the LD50, which is the total time exposure after which 50% of exposed humans will die. But this is only an estimate, and only for one energy level. We also have no way of predicting how much exposure to Xrays and natural radioactivity is necessary to increase your risk of cancer in a given organ by 1%. There are estimates of the risk of inducing breast cancer after 30 years of annual mammograms, but these are only estimates, as is the stated "safe" level of radon, a radioactive gas. In fact all radioactive safety levels are guesstimates arrived at by compromise by a committee, and have never been verified, except for accidental exposure to a runaway chain reaction, such as happened to one scientist in Los Alamos who was working with two clumps of a radioactive element and let them approach each other too closely.

     In case you think any of the above is an exaggeration, let me tell you about one incident. Shortly after 9/11, many of the upscale shopping malls were equipped with radiation detectors at their entrances. Several years ago, a male cardiac patient had a (radioactive) stress-thallium test, which involves injecting a small dose of radioactive thallium into your bloodstream when you are near peak exercise, and then scanning you with a radiation detector to see the distribution of blood to your heart when you are exercising. You then sit there for four hours, and they re-scan you to see the distribution of blood to your heart when you are at rest. An hour after this test was finished, so we are talking about what happened 5 hours after then man was injected, he went to meet his wife at the shopping mall in Short Hills, New Jersey. The residual radiation in his body triggered the radiation detectors, and the entire mall was shut down and evacuated, and everyone examined with a hand-held Geiger counter, which is how the authorities discovered what had happened.

Recommended Books Page Two

2011-04-02T10:03:00.000-07:00

Here are a few books that I have found on Amazon that I think merit your review.

Recommended Books Page One

2011-04-02T09:59:00.000-07:00

Here are a few books that I have found on Amazon that I think merit your
review.

How Doctors can Avoid Malpractice Suits

2011-03-22T21:38:00.000-07:00

     The most common cause for suing an internist, according to my malpractice insurance company, is "failure to diagnose", followed by "failure to make a timely referral". After reading most of what this company had to say, discussing events with Risk Management, and many talks with those of my patients and friends who are tort attorneys, I have developed a list of do's and dont's for practicing physicians who wish to minimize their risk of being sued. This list will probably not lead to better or more efficient or cheaper patient care, but it will reduce the malpractice exposure of any doctor who follows my recommendations to the letter. I have also thru Lexis and other search engines, verified that there is at least one malpractice case that was triggered, in part, by the physician's failure to follow one of these rules:

     1) At EVERY visit, ask the patient if he/she is suicidal, or has suicidal thoughts.

     2) Every time you prescribe any drug that acts on the central nervous system (sleeping pills, tranquilizers, anti-depressants, etc.) caution the patient not to drive or operate heavy machinery for 24 hours after taking the medicine.

     3) If any patient refuses a suggested test: mammogram, pap smear, stool for blood, fire that patient from your practice immediately. Juries have held that if the patient dies because of a refused test, you probably didn't word your advice strongly enough. The same holds true for blood tests.

     4) Never give any advice over the phone. It is basically malpractice and also a violation of most state medical laws to "prescribe", i.e. give any medical advice without examining the patient. Insist that the patient come in to see you right away, or have the patient call 911 for an ambulance to go to the ER. I know some doctors who will call 911 if the patient refuses to.

     5) Whatever the patient's problem, after you suggest a diagnosis and treatment, have the patient see a specialist in the field of the affected organ (cardiology for hypertension, GI for abdominal pain, neurology for dizziness) and tell the patient you can't continue as the personal physician unless a specialist is seen.

    6) For any abnormal blood tests, again refer at once to a specialist.

     7) If the patient, or the patient's family suggests any test; cardiac echo, brain MRI, chest CT scan, agree at once, order the test, and again refer to the appropriate specialist.

     8) Do a stress-echo and stress-thallium and cardiology referral for any pain above the waist, an abdominal and pelvic CT scan with contrast followed by an MRI and a referral to a GI doctor and a urologist for any pain below the waist, a Chest CT scan with contrast for any cough and for any smoker with a referral to a pulmonologist and a total body bone scan for any back or hip pain, followed by referral to an orthopedist. If CT scan shows nothing, do an MRI, followed by a MRA. If headache or dizziness, head CT with contrast, MRI with gadolinium, and neuro consult. This may not be cost-efficient, but a malpractice jury never cares about that.

     9) "When in doubt, refer it out".

     Of course I never practiced medicine following the above legalistic "rules", but every doctor has to consider the risks of not following those rules every time there is patient contact. And in America, if something "bad" happens to a patient, it must be someone's fault. The doctor no longer has to prove he/she did nothing wrong, but rather than he/she did everything that was "right".

   I suspect that there would be fewer malpractice suits if workmen's compensation laws applied: no contingency fees for lawyers, and a pre-set schedule of payments for partial or permament disabilities up to and including death. Don't forget the Texas jury that bankrupted Dow Chemical, because they believed "as a matter of fact': that silicone leaking from breast implants caused a lupus-like syndrome. Unfortunately Dow went bankrupt from the class-action suit. Two years later a careful study in the New England Journal of Medicine showed that there was absolutely no correlation, and certainly no evidence of cause-and-effect, but Dow remained in bankruptcy court, and none of the plaintiffs or lawyers had to return any of the money.

     What I am really saying is that with the best doctors, good medicine results from a combination of skills, intuition, and art. When I walk into an ER hospital room, I often think to myself: "This patient is sick and needs a hospital admission". Then I have to invent a diagnosis, because the insurance computers don't pay for an admission diagnosis of "looks sick", which is an absurdity:just as all you mothers out there know when your child is sick, I can see when my patient is sick. Sometimes I put down 999.90 "unknown disease", because (a) we all have at least one of those, and (b) it drives the computers wild when they try to calculate a LOS., or look for guidelines.

The Problems With Meta-Analyses (2)

2011-03-19T14:29:00.000-07:00

     I had written a more mathematical blog in May, 2009, denoting the logical and mathematical/statistical problems with meta-analyses, but since that time many more meta-analyses have been published, and the public has discussed these results as if they were clinical fact. It is important to understand that the results of a meta-analysis should be presented only as a hypothetical clinical result, to be tested forwards in a properly designed clinical format, and not accepted as proven fact (such as the recent suggestion that women who ingest calcium supplements increase their risk of heart disease). In brief, a meta-analysis collects several studies of the same problem, none of which reaches clinical or statistical significance, in the hopes that the sum can be greater than its parts, and that combining non-significant studies can reach a significant result!

   Some readily understandable problems with meta-analyses:

1) You are never told which studies the author rejects as not being acceptable for his/her meta-analysis, so you cannot form your own opinion as to the validity of rejecting those particular studies.

2) The problem of the Simpson Paradox, or the Yule-Simpson Effect: sometimes all the included studies point in one direction as being clinically significant, but the meta-analysis points in exactly the opposite direction. This has been discussed, for instance, in "Chance" magazine, published by Dartmouth University, where they showed different ways of calculating Derek Jeter's batting average, with differing results, using the same data in each case.

3) There are two different statistical models or assumptions by which the analyzer combines the effects of the individual studies: the fixed effects model and the random effects model. Each model makes different assumptions about the underlying statistical distribution of observed data,, so each calculation produces different results.

4) There are two different methods for measuring the effect of the clinical intervention: standardized mean difference or correlation. Each method produces a different end result.

5) If we look at #3 and #4, we see immediately that there are four possible combinations of analyses, leadeing to four different conclusions for the same set of studies. No one paper shows all four combinations and all four possible results.

6) Finally, the choice of what constitutes a "significant' effect in any of the included studies is purely arbitrary. When this question was studied by clinical psychologists, no two analytical scientists reached the same conclusions of what was significant in all the included studies.

     We therefore see that the result of any meta-analysis is largely dependent on the analyzer, and the reader never has enough data to redo the analysis, so the results have to be taken on faith, which is hardly a scientific result.

   "There are three kinds of lies: Lies, Damn Lies, and Statistics"-----Mark Twain

Medical Misconceptions

2011-03-11T21:45:00.000-08:00

     As a physicist as well as a practicing physician, I am always disturbed by medical statements that have no basis in experimental or clinical fact. Some statements are considered to be "obvious", some are practicalities stated by the government, and some have the inertia of years if not centuries of belief. I have always told my patients that if any doctor (including myself) makes a medical statement of "fact", they should ask the doctor where they can read about it. OTOH, if the doctor says "I believe", or "I feel", then take the advice with at least 10 grains of salt. It is, of course, more difficult when your spouse tries to impress a "fact" on you, and you can't really answer "where did you get your medical degree"?. One of my patients brought in a paragraph cut out from a magazine which explained her disease and treatment in detail. Since the article was taken from the "National Enquirer", I told her that I was not a specialist in this particular field, and she needed to consult a specialist. Now that we have the internet, I often have to "unlearn" a patient before I can "learn" him or her. BTW, the only source you should trust about cancer is the web site of the National Cancer Institute. All other institutional websites have an institutional bias. For instance, the chairman of one teaching hospital wrote a book about how the only treatment for prostate cancer is surgery, so few if any urologists at that institute would suggest either radiation or watchful waiting. This raises another point: if you want a second opinion, always go to a different institution, since there is real institutional bias. 30 years ago, when I trained, I was told that Cornell/NY Hospital only ran digitoxin levels, and not digoxin levels, so if you were an intern at NY Hospital, you had to use digitoxin to treat your heart failure patients. Similarly, at Columbia, the ANA was run daily in the lab, and the LE Prep only weekly, so that even though the LE prep was a more definitive test for lupus, all the interns had to screen with the ANA. As a final example, the body runs on thyroid hormone. (Let's forget T3 for the purpose of this discussion.) So the real test for hypo or hyper thyroid state was free T4. However, this was a radioimmunoassay , and very expensive, so we were all taught to screen with the TSH, a pituitary hormone, and only do a free T4 if the TSH was off. This meant that the patient had to be stuck twice for blood, and the correct diagnosis was delayed.

     Brief joke: The way opticians charge for eyeglasses is as follows: When they give you your eyeglasses, they say "That will be $300". If you don't flinch, they add "That's for the frames. The lenses are another $300". If you still don't flinch, they add "Each".

     The following are some of the medical "facts" that are not based on clinical studies:

     1) Marijuana is classified as a Class I drug by the FDA, which means "no possible clinical benefit or use". Nevertheless, the U.S. government grown marijuana plants in Lexington, Ky., for those patients whose glaucoma can only be successfully treated by smoking marijuana.

   2) Ecstasy, the pleasure drug used at raves, is also classified as Class I. However, at least eight psychiatrists around the country have special license to use Ecstasy on otherwise intractable schizophrenic patients.

     3) Shades of "One Flew Over the Cuckoo's Nest": A physician in Europe received the Nobel Prize in Medicine for "proving" that pre-frontal lobotomies "cured" schizophrenia. Not so.

   4) The BMI is touted as calculating your IBW, or ideal body weight for your height. This number has no basis in fact, and is merely a derived average. No one has shown that patients with a "normal" BMI live longer, and in fact a recent study in Lancet disproved this. Also, the IBW in the Metropolitan Life Insurance tables was specifically derived for patients wearing shoes.

   5) Ideal pulse at workout = 0.8x(220-age). This is also a purely fictional number derived from healthy young men. In fact, the greater your aerobic conditioning, the lower is your resting pulse and peak pulse. Just ask any marathon runner.

   6) Eating sugar causes diabetes. Just because diabetics have high sugars, it is not true that eating sugar causes it.

   7) Too much salt causes high blood pressure. Another canard, unless you are a specially genetically formed lab rat. Normal kidneys can always clear salt. But because of this belief, many of my golfers get faint and dizzy by the 13th hole, because they sweat salt plus water, and drink only water, and dilute down the salt levels of their body. Salt in the blood defends blood pressure. The salt content of blood is approximately equal to a 50/50 mix of water and Gatorade, which is how the football coach of the University of Florida developed Gatorade.

     8) For some reason, if you go to donate blood at the Red Cross, they will refuse you if your blood pressure is "too high". This is very odd, because 100 years ago, before we had any useful anti-hypertensive medicines, the only treatment that successfully lowered blood pressure was bleeding with leeches.

     9) When I went to school the food triangle had an apex and a base, and one was protein and the other was carbohydrates. Now the food triangle taught in school is exactly the reverse. Who is/was right?

   10) Labeling calories probably does not lead to weight loss. Taco Bells in LA have had to do that for the past 13 months, but the total calories consumed by the average patron did not change.

   11)Question: If the real reason for raising the drinking age to 21 was to keep drunk teen-age drivers off the road, why not let teenagers who do not have a driver's license drink?

   12) Why are all addicting foods vegetables (nicotine, alcohol, opium, cocaine, etc.)?

     13) The "normal" fasting blood sugar has been lowered from 140 to 120 to 110 to 100, but no one has shown any medical benefit or reduction in diabetic morbidity from these lowered definitions. OTOH,. if your FBS is 110, your life insurance premiums will now be higher.

   14) Medicare Part D now only pays for generic versions. However, many doctors are aware that for some drugs, especially those that act on the CNS (Ativan, Prozac, Wellbutrin) often only the brand name works. I have similar arguments with drug "management" systems such as Medco, who claim that only their preferred brand of stomach acid suppressant, such as Prevacid works. When I try to tell them that only Aciphex works on my patient, they don't want to hear it, although they know full well that although they have the same endpoint, since the two drugs have different chemical structures one will work when the other will not.

     15) I will close with the most common misperception of all, and one that we are all guilty of, and that is persisting in giving medical advice to our loved ones after it is evident that they will not follow it. After you tell a smoker to stop smoking or a heavy diabetic to lose weight more than once, they have received your message. It's not that they don't understand you, it's just that they don't want to follow your advice. And they know their actions may not be logical, but they still refuse. Some patients refuse to have a mammogram, or a colonoscope, or even to see a doctor. Many patients will refuse to follow good advice, even when they agree with it, for various reasons, some of which they do not fully understand themselves. When this does happen, you should stop and ask yourselves if you would follow medical advice that a loved one gave to you if you did not believe in it or did not feel like doing it.

Body Weight , Health, and Heart Attacks

2011-02-27T15:23:00.000-08:00

     A common mistake in medical epidemiological studies is to mistake coincidence for causality. This is a very easy trap to fall into if the predicted cause-and-effect result is one that we already believe, or would like to believe, or that previous data leads us to expect. Again, the results of epidemiological studies should be used to formulate a hypothesis to be tested in the future, and not to prove a hypothesis.

   With this in mind, let us evaluate a group of world-wide nutritional studies that was published by Lancet, the top English medical journal,the third week in February. They studied BMI's throughout the world. (for those of you in the non-medical world, this is (weight)/(height)(height), i.e. height squared. We have all been told that the greater the BMI (i.e. the heavier you are for a given height), the greater is the risk of heart disease and death. A recent anomaly reported elsewhere was a study that showed that those who were slightly overweight (BMI's between 26 and 30) had the best chance of surviving a heart attack. This result fit no theories, so it has not been further addressed, especially since this was the first evidence that maybe obesity wasn't the killer that it was claimed to be.

   The Lancet study, which studied countries through the New World, the Old World, and the Far East came up with three results that held up statistically:
     (1) Over the past 30 years the BMI is steadily increasing in all countries, almost monotonically.
   (2) Over the past 30 years, the world-wide rate of heart attacks and cardiovascular deaths is decreasing.
     (3) In the Far East, and only in the Far East, the greater the BMI, the LESS was your risk of heart attack or cardiovascular death.

     This last result, indicating that overweight is cardioprotective, has many cardiologists and statisticians scrambling to find fault with it. However, except for saying they don't believe the result, there has been no significant rebuttal of the result. It is up to we doctors and researchers to try to understand the implications of this result, if we assume it represents a true state of affairs, but since the relationship was observed for over 30 years of studies, it is difficult to claim that it is not significant, and perhaps we should re-evaluate our definition of the "normal" range of BMI's.

Germ Warfare

2011-02-26T14:07:00.000-08:00

     I was stimulated to write this blog by the report circulated to me by e-mail by the ISID (International Society of Infectious Diseases), which said that there was an outbreak of at least 21 cases of a previously unknown phenotype of the measles virus in Turkey. The ISID (www.promedmail.org) performs an important information function. For instance, it was a Dutch physician recently returned from China who gave the first report of SARS, an epidemic the Chinese government tried to keep from the newspapers. Ibsen's play "Enemy of the People" always has the chance of occurring with real people and tourists, viz. the typhoid outbreak in Gstaad 20 years ago just before the beginning of the ski season.

     This got me to thinking that the real danger to the world if a major war should break out is not atomic weapons (does anyone remember "duck and cover", and H. Rap Brown saying that "we are alive today because the Russians did not launch last night"?). The real problem would be unrestricted germ warfare. And the chosen method of attack would almost certainly be a virus, because (a) we have antibiotics that work against most bacteria, but few that work against viruses, and (b) except for a few exceptions such as anthrax spores, only viruses can be spread by fomites (inanimate objects), A further bonus is that except for the pneumonic version of the plague, it is much more difficult to spread acutely lethal bacterial infections, than to spread viruses (viz. the rapidity of the spread of many flu epicemics).

   It is generally accepted that the first attempt at germ warfare occurred during the sieges of walled cities in the 14th and 15th centuries, when the besiegers catapulted plague victims over the walls. One U.S. cavalry officer after our Civil War gave blankets to the Indians on which people with measles had lain (effect unknown). And Lord Jeffrey Amherst here in the Northeast plotted to distribute smallpox-laden blankets among the Indians in an attempt to "kill them all". Again, there is no record of the results.

     Now what would be the ideal virus, and what steps should the attacking country take to avoid "blowback"? The answer to the second question immediately answers the first. You would want to vaccinate your armed forces, police, and medical staff against your planned viral attack. The most efficient vaccine we have is for smallpox. It is also the most sensible one to use, because unlike measles it has no animal hosts, but only man (as far as we know). Therefore there is no risk of it hiding in the animal population. Smallpox has the added advantage of being rapidly spread, and quite lethal. The best way to spread it is to inoculate unvaccinated volunteers who are willing to die, wait for 7 to 10 days until their rashes appear, and they are maximally infective, and then fly them to the key cities of your chosen enemy and let them mingle among the people. Since we no longer vaccinate against smallpox this attack would be quick, very lethal, and probably unstoppable.

     Let me assure my readers that this blog does not plant ideas into anyone's head, because no one will take it seriously. Tom Clancy wrote a novel in 1997 which climaxed with a Japanese pilot flying a fully gasoline-loaded 747 into the Capitol building and killing the president, etc. No one guarded against this, and voila, along came 9/11/2001. I should also mention that all members of our armed forces are fully vacccinated against smallpox, the plague, etc. In theory there are only a few stocks of live smallpox kept tightly guarded in the U.S., Russia, and England, and we all know that if this is what the governments tell us it is probably true.

Medical Research Errors, or Don't Believe all that you Read

2011-02-04T18:24:00.000-08:00

     I did physics research for over 10 years, and clinical medical research for over 25 years. I have reviewed physics papers (as assistant editor of a physics journal) and medical papers, especially for the Annals of Internal Medicine. As a physics reviewer, I could often suggest revisions that would make the paper publishable, but as a medical reviewer I found this to be impossible. During my 10 year tenure as a reviewer in my medical field, I would estimate that I rejected 90% of the papers I reviewed, usually for lack of scientific rigor, and my negative review was never overridden by the article being published in a medical journal of similar significance.

     There are various problems with scientific rigor in medical journals, but the most serious is their improper use of statistics, followed by lack of reproducibility, i.e. other researchers cannot replicate the results. In science, this is usually due to fraud (black ink spots placed on mice) or self-delusion (N-rays in France), but in medicine it is usually a sign that the first result was not entirely correct. I always tell my patients who rush in breathlessly with the latest report of medical research to wait for the second and confirming report. The second report often does not confirm the first. I also tell them to beware of medical studies that look for surrogate endpoints (lowering of blood pressure or cholesterol) rather than significant clinical endpoints(stroke, heart attack).

     There are too many books, articles, and TV shows including some authored by doctors, that are studded with phrases such as "the evidence suggests", "it seems reasonable that", "past history shows" or all patients with or without condition X did or did not have disease Y. None of these statements contains a scientific truth, and such phrases would never appear in a physics or chemistry journal. A hard fact is rarely stated, such as that 500mg 2 x day of Vitamin C will lower your uric acid level by approximately 1.0 and thereby reduce your risk of a gout attack (this latter statement has been substantiated by research). We have very little good clinical evidence about many medical conditions, although it is almost universally agreed that antibiotics can kill bacteria and save lives, and that vaccinations are beneficial.

     We still don't understand why only 10% of smokers get lung cancer (although we know with 100% certainty that all smokers will develop emphysema if they smoke long enough---40 pack years is usually sufficient). We don't understand why different patients with high blood pressure develop problems in different organs: stroke, kidney failure, heart attack. We don't understand why one alcoholic gets cirrhosis of the liver, one dies of hemorrhagic pancreatitis, and one gets the Korsakoff Syndrome. Similarly, we cannot predict which organ will fail in a patient with insulin-dependent diabetes, or if in fact any of them will.

   The main problem, of course, is that each patient is an individual biochemical laboratory, and no two patients react the same way to any medical intervention. This is always true if the patient is on three or more drugs, since almost all pharmacological studies are done on patients on no drugs. (And no one knows how all the over-the-counter health foods interact with anything.) Many medical recommendations are based on three or fewer studies, while there are over 50 verifications of Bell's Inequality in quantum physics, and hundreds of measurements of the speed of light. Furthermore the results of a medical study apply only statistically, in that not everyone is cured of strep throat by penicillin, and some people with strep throat recover without any antibiotic at all. If I were responsible for the treatment of 1,000,000 patients, I would have no hesitation in making certain recommendations, but if I am recommending treatment for just one person, I am never 100% certain if the treatment (a) will work, and (b) is necessary.

     In a previous blog I carefully reviewed the mathematical and statistical flaws inherent in all meta-analyses, so let me just say here that every result suggested by any meta-analysis should be verified by double-blinded random testing, despite the rapidity with which the media trumpet the results of the study.

     I should also mention the problem of confounding conditions. When we do a clinical intervention study, we try to make the treated and control patients physiologically as similar as possible. When we do not, we come to the false conclusion that coffee drinkers suffer more heart attacks than do non-drinkers, until it was realized that coffee drinkers also smoke more cigarettes than the non-drinkers. We still have conflicting studies on whether tall people live longer or shorter lives than short people, and are similarly lacking in knowledge about righties versus lefties. (But I do wonder why all left-handed tennis players seem to have a natural topspin on their forehand on television.) Many men gleefully reported to their wives and significant others the one study that seemed to indicate that frequent ejaculations had a protective effect against prostate cancer, but many fewer people and organizations trumpet the many studies that show that mild alcohol ingestion is protective against heart attacks, and the fact that NO study has shown that mild alcohol ingestion contributes to heart attacks.

     And please ignore all studies reported at all medical conferences. Until these studies have been written up, reviewed and then published, there is no way for anyone to verify their accuracy. And beware doubly of the placebo effect: In the 1950's, before we had ethical treatment review boards, 12 patients with angina had open heart surgery (I will not name the surgeon or the institution). 6 patients had the "real" surgery, and the other 6 had "sham" surgery, in that they only had their sternum (chest) split open, and then were wired shut again without anything being done to their hearts. 4 out of 6 in each group had their anginal pain and symptoms relieved.

     What I am trying to say is that doctors overstate the degree of medical certainty behind many of their medical prescriptions and suggestions. Remember that before 1973 homosexuality was a psychiatric disorder, and in the new DSM-V manual you will find that narcissism will no longer be one. (Although I expect that if a drug company develops a medicine to treat narcissism it will quickly become a disease again.)

   Finally, if your internet searches seem to indicate that some doctor or institution has a "special" treatment for a disease, please remember that all doctors want to cure their patients, and many would not mind becoming famous. If someone had a new cure for lung cancer, or rheumatoid arthritis, it would not be kept secret, and doctors throughout the world would know about it. There is one case of medical secrecy in history: A family of French Huguenot doctors, the Chamberlens fled to England in the 16th century. One of them invented obstetrical forceps to aid with difficult births. (Remember that C-sections were almost uniformly fatal in those days.) They became famous for their work with difficult deliveries, and they kept the existence of obstetrical forceps secret for over 150 years. I do not think that this would be possible now.

Preventing Hypertensive Stroke

2011-01-31T07:51:00.000-08:00

     This blog is rather short, because the basic facets and results are quite clear. The biggest risk factor for stroke in the general public is high blood pressure. The first anti-hypertensive to conclusively demonstrate a reduction in stroke risk was thiazide diuretics. They apparently work by lowering the total amount of salt in the body. We also know that thiazide diuretics are synergistic with every other anti-hypertensive medicine, in that diuretics potentiate the effect of every other hypertensive treatment. In fact, if you are on two anti-hypertensive drugs, one of them should be a diuretic, unless you have some very unusual medical condition.

   So the message of this blog is that diuretics prevent strokes. I raise this point because recent medical studies have been trumpeted in the newspapers as being more effective or more potent than thiazides in lowering blood pressure. But the question to ask your doctor is if this new and "better" anti-hypertensive treatment has been shown to lower the risk of stroke. If it hasn't, then either ask him to add a diuretic, or see a specialist in hypertension, to see if yours is a special case.

     This is a small example of substituting an endpoint for a clinical result. We have seen similar problems in whether or not lowering cholesterol prevents heart attacks, or if lowering CPR is beneficial. To use my favorite analogy, just because you have a better "tool" for returning the arrow over the elevator to the lobby than simply pushing the lobby button, it doesn't mean that your tool will get the elevator down any faster.

Helping Patients to Improve Their Health ?

2011-01-18T09:45:00.000-08:00

     There has been a lot of press and discussion about how giving patients more information about their health and healthy habits in general will improve their health, but I have never seen much evidence of this. In fact, a recent 13-month study of Taco Bell, which posts the calorie count of each item in its menu, showed that customers did not decrease their total caloric intake. It's somewhat similar to smokers smoking a greater number of low-nicotine cigarettes to get the same total nicotine effect, or people eating more of a low calorie food. I also can't see how having all their electronic medical records will give them healthier habits.

     Every adult knows (or at least is told by his doctor and government authorities) that he/she can become healthier by stopping smoking, losing weight, and exercising, with very little effect on their habits. In all my years of practice I have never been able (even with the help of a nutritionist) to get any overweight new onset diabetic patient to lose weight, even after I told them that the loss of 20 pounds would probably reverse their diabetes. In fact the only patients I have ever seen voluntarily and efficiently lose weight is men after their first heart attack. The heart attack removes their denial that they could ever get seriously ill. Most of them immediately go on a diet whose major component is eating fish 7 days a week. This works, but after 6 months I have to check their blood for toxic mercury levels. The only healthy habit my patients willingly follow is that of having a glass of wine daily, fish oil twice a day, and dark chocolate. This is probably because two of the three taste pretty good, and none of it seems like real medicine.

     The basic problem is that the human brain seems to be geared to avoid a life-threatening problem only if it is perceived to be imminent, i.e. to occur in the next 10 seconds, but not if the threat is 10 or 20 years in the future. So not every driver belts in, every cigarette smoker (and they know cigarettes are also called "coffin nails") intellectually believes that cigarettes may be dangerous, but also believes that the particular cigarette being smoked at this minute will not be lethal. Every adult understands the dangers of unprotected sex, but 25% of my college student patients (male or female) have unprotected sex at least once during college, usually when they are having sex with someone who is not their usual partner.

   When I am medical ward attending, I poll my residents to see how many of them actually finished the prescribed number of days for their last antibiotic prescription, and the answer is always fewer than 75% of them. I then ask them to sit down and talk with the next ward patient who refuses a test or a prescription and try to understand their reasons and motives, rather than immediately call for a psychiatry consult. Similarly, I have regular patients who have never had a mammogram, a colonoscope, a flu vaccine, etc. However, I can usually get them to take a tetanus shot every 10 years after I explain that tetanus is usually fatal. (The same applies to yellow fever vaccine, but not always to malaria prophylaxis.)

     Many patients also try to appear healthier than they are. I usually have my diabetic patients initially do fingerstick sugars fasting in the AM and 2 hours after dinner in the PM 3 times a week. Once the HgbA1C blood test became available (for you non-doctor readers, this is a measure of the average blood sugar for the previous 3 months) it was immediately evident that most diabetic patients either wrote down a lower number for their blood sugar than the test showed, or kept on re-doing the test until they came up with a number they liked.

     We all have patients that try to reduce (on their own) the amount of blood pressure or asthma medicine that they take, because they think that the more medicine they take, the sicker they must be. I explain that the important aim is to achieve control of the problem, and it is not sensible to expose themselves to the possible side effects of any medicine unless they take enough medicine to achieve our mutual goal. Sometimes they will skip some of the medicine and not tell me, hoping that it will not show up on my examination.

   In line with the above, patients with unhealthy habits know that their habits are unhealthy, and that their refusal to alter their habits is illogical. It is precisely because their behavior is not logical that telling them more than once or twice to change their habits is non-productive, and only causes bad feelings on the part of the advisor or advisee or both. Confrontation never works in such situations. The only exception I have ever seen is when an alcoholic man's boss tells him to go and dry out for 30 days or else he will lose his job, the man dries out and stops drinking. This is because his job is intimately entwined with his ego.

     This subject will be continued in a future blog.

Urine Drug Tests

2011-01-15T14:27:00.000-08:00

     I have not read any articles recently about urine drug tests, so I thought I might discuss it here. A useful article with many excellent references was written by Karen Moeller, in the Mayo Clinic Proceedings: www.mayoclinicproceedings.com/content/83/1/66.full. If you are an old-timer such as myself, you probably remember the Yippie Handbook: "Steal This Urine Test".

     The problem for the tester is the existence of false negative tests, and of course the problem for the testee is false positive tests. As a compromise, all tests have a cutoff, above which the test is considered positive. The urine tests are almost always a screen by immunoassay for either the parent drug or a metabolite. Since, as we shall see, many OTC as well as Rx drugs can give a false positive for various "drugs of abuse" (a technical term comprising amphetamines, cannabinoids, opiates, cocaine, and phencyclidine), for legal purposes any positive screening urine drug tests must be confirmed by gas chromatography-mass spectroscopy. The immuno screening test is used because it is rapid, not labor intensive, and cheap, much in the same way that the VDRL test is used to screen for syphilis, and the FTA to confirm it. As an example of the problem with a false positive screening test, since Lyme Disease is caused by a spirochete, just as syphilis is, many patients with Lyme disease will test positive on a blood screening test for syphilis.

     One immediate problem occurs with the amphetamine assay. There are 2 chiral isomers of methamphetamine: d-methamphetamine and l-methamphetamine. The (d) and (l) prefixes stand for (dextro) and (levo) respectively. The d-isomer if dissolved in water will rotate the plane of polarization of polarized light to the Right, and the l-isomer will rotate it to the Left. Louis Pasteur showed over 100 years ago that (almost always) chemical syntheses make an equal amount of the (d) and (l) isomer, but animal enzymes will usually act on one and not the other (he used tartaric acid for this demonstration). Thus your body usually uses only d-sugar isomers (hence dextrose), and the 8 essential amino acids for protein synthesis are all l-isomers. In fact if you were fed only d-amino acids by IV, you would starve to death.

     Now even gas chromatography is not sensitive enough to distinguish between d-methamphetamine and l-amphetamine. The d-isomer works as a CNS stimulant and produces euphoria, and the l-isomer produces peripheral vasoconstriction, and thereby relieves cold symptoms. Of course the OTC drugs used for cold symptomd such as pseudoephedrine, phenylephrine, and phenylpropanolamine will produce false positive tests. Most stimulant drugs used for ADD (such as Ritalin) and most diet drugs (such as phentermine) will also produce a false positive test. More amazingly, the following are some of the Rx drugs that will give a false positive methamphetamine urine screening test: Amantadine (used for the flu and for Parkinson's Disease), Wellbutrin (buproprion), Zantac (ranitidine), Trazodone, Desipramine, Trimipramine, Labetolol (for blood pressure), Chlorpromazine, and Isoxsuprine.

     False positive tests for cannabinoids (marijuana metabolites) can be produced by Efavirenz (an anti-viral used to treat AIDS patients), ANY of the NSAIDS ( Motrin, Alleve, Celebrex, etc.), Tolmetin, and any of the proton-pump inhibitors (Nexium, Prevacid, omeprazole, etc.).

     False positive tests for phencyclidine ("Angel Dust") can be produced by Effexor (venlafaxine), Tramadol,, Advil/Motrin/Ibuprofen, Robitussin DM (dextromethorphan), Benadryl (diphenhydramine), Doxylamine, Imipramine, and Ketamine.

     False positive tests for opiates: Robitussin DM (again!), Benadryl (also again), poppy seeds, quinine, Rifampin (used to treat TB, and also occasionally added to the Rx for severe staph infections), and ALL of the quinolones (Cipro, Levaquin, etc.).

     As far as is known, no OTC or Rx drug produces a false positive test for cocaine, unless the Rx itself contains cocaine.

     For completeness, I should add the length of time that drugs of abuse can be detected in the urine:
Amphetamine---48 hrs., Barbiturates----short acting---24 hrs, long acting (e.g. phenobarb)---3 weeks, benzodiazepams-----short acting (e.g. Ativan/lorazepam)---3 days, long acting (Valium/diazepam)---30 days(!), cocaine metabolites----2 to 4 days, Phencyclidine---8 days, Marijuana---once---3 days, 4 x a week---5-7 days, daily use---10-15 days, long term heavy smoker---more than 30 days.

     I should also mention that some urine tests also use indirect testing methods, such as testing for the presence of a diuretic, which was taken by the testee in order to dilute his/her urine and cause a false positive test. If your company wants to see if you are a smoker, they will test your urine for the presence of cotinine, a metabolite of nicotine. Unfortunately, many vegetables such as tomatoes contain a high concentration of cotinine naturally, so if you are a true vegan, you may have a "true" false positive test for tobacco use, in the sense that the chemical is really in your urine, but was only derived from your diet.

     BTW, the ingestion of ethyl alcohol will produce a positive urine test for 7-12 hours.

Weight loss (#3)

2011-01-05T12:45:00.000-08:00

I think it is time to describe how to lose weight as simply as possible, and to examine how to apply these results to everyday life. From a biophysical viewpoint, if the energy input (calories) is less than the energy expended in daily motion and metabolism, we will lose weight. It is also important to remember that it takes metabolic energy to digest, process, and burn or store food, so that although fat contains 9 calories/gm, carbohydrates contain 5 cal/gm, and the average protein 4.5 cal/gm, the energy yield of each is less than this, because of the metabolic work that must be performed to make it useful to the body. Don't forget that, for instance, swallowing and peristalsis both use muscles, and these muscles require energy to function.

Again, if you ingest fewer calories than your daily expenditure, you will lose weight (and probably feel hungry throughout the process). The only painless way to lose weight is by cigarette smoking, and we deduce this from inverse data: Everyone who stops smoking gains about 10 to 15 pounds the first year, and women usually gain more than men. From this we infer that smoking not only assuages hunger, but raises our metabolic rate. And it has to be smoking, because the use of nicotine gum or patches does not lead to weight loss.

I might here mention that as far as I can see, antidepressants do not invariably lead to weight gain. Rather, depressed patients usually become vegetative, and lose interest in eating, sleeping, exercise and sex. As they become less depressed by the use of medicine, all their appetites increase.

I should also mention that most women find it impossible to lose the last 5 pounds they put on after they become pregnant and give birth. I am convinced (without any supportive evidence) that there is a permanent endocrine/metabolic change in their bodies.

Now, how can we ensure losing weight? The only method that always works (and cures adult onset diabetes as well, secondary to its enforced weight loss) is gastric banding or gastric bypass. The operation works by severely restricting the part of the stomach that can receive food at a given feeding. The patient's eating habits do not change, but if too much food is eaten at one sitting, the stomach pain is excruciating, so that patients learn to eat much, much less, and typically lose 100-150 pounds. On rare occasions, liver failure occurs 6 months to 2 years after the bypass surgery, and the failure is reversed by reversing the surgery. I have had 3 such patient, and since their fundamental eating habits were never changed, they quickly ballooned up to their previous weights.

I should also mention that between the ages of 25 and 75, your metabolic rate decreases by the equivalent of 3 to 4 pounds per year, so to paraphrase what the Red Queen told Alice in Wonderland you have to run faster or eat less each year just to maintain your current weight.

There is no evidence that posting the calories next to a food choice enables people to lose weight. All it does is spoil the pleasure of eating a hot dog at a ballpark, because you really don't want to know how many calories you are eating when you are eating for fun. It requires a lot of mental discipline to lose weight, and the human brain is not geared to avoid problems 10 years down the road, but only the dangers that are 10 seconds away. (Just as a cigarette smoker knows that cigarettes are dangerous, but feels confident that the particular cigarette he is about to smoke will not kill him.) I have told countless adult-onset diabetic patients that if they lost 10 to 20 pounds they would no longer have elevated sugars and I could stop their diabetic medicine. In all my years of practice not one has ever achieved this, even after being referred to an endocrinologist and a nutritionist.

Insofar as carbohydrates are concerned, it is wise to avoid foods with a high glycemic index. If you are dieting you should NEVER eat white potatoes or any bread (bread is really composed of "useless" calories, and white bread is the worst). It is OK to eat pasta, but never have seconds. Rice is the safest carbohydrate to eat to lose weight. In fact, many civilian captives of the Japanese in their prison camps during WWII lost a goodly amount of weight, and their diabetes went away. Before insulin, the standard nutritional treatment for diabetes was to limit the carbohydrates eaten to just rice. I should also mention here that in paleontologic excavations, skeletons from 9000B.C. when man was a hunter-gatherer show no evidence of tooth decay, but as soon as man started to cultivate carbohydrates, the later skeletons showed caries.

So how do we lose weight? I am ignoring exercise for the time being, except to note that most college graduates gain weight the first year they are working, because instead of running all over the campus and up and down stairs, they are sitting behind a desk for 8 to 10 hours each day. Again, we have to eat less, and exercise portion control. I don't believe in special diets, because few patients can keep them up forever, and it is easier to lose weight on diets that you like. I tell my patients no white potatoes or white bread, to weigh themselves on Sunday, and to re-weigh themselves the next Sunday. If no weight has been lost, I tell them to eat smaller portions any way they choose to, and to weigh themselves again the following Sunday. Repeat the process until weight is lost, and then maintain that diet with those portions. The weight loss always plateaus, because the brain is persnickety and loves the status quo, so as you lose weight, the body's metabolic rate decreases, so it becomes harder and harder to continue the weight loss. (Don't worry, the same thing happens in reverse as well: if you gain weight, the body's metabolic rate increases.) The main fact to remember is that you burn fat most readily when you feel hungry, and your liver usually has a 6 hour supply of glycogen, or animal starch. So if you feel hungry after dinner, you will start to burn fat in 6 hours, but if you don't feel hungry you start to burn fat 6 hours after you do feel hungry. So the best way to ensure fat loss is to feel hungry all the time, which most people cannot do.

The most successful at losing weight are marathoners and other long-distance runners, and anorectics. So at the extremes, both hard exercise and not eating will help you to lose weight. This shows that weight loss is definitely achievable, but no one knows how to motivate people to lose weight, any more than we know how to motivate them to stop smoking or drinking. I don't know if the dieters or the smoke-enders know themselves how or why they changed their habits.

I do think that daily exercise is part of weight loss. When I was young, we all ate "junk food" Bonbons, Dots, Chuckles, Banana splits Milky Way, Twizzlers, etc, but we ran around playing games in the school yard for 3 hours each day until dinner, and all day Saturday and Sunday. Today's children have after-school studies, practice, scheduled play dates, etc, so they have less of a chance to burn off the calories they ate. I assume they have the same food appetites that we did, so how can they lose weight without exercise? I should also mention that weight loss is especially problematic for poorer people, because protein is always more expensive than carbohydrates.
One final point: Why don't adults say to themselves "Hey, I should lose some weight" the first time their pants waists increase from 30 to 32 inches or their dress size increases from 6 to 8? Until we can answer that question I don't think we will ever solve the problem of how to help people lose weight.

And we all like ice cream because it's components are that of mother's milk: sugar and fat!

Robotic Surgery

2010-12-18T07:47:00.000-08:00

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

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

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

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

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

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

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

Aspirin and Colon Cancer

2010-12-10T15:07:00.000-08:00

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

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

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

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

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

The Ethics of Dying

2010-11-28T22:37:00.000-08:00

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

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

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

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

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

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

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

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

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

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

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

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

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

Deaths after Chiropractic

2010-11-18T23:08:00.000-08:00

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

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

www.ncbi.nlm.nih.gov/pubmed/20642715

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

OTC Phenypropylamine---increased stroke risk

2010-11-17T21:01:00.000-08:00

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

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

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

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

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

The FDA link is: http://www.fda.gov/cder/druginfopage/ppa

Dabigatran: a replacement for Coumadin and Lovenox?

2010-11-14T12:57:00.000-08:00

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

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

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

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

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

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

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

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

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

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

4) Any deep vein thrombosis

5) Any pulmonary embolus

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

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

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

9) ? Patients with the lupus anticoagulant

10) Patients with factor V or Leiden problems

11) Patients with polycythemia or polythrombocytosis

12) Patients with TIA or embolic stroke

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

etc., etc., etc.

Please feel free to post any other suggestions.

Medical Beliefs and Medical Treatment

2010-11-08T12:16:00.000-08:00

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

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

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

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

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

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

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

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

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

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

Medication, Prescribing, and Timing

2010-10-27T14:20:00.001-07:00

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

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

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

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

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

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

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

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

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

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

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

Medical Malpractice

2010-10-22T21:07:00.000-07:00

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

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

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

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

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

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

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

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

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

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

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

Rx. Drugs, Pharmacology, and Side Effects Part I

2010-10-17T11:47:00.000-07:00

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

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

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

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

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

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

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

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

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

Stress, Part II

2010-10-16T00:13:00.000-07:00

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

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

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

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

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

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

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

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

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

Does Calcium Intake Increase Cardiac Risk?

2010-10-15T23:58:00.000-07:00

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

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

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

Why (Single) Family Practice is Dying

2010-09-26T22:47:00.000-07:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Basic Care by Doctors for Patients

2010-09-14T22:18:00.000-07:00

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

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

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

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

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

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

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

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

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

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

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

If no mammogram in the past year, examine breasts.

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

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

Ask about any veneral diseases, specifically herpes.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How to Minimize Arguments with your Teenagers, Part 1

2010-08-25T22:46:00.000-07:00

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

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

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

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

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

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

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

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

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

Medical Myths and Magical Thinking

2010-08-21T22:33:00.000-07:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Medical Information and Mis-information (Part 1)

2010-08-21T11:09:00.000-07:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Men and Women Think Differently

2010-06-23T10:41:00.000-07:00

Hooray for the State of Wyoming, the only state that gave women the right to vote in its original constitution.

My wife says that I tend to overgeneralize, so in all fairness, when I write "men" or "boys" or "women" or "girls" please mentally insert the phrase "the majority of________in my experience". But it is true that men and women view and react to the world in a very different manner, because society trains them differently and imposes different standards and expectations on them. Basically, women think both "micro" as well as "family group", and feel selfish if they think of themselves first. Women usually feel guilty when they leave a drunken, abusive husband. Men, on the other hand, think "macro", and never think they are being selfish if they satisfy their own needs before they think of others. Women buy into the education system and therefore are much more diligent about school and homework than are boys.

We men know we will never understand half of what women are thinking and feeling, but women are determined to try to teach us. I don't think it can be done. As a simple example, girls walk around puddles and boys jump into them. Girls have neat handwriting in school and color within the lines, while boys have extremely sloppy handwriting and don't color within the lines. (And boys never dot their "i's" with circles, let alone little hearts.) Few if any men have said "it's time to redecorate the living room".

It is true that the men "decide" the major issues: should we a-bomb Iraq, should we put a man on Mars, should we trade with Cuba, while women decide the "minor" issues: where should the family live, which school should the children attend, do they need an after-school tutor.

A fundamental problem is that if a girl means to signify thought (A) by action (B), the boy generally means to signal thought (C) by the same action, so the girl misinterprets the boy's action. A simple process that creates a lot of emotional stress in women when dating is the man's ending the evening with the phrase "I'll call you". When a man tells that to another man, it means he will call his friend sometime between today and his deathbed. Since men usually use the telephone to convey information rather than to visit, most men can't remember the last time they spoke on the telephone to a particular friend, or that they promised to call anyone, let alone within a definite time period. Men also talk to other men in a way that would cause instant enmity between two women if one talked to the other in the same fashion.

Men consider errors of omission a minor sin. I have three male friends with whom I grew up and still see regularly. Sometimes one of us will send the other a birthday card or, more rarely, a birthday present, but we don't keep score, and it doesn't matter, and we won't stop being best friends because of a forgotten birthday. In fact, boys may have a "best pal", but never a "best friend" as girls do. Men also always split the dinner bill evenly, without checking who ate what.

On the other hand, society seems to hold wives responsible (or wives think it does, and accept the responsibility) for how their husbands dress when they go out. Every man has heard the phrase "you're wearing THAT???". Men also wish that our wives and girlfriends never ask us if they look different, or if a dress makes them look heavy. We love the way you look most of the time, and usually don't notice details. And we rarely, if ever, look heavy to ourselves: looking face on at a mirror, a woman sees her hips, but a man does not see his protruding stomach that hangs over his belt.

BTL, or tubal ligation for sterilization is abdominal surgery, and a vasectomy is easier surgery, external to the abdomen, and is an office procedure. But somehow, in the majority of marriages, the wife gets the BTL when the couple wants to make birth control permanent. Men shudder at the thought of a knife in that vicinity.

It never occurs to men that we can be physically hurt. So when the plane lands, we don't call home to our girlfriend or mother to say we arrived safely. (Calling the wife comes under the heading of keeping the peace.) On the other hand, most women fax a copy of their itinerary to at least two people, one friend and one relative, a concept that is foreign to most men.

It never occurs to men that they won't be able to get married when they want to.

Married men will never "get it" that they cannot excuse an affair with the statement "but I didn't love her".

BTW, everyone is on his/her best behavior when they are dating, so if there are things you don't like about the other person, they will not improve with time. Albert Einstein (yes, that one) once said: "The tragedy of marriage is that each husband expects his wife never to change, and each wife expects to change her husband, and both are doomed to be disappointed".

Men prefer laws, and women prefer justice. So men will "cheat" within the laws of baseball (remember Alvin Dark of the NY Giants and his running start to tag up?) and think it legal if they win without breaking the letter of the laws of the game. Since women are trained by society to fit in and make no waves, they seem to take some part of all professional criticism personally, and thereby fail to get the maximum benefit from it. In the same vein, I doubt that a man would "throw" a baseball game to let his brother's team win, as Geena Davis did for her sister in "A Game of Their Own".

You will never convince a school-age boy that school is anything but jail (and I was a straight-A student with SP classes in JHS, and valedictorian and all of that). He will never understand why there is any value in writing a book report after he has read it. "But I read it, didn't I?" When, however, he discovers what he wants to do with his life, he will buckle down and study intensively, and society says "he found himself".

It was extremely clever of the men who passed laws against abortion to penalize the doctor heavily, but never indict the pregnant woman as an accessory before or after the fact, because they know that unless you are in a dictatorship such as Romania was, you can't get such a law passed or the women punished. The reverse happens in prostitution. In the the case of the Mayflower Madam, the prosecutor went after the madam and not the important government employees who utilized her services. Why didn't the grand jury expose their names? Society gives much more sexual slack to men than it does to women, because men make the laws. BTW, did Wilt Chamberlain, who confessed (or bragged?) about having slept with over 13,500 women have no problem with "sex addiction" because he wasn't married, unlike Tiger Woods and Spitzer? Whch leads to a separate philosophical-social-moral question: why is it legal for a woman to sleep with a stranger for free, but illegal to charge him money for the same service?

At least pregnant high school seniors no longer have to leave school for home schooling, but they are still being dropped from Arista after they become pregnant, as if pregnancy diminishes and taints their academic accomplishments. The father, of course, is not forced to drop out of any school extra-curricular activity.

And after marriage, the wife is suddenly and magically given social responsibility for remembering all dates. If the husband forgets his mother's birthday, somehow the wife gets blamed. And when women talk to their daughters and daughters-in-law, they are much more conscious of the effect of their words on the listener than men are (cf. the book "Walking on Eggshells"). I always know by the tone in her voice when my wife is talking to our daughter.

Mothers also get more tired than do fathers, because most mothers sleep with one eye and one ear open to hear the children crying, because they are concerned that their husband will not hear them.

Unlike women, men NEVER make eye contact with or talk to another man in a bathroom, especially if he is at the next urinal. But we are allowed to greet a friend in the street with just a small nod of the head, rather than stopping to talk. And if he has his fly open, it is a rare man who will mention it to him.

Men can let a phone ring without answering it, but women at home usually cannot. I have difficulty convincing my female patients to take an hour's vacation by turning their cell phone off for one hour/day.

But remember that without women to civilize us, we would all be living in the society depicted in "Lord of the Flies".

Useless Medical Screening Tests

2010-06-16T19:55:00.000-07:00

Let me begin by defining what I mean by useless: the results of the test are of no use to the patient and cannot be used to improve the patient's health. There are four classes of screening tests, and I will discuss them each in turn, as well as discussing how to interpret tests and their basic limitations. Just bear in mind (except for a few tests such a red cell blood count and oxygen saturation) that a negative test proves absolutely nothing, that any abnormal test should be repeated before acting on it or worrying about it, and that NO DOCTOR EVER GOT SUED FOR ORDERING A TEST, but only for not ordering one.

The first consideration is the ability and skill of the interpreter (and in the case of ultrasounds such as cardiac echoes, the skill of the technician) and the skill of the laboratory tech.. There are two different terms to describe the error due to the observer/reader/interpreter: inter-observer variation and intra-observer variation. Recall that at the bottom of all mammogram reports is a statement that they can miss cancer 10% of the time. The inter-observer variation, for X-rays, is the percentage of times that a another radiologist differs from the interpretation of the first radiologist. The intra-observer variation is the percentage of times the first reader will disagree with him/herself when he/she re-reads the X-ray one year from now. Neither percentage is ever reported with the test result (which is usually 5 to 15 %).

Next, we have the standard error of the test. The "normal" range given for a blood test is usually the United States average (?men ?women? ?ethnic group ?age range) for the test in question plus or minus two standard deviations. Therefore at least 5% of patients are "abnormal" in any given test without having an illness. Racial variation is never mentioned, but I know from experience that females of a certain racial group average 3.5K in their white blood cell count, and not 4.5K. For that matter, all Inca Indians are blood type O, which will affect some of their blood tests. However, the standard error of the test itself is never given (hematocrit from the hospital lab = 45% +/- what %?). No blood test is 100% accurate, and the error bars are vital for proper interpretation of the test. I will not even start to discuss the diurnal variation (cortisol is higher in the AM, serum iron is higher in the PM), or the fact whether a male gives an AM urine sample standing or lying down can affect the % of protein in the urine, and that many joggers will test positive for blood in their stool (and possibly their urine) on the days that they jog. So when you see a numerical lab test posted, you are told the "normal" range, but never the probable per cent error in the measurement itself, which may be larger than the gap between the patient's value and the "normal" one. And what if a patient's test value has an annual variation? We know that gastric and duodenal ulcer bleedings used to peak in the spring and the fall. What else can vary with time? For that matter, has any one seen a table of the variation in the basic lab tests throughout a female's menstrual cycle? And please remember that the absolute systematic lab error and the interpretation variability of the observer, lab tech or radiologist should be added because these errors are independent of each other.

A screening test is ordered for one of four reasons: (a) you are having surgery, and the anesthesiologist or surgeon insists on it, (b) the doctor thinks it will be of benefit in managing your health, (c) the patient asks for it, either for himself or because a spouse or a friend, or an article suggested it, and (d) a van pulled up to his nursing home or city hall and offered the screening test for a "special" price (usually an ultrasound of your carotid and femoral arteries, and your abdominal aorta.).

The fourth reason seems to me to be morally and ethically wrong on the part of the tester. He/she performs the test, and then takes absolutely no responsibility for applying the results to you, but instead essentially abandons you (after taking your money) and tells you to take the results to your doctor. This is a violation in spirit of the Hippocratic Oath.

When the patient or spouse or friend asks for a test, I used to try to explain why that test might not be indicated (e.g. a cardiac stress test in a young patient who has had chest pain from an anxiety attack). But, since even "healthy" young adults can drop dead suddenly, the better part of valor is to order not one, but two stress tests (echo and thallium) and then refer the patient to a cardiologist as well, thus minimizing the chance of a malpractice suit. As far as Chest CT scans for coronary artery calcification is concerned, why not cut to the chase and do a stress-thallium test, to see dynamically how well the coronary arteries nourish the muscles of the heart?

Almost all screening blood tests for cancer are suspect, with the exception of alpha-fetal protein or beta-HCG in patients with chronic hepatitis or cirrhosis who you are screening for hepatocellular cancer. The other tests: CA-125, CEA, CA-19-, CA-15-, etc, are not useful to test for the presence of the disease, nor is a vaginal ultrasound to look for ovarian cancer. The blood tests are, however, useful after the cancer has been found and operated on, to screen for recurrence of cancer.

I have deliberately omitted any mention of PSA, because there is not yet any conclusive evidence that treating prostate cancer saves lives.

The jury on whether CRP has causative value or is just a marker similar to the elevator arrow in the lobby is still out. The latest study was a meta-analysis; for a general criticism of this type of study I refer you to an earlier blog of mine "Analysis of Meta-Analysis".

TSH, or Thyroid Stimulating Hormone is another useless screening test. The body runs on free T4 (actually free T3, but you need to measure that only if you suspect T3 toxicosis). If the TSH is off, then doctors measure the free T4. But I just start with the free T4---why stick the patient twice? I of course repeat the measurement of free T4 along with TSH before starting treatment. Anyway, historically the TSH was easier and cheaper to measure because free T4 is measured by radioimmunoassay (and Rosalind Yarrow got the Nobel Prize for developing the technique of measuring hormones by radioimmunoassay, but because she was a woman and worked at a VA hospital, she couldn't get her early work published in the Journal of Clinical Investigation). But now both T4 and TSH are same day measurements, so if your doctor screens with only the TSH, he is doing you a disservice. Some doctors will measure the free T4 and the TSH at the same time, which makes perfect clinical sense. There is also no evidence that if the TSH is elevated and the free T4 is normal that you need thyroid supplement. In fact, excess thyroid hormone can lead to osteoporosis.

Periodic chest-Xrays and sputum for cytology every 3 months have not been found to be useful to discover lung cancer at an early, curable stage, according to two studies, one at the Mayo Clinic, and the other at Johns Hopkins. The question of the usefulness of spiral chest CT to detect early lung cancer is being studied right now.

Question: how often should a pap smear, a mammogram, and a stool for blood, all of which are useful in detecting cancer at an early and curable stage, be offered to the patient? Once a year, once every 6 months, once every three months, once every month? No one has ever tried to determine the optimum testing interval for any of these tests.

If an anesthesiologist or surgeon requires a test, then you have no choice, unfortunately, because the surgery will not be done without them. An EKG in the previous 6 months is a reasonable request, because the repeat heart attack rate is elevated during surgery for 6 months after a heart attack. However numerous studies (see the Cochrane reports) have shown that pulmonary problems and bleeding problems can generally be detected by a proper history and interview, and a Chest Xray, and the clotting tests PT and PTT are not routinely needed. On the other hand, if there is unexpected bleeding or pneumonia after surgery, someone might get sued if the tests were not done, even if the USPHS guidelines do not recommend them.

Finally we have the question of how to handle a patient who refuses a test. It would seem logical to just make a note in the chart. However, several years ago, a female who refused pap smears for 5 years in a row developed cervical cancer that was ultimately fatal. Despite the documentation of the patient's refusal, with the note in the chart signed by the patient, the plaintiff lawyer for the estate claimed that if the doctor had really explained the risks of not doing the test, and the patient had really understood them, she never would have refused the test. The California jury found for the plaintiff! Consequently, many doctors will "fire" patients who refuse to do certain tests.

I know of no medical use from the results of analyzing the heavy metals in your hair.

FINGERPRINTS: I know this doesn't quite fit the topic, but this should be checked out. It is absolutely true that fingerprints are unique to a given individual, and even identical twins have different fingerprints. However, that does not translate into 100% accuracy in identifying a "latent" fingerprint on an object as coming from a particular person. Recall how a California lawyer's fingerprint was identified as being on some wrapping paper they found at the deliberate explosion in the Madrid subway station but later on they found the real culprits in Europe? Two fingerprints apparently "agree" if a fingerprint "expert" says they agree, much as a psychiatrist testifies that you are sane or insane. However, if you look further into this problem of identification, there is no agreed upon standard as to what constitutes a match. How many "points" have to agree? 6,7,8? And what if some points disagree? And no fingerprint expert will ever admit that there is no "gold standard", but only a judgment call.

Lie detectors are absolutely forbidden to be used to establish guilt or innocence in US federal or state courts. They are too unreliable and non-reproducible, as well as operator/interpreter dependent. There was an article about this in JAMA 3 to 5 years ago. But the CIA and FBI still use them, and DA's often request them.

Urine screening drug tests. The best book about this is probably still Abbie Hoffman's "Steal This Urine Test". The urine tests usually only test for a chemical fragment of the forbidden chemical, and are therefore not very reliable. Also cutoff values are needed for a test to be positive. If the cutoff is set too low, there will be many false positives. For instance, co-nicotine is a metabolite of ordinary vegetables (especially tomatoes) as well as nicotine. So if your urine tests positive for co-nicotine, are you a cigarette smoker or a vegetarian? And remember when Elaine on the "Seinfeld" show flunked her urine test for opium because she had eaten a poppy seed bagel? That has happened in real life as well.

Finally given the fact that 5% of patients statistically are expected to be abnormal on any given blood test, the odds that you will have one abnormal result from a panel of 20 tests when you are healthy is approximately 50%!

And ask your internist if he/she personally reviews ALL Xrays and ultrasounds taken of his/her patients with the radiologist, whether or not the report is normal. I always do, and the Xray report gets modified 10% of the time. Just as in my intern days, the most common overread is cardiomegaly on a chest Xray because the patient did not take a deep enough breath.

How to be a Healthier Patient

2010-05-30T22:22:00.000-07:00

The list that follows is by all means not inclusive, and if any of you out there want to contribute to the list, please do so.

1) Please inform the doctor if you plan to (a) change the dose of a medicine or drop it entirely, or (b) not see the specialist to whom you were referred, or (c) plan not to do a suggested test.

2) Be aware of your family history. The risk of diabetes increases with age, and even more so if any relative has adult-onset diabetes and you are overweight. The risk for Alzheimer's Disease and coronary artery disease is also inherited. If either parent smoked and developed lung cancer, you shouldn't even think about smoking. If either parent or sibling had colon cancer, you should start colonoscopies at age 40, and have one every 5 years.

3)Feel free to search the internet about your disease, at the same time that you try to ignore the well-meaning advice from family members and friends. They may be angry with you for not asking for a different test, not getting another opinion, not seeing the doctor they recommend, etc.,, but remind them that it is your body, and it is more important to please yourself and feel comfortable with your medical decisions than to please them Discuss the internet results with at most one person. Once you have decided on a treatment plan, try not to second-guess yourself.
Never look up your symptoms, because you may imagine you have horrible diseases, as many second-year medical students do during their course in abnormal human pathology.

4)Be sure you have a signed and notarized copy of your pre-terminal and terminal wishes, and discuss this with your doctor and make sure both he and your medical power-of-attorney have copies.

5) Please make sure that your tetanus, shingles, pneumovax vaccines etc. are received at the recommended time intervals. (Vaccination is discussed in an earlier blog.)

6)You can be the best patient in the world, but sugar, cholesterol, and blood pressure all usually increase with age. By observing your doctor's recommendations, you can reduce the rate of increase of risk.

7)Avoid brand new "treatments" that only one doctor knows about. There are very few secrets in medicine, because all doctors want to cure their patients. If you hear/read about a new medical "development", you should wait for the second published paper. If it is an announcement after a talk at a medical conference, or shown on a TV talk show, then the results probably weren't reviewed at all. (Remember when a "study" claimed to show that coffee drinking increased the risk of pancreatic cancer? Or that lemon in hot tea in a styrofoam cup leached out a dangerous and carcinogenic chemical?) For that matter, they jury is still out on the safety of charcoaling meat, but no one seems to worry about this any more.

8) Please make sure your family doctor gets a copy of ALL your tests, both blood and Xrays, wherever they are done, especially including the emergency room. It is important for your health that at least one doctor has all your health records. (And if you want your doctor to use an electronic record storage system, I have received notices in the past 2 years from 3 Veterans' Hospitals that their system was hacked. Would you trust the fact that you are a married, bisexual, cocaine-using AIDS patient to the security of the internet?)

9) If you can, try to exercise non-stop for at least 30 minutes 3 times a week. The maximum exercise pulse rate is a myth. (Bjorn Borg's resting pulse when he won the French Open was 34, which is also typical of many marathoners.) You should exercise at such a rate that at the end of your workout you feel that you have exercised. Walking is great, swimming is a no-load exercise that shouldn't stress any joints, and if you use a treadmill, setting it on an incline leads to an unusual walking pattern.

10) If you want to lose weight, remember that no one stays on a fancy diet forever. Just use portion control, and be satisfied with a spoonful of chocolate ice cream rather than the whole pint. You burn fat when you feel hungry, so always leave the dinner table before you feel full. You don't even need a scale. Just feel how your clothes get looser. For a man, one belt notch, aka 2" around the waist, is about 10 pounds. If you are more than 100 pounds overweight and a diabetic, the most certain treatment to date seems to be gastric banding, but ask the surgeon how many he/she does a year. Also, remember that your metabolism slows down each year until you are about 75 years old, so if you don't reduce what you eat, you will probably gain 3 to 4 pounds each year. Just recall what you weighed when you graduated high school or college, or before you got married, or before your first pregnancy.

11) As of this date, there is NO evidence that treatment of prostate cancer saves lives (which doesn't mean that it does not, but only that there is no proof of its effectiveness.) However, I have never seen a wife who would let her husband not treat his cancer, so if you believe in "watchful waiting", then don't have the PSA test if you are married.

12) Please tell the doctor the whole truth and any and all complaints, whether the doctor asks you about them or not. Too many patients are embarrassed to discuss certain issues (is sex with your partner satisfying?), or do not raise certain complaints because they fear the possible diagnostic consequences. Too many men minimize their symptoms (men will almost always be macho with other men). Patients rarely discuss habits that they feel are demeaning or childish, or make them seem less than perfect in their own eyes or the eyes of their doctor. Remember that we doctors have really seen it all, both in our offices and in the emergency room, and we are not shocked, censoring, or belittling. We really do want to help you, and it is no longer true that an alcoholic is any patient who has a drink a day more than his/her doctor does.

13) Please only have protected sex. Too many of my college students don't. I tell all my female patients to keep a condom in their purse, don't tell the guy that you are on the pill, and that "if he doesn't put it on, he doesn't put it in".

14) If you are concerned that you may have AIDS or another sexually transmitted disease, then donate a unit of blood to the Red Cross. They will test your blood for AIDS, syphilis, hepatitis A,B,and C, West Nile Virus, and a few other disease, and the tests are run free of charge. Also, the country can always use another unit of blood, and there will be no record in your doctor's office chart for your life insurance company to wonder why you had an AIDS test.

15) Whether or not you have high blood pressure or diabetes, you should review your diet with a competent nutritionist.

16) For what it's worth, there have been at least two studies showing that women (but not men) who drink regular coffee decrease their risk of developing adult-onset diabetes.

17) Lastly, even the government now admits that daily (for men) and thrice weekly (for women) alcohol ingestion decreases the risk of coronary artery disease, heart attacks, and strokes. (See my previous blog for more details about the health benefits of alcohol.)

18) And you should probably see your doctor to review your health and be thoroughly examined once a year, but I know of no studies that support this suggestion.

A Day in the Life of an Internist

2010-05-29T21:21:00.000-07:00

I received what I think was the best clinical training in the USA, both at my medical school and in my internal medicine residency at a big-city hospital with a long and meritorious history of treating both private and ward patients. I learned from my mentors that the patient should always be treated with the utmost courtesy, and listened to as carefully as possible. It is absolutely true that a properly taken history will give the correct diagnosis 85-90% of the time, and the physical exam and lab tests usually just confirm your impression. Since I have observed both from what my patients tell me and from observing my medical interns and residents at work that human doctor-patient interactions have deteriorated (which does not, unfortunately, show up in the morbidity or mortality tables), I would like to describe to all my readers how I practice medicine.

When I started practice, I allotted 60 minutes to a new history and physical, 45 minutes for an annual physical, and 30 minutes for any other visit. I have had to reduce this to 45 minutes, 30 minutes, and 20 minutes respectively, because office fees keep on dropping, but I think what I have now is a irreducible minimum amount of time for a visit, and I could not lower it further in good conscience. My patients also know that if they call my office before 10AM I will see them that day. I also always maintain eye contact, taking very few notes, and NEVER looking down at the keyboard of a laptop (I don't have one in the office) while I am taking a history.

I begin by going out to the waiting room and escorting the patient into my consulting room. (No, I have no PA's or NP's, but only a lab tech who does EKG's and gives vaccinations.) After talking with the patient, I then escort the patient into the exam room, and then wait outside while they disrobe and put on an examination gown. I then enter the room (with a chaperone if it is a physical exam of a female patient) and examine the patient. I then leave the room, the patient dresses, and comes back to the consultation room. I then discuss my findings and tentative diagnoses, and discuss the lab tests and Xrays I am ordering, and review the EKG with the patient. Then I explain why I am prescribing medicine, what I am expecting the medicine to do, and when or under what circumstances the patient should call me (or I the patient). When the lab tests and Xray reports are received by me, I make a copy of them and mail the copy to the patient along with a note discussing with the patient our next plans, and always ask the patient to call or come in to see me for further clarification. A copy of my note is also placed in the patient chart.

I feel that a good doctor is a good teacher, and one of my obligations is to educate my patients as well as possible. I also suggest they use the internet only to look up diseases, and not symptoms, because all symptoms can be due to AIDS, Alzheimer's disease, and cancer.
I normally can explain things to my patients' satisfaction, and refer them to a specialist if I cannot. The problem always arises when the patient is satisfied with less medical information than the spouse, other family members, or friends want to know. I firmly believe in patient privacy, and that the patient is always right. (Although the patient can be legally right and morally unfair; e.g. in not disclosing a diagnosis of cancer to the spouse.) But if I tell a patient that his Chest X-ray shows a mass and I want to get a CT scan of the lesion to help diagnose it, and he does not ask me if the mass could be cancer, then he is not prepared to consider that diagnosis at this time.

Every patient has certain medical beliefs, and therefore will accept some treatments and tests, but not others. I have no Christian Scientists in my practice, but I do have some Jehovah's Witnesses who will not accept blood transfusions. At Yom Kippur, a few Orthodox Jews always ask me if fasting includes not taking any medicines, and I tell them to verify with their rabbi that health takes precedence over religious practices. I do have diabetic patients who will not take insulin, because in their belief system if you take insulin you are a true diabetic, while if you only take pills you just have a "sugar problem". I have patients who refuse mammograms, vaccinations, fecal blood tests, pap smears. I have patients who refuse to let me take their weight. I have patients whose spouses don't believe in sleeping pills, or perhaps in antidepressants, so they have to hide them, and pay for the drugs themselves if they are on their spouse's medical plan.

Every patient with "bad" habits knows that reform is needed, but they are not prepared yet to give up the pleasures of smoking, or deny themselves oral gratification to lose weight. The human brain doesn't handle the future very well, so to us a "bird in the hand is worth two in the bush", or $10 today is better than $20 one year from now. We'd rather look for amulets and gimmicks: copper bracelets to treat rheumatism, ear staples to reduce hunger, or magnets in your shoes (should the North Pole or the South Pole of the magnet face up?) to treat back pain.

So I give my patients the best advice I know and educate them as well as I can using anatomy books, skeletons, etc. But my ego is never on the line,so I never take it personally when a patient doesn't follow my advice, but I do ask them to let me know if they are going to stop a prescribed medicine. I also don't take it personally if they change doctors, since they have an absolute right to their body. Too many patients stay with a doctor or dentist with whom they are dissatisfied
because they don't want to be rude and hurt the doctor's feelings.

One frustration with HIPAA: In the "Old days", if I felt a patient had become an unsafe driver, I could write a letter to the DMV, and they would require a repeat road driving test within 60 days, or the license would be revoked. The DMV has now informed me that due to the HIPAA
laws, I cannot write such a letter without the patient's explicit consent.

I am on call from 8AM Monday morning until 5PM Friday afternoon. I split weekend coverage with another group (I am a solo practitioner, in part because doctors get paid more for doing the cardiac cath. than diagnosing that the cath. is needed). I tell my service to find me if they cannot find my covering doctor. I also tell my service that I don't do pharmacy refills after 6PM. I tell my patients that whether they call the office or my answering service, if I don't call them back within 30 minutes they should call me again to make sure I got their message. You might note that my total hours on call greatly exceed those allowed for medical residents, although I am 30 years older than most of them, and certainly don't have as much non-sleep stamina as they do. I also don't have the luxury of calling an older attending for advice. But if I told a patient who calls me at 10PM with a medical problem that I have been up and on call for 16 hours, and they should go to the Emergency Room to be seen by a well-rested physician, I don't think they would like the suggestion.

I might mention that for me physical diagnosis is fairly straightforward, and I see one of my main jobs as reducing stress in my patients. I have a T-shirt that says "Stress is when your gut says "No", and your mouth says "Of course. I'd be glad to." Therefore, I ask all my patients the same two questions at their annual physical: (1) Do you look forward to going to work in the AM? (or your spouse's leaving the house). (2) Do you look forward to coming home to your spouse and household at the end of the day (or seeing your spouse come home)?

Anything you do that your brain does not want you to do will cause stress, and the more stress, the more pain your unhappy brain will cause your body. As a trivial example, most females traveling away on a weekend business trip are constipated while they are away from home---something to do with strange toilets. This is just an observation and not an anti-female statement. Similarly, most males who have not served in the armed forces have difficulty urinating if another male is at the urinal immediately next to them. In this vein, I tell all my young adult patients to make sure they like their jobs before they acquire a spouse, 2 children, and a mortgage.

For completeness, but also to safeguard my patients, I keep a complete problem list (operations, treatable conditions, allergies, home stresses, medicines) in the front of the chart, but any fact that might cause embarrassment if read by a spouse is written in my private code(e.g. uses cocaine, has affairs, gave a baby up for adoption at age 14, etc.) Again, my patient is always
right, and I will defend this right as firmly as I can. And if you haven't already guessed, I think that internal medicine is the most wonderful field in the world!

Health benefits of Alcohol

2010-05-27T19:07:00.000-07:00

Those of you who have read my blog regularly know that I think that alcohol is a valuable medicine that lowers the heart-attack risk. This whole subject was recently reviewed in the Journal of the American Medical Association in the May 26, 2010 issue (vol. 303, # 20, pp. 2065-2073). It is a fairly comprehensive review, with an extensive list of references. Before summarizing the review, I should like to iterate my opinions:

(1) We should lower the legal drinking age to 16. The age was forcibly raised to 21 by the U.S. Gov't, who threatened to reduce federal aid for highway construction to any state (e.g. New York) that did not raise the age to 21. The result is that many adolescents do their first serious drinking at college, away from parental supervision, and without the necessity of coming home to their parents in a somewhat sober condition. The system is even worse at state colleges. My daughter went to a state college, which was kept rigorously dry, even in the fraternity houses. The only result is that the students went off-campus to drink, and drove back to their dorms drunk. I hardly think that this is an improvement.

(2) If the greatest fear is that of teen-age drunken driving, then why not make it legal for teenagers who do NOT have a driving license to drink?

(3) My oldest grand-nephew just finished a 3 year tour in the Marines. He is allowed to drive a tank, operate a 50. caliber machine gun, a SAW, and kill our enemies, but was not even allowed to drink 3.2 beer on his base. There is something wrong with this picture if we trust him to kill responsibly, but not to drink responsibly.

The JAMA article made the following points, all of which were referenced to published articles. I should add that we still do not know the direct mechanism by which alcohol exerts its beneficial effects.

(1) Alcohol increases the "good' cholesterol HDL-C, in a dose-dependent effect.

(2) Alcohol decreases the level of fibrinogen, a clotting factor.

(3) Alcohol increases insulin sensitivity, and decreases the generation of glucose by the liver, so its ingestion opposes diabetes by two different mechanisms.

(4) Alcohol prolongs bleeding time.

(5) There is also an inverse relationship between alcohol intake and risk for stroke.

(6) All alcoholic beverages appear to be equipotent, and seem to benefit men more than women, provided that the alcohol is ingested on a regular basis.

(7) Alcohol does contain calories, and also increases a woman's risk for breast cancer (but the latest Danish study showed that pregnant women can imbibe a drink a day without harm to the fetus).

Overall, since cardiac disease causes the most deaths in the US, and since regular alcohol use can reduce the risk of coronary artery disease by as much as 30%, I think that doctors should consider recommending this as a daily medicine to men, and perhaps thrice weekly to women.

When is a Low Salt Diet Beneficial (if ever)

2010-04-25T21:32:00.000-07:00

I was upset, both from a medical and a mathematical point of view, after I read the paper published in "Annals of Internal Medicine" by Crystal Smith-Spangler and others: "Population Strategies to Decrease Sodium Intake",Ann.Int.Med. 2010;152:481-487, the lead article in the Annals volume published on April 20 of this year. I have been a reviewer for Annals for over 10 years. I can assure you that I would have rejected this article immediately. I never had an article I rejected overridden by the editor-in-chief, but sometimes the article in question would be published in a journal with less strict criteria.

I object to this paper on epidemiological grounds, on mathematical grounds, and on moral grounds as well.I think we all agree that blood pressure is a monotonically increasing function of the amount of daily NaCl consumption. We also note that increased blood pressure puts one at risk for strokes (CVA's) as well as heart attacks (MI's). The question of course is twofold: does lowering blood pressure reduce the risk or rate of CVA's and MI's? And furthermore, by how much can we reduce blood pressure "the silent killer, by decreasing the salt in the diet.

I will pass over the fact that some heart failure patients on NY Class III or IV worsen their faliure when their salt intake is lessened. I will also ignore the fact that there is no city-wide Institutional Review Board to evaluate the safety of this intervention in various groups of patients, and, of course, the "patients" in an entire city or country are not all consulting adults. So we are treating/testing a group of involuntary "volunteers".

Since correlation is NOT causation, we first have to see if lowering dietary salt lowers cardiovascular events (presumably by lowering blood pressure). Giving a patient a diuretic makes his kidneys excrete extra salt, so a daily water pill mimics a low salt diet somewhat. The result of diuretic treatment to lower blood pressure was that the incidence of CVA's was reduced. but not that of MI's.

To add further spice to the stories, the authors claimed that a 9.7% reduction in salt intake, as achieved by the British Government, would attain a 1.25mm (i.e. 1%) reduction in systolic blood pressure, and this would prevent 513,885 strokes and 480,358 heart attacks.

This not only looks too good to be true, it is too good to be true. The intra-observer error/statistical deviation in measuring blood pressure is+/- 2 mm.The interobserver error is worse, and is +/- 3 to 4 mm. Hg. (Not unlike the radiologist ' mammogram report that says they miss 10% of cancers). This would be similar to my claiming that since the measured speed of light is 186,272 miles/second, and I measured it to be 186,273 +/- 2 miles/sec., it is time to change the accepted value of the speed of light.

This is also like the situation where the government, seeing that pumping auto brakes helps to reduce the skidding of a car insisted on installing an automatic pumping system on the brakes, the ABS. You got a car insurance reduction for doing this,but it did not decrease the number of accidents after a skid, and now it is no longer mandatory. I also am skipping over the fact that the NTSB knew that if they required air bags to explode/expand rapidly enough to protect you even when you were not belted in, then children in the front seat might be hurt. They deliberately did not mention this fact to Congress, in fear that the air bag law might not be pass. They just admitted the week of May 16 that the air bags cause more damage to front-seat passengers and drivers who are belted-in rather than those who are not. Why believe ANY government reports or recommendations unless you can study the basic data from which the recommendations were derived?

Apropos of poor math training, tonight we attempted to give our waitress the check with a coupon good for an $25 discount, and asked her to divide the bill into 2/3 and 1/3 with tax and tip. It took her only 20 minutes (!). Hooray for the new math.

What I am saying again is that correlation is not causation, and we can only hope that the low salt diet will be of benefit to some patients, and not too harmful to others.

BTW, if you have a blood pressure problem, please make sure your doctor measures the blood pressure in both arms.