There have been many articles published about the benefits of electronic medical records. The US gov't has appropriated millions of dollars to aid in their development and adoption. The claim is that the adoption of such systems will save money by reducing the number of duplicated tests and also reduce patient mortality and morbidity because fewer errors will be made.
I will leave aside the question of the possible (unproven as yet) benefits of computer-generated hospital records and notes. I will note,however, that computerized hospital notes and orders use up more of a doctor's time, and that is the one dimension we already have too little of. It used to take me 5 minutes to admit a patient with pen and paper. Now it takes at least 25 minutes on a computer, in part because of "mission creep". By mission creep I allude for instance to the U.S. Census, which is mandated by the U.S. Constitution to do a head count every 10 years to re-apportion U.S. Congressional districts among the states, but now also requires you to tell the government how many bathrooms, bedrooms, and telephones you have, among other details. And when the computer crashes, all the residents are helpless.
I admit to two hospitals. In one of them, I cannot even admit a patient unless I answer the question: should the patient I am admitting have a flu and pneumonia vaccine at discharge (and there is no place to indicate that the patient refuses). In the other hospital (and only God knows why) they ask for the birth date of the admitting doctor. This information can't possibly help the patient, but someone wants the information. They even set up the answer matrix so that 00-00-0000 does not work.So now most of the doctors were born on 11-11-1911, because that is the easiest number to write that the computer will accept.
I am also concerned because not once in the past 5 years has a nurse called me from the ward to ask if my drug order was correct. The order goes by the computer to the pharmacy dept., who delivers it pre-labeled to the floor. The nurses seem to think that a computer-generated label must be correct, and besides, the pharmacy filled it. Of course the pharmacologist does not know the patient nearly as well as the nurse does, but it is efficient! I don't even want to discuss my reaction when I ask an intern for a patient's Hct. , and I am told that it isn't in the computer yet. It never occurs to them that the number is generated by the hematology laboratory, and you can call them up for the result.
Now let's look at electronic medical records, and their benefit for the patient. When I started practice, I used to give all my patients a photo-reduced copy of their EKG to keep with them , because when a patient hits the ER with chest pain, the doctor certainly wants to know what the previous EKG looked like. I found that fewer than 10% of patients carried the copy with them, so I stopped this practice.
Now a doctor's medical record system is supposed to be compliant with and interactive with the hospital system. This requires you to be HIPAA compliant which means the changing of your hospital password every 90 days, or else you cannot log on to the hospital computer. How in the world can two hospital computers exchange data? I can't imagine changing your password every 90 days for every hospital in the US, and the SmartCard still requires a password.
I also know that every doctor wants to review Xrays and MRI results personally before surgery, etc. So even if I have a transmitted electronic report about the result of an MRI, I would want to repeat it if the patient's treatment depended on it. This also holds true for cardiac echoes, stress tests, cardiac angiograms,etc. If you were a patient, wouldn't you want your doctor to personally review a study before operating? You also would not trust the result of a technically difficult lab test (e.g. N-terminal parathyroid hormone) unless you had total faith in the lab, and therefore you would probably repeat the test. And if different labs with different techniques have different normal ranges, this complicates matters still further. Similarly, where cancer is concerned, the pathologist and oncologist will want to review the biopsy slides personally, rather than rely on a written report.
All the above can be summarized by saying that no doctor would depend on a written report alone, but would want to see the actual data. If details are needed in the ER about a patient, then the ER doctor will probably communicate with the family doctor for information that is not in the computer system (e.g. the patient uses cocaine, is bisexual, etc.) because no computer system is totally secure. There is always critical data about a patient that is known very well by the family doctor but never makes it into the chart because of its sensitive nature. I would never write down in an office chart that a patient hates his wife or is having an affair if I know the wife has legal access to the chart, or vice versa. I am not being paranoid about the non-security of data in the hospital system, because in the last 2 years I have received communications from 3 Veteran's Hospitals that their information systems have been hacked.
I yield to no one in agreeing that computers are terrific for transferring information. What concerns me is the uncritical acceptance of information on a computer, and where the paper backup is when the system crashes. When patient lives are at stake, there must be accessible backup. As I recall, a few months ago LAX had to divert planes for 3 hours because of a malfunction in the computer program that linked their radar systems. There have also been recent articles on radiation overdoses received by patients because the technicians did not understand the intricacies of computer-operated radiation beams. And with a typical automobile having 30 computers with thousands of lines of code, it's a miracle that there aren't more recalls.
Let me close with the following anecdote (and I repeat that I am not a Luddite, and was an early fan of Wylbur): "Ladies and Gentlemen, welcome to the first fully automatic transcontinental airplane ride that is fully operated by onboard computers. We have 3 computers, and therefore double redundancy for safety. This system has been tested thousands of times. Relax as we take off, and be assured that absolutely nothing can go wrong, go wrong, go wrong, go wrong, go wrong,....."
Saturday, February 6, 2010
Friday, January 22, 2010
Cholesterol, Statins, Zetia,Niacin, ASCVD, and MI's
This blog was stimulated by several recent articles and studies about statins, zetia, Niacin, ASCVD, and MI's. We must not lose sight of the fact that virtually all researchers have concluded that an MI is triggered by the rupture of an atheromatous plaque in a coronary artery, although the actual rupture has not, I think, ever been seen dynamically. Nevertheless, when a coronary artery is found clotted off at autopsy, and the clot is adjacent to and newer than the plaque, and the surrounding tissue is necrosed, then the conclusion is probably correct.
The first fact to notice at such an autopsy is that the atheromatous-clotted artery, as a rule, has a larger diameter anatomically before and after the clot than does another coronary artery. In other words, the probability of a rupture-to-clot process does not seem to depend vitally on the pre-clot diameter, although there is, of course, some influence. Just recall how many times an artery with 97%-99% stenosis is not occluded, but is stented instead.
So we then come to the question: what causes (or prevents) the plaque in a coronary artery from rupturing, clotting off the artery, and causing an MI? Clearly there must be some degree of inflammation which sets the plaque up to be susceptible to the shearing force of coronary blood flow. So we can have some equation that the probability of clot formation varies as (C)x(probability of plaque)x(?thickness of plaque)x(probability of rupture), where C is a factor to indicate that an MI has occurred before; if C=1 we are dealing with primary prevention, and if C is greater than one, we are dealing with secondary prevention.
Since we have plenty of data on secondary prevention, I am going to concentrate on primary prevention. Now CRP, a measure of inflammation, has been variously correlated with the risk of MI as has 81 mg/day of ASA, with no clear-cut primary prevention shown by either lowering CRP or by daily ASA. But in experimental physics we have a saying: If you are arguing about the significance of data, then the data is not significant, similar to the last data point in a particle physics experiment.
We do know that diabetes, cigarette smoking and hypertension are synergistic with cholesterol levels in causing a plaque as well as a clot. This shows at least two mechanisms at work, since it is difficult to imagine that hypertension increases local plaque inflammation. Similarly Zetia, which lowers cholesterol, does not seem to increase coronary artery diameter, but these studies did not look at MI or CVA as an endpoint, so we don't know if Zetia affects plaque inflammation and rupture. A curious observation is that if your "native" cholesterol is 200, your risk of an MI is greater than if Crestor was used to lower your native cholesterol from 240 to 200. This clearly indicates to me that statins have an additional preventive effect, probably lowering inflammation of the plaque, over and above lowering cholesterol and/or reducing the size of the plaque. Similarly Niacin, which raises HDL, has a beneficial effect beyond its size effect, and probably lowers inflammation as well. And patients (usually female) with cholesterols over 300 and 85+ years old without and ASCVD are outside our explanations and models.
But to me, the most amazing drug is C2H5OH, or ethanol. In matched pairs, people who drink "moderately" (= 1 drink/day for men, and one every other day for women) have a lower heart attack rate and LARGER DIAMETER CORONARY ARTERIES AT AUTOPSY than do non-drinkers. This result holds for numerous studies with whiskey, beer, slivovitz (plum brandy), scotch, etc,in homogeneous populations (e.g.native-born Japanese males in Hawaii) and seems to be a pure alcohol effect. We have known this since 1974 (see article in JAMA). No one knows the mechanism by which this occurs, but I assume constant research is going on. Since young people already have atheromatous plaques, then if we want to reduce heart disease in our older population, it seems to me we should encourage a glass of wine with dinner starting with high school seniors. There is no argument in the literature about this effect, as there is about lowering CRP, adding ASA, or lowering salt in the diet.
With regard to lowering salt in the diet, there were two long articles (one pro and one con) about this subject published years ago in Lancet. The con argument was that just as eating sugar will not make you a diabetic, so will eating salt (with normal kidney function) not give you hypertension. I have a more fundamental ethical objection to imposing salt reduction. In hospitals and research clinics, when an experiment is performed on human subjects, it must be passed by the Institutional Review Board, and each subject must be warned of possible negative side effects and given a chance to withdraw. No such board will review the law if low salt diets are mandated, and I am concerned that 10 years down the road we may learn that we have done irreversible harm to the subjects, our fellow citizens, or to the children in school cafeterias.
The first fact to notice at such an autopsy is that the atheromatous-clotted artery, as a rule, has a larger diameter anatomically before and after the clot than does another coronary artery. In other words, the probability of a rupture-to-clot process does not seem to depend vitally on the pre-clot diameter, although there is, of course, some influence. Just recall how many times an artery with 97%-99% stenosis is not occluded, but is stented instead.
So we then come to the question: what causes (or prevents) the plaque in a coronary artery from rupturing, clotting off the artery, and causing an MI? Clearly there must be some degree of inflammation which sets the plaque up to be susceptible to the shearing force of coronary blood flow. So we can have some equation that the probability of clot formation varies as (C)x(probability of plaque)x(?thickness of plaque)x(probability of rupture), where C is a factor to indicate that an MI has occurred before; if C=1 we are dealing with primary prevention, and if C is greater than one, we are dealing with secondary prevention.
Since we have plenty of data on secondary prevention, I am going to concentrate on primary prevention. Now CRP, a measure of inflammation, has been variously correlated with the risk of MI as has 81 mg/day of ASA, with no clear-cut primary prevention shown by either lowering CRP or by daily ASA. But in experimental physics we have a saying: If you are arguing about the significance of data, then the data is not significant, similar to the last data point in a particle physics experiment.
We do know that diabetes, cigarette smoking and hypertension are synergistic with cholesterol levels in causing a plaque as well as a clot. This shows at least two mechanisms at work, since it is difficult to imagine that hypertension increases local plaque inflammation. Similarly Zetia, which lowers cholesterol, does not seem to increase coronary artery diameter, but these studies did not look at MI or CVA as an endpoint, so we don't know if Zetia affects plaque inflammation and rupture. A curious observation is that if your "native" cholesterol is 200, your risk of an MI is greater than if Crestor was used to lower your native cholesterol from 240 to 200. This clearly indicates to me that statins have an additional preventive effect, probably lowering inflammation of the plaque, over and above lowering cholesterol and/or reducing the size of the plaque. Similarly Niacin, which raises HDL, has a beneficial effect beyond its size effect, and probably lowers inflammation as well. And patients (usually female) with cholesterols over 300 and 85+ years old without and ASCVD are outside our explanations and models.
But to me, the most amazing drug is C2H5OH, or ethanol. In matched pairs, people who drink "moderately" (= 1 drink/day for men, and one every other day for women) have a lower heart attack rate and LARGER DIAMETER CORONARY ARTERIES AT AUTOPSY than do non-drinkers. This result holds for numerous studies with whiskey, beer, slivovitz (plum brandy), scotch, etc,in homogeneous populations (e.g.native-born Japanese males in Hawaii) and seems to be a pure alcohol effect. We have known this since 1974 (see article in JAMA). No one knows the mechanism by which this occurs, but I assume constant research is going on. Since young people already have atheromatous plaques, then if we want to reduce heart disease in our older population, it seems to me we should encourage a glass of wine with dinner starting with high school seniors. There is no argument in the literature about this effect, as there is about lowering CRP, adding ASA, or lowering salt in the diet.
With regard to lowering salt in the diet, there were two long articles (one pro and one con) about this subject published years ago in Lancet. The con argument was that just as eating sugar will not make you a diabetic, so will eating salt (with normal kidney function) not give you hypertension. I have a more fundamental ethical objection to imposing salt reduction. In hospitals and research clinics, when an experiment is performed on human subjects, it must be passed by the Institutional Review Board, and each subject must be warned of possible negative side effects and given a chance to withdraw. No such board will review the law if low salt diets are mandated, and I am concerned that 10 years down the road we may learn that we have done irreversible harm to the subjects, our fellow citizens, or to the children in school cafeterias.
Friday, January 8, 2010
Mental Stress and Physical Discomfort
I have observed time and time again, that when your mind is stressed your body will start to hurt, or you will have some physical symptom. Mental stress almost always comes from doing something emotionally in a family situation, or physically in a non-work situation, that you do not want to do. As a rule, this is also connected with the thought of feeling guilty if you do not do the particular act, whether you want to or not. Boredom, for instance, is low-level anger,triggered because you do not want to be where you are (music concert, college class, visiting in-laws, etc. ), and typically occurs when you are doing something in a group/social situation where you feel you "have" to be. As you get older, you do fewer of these unwanted things, (a) because society puts less pressure on you, and (b) you feel more entitled to spoil yourself and be kind to yourself without feeling guilty or "selfish".
Your entire gut from the back of your throat to the top of your rectum is under autonomic control, i.e. the brain signals the spinal cord and the spinal cord signals the gut for digestion, peristalsis, and defecation. It is totally out of your voluntary control. Many of my working women, when they go away to a hotel on a business trip, are incapable of moving their bowels until they get home. Many men cannot relax enough to urinate when another man is standing at the neighboring stall. Many men also cannot get an erection when they are in bed with their wives if they have unconscious anger towards her. Most of my patients with irritable bowel syndrome have some degree of chronic stress or are suppressing anger or anxiety.
At the first and every annual visit thereafter I ask all my patients, male and female, the same two questions: (a) Do you look forward to going to work in the AM? and (b) Do you look forward to coming home at night? If I am seeing a non-working spouse, I ask a similar questions about the feelings when the other spouse leaves for work in the AM and returns home in the PM. I also ask teenagers if they look forward to going to high school (many girls and few boys do).
When it comes to school, many students see it as a form of jail. It is less of a problem with girls than boys, because girls seem to buy into the system at an earlier age. Hence, for instance, girls always have neater handwriting than boys do, because boys don't care. This persists into adulthood: in the hospital charts I can usually distinguish male student notes from female student notes by their penmanship. But it is not a matter of lack of fine motor control, or else men could not become watchmakers. As I often tell parents, many boys don't have ADD, but rather DGD (Don't Give a Damn) disease about school, especially when it comes to homework. Of course Adderall, Ritalin, coffee, and most other CNS stimulants help everyone focus better and do better on SAT's.
Men have a slight advantage in that most of their stress is work-connected, and therefore has finite boundaries. Women, however, feel responsible for the happiness of the whole family, and often feel guilty and responsible if any family member is unhappy. In general, I have found that if a daughter gets a divorce, the father feels sorry for her, and the mother wonders what she (the mother) did that was wrong in raising her. Often, if the husband has a problem with his mother, the wife takes care of all the social interactions with her mother-in-law, even when the wife has problems with her as well. Men seem to get a free ride away from many of the emotional stresses in the family: as Jerry Steinfeld infamously put it "We men are expected to be shallow.".
True love is overwhelming, and therefore makes parents and governments alike equally nervous, because they realize they are powerless to control it. Forget about Romeo and Juliet, or how Lancelot's and Guinevere's mutual love wrecked King Arthur's Court. If Julius Caesar had not been in love with Cleopatra, the history of the Roman world would have been different. Similarly with Marc Antony and Cleopatra, and King George of England and Wallis Simpson.
I leave the question of King David, Bathsheba and Uriah the Hittite to biblical historians, and just note it in passing. When teenagers fall in love, they see only the immediate present and their utter happiness, while the parents look 20 years down the road, and worry if their new in-law will fit properly into their society, both economic and social. For my married patients who are totally in love, the rest of the world always takes second place, and those who are not completely in love never quite "get it". Those totally in love seem to awaken every morning and say to themselves: "How can I spoil my loved one and myself today?", and never feel selfish about so thinking.
The anger at being "forced" socially to do what one doesn't want to do builds up slowly, but is more present than we allow ourselves to recognize. Every time you say to yourself I "should" do something, it is really the outside world, society, or your family (usually your parents) saying it. Men can partially discharge the anger through physical outlets, physical aggression or getting drunk, but women are more likely to suppress the anger, since anger is not a socially acceptable emotion for most women, and was probably discouraged from early childhood on, until the suppression of anger became automatic and internalized. The female child also starts to feel de-legitimized and ego-dystonic by being told that she should not feel a certain emotion. Suppressed anger almost always leads to depression. This is probably why almost all surveys show that single women are happier than married women, since married women are burdened by more social "shoulds".
Since many fatigue and pain states have an emotional basis, the next time you feel tired, or yawn, or feel bored, or have pain, or a GI upset, or a sore back, etc., try asking yourself: "What is stressing me? What am I doing or planning to do that I don't really want to do?". Then tell yourself that you are not being selfish if you protect your mental and emotional peace, and refuse to do or stop doing the unwanted action. If someone else is involved, and he/she really cares about you, they would want you to do what you want to do, wouldn't they?
Your entire gut from the back of your throat to the top of your rectum is under autonomic control, i.e. the brain signals the spinal cord and the spinal cord signals the gut for digestion, peristalsis, and defecation. It is totally out of your voluntary control. Many of my working women, when they go away to a hotel on a business trip, are incapable of moving their bowels until they get home. Many men cannot relax enough to urinate when another man is standing at the neighboring stall. Many men also cannot get an erection when they are in bed with their wives if they have unconscious anger towards her. Most of my patients with irritable bowel syndrome have some degree of chronic stress or are suppressing anger or anxiety.
At the first and every annual visit thereafter I ask all my patients, male and female, the same two questions: (a) Do you look forward to going to work in the AM? and (b) Do you look forward to coming home at night? If I am seeing a non-working spouse, I ask a similar questions about the feelings when the other spouse leaves for work in the AM and returns home in the PM. I also ask teenagers if they look forward to going to high school (many girls and few boys do).
When it comes to school, many students see it as a form of jail. It is less of a problem with girls than boys, because girls seem to buy into the system at an earlier age. Hence, for instance, girls always have neater handwriting than boys do, because boys don't care. This persists into adulthood: in the hospital charts I can usually distinguish male student notes from female student notes by their penmanship. But it is not a matter of lack of fine motor control, or else men could not become watchmakers. As I often tell parents, many boys don't have ADD, but rather DGD (Don't Give a Damn) disease about school, especially when it comes to homework. Of course Adderall, Ritalin, coffee, and most other CNS stimulants help everyone focus better and do better on SAT's.
Men have a slight advantage in that most of their stress is work-connected, and therefore has finite boundaries. Women, however, feel responsible for the happiness of the whole family, and often feel guilty and responsible if any family member is unhappy. In general, I have found that if a daughter gets a divorce, the father feels sorry for her, and the mother wonders what she (the mother) did that was wrong in raising her. Often, if the husband has a problem with his mother, the wife takes care of all the social interactions with her mother-in-law, even when the wife has problems with her as well. Men seem to get a free ride away from many of the emotional stresses in the family: as Jerry Steinfeld infamously put it "We men are expected to be shallow.".
True love is overwhelming, and therefore makes parents and governments alike equally nervous, because they realize they are powerless to control it. Forget about Romeo and Juliet, or how Lancelot's and Guinevere's mutual love wrecked King Arthur's Court. If Julius Caesar had not been in love with Cleopatra, the history of the Roman world would have been different. Similarly with Marc Antony and Cleopatra, and King George of England and Wallis Simpson.
I leave the question of King David, Bathsheba and Uriah the Hittite to biblical historians, and just note it in passing. When teenagers fall in love, they see only the immediate present and their utter happiness, while the parents look 20 years down the road, and worry if their new in-law will fit properly into their society, both economic and social. For my married patients who are totally in love, the rest of the world always takes second place, and those who are not completely in love never quite "get it". Those totally in love seem to awaken every morning and say to themselves: "How can I spoil my loved one and myself today?", and never feel selfish about so thinking.
The anger at being "forced" socially to do what one doesn't want to do builds up slowly, but is more present than we allow ourselves to recognize. Every time you say to yourself I "should" do something, it is really the outside world, society, or your family (usually your parents) saying it. Men can partially discharge the anger through physical outlets, physical aggression or getting drunk, but women are more likely to suppress the anger, since anger is not a socially acceptable emotion for most women, and was probably discouraged from early childhood on, until the suppression of anger became automatic and internalized. The female child also starts to feel de-legitimized and ego-dystonic by being told that she should not feel a certain emotion. Suppressed anger almost always leads to depression. This is probably why almost all surveys show that single women are happier than married women, since married women are burdened by more social "shoulds".
Since many fatigue and pain states have an emotional basis, the next time you feel tired, or yawn, or feel bored, or have pain, or a GI upset, or a sore back, etc., try asking yourself: "What is stressing me? What am I doing or planning to do that I don't really want to do?". Then tell yourself that you are not being selfish if you protect your mental and emotional peace, and refuse to do or stop doing the unwanted action. If someone else is involved, and he/she really cares about you, they would want you to do what you want to do, wouldn't they?
Monday, December 21, 2009
Addiction, Part I
We are here going to discuss addiction and the various degrees and sub-categories thereof: dependence, habit, obsession-compulsion, drug abuse, enabler, conditioned reflex, and illegal drug use. We shall see that the categories are not clear-cut, boundaries of groups are not precise, and behavioral scientists disagree about definitions. This discussion will not include membership in religious sects and drug use in their rituals,since that will be discussed in a future blog.
Again, many of the above definitions are conditioned by our culture (see my previous blog on insanity). The old joke that an alcoholic is someone who drinks more than his doctor does is particularly relevant here. Many doctors forget that they define what is "normal" for their patients, and doctors, especially psychiatrists, have to be careful to maintain a "poker face". (It is trivial to add here that if you are demonstrating cardiac auscultation to a medical student on a female patient with a V/VI holosystolic murmur, you should refrain from using the phrase "a palpable thrill".)
First of all, the label of "enabler" should be stricken. The only way to influence the legal behavior of someone with whom you are involved is by request, by order, by saying "do it if you love me", or by threatening to leave if the behavior does not stop, i.e. basically by compulsion. I have found, for instance, in 25 years of practice that the only way to force a male alcoholic to stop is for his boss to threaten him with loss of his job, and, in the case of women, for the judge to threaten them with loss of their children. Only then is their ego threatened enough to change their behavior, and it still generally involves at least 30 days inpatient treatment. You are not responsible if your loved one continues self-destructive behavior, although their "right" to self-destruction does not mean that it is the "right" thing to do. Of course, if their behavior damages them permanently, you have the job of caring for them, which seems to be grossly unfair. As a simple example, if your spouse chews his/her fingernails, are you a fingernail-chewing enabler? I know that it is painful to watch such behavior, but as I often tell spouses, smokers know they shouldn't smoke, overweight people and diabetics know they should lose weight,etc.But once you tell them more than twice, you are nagging them, and my male patients tell me they react to such nagging with anger and passive-aggressive behavior. It is not enabling to stay with someone whose behavior you disagree with or you feel is self-destructive, any more than the person can be cured by your walking out. (When children are present, however, the answer may be different, and then case-by-case analysis and judgment is needed.)
Obsessive-compulsive behavior is best described as repetitive behavior that the patient wishes he/she could stop, or that interferes with the ability to work, love, or play (pace Freud). Again, I am deliberately omitting any discussion of religion, including the behavior of self-flagellation so brilliantly shown in "The Seventh Seal". This problem is very difficult to treat psychiatrically, since the behavior is a substitute to ward off anxiety, and the true cause cannot always be found. The unwanted behavior can range from going back home to make sure the oven is turned off, to washing your hands 20 times a day, to taking one hour to put on makeup, etc. Anorexia is probably the end-point of o-c worrying and behavior about one's weight and self-image. At what point does compulsive self-pleasuring become a true problem? (The latest data shows that 95% of college men self-pleasure , and the other 5% are liars.) If the o-c behavior is mild, the patient will probably not even admit it as such (how many baths a day is too many, when 100 years ago only upper-class Englishmen bathed as often as once a week?). If you are a compulsive gambler as Michael Jordan apparently may have been, but you can afford to lose $100,000/month, is it still a problem?
Habit is just mild o-c behavior that is socially acceptable, and later becomes reassuring to the user. It is not threatening or dangerous, and can even engender a sense of pleasure, similar to the baseball player who always makes sure to step on the foul line when leaving the playing field, and avoiding it upon entering. In fact, alteration of habits is often an early indication of mental change, whether the change is falling in love, or early Alzheimers.
Addiction is the most complex behavior of all, and the most difficult to define. Classically, addiction to a drug is defined as a combination of drug-seeking behavior, even if it is illegal, tolerance, and withdrawal effects upon abrupt cessation. (I once took care of a patient who was admitted at his request to help him break his addiction to a legal drug:he swallowed up to 40 nitro-glycerine tablets a day, because he enjoyed the sensation triggered by abrupt drops in blood pressure.)The worst withdrawal effects are seen with CNS depressants, such as alcohol, tranquilizers, and other "downers", since the brain generates counter-chemicals which stimulate the brain, and the abrupt cessation of the drug lets the self-generated stimulating chemicals run riot, and hence the shakes, sweats, DT's, and the like which can kill the patient. Some doctors would say that a truly addicting drug is one that kills you if you stop it abruptly, or one that makes you feel compelled to increase the dosage, because of tolerance, until it kills or seriously damages your body, such as methamphetamine or other "upper" use.
People also talk about "sex addiction", "gambling addiction", caffeine addiction, etc. None of these is acutely dangerous to the body (and, in fact, several studies have shown that caffeine is protective against adult-onset diabetes, especially in females). IMHO, all that is happening is that the immediate gratification and pleasure from the act far outweighs any thought of future problem. All babies demand instant gratification, and part of growing up is learning to defer this desire. However, it is extremely difficult to "prove" that hedonism is not a viable philosophy. The question of "rational" or Appolonian behavior vs. pleasure-seeking or Dionysian behavior is a motif that repeatedly recurs in human history. Euripides demonstrated the two sides in his play "The Bacchae", the 17th century English had the Cavaliers vs. the Roundheads, we had the Drys vs. the Wets,and today it is said that sex is a natural human occurrence in Europe, and an obsession in America. In South America, where the children are too poor to buy cocaine, they stuff rags in the gas tanks of autos and sniff the fumes to get high and escape their lives temporarily.
It is very odd that smoking cigarettes creates a pleasant feeling,
since the first few cigarettes make you cough horribly, so the pleasure is partly learned, as it is with marijuana. I also have trouble labeling it a true addiction (I know that most people disagree with me here) since anyone who takes a 12 hour plane ride stops smoking for at least that long, without any acute withdrawal symptoms. Most smokers "know" that cigarette smoking is health-threatening, but they feel that the particular cigarette they are about to smoke at this moment will not be especially damaging. Nicotine is an amazing drug about which we know very little: how does it both quench hunger and help one feel more comfortable after a full meal? Why does it have a calming effect? Why have various European studies shown that smokers apparently have a lower incidence of Parkinson's Disease? I tell my smokers that while they may not all get cancer, I can guarantee with 100% certainty the development of COPD/emphysema, and eventual dependence on an oxygen tank. In fact, sophisticated pulmonary function studies (not generally available outside of research labs) will show premature small airways closure in almost all smokers. Because of this, I prescribe Spiriva (ipatronium) inhalers for all my smoking patients. This drug has been demonstrated to slow the natural progression of symptomatic emphysema in non-smokers, and I can only hope that it will do the same for smokers.
At this point, I would like to show how some of the observed facts quoted above should suggest hypotheses which, in turn, require well-designed experiments to verify or disprove:
1) Why does coffee (? caffeine) drinking prevent or delay the onset of adult diabetes? Does it have to do with the effect of caffeine on the beta cells of the pancreas? We know that epinephrine (aka adrenaline in England) has an effect on these cells. Is there a local effect on potassium flux across the membranes of these cells? A proper experiment should tell us more about the nature of diabetes.
2) If cigarette smokers have a lower incidence of Parkinson's Disease, does this mean that stimulation of the nicotinic receptors in the human brain affects the dopaminergic neurons? Would a nicotine patch or daily use of nicotine gum have the same effect? We do know that smoking cigarettes seems to have a calming effect on some schizophrenics, so there is some nicotine---neural pathway or interaction occurring; we just don't know what it is, or if it can be stimulated without cigarettes.
3) It was simple observations that led the great scientists to marvelous concepts. Aristotle claimed that heavy bodies fell faster than lighter bodies, and Galileo asked himself (? the first gedanken experiment) what would happen if a heavy body were tied by string to a lighter body, and the two were dropped together. Einstein asked himself what the universe would look like if he rode on a beam of light at the speed of light, and developed the Theory of Special Relativity. He later used the Galilean result that all bodies fell at the same rate, and therefore had the same acceleration in a gravitational field. Since Force= (mass)x(acceleration)= (mass)x (gravity), this meant that inertial mass was equal to or equivalent to gravitational mass, and from this he developed the Theory of General Relativity.
I just realized that this blog is running longer than most of them, because this is a complex field, with much qualitative and little quantitative data. I will continue the discussion in a future blog. Just bear in mind that your brain tries to operate on the "seek pleasure, avoid pain" principle, and that it takes a lot of social training to prevent people from continual self-gratification, (see Freud's "Civilization and its Discontents"). When you were a baby you felt uncomfortable, cried, and your mother soothed you, usually with food or by holding you. Just like Pavlov's dog, we became conditioned to instant soothing, and it took a lot of training by our parents and schools to modify this. I'll leave you with the following experimental result: a biologist took lab rats, inserted an electrode into the pleasure center of their brains, connected the electrode to a battery, and connected the battery wiring to a bar in their cages. Every time a lab rat pushed the bar, the rat received an instant jolt of "pleasure". Every rat, without exception, pushed the bar repetitively and non-stop until death occurred from dehydration and starvation.This occurred even though rats, unlike humans, have no knowledge of death, and therefore no fear of it or need to blot such thoughts out by getting high.
Again, many of the above definitions are conditioned by our culture (see my previous blog on insanity). The old joke that an alcoholic is someone who drinks more than his doctor does is particularly relevant here. Many doctors forget that they define what is "normal" for their patients, and doctors, especially psychiatrists, have to be careful to maintain a "poker face". (It is trivial to add here that if you are demonstrating cardiac auscultation to a medical student on a female patient with a V/VI holosystolic murmur, you should refrain from using the phrase "a palpable thrill".)
First of all, the label of "enabler" should be stricken. The only way to influence the legal behavior of someone with whom you are involved is by request, by order, by saying "do it if you love me", or by threatening to leave if the behavior does not stop, i.e. basically by compulsion. I have found, for instance, in 25 years of practice that the only way to force a male alcoholic to stop is for his boss to threaten him with loss of his job, and, in the case of women, for the judge to threaten them with loss of their children. Only then is their ego threatened enough to change their behavior, and it still generally involves at least 30 days inpatient treatment. You are not responsible if your loved one continues self-destructive behavior, although their "right" to self-destruction does not mean that it is the "right" thing to do. Of course, if their behavior damages them permanently, you have the job of caring for them, which seems to be grossly unfair. As a simple example, if your spouse chews his/her fingernails, are you a fingernail-chewing enabler? I know that it is painful to watch such behavior, but as I often tell spouses, smokers know they shouldn't smoke, overweight people and diabetics know they should lose weight,etc.But once you tell them more than twice, you are nagging them, and my male patients tell me they react to such nagging with anger and passive-aggressive behavior. It is not enabling to stay with someone whose behavior you disagree with or you feel is self-destructive, any more than the person can be cured by your walking out. (When children are present, however, the answer may be different, and then case-by-case analysis and judgment is needed.)
Obsessive-compulsive behavior is best described as repetitive behavior that the patient wishes he/she could stop, or that interferes with the ability to work, love, or play (pace Freud). Again, I am deliberately omitting any discussion of religion, including the behavior of self-flagellation so brilliantly shown in "The Seventh Seal". This problem is very difficult to treat psychiatrically, since the behavior is a substitute to ward off anxiety, and the true cause cannot always be found. The unwanted behavior can range from going back home to make sure the oven is turned off, to washing your hands 20 times a day, to taking one hour to put on makeup, etc. Anorexia is probably the end-point of o-c worrying and behavior about one's weight and self-image. At what point does compulsive self-pleasuring become a true problem? (The latest data shows that 95% of college men self-pleasure , and the other 5% are liars.) If the o-c behavior is mild, the patient will probably not even admit it as such (how many baths a day is too many, when 100 years ago only upper-class Englishmen bathed as often as once a week?). If you are a compulsive gambler as Michael Jordan apparently may have been, but you can afford to lose $100,000/month, is it still a problem?
Habit is just mild o-c behavior that is socially acceptable, and later becomes reassuring to the user. It is not threatening or dangerous, and can even engender a sense of pleasure, similar to the baseball player who always makes sure to step on the foul line when leaving the playing field, and avoiding it upon entering. In fact, alteration of habits is often an early indication of mental change, whether the change is falling in love, or early Alzheimers.
Addiction is the most complex behavior of all, and the most difficult to define. Classically, addiction to a drug is defined as a combination of drug-seeking behavior, even if it is illegal, tolerance, and withdrawal effects upon abrupt cessation. (I once took care of a patient who was admitted at his request to help him break his addiction to a legal drug:he swallowed up to 40 nitro-glycerine tablets a day, because he enjoyed the sensation triggered by abrupt drops in blood pressure.)The worst withdrawal effects are seen with CNS depressants, such as alcohol, tranquilizers, and other "downers", since the brain generates counter-chemicals which stimulate the brain, and the abrupt cessation of the drug lets the self-generated stimulating chemicals run riot, and hence the shakes, sweats, DT's, and the like which can kill the patient. Some doctors would say that a truly addicting drug is one that kills you if you stop it abruptly, or one that makes you feel compelled to increase the dosage, because of tolerance, until it kills or seriously damages your body, such as methamphetamine or other "upper" use.
People also talk about "sex addiction", "gambling addiction", caffeine addiction, etc. None of these is acutely dangerous to the body (and, in fact, several studies have shown that caffeine is protective against adult-onset diabetes, especially in females). IMHO, all that is happening is that the immediate gratification and pleasure from the act far outweighs any thought of future problem. All babies demand instant gratification, and part of growing up is learning to defer this desire. However, it is extremely difficult to "prove" that hedonism is not a viable philosophy. The question of "rational" or Appolonian behavior vs. pleasure-seeking or Dionysian behavior is a motif that repeatedly recurs in human history. Euripides demonstrated the two sides in his play "The Bacchae", the 17th century English had the Cavaliers vs. the Roundheads, we had the Drys vs. the Wets,and today it is said that sex is a natural human occurrence in Europe, and an obsession in America. In South America, where the children are too poor to buy cocaine, they stuff rags in the gas tanks of autos and sniff the fumes to get high and escape their lives temporarily.
It is very odd that smoking cigarettes creates a pleasant feeling,
since the first few cigarettes make you cough horribly, so the pleasure is partly learned, as it is with marijuana. I also have trouble labeling it a true addiction (I know that most people disagree with me here) since anyone who takes a 12 hour plane ride stops smoking for at least that long, without any acute withdrawal symptoms. Most smokers "know" that cigarette smoking is health-threatening, but they feel that the particular cigarette they are about to smoke at this moment will not be especially damaging. Nicotine is an amazing drug about which we know very little: how does it both quench hunger and help one feel more comfortable after a full meal? Why does it have a calming effect? Why have various European studies shown that smokers apparently have a lower incidence of Parkinson's Disease? I tell my smokers that while they may not all get cancer, I can guarantee with 100% certainty the development of COPD/emphysema, and eventual dependence on an oxygen tank. In fact, sophisticated pulmonary function studies (not generally available outside of research labs) will show premature small airways closure in almost all smokers. Because of this, I prescribe Spiriva (ipatronium) inhalers for all my smoking patients. This drug has been demonstrated to slow the natural progression of symptomatic emphysema in non-smokers, and I can only hope that it will do the same for smokers.
At this point, I would like to show how some of the observed facts quoted above should suggest hypotheses which, in turn, require well-designed experiments to verify or disprove:
1) Why does coffee (? caffeine) drinking prevent or delay the onset of adult diabetes? Does it have to do with the effect of caffeine on the beta cells of the pancreas? We know that epinephrine (aka adrenaline in England) has an effect on these cells. Is there a local effect on potassium flux across the membranes of these cells? A proper experiment should tell us more about the nature of diabetes.
2) If cigarette smokers have a lower incidence of Parkinson's Disease, does this mean that stimulation of the nicotinic receptors in the human brain affects the dopaminergic neurons? Would a nicotine patch or daily use of nicotine gum have the same effect? We do know that smoking cigarettes seems to have a calming effect on some schizophrenics, so there is some nicotine---neural pathway or interaction occurring; we just don't know what it is, or if it can be stimulated without cigarettes.
3) It was simple observations that led the great scientists to marvelous concepts. Aristotle claimed that heavy bodies fell faster than lighter bodies, and Galileo asked himself (? the first gedanken experiment) what would happen if a heavy body were tied by string to a lighter body, and the two were dropped together. Einstein asked himself what the universe would look like if he rode on a beam of light at the speed of light, and developed the Theory of Special Relativity. He later used the Galilean result that all bodies fell at the same rate, and therefore had the same acceleration in a gravitational field. Since Force= (mass)x(acceleration)= (mass)x (gravity), this meant that inertial mass was equal to or equivalent to gravitational mass, and from this he developed the Theory of General Relativity.
I just realized that this blog is running longer than most of them, because this is a complex field, with much qualitative and little quantitative data. I will continue the discussion in a future blog. Just bear in mind that your brain tries to operate on the "seek pleasure, avoid pain" principle, and that it takes a lot of social training to prevent people from continual self-gratification, (see Freud's "Civilization and its Discontents"). When you were a baby you felt uncomfortable, cried, and your mother soothed you, usually with food or by holding you. Just like Pavlov's dog, we became conditioned to instant soothing, and it took a lot of training by our parents and schools to modify this. I'll leave you with the following experimental result: a biologist took lab rats, inserted an electrode into the pleasure center of their brains, connected the electrode to a battery, and connected the battery wiring to a bar in their cages. Every time a lab rat pushed the bar, the rat received an instant jolt of "pleasure". Every rat, without exception, pushed the bar repetitively and non-stop until death occurred from dehydration and starvation.This occurred even though rats, unlike humans, have no knowledge of death, and therefore no fear of it or need to blot such thoughts out by getting high.
Sunday, December 6, 2009
Insanity
The first fact to realize about insanity is that it is a culturally defined disease, in the sense that the culture and/or society decide what "normal" is. If something is sufficiently unusual and uncommon, and not explicable by reason or understood as having a well-defined cause, then society will often label the action as evidence of an "unsound mind". For instance, until the American Psychiatric Society voted (and not by 100% to zero) that homosexuality was not a mental disease, homosexuals were often "treated" by psychiatrists. Similarly, in the 1950's and 1960's, if a Russian citizen claimed that communism was not the best political system, he was often classified as schizophrenic, confined to a mental hospital, and treated with Thorazine and other anti-psychotics. In the Southern USA before 1860, if a black slave wanted to run away, he was often labeled as "crazy because of 'escapitis'", because why would he try to run away if he were not insane.
You also cannot "prove" that you are sane. It generally takes the testimony of two psychiatrists who have examined you to certify that you are insane or not insane. The default assumption is that you are sane, unless a judge requires you to prove you are sane before he will let you stand trial. Of course, the psychiatrists are themselves culturally bound, so that an American who attempts suicide is considered to have a mental problem, while a Japanese who attempts hari-kari is not, and probably everyone who sees Shakespeare's "Julius Caesar" understands Brutus' suicide. If you saw and spoke with the image of your dead grandmother, you might be considered insane, unless you were a teenage girl from a Latin American culture, where such such events can occur on or near her fifteenth birthday.
Then we come to the insanity defense. I am not commenting pro or con on its use, but how can you decide today that someone was insane two years, ago, if he/she were not examined at that time. However, most doctors will label a person as having a drinking problem, if the patient has drinks more on a daily basis than does the doctor. Similarly, as I tell my residents time and time again, all prescribing is a negotiating process, so if a hospitalized patient refuses to take a prescribed medicine, this is not grounds for a psychiatric consult.
One problem that occurs frequently is with people who hear voices or see images and claim that such sensations came from God. Clearly one cannot "prove" by any logical process that they were not, any more than they can prove that they were. There is a condition called the "Jerusalem Syndrome", wherein pious Christians and Jews are so overcome with the holiness of Jerusalem when they land at Lod airport that they become instantly convinced that they are the Jewish or Christian Messiah. There is a ward of Jerusalem Hospital that has permanently set aside beds for members of this group. Bernadette of Lourdes and Joan of Arc had difficulty convincing the authorities that they were divinely inspired while Abraham had no difficulty believing that the Lord commanded him to sacrifice his son, nor did Joseph Smith have difficulty believing in the Angel Moroni. Since religion is part of every culture, ideations that might otherwise be considered manifestations of paranoia are acceptable when they occur in a religious context.
In Salem, Massachusetts, women were judicially killed for being witches. Such behavior is not condoned now in the United States. However, there is a mental condition that occurs in males from Asia (especially Japan) as well as males in West Africa: They become convinced that their penis is shrinking and being pulled up and vanishing inside their bodies. Some men even go so far as to tie weights with ropes to their penises to arrest this process. However, in Africa, this belief is considered as evidence that a witch has placed a curse on you, and the immediate cure is to kill the witch. This has occurred, and the males involved are never prosecuted. I might observe in all societies it seems that only female witches are executed, and never male warlocks.
I would like to close this blog with a comment on free will. Most of us believe that we have free will, but most psychiatrists do not so believe. They believe that we are bound up in childhood problems, and try to solve them in the adult world in which we live. We try to resolve the unsolved problems of childhood and therefore (they believe) we marry the person who is most similar to the parent with whom we had the most problems.
This raises the question/problem of how much free will any of us have if we are still trying to solve childhood problems as an adult, since we never recognize the displacement 1nvolved in the battle(s). Since the justice system can only function logically and properly and fairly if we all have free will, that is precisely the default belief of all justice systems. Therefore you are responsible for all of actions, unless you can prove that you are not. To have any justice system function, it must be assumed, incorrectly or not, that you are legally responsible for 100% of your actions; this is the same assumption we make on Voting Day, as well as when we choose members of a jury.
You also cannot "prove" that you are sane. It generally takes the testimony of two psychiatrists who have examined you to certify that you are insane or not insane. The default assumption is that you are sane, unless a judge requires you to prove you are sane before he will let you stand trial. Of course, the psychiatrists are themselves culturally bound, so that an American who attempts suicide is considered to have a mental problem, while a Japanese who attempts hari-kari is not, and probably everyone who sees Shakespeare's "Julius Caesar" understands Brutus' suicide. If you saw and spoke with the image of your dead grandmother, you might be considered insane, unless you were a teenage girl from a Latin American culture, where such such events can occur on or near her fifteenth birthday.
Then we come to the insanity defense. I am not commenting pro or con on its use, but how can you decide today that someone was insane two years, ago, if he/she were not examined at that time. However, most doctors will label a person as having a drinking problem, if the patient has drinks more on a daily basis than does the doctor. Similarly, as I tell my residents time and time again, all prescribing is a negotiating process, so if a hospitalized patient refuses to take a prescribed medicine, this is not grounds for a psychiatric consult.
One problem that occurs frequently is with people who hear voices or see images and claim that such sensations came from God. Clearly one cannot "prove" by any logical process that they were not, any more than they can prove that they were. There is a condition called the "Jerusalem Syndrome", wherein pious Christians and Jews are so overcome with the holiness of Jerusalem when they land at Lod airport that they become instantly convinced that they are the Jewish or Christian Messiah. There is a ward of Jerusalem Hospital that has permanently set aside beds for members of this group. Bernadette of Lourdes and Joan of Arc had difficulty convincing the authorities that they were divinely inspired while Abraham had no difficulty believing that the Lord commanded him to sacrifice his son, nor did Joseph Smith have difficulty believing in the Angel Moroni. Since religion is part of every culture, ideations that might otherwise be considered manifestations of paranoia are acceptable when they occur in a religious context.
In Salem, Massachusetts, women were judicially killed for being witches. Such behavior is not condoned now in the United States. However, there is a mental condition that occurs in males from Asia (especially Japan) as well as males in West Africa: They become convinced that their penis is shrinking and being pulled up and vanishing inside their bodies. Some men even go so far as to tie weights with ropes to their penises to arrest this process. However, in Africa, this belief is considered as evidence that a witch has placed a curse on you, and the immediate cure is to kill the witch. This has occurred, and the males involved are never prosecuted. I might observe in all societies it seems that only female witches are executed, and never male warlocks.
I would like to close this blog with a comment on free will. Most of us believe that we have free will, but most psychiatrists do not so believe. They believe that we are bound up in childhood problems, and try to solve them in the adult world in which we live. We try to resolve the unsolved problems of childhood and therefore (they believe) we marry the person who is most similar to the parent with whom we had the most problems.
This raises the question/problem of how much free will any of us have if we are still trying to solve childhood problems as an adult, since we never recognize the displacement 1nvolved in the battle(s). Since the justice system can only function logically and properly and fairly if we all have free will, that is precisely the default belief of all justice systems. Therefore you are responsible for all of actions, unless you can prove that you are not. To have any justice system function, it must be assumed, incorrectly or not, that you are legally responsible for 100% of your actions; this is the same assumption we make on Voting Day, as well as when we choose members of a jury.
Tuesday, November 17, 2009
Mammograms, Zetia/Vytorin, Proscar,Folic Acid
I have received many phone calls from my patients and e-mails from readers on my bloglist about 3 different reports about medical research results: an article in the NY Times by Gina Kolata(Proscar), a report from a cardiac conference(Zetia/Vytorin), and recommendations from a medical study group (mammograms). I received no inquiries about an article in Lancet (folic acid), but I guess few people read British medical journals, even though Lancet antedates both NEJM and JAMA, and their letters to the editor are invaluable. My comments on these are probably applicable to many reports of medical results, and I leave it to my readers to evaluate any such reports.
First, some general comments. In many areas of non-precise science (I am therefore excluding mathematics, chemistry and physics) when recommendations are made, there is both a majority report/recommendation, and a minority report. However, in medicine, except as a rebuttal to a journal article (e.g. the discussion in Lancet as to whether or not reducing total salt in the diet saves lives) we never see the minority report. I doubt that 20 doctors (or 20 anyones) ever agree 100% on a committee report, and it would be nice to see the minority report (cf. the arguments about global warming) so we can try to make our own decision. Furthermore, most refereed journal articles require the authors to make the source data available on request, but this does not happen with medical committee recommendations, so we have no way to judge how they arrived at their recommendations, or what compromises were made (e.g. how did the government first decide that total cholesterol levels should be below 240?). Was it the same way that Congress decided on 27.5% as the oil depletion allowance, i.e. a compromise?
The recent recommendations on the starting age and frequency of mammograms are a case in point. There was no minority report, and the data on which the recommendations were made are not available. I only fear that HMO's will seize on this report to pay for fewer mammograms, as Medicare once did. I have never had a problem with ordering a test for a patient even if I was absolutely certain the result would be negative, because the patient's peace of mind is important to me.
There is absolutely no way to know for a given individual how often a mammogram should be done (why not every 6 months to detect fast-growing cancers?), or at what age the mammograms should start. I also have some 90 year old women who have never had a mammogram, and have never had breast cancer, and so far they are right as well.
The article about men not taking Proscar even though men on Proscar have a lower incidence of prostate cancer did not properly emphasize the fact that if prostate cancer does occur when a man is taking Proscar it is much more aggressive, and has a higher Gleason score. On the other hand, taking both Proscar and Flomax decreases a man's probability of needing a TURP of the prostate to relieve blockage caused by a growing prostate. Also, some men do not like taking Proscar because it diminishes the amount of fluid in the ejaculate by at least 50%, and these men do not enjoy the different sensation, because their orgasms are therefore shorter. Why not just say that men who do not take Proscar are "pharmacologically autonomous"?
Both Zetia and Vytorin decrease cholesterol, which is all the FDA required them to do. Studies on other statins as well as on Niacin showed that lowering cholesterol by these chemicals reduced the risk of second heart attacks and strokes, as well as the risk of first heart attacks. (I have never seen a study on diet, lower cholesterol, and heart attacks.) The FDA then assumed that any chemical lowering of cholesterol was beneficial, as does the entire medical establishment.
The study of Zetia/Vytorin showed that they did not cause regression of the narrowing of the intima of a major artery. However, this is a secondary surrogate marker for strokes and heart attacks. If heart attacks are caused by rupture of plaque (as many cardiologists believe) then stabilizing the plaque (are statins anti-inflammatory as aspirin is?) is more important than the lumen diameter, after a certain narrowing. No one has shown that lowering the cholesterol with Zetia or Vytorin does NOT reduce the risk of heart attack or stroke, just as no one has shown that intimal regression is a valid surrogate for MI's and CVA's.
The latest issue of Lancet reported a large study that showed that fortifying the diet with folic acid, which successfully lowered neural tube defects in infants, INCREASED the risk of cancer. I wonder what the USA and FDA will do with this study. It certainly should be repeated. But studies showing that vitamin ingestion can cause problems rarely make headlines in America. Maybe we should revise the recent recommendations which raised the RDA for folate from 0.4mg to 0.8mg?
Thought for the month: Why does the full moon appear larger when it rises in the East than it does when it is directly overhead?
First, some general comments. In many areas of non-precise science (I am therefore excluding mathematics, chemistry and physics) when recommendations are made, there is both a majority report/recommendation, and a minority report. However, in medicine, except as a rebuttal to a journal article (e.g. the discussion in Lancet as to whether or not reducing total salt in the diet saves lives) we never see the minority report. I doubt that 20 doctors (or 20 anyones) ever agree 100% on a committee report, and it would be nice to see the minority report (cf. the arguments about global warming) so we can try to make our own decision. Furthermore, most refereed journal articles require the authors to make the source data available on request, but this does not happen with medical committee recommendations, so we have no way to judge how they arrived at their recommendations, or what compromises were made (e.g. how did the government first decide that total cholesterol levels should be below 240?). Was it the same way that Congress decided on 27.5% as the oil depletion allowance, i.e. a compromise?
The recent recommendations on the starting age and frequency of mammograms are a case in point. There was no minority report, and the data on which the recommendations were made are not available. I only fear that HMO's will seize on this report to pay for fewer mammograms, as Medicare once did. I have never had a problem with ordering a test for a patient even if I was absolutely certain the result would be negative, because the patient's peace of mind is important to me.
There is absolutely no way to know for a given individual how often a mammogram should be done (why not every 6 months to detect fast-growing cancers?), or at what age the mammograms should start. I also have some 90 year old women who have never had a mammogram, and have never had breast cancer, and so far they are right as well.
The article about men not taking Proscar even though men on Proscar have a lower incidence of prostate cancer did not properly emphasize the fact that if prostate cancer does occur when a man is taking Proscar it is much more aggressive, and has a higher Gleason score. On the other hand, taking both Proscar and Flomax decreases a man's probability of needing a TURP of the prostate to relieve blockage caused by a growing prostate. Also, some men do not like taking Proscar because it diminishes the amount of fluid in the ejaculate by at least 50%, and these men do not enjoy the different sensation, because their orgasms are therefore shorter. Why not just say that men who do not take Proscar are "pharmacologically autonomous"?
Both Zetia and Vytorin decrease cholesterol, which is all the FDA required them to do. Studies on other statins as well as on Niacin showed that lowering cholesterol by these chemicals reduced the risk of second heart attacks and strokes, as well as the risk of first heart attacks. (I have never seen a study on diet, lower cholesterol, and heart attacks.) The FDA then assumed that any chemical lowering of cholesterol was beneficial, as does the entire medical establishment.
The study of Zetia/Vytorin showed that they did not cause regression of the narrowing of the intima of a major artery. However, this is a secondary surrogate marker for strokes and heart attacks. If heart attacks are caused by rupture of plaque (as many cardiologists believe) then stabilizing the plaque (are statins anti-inflammatory as aspirin is?) is more important than the lumen diameter, after a certain narrowing. No one has shown that lowering the cholesterol with Zetia or Vytorin does NOT reduce the risk of heart attack or stroke, just as no one has shown that intimal regression is a valid surrogate for MI's and CVA's.
The latest issue of Lancet reported a large study that showed that fortifying the diet with folic acid, which successfully lowered neural tube defects in infants, INCREASED the risk of cancer. I wonder what the USA and FDA will do with this study. It certainly should be repeated. But studies showing that vitamin ingestion can cause problems rarely make headlines in America. Maybe we should revise the recent recommendations which raised the RDA for folate from 0.4mg to 0.8mg?
Thought for the month: Why does the full moon appear larger when it rises in the East than it does when it is directly overhead?
Monday, November 16, 2009
Universal Health Care: What it Should Contain
Many patients and friends have asked me during the past months what I would like to see in universal health care. I only want a system that is best for my patients, and takes the least paperwork time for me. Any system, of course, will always pay less for thinking than for doing (i.e. operating) because it is difficult to measure thinking. I defer the question of outcome measurements to another blog.
1) We already have socialized medicine, and it is called Medicare and the VA Hospitals, and none of the users of the systems seems very much dissatisfied with it. And, in fact, middle-class parents paying to put their children thru college, etc., would find it difficult if not impossible to provide dollar for medical dollar coverage for their elderly parents, as they would have to do without Medicare.
2) You are allowed (by law) to keep your same cell phone number for life, if you want to, and don't have to change it every time you switch carriers. But when you are transferred from HMO A to HMO B because your company got a better premium deal from the second company,you suddenly have to scurry around and find a new internist, gynecologist, pediatrician, and any other specialist you are seeing. This is manifestly unfair, inefficient, and disrupts the smooth flow of medical care-taking. It's one thing if a patient chooses to leave a doctor, but to be forced to leave a doctor is unconscionable and stressful. And what if you are a Cigna patient but the world's expert is an Oxford surgeon? Then you have to pay his full bill, with no insurance deduction. You should be able to KEEP THE SAME FAMILY DOCTOR FOR LIFE!
3) Many patients are tied to their jobs thru their health insurance. If they stop working or switch their jobs, their wife and children may not be covered, or there may be very special coverage available only while they work for this particular company.
4) A minor point: why does the family coverage for your children stop when they are 23 years old?
4) A stronger point: If you and your wife both have paid premiums for a $100K fire policy on your house, and it burns down, you both get paid $100K., because you each have a policy. But if you and you wife both have paid medical premiums for a family policy, and you get a heart attack,you can only collect doctor and hospital bills from one of your policies. This means the other one was invalidated for this case, and all the premiums (10, 20 30 years' worth)are sheer profit for the company. Why should this be? It's like reverse double-dipping,only this time your pockets are the ones being directly dipped into.
5) I should not have to waste my time calling up for permission for MRI's. I don't have to do it for MCR, but most HMO's want me to expose a patient to cancer-causing Xrays of a CT exam before they allow an MRI, or I have to spend a lot of time (my least fungible recourse) convincing them otherwise.
6) I could also save time if I didn't have to call the drug management company to explain why the drug I chose for my patient is preferable to their chosen (and cheaper) drug. They don't know the patients. (Actually, must drug stores and wholesalers make a greater per cent profit on generics than brand names, because no one outside the field knows how cheap it is to make a generic.)
7) They should not make Electronic Medical Records mandatory until they have proved that they save money, or at least patient morbidity. There has been no clear evidence of this yet.All I know is that in the "good old days" I could admit a patient and write a set of orders with pen and paper in 5 minutes. Now with filling out the matrix in the computer form in the sequence of questions they ask me (e.g. what is my patient's flu vaccine status, a fact I always put down in my admitting note) punching in my date of birth xx-xx-xxxx (not a code) just more information collected, so all doctors tend to be born on 11-11-1911) it takes me at least 25 minutes to admit a patient. This is not progress, but more on the EMR on another blog.Sometimes when I get tired of all the pettifogging, if it is my personal patient, I just put down patient refuses".
In summary: keep the same doctor for life, and also solve the problem of who will pay for abortions, because as long as we have both men and women, married or unmarried, we will have unwanted pregnancies,
1) We already have socialized medicine, and it is called Medicare and the VA Hospitals, and none of the users of the systems seems very much dissatisfied with it. And, in fact, middle-class parents paying to put their children thru college, etc., would find it difficult if not impossible to provide dollar for medical dollar coverage for their elderly parents, as they would have to do without Medicare.
2) You are allowed (by law) to keep your same cell phone number for life, if you want to, and don't have to change it every time you switch carriers. But when you are transferred from HMO A to HMO B because your company got a better premium deal from the second company,you suddenly have to scurry around and find a new internist, gynecologist, pediatrician, and any other specialist you are seeing. This is manifestly unfair, inefficient, and disrupts the smooth flow of medical care-taking. It's one thing if a patient chooses to leave a doctor, but to be forced to leave a doctor is unconscionable and stressful. And what if you are a Cigna patient but the world's expert is an Oxford surgeon? Then you have to pay his full bill, with no insurance deduction. You should be able to KEEP THE SAME FAMILY DOCTOR FOR LIFE!
3) Many patients are tied to their jobs thru their health insurance. If they stop working or switch their jobs, their wife and children may not be covered, or there may be very special coverage available only while they work for this particular company.
4) A minor point: why does the family coverage for your children stop when they are 23 years old?
4) A stronger point: If you and your wife both have paid premiums for a $100K fire policy on your house, and it burns down, you both get paid $100K., because you each have a policy. But if you and you wife both have paid medical premiums for a family policy, and you get a heart attack,you can only collect doctor and hospital bills from one of your policies. This means the other one was invalidated for this case, and all the premiums (10, 20 30 years' worth)are sheer profit for the company. Why should this be? It's like reverse double-dipping,only this time your pockets are the ones being directly dipped into.
5) I should not have to waste my time calling up for permission for MRI's. I don't have to do it for MCR, but most HMO's want me to expose a patient to cancer-causing Xrays of a CT exam before they allow an MRI, or I have to spend a lot of time (my least fungible recourse) convincing them otherwise.
6) I could also save time if I didn't have to call the drug management company to explain why the drug I chose for my patient is preferable to their chosen (and cheaper) drug. They don't know the patients. (Actually, must drug stores and wholesalers make a greater per cent profit on generics than brand names, because no one outside the field knows how cheap it is to make a generic.)
7) They should not make Electronic Medical Records mandatory until they have proved that they save money, or at least patient morbidity. There has been no clear evidence of this yet.All I know is that in the "good old days" I could admit a patient and write a set of orders with pen and paper in 5 minutes. Now with filling out the matrix in the computer form in the sequence of questions they ask me (e.g. what is my patient's flu vaccine status, a fact I always put down in my admitting note) punching in my date of birth xx-xx-xxxx (not a code) just more information collected, so all doctors tend to be born on 11-11-1911) it takes me at least 25 minutes to admit a patient. This is not progress, but more on the EMR on another blog.Sometimes when I get tired of all the pettifogging, if it is my personal patient, I just put down patient refuses".
In summary: keep the same doctor for life, and also solve the problem of who will pay for abortions, because as long as we have both men and women, married or unmarried, we will have unwanted pregnancies,
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