This blog is an attempt by a family physician to evaluate "Obamacare" from the perspective of a patient, since the bill will affect them the most. To begin with, the same arguments made today against "Obamacare" were made 35 years ago against Medicare, and by the same groups. Almost all of my MCR patients today are more than satisfied with the system, and their children are even more so, since they can spend their money on their children's college education instead of on their parents' medical bills.
The first modern government to start government medical insurance as well as social security and workmen's compensation was that of Prussia under Otto von Bismarck in 1887 (cf. "Blood and Iron"), because he felt that a socially secure worker was a better worker. The first state government to mandate health care was Massachusetts. I don't yet know how it is working out, except that there is always a dearth of primary care physicians, since diagnosis and thinking through are not well-compensated. I think that it is wonderful that the parents' coverage of their children will be extended to age 26, since fewer newly-minted college graduates are getting immediate jobs.
Initially, the plan will cost more than is predicted, because fewer people will die. This was discovered when MCR covered dialysis in all ESRD patients. Without dialysis, many patients died of their renal disease. With dialysis, many lived longer lives, and therefore cost the system more.
I also envision that with state-controlled insurance, you won't have to go scurrying to find a new internist, gynecologist and pediatrician just because your employer changed medical insurance companies.
The one economic calculation that is never done, however, is how much living people contribute to government finances. If you dropped dead from a heart atack now, then that is the end. If they call 911, do CRP, rush you to the hospital and do emergency CABG surgery, the economists say that you cost the system $30,00 in medical expenses. No one adds that now you will work and pay taxes for another 20 years, and yourtaxes will amount to much more than $30,000.
Medical economics is also unpredictable: I bought a lot of Pfizer and Merck stock years ago, because they had the largest and most aggressive sales force. I reasoned that the more drugs people bought, the longer they lived, and the longer they lived, the more drugs they bought, so drug stocks should rise forever. When the drug stocks flattened out for 2 years, I realized that the market made no sense to me, and got totally out.
We will also spend less on acute medical care if everyone has his/her own doctor, because workups of medical problems in the emergency room is enormously expensive, while your family doctor who knows you can diagnose your problem with much fewer tests (e.g. he will not order a CT scan of yuor brain for ordinary dizziness).
BTW, the best way to diminish medical malpractice suits is to eliminate contingency fees. This law could be passed by any state legislature. At the same time, perhaps we should eliminate medical class action suits as well. Dow went bankrupt because a Texas jury was convinced of the "fact" that leaking silicone breast implants caused chemical lupus in susceptible females. Of course the fact that an article in NEJM demonstrated 2 years later that the association was not one of cause-and-effect did nothing to reverse Dow's financial position.
We should be very cautious about following any government guidelines for medical treatment. As I have stated before, it is very unlikely that a panel of 20 physicians agree 100% on anything, but unlike the arguments about global warming, we never get to see a minority report. The "normal" value of glucose and of cholesterol keep on being lowered, although statins seem to benefit everyone regardless of their cholesterol level, and intense control of diabetes seems to benefit few, if any (but if you are over the limit it does raise your life insurance premium). The suggestion that mammograms do not benefit women in their 40's was met with a storm of protest. A Nobel prize in medicine was given to the doctor who "proved" that pre-frontal lobotomies cured schizophrenia.The drug Singulair came out 2 months after the guidelines for asthma treatment were published. The only pro/con discussion about benefits or lack thereof of lowering salt in the diet was published in Lancet more than 10 years ago. The government knows that moderate use of alcohol reduces heart attack risk, but they still don't recommend starting. No patient is "average", and every patient is "special", best known by his family doctor, and we are spending too much time excplaining to insurance companies and Medicare Part D that in this particular patient the generic drug does not work as well as the brand name does.
The overall economic picture is that medical care saves lives, technology works but gets increasingly more expensive, and we wil end up rationing by time, availability, or money
Saturday, April 17, 2010
Monday, March 8, 2010
Prostate, Prostate CA, BPH, and economics
There has been much written in the news lately about the prostate: prostate cancer, new guidelines for Dx. and Rx., robotic prostate surgery, and a recent article in Archives of Internal Medicine (vol 170, #5, 3/8/10, pp 451-452)by Dr. M. Barry.
Just as an aside, "regular" prostate surgery is generally done in less than 2 hours, and robotic surgery generally takes longer than 3 hours. If you undergo more than 2.5 hours Operating room time,the risk of complications rises sharply.
What it all boils down to is that THERE IS NO INCONTROVERTIBLE EVIDENCE THAT TREATING PROSTATE CANCER SAVES LIVES.This does not mean that every male with prostate cancer will die from the cancer, but only that no treatment has been shown to cure it. The only study that has not been done is to do quadrant biopsies on all males annually, beginning at age 40, and treating all cancers with a Gleason score of 3 or less. Once prostate cancer is diagnosed (prompted by a rectal exam or an elevated PSA) surveys have shown that your family doctor will often recommend watchful waiting, your urologist will most likely recommend surgery, and a radiation oncologist will most likely recommend radiation. Since there is no evidence that treatment saves lives, it is difficult to justify an annual PSA test, unless the patient agrees to treatment. And, based upon my office experience, his wife will never agree to watchful waiting, so send the lab results to his office.
Once the CA is treated, many men have a few months of urinary incontinence, and/or erectile dysfunction. This may last for 2 years, or be permanent. If the ED seems to be permanent, the most satisfying treatment seems to be to transplant the 12th rib to the center of the penis, so that the "erection" is permanent.
Since the prostate grows without limit, all men will eventually have symptoms of BPH, evidenced by having to get up at night to urinate, or reduction in urinary stream force,etc. The prescribed treatment is with selective alpha-blockers, and/or reductase inhibitors (Proscar, etc.)The newest selective alpha-blocker, which has the least effect on the ciliary artery and therefore is the safest vis-a-vis future cataract surgery, is Rapaflo, (silodosin) 4mg or 8mg at bedtime. Only the combination of a reductase inhibitor plus an alpha-blocker has been shown to reduce the future need for a TURP to open up the prostatic urethra. However, since the old TURP involved inserting a rotatable knife thru the penis and up to the prostate, much like a Roto-rooter operation, and the procedure is now relatively bloodless and pain-free when done with the "green light" laser, not all men opt for the two drugs, especially since Proscar and its relatives diminish the amount of seminal fluid that is ejaculated. One should also remember that alpha blockers can increase the amount of retrograde ejaculation, i.e. backwards into the bladder, rather than forward and out of the urethra.
As for economics, why do you think surgeons recommend surgery and radiators recommend radiation? This leads into the larger question of economics. It is somewhat paradoxical that in today's times, microeconomics would suggest that you save your money, while macroeconomics wants you to help America spend its way out of the recession.
As a former mathematical and experimental physicist, I have looked into the mathematics, models and predictions of all branches of economics, and they all have the same fallacy: They assume that humans are always rational, and never panic sell or binge buy. This is clearly not the case (cf. "The Madness of Crowds"), but since arbitrary,"irrational" behavior cannot be mathematically modeled, calculated or predicted, it is excluded from ALL economic mathematics and their models. When the Black-Scholes "Theorem" was used to model the portfolio of Long Term Capital Funding, it was implicit in their model that no major country would fail to support its own currency. No allowance was made for this occurrence because (a) its happening was abrupt and unpredictable, and (b) the results depended on which country forfeited its currency. Therefore, when Russia defaulted on the ruble, LTCF would have gone bankrupt to the tune of $4B, but the U.S. Gov't bailed them out.
I won't even go into the required nonlinearity of any market model,that is caused by feedback. What we are dealing with here is the drunkard looking under the lamppost for his lost auto keys because the light is better there, rather than in the dark up the block where he actually dropped them. (And no, I lost no money in the market plunge.) People feel more comfortable with a "prediction" created by mathematics, even though GIGO is operating on a huge scale. Now in physics, if the result of an experiment differs from that predicted by our model of the world, we change our model. But economists cannot change their models, because catastrophe theory is too difficult to be mathematically tractable enough to use for predictions (see Rene Thom's work on this problem).
There are and seemingly will always be market crashes, because it is impossible to predict their occurrence or their nature (?something similar to earthquake prediction). No matter what the model, it basically assumes that the past can be used to model the future. How a tulip bulb crash can model Penn Central or the crash of 1873 is not clear to me. It is the question of predicting individual economic behavior vs. mass economic behavior. We have the same problem in medicine. I have no problem recommending that 1,000,000 women have annual mammograms beginning at age ??, but I have 25 female patients over the age of 85 who have never had mammograms or breast cancer, and so far they are right, too.
Just as an aside, "regular" prostate surgery is generally done in less than 2 hours, and robotic surgery generally takes longer than 3 hours. If you undergo more than 2.5 hours Operating room time,the risk of complications rises sharply.
What it all boils down to is that THERE IS NO INCONTROVERTIBLE EVIDENCE THAT TREATING PROSTATE CANCER SAVES LIVES.This does not mean that every male with prostate cancer will die from the cancer, but only that no treatment has been shown to cure it. The only study that has not been done is to do quadrant biopsies on all males annually, beginning at age 40, and treating all cancers with a Gleason score of 3 or less. Once prostate cancer is diagnosed (prompted by a rectal exam or an elevated PSA) surveys have shown that your family doctor will often recommend watchful waiting, your urologist will most likely recommend surgery, and a radiation oncologist will most likely recommend radiation. Since there is no evidence that treatment saves lives, it is difficult to justify an annual PSA test, unless the patient agrees to treatment. And, based upon my office experience, his wife will never agree to watchful waiting, so send the lab results to his office.
Once the CA is treated, many men have a few months of urinary incontinence, and/or erectile dysfunction. This may last for 2 years, or be permanent. If the ED seems to be permanent, the most satisfying treatment seems to be to transplant the 12th rib to the center of the penis, so that the "erection" is permanent.
Since the prostate grows without limit, all men will eventually have symptoms of BPH, evidenced by having to get up at night to urinate, or reduction in urinary stream force,etc. The prescribed treatment is with selective alpha-blockers, and/or reductase inhibitors (Proscar, etc.)The newest selective alpha-blocker, which has the least effect on the ciliary artery and therefore is the safest vis-a-vis future cataract surgery, is Rapaflo, (silodosin) 4mg or 8mg at bedtime. Only the combination of a reductase inhibitor plus an alpha-blocker has been shown to reduce the future need for a TURP to open up the prostatic urethra. However, since the old TURP involved inserting a rotatable knife thru the penis and up to the prostate, much like a Roto-rooter operation, and the procedure is now relatively bloodless and pain-free when done with the "green light" laser, not all men opt for the two drugs, especially since Proscar and its relatives diminish the amount of seminal fluid that is ejaculated. One should also remember that alpha blockers can increase the amount of retrograde ejaculation, i.e. backwards into the bladder, rather than forward and out of the urethra.
As for economics, why do you think surgeons recommend surgery and radiators recommend radiation? This leads into the larger question of economics. It is somewhat paradoxical that in today's times, microeconomics would suggest that you save your money, while macroeconomics wants you to help America spend its way out of the recession.
As a former mathematical and experimental physicist, I have looked into the mathematics, models and predictions of all branches of economics, and they all have the same fallacy: They assume that humans are always rational, and never panic sell or binge buy. This is clearly not the case (cf. "The Madness of Crowds"), but since arbitrary,"irrational" behavior cannot be mathematically modeled, calculated or predicted, it is excluded from ALL economic mathematics and their models. When the Black-Scholes "Theorem" was used to model the portfolio of Long Term Capital Funding, it was implicit in their model that no major country would fail to support its own currency. No allowance was made for this occurrence because (a) its happening was abrupt and unpredictable, and (b) the results depended on which country forfeited its currency. Therefore, when Russia defaulted on the ruble, LTCF would have gone bankrupt to the tune of $4B, but the U.S. Gov't bailed them out.
I won't even go into the required nonlinearity of any market model,that is caused by feedback. What we are dealing with here is the drunkard looking under the lamppost for his lost auto keys because the light is better there, rather than in the dark up the block where he actually dropped them. (And no, I lost no money in the market plunge.) People feel more comfortable with a "prediction" created by mathematics, even though GIGO is operating on a huge scale. Now in physics, if the result of an experiment differs from that predicted by our model of the world, we change our model. But economists cannot change their models, because catastrophe theory is too difficult to be mathematically tractable enough to use for predictions (see Rene Thom's work on this problem).
There are and seemingly will always be market crashes, because it is impossible to predict their occurrence or their nature (?something similar to earthquake prediction). No matter what the model, it basically assumes that the past can be used to model the future. How a tulip bulb crash can model Penn Central or the crash of 1873 is not clear to me. It is the question of predicting individual economic behavior vs. mass economic behavior. We have the same problem in medicine. I have no problem recommending that 1,000,000 women have annual mammograms beginning at age ??, but I have 25 female patients over the age of 85 who have never had mammograms or breast cancer, and so far they are right, too.
Tuesday, February 16, 2010
Weight Loss, Nutrition, Low Salt, Low Sugar
This blog was stimulated by the recent surge to have government endorse/require lower salt in the diet. There is, of course, no direct evidence that a low salt diet prolongs life. In the recommendations, lowering salt in the diet is taken as a surrogate for lowering blood pressure. It is assumed that lowering the amount of salt in the diet by 3 grams/day will lower systolic blood pressure between 3.5 and 5.5 mm; no estimate is given for the effect on diastolic blood pressure (is there any?). It is claimed that this will reduce death by heart attacks and other problems.
High blood pressure is a demonstrated risk (i.e. there a correlation, but an 0.80 correlation is a 0.8x0.8 or 64% estimate) for strokes, hypertensive heart disease, and abdominal aortic aneurysms (the latter in male smokers). However, every study of lowering blood pressure (usually by diuretics) only shows a reduction in the risk of strokes; there is NO demonstrated reduction in mortality or hypertensive heart disease. I should also mention that reduction of blood pressure by beta-blockers alone has shown no reduction in any risk of stroke or heart attack. In addition, there has been no prospective study to see if lowering the amount of salt in the diet has any injurious effect, and a lot of medicine is counter-intuitive. I recall a study that lowering the salt in the diet INcreases the risk for heart failure, but who really knows?
A related dietary question deals with lowering the amount of sugar in the diet (?by taxing sodas). I pause here to remind my lay readers that just because diabetes is evidenced by elevated blood sugar, this does NOT mean that increasing the amount of sugar in your diet causes diabetes, assuming you gain no weight. And we will also ignore the white lab rat study that shows that if we keep lab rats 30% below their IBW (and who determines the Ideal Body Weight for a lab rat?) they live longer. The flip side is the recent studies that demonstrate that overweight adult humans (BMI 26-29) have an increased chance of surviving a heart attack.
Now let us assume that we wish to lose weight. What is the most efficient and surest way to do this? (Remember that when you lose weight as an adult, your fat cells shrink, and get smaller and have a smaller net surface area for metabolism.) Of course, the obvious method is to eat less. No one was overweight in a concentration camp. The lap-band surgery shrinks the functioning volume of your stomach, so you can't ingest many calories, and again you lose weight, and usually cure your diabetes as well. Anorectics have absolutely no problem in losing weight. In another vein,liposuction sucks the fat cells away from your body,and these cells can never increase in size again.
But the brain demands homeostasis, and strives to keep your body parameters as constant as possible. Most people's weight varies very little from year to year. All nutritionists agree that 3500 calories = 1 pound. If you divide 3500 by 350 days, you find that you have to micromanage your food intake to plus or minus 10 calories a day to keep your weight constant for the year. Not even the most dedicated fanatic can do this. Obviously, the brain has a mechanism to raise or lower your metabolism to keep your weight constant, sort of a feedback mechanism, which has nothing to do with leptin. This metabolic/mass inertia is what makes it equally difficult to gain or lose a lot of weight. In fact studies have shown that when you gain weight, your metabolism increases, and when you lose weight, your metabolism decreases, in a true negative feedback manner, which is why most dieters hit intermittent weight plateaus.
In order to lose weight, you must feel good about yourself, and be relatively happy and free from anger. Food was the first pleasure, given to you by your mother. It is very difficult to deny yourself this pleasure if you are not "in a good place". If you are mentally at peace, then you can walk around hungry without feeling (emotionally) deprived. You can be satisfied by the flavor of half a chocolate chip cookie rather than a whole box of Mallomars. So losing weight is not a matter of pure will-power, but rather a matter of not being too out of rhythm with the world and ego-dystonic. This is not to say that all overweight people are neurotic. Many are very happy with themselves, and see no need to change their body habitus. Your self-image is everything to you, and this is what we all rely on and judge ourselves by. This is why I don't think special diets are the answer. We all eat the way we like, and no one does Weight Watchers forever. The answer is always portion control. Why torture yourself by eating foods you don't like , instead of simply eating less of the foods you do like?
Let me close by saying eating "healthy" food is less important than eating less and losing weight. We know very little about nutrition. When I went to school as a child, the food pyramid was the exact inversion of what it is now. We don't even know (i.e. have good evidence) if the biggest meal of the day should be breakfast, lunch, or dinner. Should we have one large meal a day or six small ones. For every study, there is a counter-study. Do lefties live longer than righties? Do short people live longer than tall people? Why does overall health correlate so strongly with economic position in life? Maybe we all would be healthier if everyone were a millionaire? Any time any person or authority tries to tell you that something is "good" for you, or "good for your health" always ask the same question we asked reflexively in physics and on hospital rounds: "Do you have a published article to support that opinion?".
High blood pressure is a demonstrated risk (i.e. there a correlation, but an 0.80 correlation is a 0.8x0.8 or 64% estimate) for strokes, hypertensive heart disease, and abdominal aortic aneurysms (the latter in male smokers). However, every study of lowering blood pressure (usually by diuretics) only shows a reduction in the risk of strokes; there is NO demonstrated reduction in mortality or hypertensive heart disease. I should also mention that reduction of blood pressure by beta-blockers alone has shown no reduction in any risk of stroke or heart attack. In addition, there has been no prospective study to see if lowering the amount of salt in the diet has any injurious effect, and a lot of medicine is counter-intuitive. I recall a study that lowering the salt in the diet INcreases the risk for heart failure, but who really knows?
A related dietary question deals with lowering the amount of sugar in the diet (?by taxing sodas). I pause here to remind my lay readers that just because diabetes is evidenced by elevated blood sugar, this does NOT mean that increasing the amount of sugar in your diet causes diabetes, assuming you gain no weight. And we will also ignore the white lab rat study that shows that if we keep lab rats 30% below their IBW (and who determines the Ideal Body Weight for a lab rat?) they live longer. The flip side is the recent studies that demonstrate that overweight adult humans (BMI 26-29) have an increased chance of surviving a heart attack.
Now let us assume that we wish to lose weight. What is the most efficient and surest way to do this? (Remember that when you lose weight as an adult, your fat cells shrink, and get smaller and have a smaller net surface area for metabolism.) Of course, the obvious method is to eat less. No one was overweight in a concentration camp. The lap-band surgery shrinks the functioning volume of your stomach, so you can't ingest many calories, and again you lose weight, and usually cure your diabetes as well. Anorectics have absolutely no problem in losing weight. In another vein,liposuction sucks the fat cells away from your body,and these cells can never increase in size again.
But the brain demands homeostasis, and strives to keep your body parameters as constant as possible. Most people's weight varies very little from year to year. All nutritionists agree that 3500 calories = 1 pound. If you divide 3500 by 350 days, you find that you have to micromanage your food intake to plus or minus 10 calories a day to keep your weight constant for the year. Not even the most dedicated fanatic can do this. Obviously, the brain has a mechanism to raise or lower your metabolism to keep your weight constant, sort of a feedback mechanism, which has nothing to do with leptin. This metabolic/mass inertia is what makes it equally difficult to gain or lose a lot of weight. In fact studies have shown that when you gain weight, your metabolism increases, and when you lose weight, your metabolism decreases, in a true negative feedback manner, which is why most dieters hit intermittent weight plateaus.
In order to lose weight, you must feel good about yourself, and be relatively happy and free from anger. Food was the first pleasure, given to you by your mother. It is very difficult to deny yourself this pleasure if you are not "in a good place". If you are mentally at peace, then you can walk around hungry without feeling (emotionally) deprived. You can be satisfied by the flavor of half a chocolate chip cookie rather than a whole box of Mallomars. So losing weight is not a matter of pure will-power, but rather a matter of not being too out of rhythm with the world and ego-dystonic. This is not to say that all overweight people are neurotic. Many are very happy with themselves, and see no need to change their body habitus. Your self-image is everything to you, and this is what we all rely on and judge ourselves by. This is why I don't think special diets are the answer. We all eat the way we like, and no one does Weight Watchers forever. The answer is always portion control. Why torture yourself by eating foods you don't like , instead of simply eating less of the foods you do like?
Let me close by saying eating "healthy" food is less important than eating less and losing weight. We know very little about nutrition. When I went to school as a child, the food pyramid was the exact inversion of what it is now. We don't even know (i.e. have good evidence) if the biggest meal of the day should be breakfast, lunch, or dinner. Should we have one large meal a day or six small ones. For every study, there is a counter-study. Do lefties live longer than righties? Do short people live longer than tall people? Why does overall health correlate so strongly with economic position in life? Maybe we all would be healthier if everyone were a millionaire? Any time any person or authority tries to tell you that something is "good" for you, or "good for your health" always ask the same question we asked reflexively in physics and on hospital rounds: "Do you have a published article to support that opinion?".
Saturday, February 6, 2010
Electronic Medical Records
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,....."
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,....."
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.
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