Thursday, December 31, 2009

Tips (Marin IJ)

Unless you’re a masochist, a trip to your local Emergency Department (ED) is most likely an unpleasant proposition. Such a journey is replete with anxiety-provoking features; an impersonal waiting room, sharp needles, blood (often your own), shrill alarms, and uncertainty about what’s coming next.

It’s not surprising, then, that most people don’t consider the logistics of an ED visit ahead of time. But they should. Not doing so is like going into the backcountry without a “ten essentials” survival kit – things will probably turn out fine, but you’ll be awfully bummed if they don’t. Fortunately, with some simple preparations, you can minimize both the risk and the hassle of a sudden illness.

Last weekend, during a busy ED shift, I asked a patient what the worst thing about his visit was. “I think you know,” he replied, “…it was the wait.” Sadly, that captures an unavoidable reality about Emergency Departments and brings me to my first tip – be prepared to wait. Of course, most of you know this already. But nonetheless, some people still think that an ED functions like a restaurant – first come, first served. This is simply not true – many different variables determine who gets seen and when, but the bottom line is that we triage based on severity; the more life-threatening your illness appears to be, the quicker you will be seen. Thus, if you come to the ED with a gouty toe, expect to wait, but if you have a crushing chest pain and are asked to wait, something is wrong and you should speak up. And if your gouty toe can’t stand the ED waiting room, you might consider alternatives– your regular physician offers personalized and (usually) cheaper care. A visit to the web (Kaiser members can visit or a call to a health advice line can offer helpful perspective. If you do end up on your way to the ED, bring a book or perhaps your Christmas Kindle. I recommend loading Complications by Atul Gawande.

Speaking of complications, one that makes all emergency physicians nervous is aspiration –vomiting stuff from your stomach to your lungs. This is of particular concern during procedures that need sedation. So, if you’ve taken a bad tumble and your arm is as floppy as a fish, avoid stopping at the drive-thru on the way to the hospital. If you do eat or drink anything, it may delay your procedure by up to six hours.

While food is off the table at this point, clean underwear is not. Most patients in the ED will be expected to strip down to their skivvies, (in order to get a complete physical exam) so you might as well make a point of donning a clean set. Like underwear, another thing that should be up-to-date as you enter the ED is your list of medications. You will undoubtedly be asked about your meds, so rather than relying on your memory, have a card ready in your wallet. Be sure you include over-the-counter medications and supplements and note any drug allergies. Given the ubiquitous computer, this may seem unnecessary. But, believe me, it is extremely helpful – I trust diligent patients’ written records of their medications more than the ones I find on my computer screen.

Once you’ve made it through triage, set your cellphone to vibrate and get ready to tell your story. This is vital – how you communicate with your doctor at this juncture will go a long way towards determining the appropriateness of your work-up. Once a medical professional (doctor or nurse) arrives, start with compliments (we all like them!) and avoid gender stereotyping – there are many male nurses and a whole lot of female physicians, and most of us dress very much the same. After you’re done with the pleasantries and have figured out who is who, be clear about why you came to the ED and about your expectations. In the ED, we are very good at recognizing and treating emergent medical problems, and not so good at treating chronic ones. So, tell us what is new and, when you are being questioned, stick to that subject as much as possible. For example, you are likely to befuddle your doctor if you interrupt his line of questioning about abdominal discomfort to tell him about years of foot pain.

Finally, as the visit unfolds, consider this; more tests do not necessarily mean better care; questions about your diagnosis and treatment are better at the end of your visit than the beginning; and every pet owner should have a back-up pet sitter. Amazingly, pet care seems to be (in my unofficial estimation), the #1 reason why people leave the ED against medical advice. I’m an animal lover myself, still, it is hard to understand why someone having a heart attack leaves the hospital so that they can take Barky out for a pee. But, it happens frequently. So please, set up an emergency pet-care system – a list of people who can take care of your pet while you take care of yourself. Don’t be afraid to ask hospital personnel to help you make those phone calls. Better to stay in the hospital for a day or so then to stoically make it home for one last walk with Barky.

There you go, tips from someone who’s been there before. I hope you won’t have to put them to use.

Wednesday, December 23, 2009

Letter to Santa (Marin IJ)

Doctor I.M. Igloo North Pole Community Health Clinic, North Pole

Dear Mister Claus,

I am writing to ask your indulgence with a manifesto of unsolicited advice. Being mindful of the vast amount of correspondence you receive, I nonetheless ask that you pay close attention to this letter, as it is of immense importance. Truth be told, it may be a matter of life or death.

Mister Claus, you are too fat. That is impolitic, I know, but based on the data from your most recent check-up, you are, without a doubt, morbidly obese. Mr. Claus, have you heard about the BMI? No, this is not new Xbox lingo; it is your body mass index. And yours is unsightly; like a gift wrapped in toilet tissue. Based on your height and weight you have a BMI of 44 – which is far above the normal range of 25 to 30. This, I’m afraid, places you in danger of myriad medical conditions: diabetes, high blood pressure, heart disease, and arthritis, to name a handful. It also amplifies the chimney-related occupational risk you face each December 24th. In sum, this is a great jolly health disaster just waiting to happen.

Mister Claus, perhaps you saw the recent Harvard study published in the New England Journal of Medicine? The authors calculated future life expectancies based on current and historical data and found that the heavy tide of obesity will likely wipe out all of the societal benefits of smoking cessation efforts. I shall quote Susan T. Stewart, Ph.D., lead author on the study; "In the past 15 years, smoking rates have declined by 20 percent, but obesity rates have increased by 48 percent. If past trends continue, nearly half of the population (45 percent) is projected to be obese by 2020." Now, this is a sensitive topic for many people, and I recognize that, genetically speaking, people come in all shapes and sizes. Maintaining a healthy weight is much easier for some than for others. But, nonetheless I fear that you have chosen image over sensibility.

So, Mister Claus, because I am greatly concerned for your well being (not to mention that of the world’s children), I have put together a holiday wish-list for your health.

1) Mini-size the portions. I have heard that Mrs. Claus makes a delicious potpie and that your home is filled with candy canes and sugarplums. Temptation is everywhere in your cozy nook of the world. All I would ask is that you keep the portions reasonable and only eat when you are hungry. One more thing, don’t feel obligated to politely consume each tasty morsel left for you above the fireplace – save some for the Grinch, his frame can spare an extra cookie or two. And, for goodness sake, have some broccoli with your potatoes – not only does it help fill you up, but it also contains phytochemicals that may help ward off diabetes, heart disease and obesity.

2) Pay attention to the calories when dining out. Eating well on the road is tough, I don’t have to tell you that. But, you should know that most people grossly underestimate the number of calories in a restaurant meal. Restaurant chains may soon be required to calorie-label their menus. In the meantime, you might consider gifting yourself a copy of Eat This Not That! 2010. This useful tome gives you an idea of the calories in common restaurant meals. For instance, the grilled chicken and avocado club at the Cheesecake Factory brings home over 1700 calories (better split that with the Missus). And, one last thing, when you park the sleigh at the convenience store, just say No-Nos to the Ho-Hos.

3) Don’t let the reindeer do all the work. Or the elves for that matter. A year’s worth of armchair-based supervision followed by a night of sitting in a sleigh is appallingly sedentary. Like many people, I am sure that you find it difficult to carve out dedicated time for exercise. So, why not make exertion part of your work? You may have seen the recent evidence that suggests that men who walk or bike to work enjoy better health than those who do not (even when controlling for other types of physical activity). I recommend that you outfit your sleigh with a bicycle apparatus – that way you can give Prancer and Dasher and the boys a little assistance, while servicing your waistline at the same time.

4) Every now and again, consider your own happiness. You may laugh for the children and smile for the camera, but I suspect that your mental health is not as robust as you would have us believe. Research has shown a link between obesity and depression, although it is hard to know which leads to the other. But, whatever the causal link, I am confident that you will find greater contentment with lesser corpulence.

Mister Claus, thanks for your tolerance with my badgering counsel. Your time is valuable, that I know, but so is your continued good health. Indulge less, live better.


Dr. I.M. Igloo

On Empathy (Marin IJ)

Contemporary medical practice has many virtues – it is diverse, e-savvy, and employs an amazing array of diagnostic and therapeutic tools. Modern medicine can open clogged arteries, replace vital organs, and restore 20/20 vision. It can defeat nasty germs and remove tumors with microscopic precision. And, lest we forget, it can also laser away body hair and make wrinkles disappear (temporarily, that is). I think you’ll agree, medical care today is truly amazing – most of the time. One area, however, where the system struggles is in the practice of empathy – the acknowledgment and understanding of a patient’s physical and emotional condition. It’s not that we don’t understand the benefits of empathy; on the contrary, evidence shows that patients with empathetic physicians are more satisfied and more compliant with their treatment regimens. Rather, it’s that empathy, in comparison with the nuts and bolts of diagnosis and treatment, is both underappreciated and under-nurtured.

According to a study in Academic Medicine (2008), the “hardening” of physician’s hearts begins in medical school. Using a standardized questionnaire, the vicarious empathy (spontaneous empathetic response) of 419 University of Arkansas medical students was measured at the beginning of each year of school. Over time, the researchers found a significant decline in student empathy scores – especially after the first and third year. There are a number of potential explanations for these findings – academic work-load and stress, poor clinical role models, and, especially after medical rotations begin in the third year, a need for an emotional defense system. But whatever the reason or reasons, the empathy drain often continues from training into clinical practice. Even those doctors who can recover their emotional idealism find that the realties of the business – crowded waiting rooms, voluminous charting and coding, complicated protocols and guidelines, and litigation – tend to squeeze out the very thing they need most to act empathetically – time…time to listen to what patients have to say. But, since time and patient volume tend to be unyielding obstacles, are there other ways that medical professionals can nurture their empathy back to health?

Karl Pilkington, co-host of the Ricky Gervais Guide to Medicine, has a far-fetched solution: a machine that transports the patient’s feelings directly into his or her doctor’s body. In other words, an empathy machine that “makes my doctor feel like me.” In Pilkington’s farcical universe, physicians-in-training would use this machine to experience a vast array of sensations that their patients may someday visit them with. For example, they may experience “a swift kick in the bullocks so that they can remember what that feels like.” As ridiculous as this example is, there is a spot on principle embedded in Pilkington’s proposal. A recent study found that new mothers scored higher on empathy scores when watching videotapes of other new mothers than did women without children. But, absent a means of making medical professionals experience all relative conditions, what else can be done?

A group of seventy Rochester, New York, primary care physicians received a 12-month training (2 months intensive, 10 months maintenance) in mindfulness that included a component of cognitive empathy – which is distinguished from vicarious empathy in that the providers make a conscious effort to understand what their patients are experiencing. These providers were tested before, during, and after this training on a series of wellness scales – including burnout, mindfulness and empathy – and the results were published in JAMA this past September. The investigators found modest, but consistent improvements across many scales, including a several percent improvement in empathy scores, leading them to conclude that “participation in a mindful communication program was associated with short-term and sustained improvements in well-being and attitudes associated with patient-centered care.” This study offers hope that it is possible to train physicians in the practice of empathy, but is certainly limited in its wide-scale feasibility (the program required approximately fifty total hours of training) and its results (modest improvements that may or may not have persisted after the maintenance program ended). And while I applaud such efforts to remind doctors of the importance of empathy, both for their own good as well as for that of their patients, ultimately we must take a broader view of the topic.

Look around you, or think about the interactions you’ve had so far today. I think you’ll agree with me when I say that empathy is in short supply these days. And while few of us expect empathy from the executives of a Fortune 500 company, most of us expect it from our doctors. But, the two are connected. Doesn’t it make sense that the amount of empathy in our medical system would closely mirror the amount of empathy practiced in our society? In a get-rich-fast, quick fix, “me” time, bottom-line driven society like ours it is awfully difficult to expect a different ethos from medicine. So, while individual physicians can and should (and do) attempt to bring greater empathy to their care, as we enter the holiday season, we might each consider how we can bring greater empathy into our society at large.

Seasonal Myths (Marin IJ)

Did you know that the scent of mistletoe stimulates saliva production and that the taste of eggnog boosts serotonin levels? And did you know that second-graders who believe in Santa Claus do worse on standardized tests than non-believers? I bet you didn't and there is a good reason why – these associations have no basis in fact. Still, if enough people were to repeat them, they might easily become accepted as truth. Take, for example, the popular belief that the tryptophan in turkey makes you sleepy. While turkey does contain tryptophan (an amino acid with sleep-inducing properties), it doesn't contain any more of it than beef or chicken. In fact, sunflower seeds and soybeans are both richer in trypotphan than turkey. Which means that the post-Thanksgiving dinner drowsiness you recently experienced was most likely due to other holiday indulgences – such as alcohol and carbohydrate intake.

Last year, in the spirit of dispelling such seasonal myths, the British Medical Journal published a scientific review of some common holiday-related beliefs. I was surprised by some of the content and must admit that in the past I’ve contributed to the urban legends that the article debunks. And I suspect some of you have too. So, this holiday season, I’d like to give us all the gift of some solid scientific evidence.

*Poinsettia plants are not toxic.
A poison control center study reviewing more than 800,000 poinsettia leaf ingestions did not find a single case of significant toxicity. In fact, 96% of ingestions did not even require medical evaluation. And in another study, scientists were unable to kill rats (they are clearly not alone in this predicament) with poinsettia – even after feeding them the equivalent of more than 500 leaves. So, while not to be encouraged, should junior mistake a poinsettia for a festive treat, there is no reason to panic.

*People are not more depressed during the holidays.
A U.S. study spanning 35 years did not find an increase in suicide rates over the holidays – a finding corroborated by evidence from other countries. This is not to say that people don’t get bummed out over the holidays, just that the amount and degree of depression around this time of year is probably no different than during the rest of the year.

*Children who eat sugar are not more hyper; but their parents might be.
Twelve well-designed studies have not found an association between sugary food and hyper-activity levels. Parents, though, are more likely to rate their child's behavior as "hyper-active" after they have watched them drink a sugary drink. So, the sugar-hyper-activity connection may only exist in mom and dad’s mind. The link between sugar and rotten teeth, on the other hand, is quite real so there is good reason to be hyper-active about post-candy tooth brushing.

*Nighttime binging is not more fattening than daytime binging.
This was news to me. I have often warned my patients against feasting late at night and advised them that people who skip breakfast are more likely to gain weight. It turns out that the latter is true, but not because breakfast-skippers binge at night, but rather because they eat more during the rest of the day. Several good studies have failed to establish a connection between late-night eating and obesity. So, feel free to enjoy the occasional midnight snack, but know that the age-old association between holiday-related overeating and weight gain is no myth.

I’m thankful that the British Medical Journal has given us less to stress about these holidays, but also know that there are some genuine seasonal health threats that deserve mention.

*Heart-related deaths are more common during the holidays.

It is not exactly clear why, but very good evidence shows that the rate of heart-related deaths spikes at Christmas and New Years. To minimize your risk of a Merry Christmas Coronary; consume only moderate amounts of calories, salt, and alcohol, avoid excessive exposure to air-based pollutants like smoke from a wood burning stove, and don’t engage in too much robust exertion after big meals. If you experience any new and concerning symptoms (such as feeling like there’s an elephant sitting on your chest), please don’t delay your trip to the hospital until after the presents are all unwrapped.

*Festive dinners tend to get stuck in the esophagus.

Whether it is Christmas goose or Chanukah brisket, one of the biggest risks of a holiday meal is that it won't make it to its intended destination. Getting a chunk of beef lodged in your esophagus may be a good way to limit caloric intake, but it also may lead to a visit to you local Emergency Department and an encounter with a grumpy gastroenterologist. So remember, on Christmas day, the best gift you can give Grandpa may be to remind him to cut his dinner into safely-sized chunks.

*Space heaters have Scrooge-like tendencies.

Not only are space heaters energy hogs, they also poise an under-recognized health risk – an unsightly rash called erythema ab igne. If you spend hours nestled close to a space heater – in the office or bedroom – you are at risk for developing this web-like discoloration which may result in permanent pigmentation changes and perhaps even skin cancer. So, take it easy on your skin (and mother nature) and turn down the space heater.

On that note, I am off to salivate under the mistletoe. Happy Holidays.

Vreeman RC, Carroll AE. BMJ 2008;337:a2769

Monday, November 9, 2009

Handy Information (Marin IJ)

In today’s digital age, in which broadband is ubiquitous and multi-tasking epidemic, fifteen seconds can seem like a long time. Fifteen seconds is enough time to do all sorts of productive things: download a new iPhone app, send a hilarious text message, or set up a DVR recording. It is also long enough for the Niners to throw three incomplete passes and for the discerning reader to glean all useful information from the front page of the newspaper.

You get the picture – a lot can happen in a quarter of a minute. Which is why it can seem like an awfully long time to spend washing your hands. But, fifteen seconds is actually the minimum amount of time that you should dedicate to a proper hand washing (with soap and warm water). This advice comes from me, yes, but more importantly from the Centers for Disease Control and Prevention (CDC) – which, in these epidemic times, is one of many entities stressing the importance of good hand hygiene.

In hospitals, cleanliness has been an important topic for over a century – ever since Ignaz Semmelweis demonstrated that by disinfecting their hands between patient visits, hospital personnel could substantially decrease maternal death rates after child birth. Nowadays, hospital accreditors watch closely, eyes on the clock, to make sure medical staff follow the fifteen-second rule. Even with such scrutiny, it can be hard to comply. Imagine the success rate that daycare centers must have getting young children to stand at the sink for 15 seconds. I, for one, consider it a victory if I can get my four-year-old daughter to wash her hands at all – fifteen seconds of hand scrubbing is nearly impossible without bribery. No wonder, then, that the public clamors for easier, faster alternatives such as hand sanitizers and antibacterial soaps. So, in the spirit of infection control, let’s review a few of these competitors.

Alcohol Gel Sanitizer
This is what I use, dozens of times a day, in the Emergency Department. A little squirt of crisp, clear ethanol gel, several rubs of the hands, and I am good to go. Alcohol gel products (such as Purell) have many advantages; they are quick, convenient and have excellent across-the-board germ killing action. Says Dr. David Witt, an infectious disease expert at San Rafael Kaiser, “For most purposes, they are equivalent to a complete washing of the hands with soap and water. They should be encouraged in situations where access to soap and water is limited.” The CDC agrees. If you choose to use alcohol-based sanitizers for on-the-go situations, you should look for those containing more than 60% alcohol (lower alcohol concentrations are of questionable value.) But, before you Purell-up and bar soap-out, a few words of caution. Alcohol gels do remove natural hand oils, and can cause dry hands – although I personally don’t find this to be a problem. Also, because of their high alcohol content, use these gels with extreme caution around: small children with curious palates, alcoholics desperate for a drink, and pyromaniacs. Alcohol gels can be both intoxicating and flammable.

Tricolsan is an organic compound found in many products – such as soaps, deodorants, and cleaning supplies – and even is imbedded in things such as kitchen utensils, bedding and socks. You probably don’t have any idea how much triclosan you have in your daily life but I recommend limiting it as much as possible. Why? Because 1) antibacterial soaps (such as those containing triclosan) have not proven to be any more effective than plain soaps, 2) triclosan can stick around in the environment for quite a long time and when it degrades it forms potentially toxic dioxin products and 3) the widespread use of this product has generated (as yet unproven) concerns about creating bacterial resistance.

Natural Hand Sanitizers

These products, made with thyme, oregano or other plant oils with antimicrobial properties, advertise that they are effective in killing all sorts of germs. My wife, a longtime fan of natural products, put one such product to the test in her microbiology lab: CleanWell All-Natural Hand Sanitizer, made with Thymus Vulgaris Oil and purporting that it is “proven to kill 99.99% of germs naturally.” Apparently, among the 0.01% of germs that CleanWell does not kill naturally is E. coli – spraying this sanitizer on various dilutions of E. coli cultures did little to impede the bacteria’s growth. Thus, I would advise that such products are probably not as good as a good hand washing.

To summarize this topic, in fifteen seconds or so, keep your hands clean, especially if you are sick or in a high-risk situation (such as at a hospital, daycare center or petting zoo). And while alternatives exist, the safest hand hygiene option for most remains a quarter minute of good ol’soap and warm water. When illness lurks nearby, this is time well spent.

Monday, October 26, 2009

Do your homework before using alternative treatments (Marin IJ)

A FRIEND asked me this year for medical advice about an affliction that was puzzling and disturbing him.

Why, he wondered, had his sense of smell deserted him. The condition began with a bout of the sniffles, but weeks later and snot-free, it persisted. He could faintly pick up some scents, but only with great effort - such as if he leaned over a bowl of onions or buried his face in a lilac bush.

I was perplexed, but not overly concerned. I told him that it was probably the lingering, but temporary, effects of a cold.

A month went by and my friend's problem persisted. At best, he could smell 15 to 20 percent of normal and if he got the least bit congested, that sent him back to zero.

Now concerned, I considered the day-to-day ramifications of his condition; savory meals unappreciated, spring days muted, underarm ripeness untreated and backyard canine bombs unnoticed. And, I contemplated the notion that while modern civilization has diminished the survival importance of a keen sense of smell, there are situations where smell can warn of imminent danger; as with the decayed cabbage of a propane leak, the garlic odor of toxic organophosphate chemicals or the bitter almond of cyanide gas on the loose.

This past June, as I was just beginning to appreciate the extent of my friend's loss, I saw a news headline that offered a clue to its cause: "FDA says Zicam Nasal Spray can cause loss of smell."

The Food and Drug Administration, based on 130 different complaints,
was advising consumers to stop using Zicam's nasal gel and swab products.

I asked my friend about Zicam and yes, he had used their nasal swab many months before. And he recalled it quite clearly because the product had caused an immediate and intense burning sensation. Thus, he was not surprised to learn of the FDA's notice - he had long suspected that his loss of smell was due to Zicam. But, he was frustrated; Zicam was a homeopathic brand - natural and presumably safe. And, sadly, that is where he and many others had been led astray.

As a recent onslaught of news reports have emphasized, alternative treatments (such as homeopathic preparations) are not guaranteed to be either effective or safe. In fact, in some cases they are far riskier than conventional treatments. This I know from my own practice.

As an emergency physician, I treat many patients who use alternative therapies. This is not surprising; a CDC survey study of 32,000 Americans found that 38 percent of adults and 12 percent of children had used some sort of alternative medical therapy in the previous year.

Rarely do I encounter people who clearly benefit from alternative therapies (although I know there are many who do). Rather, I see those people for whom they have gone awry; such as the woman with a devastating vertebral artery dissection after a chiropractic adjustment or the young man with gastrointestinal bleeding caused by a Chinese herbal medicine.

And I am also aware that most alternative treatments are of no proven benefit.

There are exceptions, such as fish oil and melatonin, but these are rare. In fact, recent studies have rebuffed the therapeutic clams of St. John's Wort, Vitamin E, and Gingko Biloba. This evidence, coupled with the often-disingenuous marketing of alternative products has made me inclined to view anything labeled "natural," or "homeopathic" with suspicion.

For example, during a recent foray to my local, premium-priced natural food store, I encountered one homeopathic medicine of dubious value after another: Bronchial Wellness Herbal Syrup ($19.98 for a plantain-laced elixir), Male Sexual Vitality Tonic ($16.79 based on Ginseng's supposed and unfounded libido stimulation properties) and ChlorOxygen ($17.98 for a "cleansing" product primarily designed to cleanse the wallet). Ironically, some of the folks who purchase these aggressively priced products are the same ones who consider childhood vaccines a moneymaking scam.

Traditional medicine is far from perfect, and I have, in sum, seen far more complications from conventional treatments than from alternative therapies. Pharmaceutical companies and medical device makers use disingenuous marketing and some physicians prescribe medications of dubious value. But nonetheless, the basic process by which mainstream medical therapies are evaluated is much more rigorous, evidence-based and safety-conscious than that of alternative ones.

Fortunately, this is starting to change, in large part due to the work of the National Center for Complementary and Alternative Medicine (NCCAM) - the branch of the National Institute of Health that recently released its research into Gingko and St. John's Wort. As NCCAM's work continues, I suspect that the list of discredited alternative therapies will grow and entrepreneurs will have to scramble to develop a new line of "miraculous and all natural" treatments to fill the void and empty the wallet.

So, far be it from me to tell people not to use unproven alternative treatments - for some these therapies help.

What I advise, however, if that before you use a new homeopathic product picked off the shelves of your local vitamin emporium is to exercise due diligence. Take a look at the ingredients, Google the product online to search for pending lawsuits or claims of harm, and look it up on quackwatch ( and the NNCAM site ( If everything checks out, use with caution. Otherwise, you should be prepared to contact your friendly product liability lawyer. Speaking of which, if anyone has a recommendation, I have a friend in need.

Tuesday, October 13, 2009

Priorities (Marin IJ)

September 30th, 2009

During the last several months of health reform debate, there has been a lot of scary talk. We’ve been cautioned about bankruptcy, denial of coverage, and pre-existing conditions. We’ve been subjected to speculation about delayed procedures and death panels with a mandate to pull the plug on grandma.

Surely, there are many inequities in our health system and with proposed change comes angst, but whether you are for, against or indifferent towards reform, please pause and remember how lucky we are. We live in a country that has a medical safety net; highly specialized emergency departments capable of treating anyone, anywhere, anytime. This safety net may be expensive, imperfect and severely strained – but it exists. Many around the world are not so fortunate.

Dr. Vicki Martinez, a colleague of mine in the Emergency Department, travels each year to Guatemala to provide free medical care. She works with an organization called Faith in Practice ( that has been sending volunteer medical teams to Guatemala for the last 16 years. These teams travel to the most remote and poorest parts of the country, setting up makeshift clinics in rural villages and providing very basic treatment; antibiotics for parasitic infections caused by contaminated water, pain relief for debilitating arthritis, dental care, and simple surgical procedures. Extremely ill patients are evacuated to urban hospitals. In her journal, Dr. Martinez writes about the heartrending circumstances she encounters: “Today we treated a gravely-ill one-month-old infant with cleft lip and palate. Before we could transfer him, we found the baby mottled and dead in its mother’s arms, she unaware. Our horrified team did its best to console her and deal with the death. To us, the loss of a baby would be our greatest nightmare. In truth, the loss of this woman’s 10th baby with its severe birth defect was just an expected tragedy in a life of struggle.” And, from elsewhere in her journal: “It broke my heart to see young people that would certainly die because they were born in the wrong country. I was sure one 21-year-old mother of three had lymphoma by the multiple lymph node masses she had. Sadly enough, if you are poor with an expensive, chronic disease in Guatemala, you are out of luck for treatment. Another young man appeared to be dying of cancer. The most we could do was to help prepare the family for reality and give him pain medicine to ease his suffering.” Each year, I see Dr. Martinez return from Guatemala with a renewed sense of what it means to a physician and extreme gratitude for the health resources at her disposal here at home.

Dr. Scott Cohen, a pediatric colleague, was so horrified by the conditions that he saw during a three-month visit to the Guatemalan jungles that he founded a non-profit organization – the Global Pediatric Alliance ( – to address some of the health needs of the indigenous peoples of Latin America. Most pressing among these are clean water, de-hydration treatment, and child-birthing skills. This last need is particularly grave – approximately 85% of women in these jungles deliver their babies in huts without medical assistance. And consider that out of all female deaths between the ages of 16 and 40 in Latin America, one in five is due to complications during pregnancy or labor. In contrast, in the U.S., a total of 569 women died during childbirth in 2006 – less than half the number of young women who died from accidental drowning.

“I feel that as a physician,” Dr. Cohen told me “I have a responsibility to care about patients in other parts of the world whom I may never have a chance to meet.” He has accomplished this by helping to train midwives and give them the skills and equipment to recognize complications of childbirth, such as bleeding, early on, so that an expectant mother can make it to the hospital – rather then bleed to death in her hut.

When I reflect on the medical care available to Guatemalans and others in the third world, it is clear to me how fortunate we are in this country and what we take for granted. This is not an argument for or against change in our system; it’s just the way it is. But, I think that the experiences of my colleagues in Guatemala highlight what our health priorities can and should be; basic preventive care, in particular for societies’ most vulnerable populations. A good place to start would be improving out infant mortality rate – currently ranked 29th in the world – on par with Poland and Slovakia. Now, that is truly scary.

When Smelling Like a Fish is Worth It (Marin IJ)

October 12th, 2009

For the last several months I’ve been taking a remarkable nutritional supplement that does all of the following:

• Lowers my triglyceride levels and helps keep me trim and lean
• Decreases my risk of developing coronary artery disease (heart disease) and dying suddenly due to a heart arrhythmia
• Alleviates my joint pain and helps keep my mood (more or less) mellow
• Prompts my wife to sometimes tell me “You smell like an aquarium”

No, I haven’t been feasting on our family goldfish. Rather, I’ve been enjoying the myriad benefits of fish oil supplements.

For decades, researchers have wondered why heart disease is much less common among the Japanese than Westerners. While some have proposed a genetic explanation, a 2008 study published in the Journal of the American College of Cardiology seems to suggest otherwise. This investigation found significantly less hardening of the arteries (atherosclerosis) in middle-aged Japanese men compared to middle-aged American men – but only in Japanese men living in Japan. In other words, American men of Japanese descent had similar levels of atherosclerosis as Americans of non-Japanese descent.
What then, was the major difference between the Japanese and the Japanese Americans? Diet. In particular, the blood levels of omega-3 fatty acids (omega-3s) from the consumption of fish species such as salmon, tuna and mackerel. These fatty acids, which are known to biochemists as docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), are thought to have anti-inflammatory and anti-clotting properties that deliver significant health benefits. Recent scientific evidence has given omega-3s even more kudos, such that they are well on their way to becoming standard therapy for patients with, or at risk for, heart disease. Consider, for instance, a study published in the Mayo Clinic Proceedings, which found that life-style changes combined with the consumption of fish oil, and red yeast rice decreased LDL “bad” cholesterol levels by 42% – a reduction similar to that seen with the prescription cholesterol-reducing medication simvastatin (Zocor). In comparison to the simvastatin group, the fish oil group had a significant reduction in triglyceride levels (29% vs. 9%). Based on this and other supporting evidence, omega-3s have become the first nutritional supplement ever officially endorsed by the American Heart Association (AHA).

So, the available evidence suggests that omega-3s are beneficial. The next question is how one can smartly and safely incorporate them into their dietary routine. Well, to start with, not all omega-3s are equal – fish-derived sources seem to be more beneficial than plant-based sources (such alpha-linolenic acid – ALA – from flax-seed or olive oil). Unfortunately, studies have demonstrated that certain fish, especially those high in the food chain, have potentially dangerous levels of toxins such as mercury, lead, pesticides (like DDT) and polychlorinated biphenyls (PCBs). Thus, the Japanese approach to eating fish (for breakfast, lunch, dinner and midnight snack) might put you at risk for serious toxicity. And how about fish oil supplements, are they safe? We know that over-the-counter supplements can be dangerous – take, for example, a study of 500 Chinese patent medical products that found that ten percent contained undeclared drugs or potentially toxic levels of heavy metals. But, don’t despair – research suggests that U.S. fish oil products are safe from contamination. A group from Massachusetts General Hospital has tested commercially available preparations of fish oil for toxins (by puncturing the capsules and sending them to the lab for analysis). Luckily, they found undetectable, or nearly undetectable levels of heavy metals (including mercury) and PCBs. One of the brands tested was the brand I personally use, Kirkland, found at the local Costco. The online reviews of the product are stellar, and also suggest an additional benefit:

"I supplement my dog's food with this fish oil,” comments one reviewer, “and it works great to keep his coat shiny. The amazing thing is that is also helps with the ‘doggy’ smell. We used to have to bathe the dog every 2 weeks, but now it is around 2 months before he starts smelling like ‘dog’."

Well, that is pretty remarkable and although I am not sure about the proper dosing for canines, I can tell you that human-based dosing recommendations vary and that people with a history of ulcers or bleeding disorders should be careful because omega-3s do increase the risk of bleeding. In most folks, however, a preventive dose of 250 to 500mg of DHA/EPA per day should be safe and sufficient. The AHA recommends that those with known heart disease take one gram a day and those with high triglycerides may need as much as four grams a day. The main side effect seems to be the occasional fishy burp – which can be alleviated with a hearty meal, a dash of mouthwash, or a dollop of mint jelly.

So, after researching the topic, I have decided to continue my supplementation habit and hope that my wife forgives the occasional whiff of an aquarium. Afterall, one’s heart is more important than one’s breath. Isn’t it?

Monday, September 14, 2009

Malignant Mobiles? (Marin IJ)

Can you guess when the following passage was written: "For three decades the medical controversy over the part played by smoking in the rise of cancer of the lung has been largely kept from public notice"?

This was the lead to Roy Norr's 1952 expose, "Cancer by the Carton." For years prior to its publication, evidence that cigarettes were a health hazard had been accumulating. But, cigarettes were also a big part of American life, and when the Marlboro Man and his industry assured consumers there was nothing to worry about, they kept on smoking.

So, when do you think this label was placed on cigarette cartons: "Caution: Cigarette Smoking May be Hazardous to Your Health"?

It took 14 more years. By then, millions of Americans had developed lung cancer and heart disease. With the benefit of hindsight, we can call the cigarette story a classic, cautionary tale that demonstrates how long it takes to firmly establish and publicize a link between an environmental exposure and a disease. This is especially true when the disease is one, like cancer, that usually takes many years to develop. Hence, many public health experts preach a precautionary principle; if we think something in the environment might be dangerous, we should limit exposure.

In the last year I've diagnosed three patients with brain cancer. This, in and of itself, is unusual; brain cancer occurs in about six out of 100,000 people. But what made this particularly surprising was that these patients were all relatively young (in their 40s) and otherwise healthy. Beyond that, they shared a common habit; years of talking on cellular phones for hours a day. In one case, the patient's cellphone use was significant enough for him to ask me if I thought his phone caused his cancer. Now, I know it is dangerous to extrapolate large-scale causality from the circumstances of a handful of patients, but this cluster of diagnoses has me scratching my head.

For more than a decade, researchers have searched for a connection between electromagnetic radiation (EMR) exposure from cell phones and brain cancer. We know that low-level EMR, such as the radio frequencies emitted by cell phones, can cause headaches, auditory disturbances and short-term memory loss. EMR has also been implicated in DNA changes that may be precursors to cancer, and a recent study demonstrated that men who use cell phones more than four hours a day have significantly lower sperm quality than those who do not. As for cell phones and brain cancer, we have been awaiting the publication of what was supposed to be the definitive study - the multiyear, multinational and multimillion dollar "Interphone" study. Heavily subsidized by the telecom industry, it involves 14,000 subjects and spans 2000 to 2006. We've already had a preview of the data, without clear evidence of a cellphone-cancer link. But, before you disconnect your landline and toss it out the window, consider this:Ê

- Lennart Hardell, a Swedish researcher, has grouped the preliminary Interphone analysis with outside studies and observed a 280 percent increased risk of cancer in people using their digital cell phones for greater than an hour a day for 10 years.

- An international group of established researchers recently released a report, "Cell phones and brain tumors: 15 reasons for concern," which detailed numerous flaws with the Interphone study design, including the fact that the study did not enroll children or young adults - populations suspected to be at greater risk from radiation exposure. I asked Dr. Ronald B. Herberman, founding and long-term director of the prestigious University of Pittsburgh Cancer Institute about the report. He wrote:

"I find this critique, focused on design flaws in the Interphone study, to be well argued. I believe it will be very important for another, better-designed study to be performed. Some of the major concerns about the Interphone design could be avoided if the cellphone service providers would cooperate and provide information from their billing records about the extent of cellphone use by participants in the study. In the meanwhile, I continue to be quite concerned about the overall evidence for potential increased risk for brain tumors that has been associated with frequent use of cell phones for more than 10 years, particularly by children or young adults."

- Despite the fact that more than 80 percent of Americans own cell phones, there is no U.S. federally funded effort to study their potential health effects. This will likely be discussed at Sen. Arlen Specter's Senate hearings with cellphone researchers scheduled for this week.

So, with the results of Interphone in dispute prior to publication and with approximately 4 billion cellular phone users worldwide, including hundreds of millions of children and young adults, how concerned should we be? Concerned enough to change behavior.

Cell phones may not be physically addictive like nicotine, but for some people they are an addiction of convenience and communication. Those who spend their days with a cellphone glued to their ear or who allow their teenager to sleep with a phone under her pillow (so she can be sure to respond to any urgent midnight text messages) might want to consider the lesson of "Cancer by the Carton" - by the time we reach consensus regarding cell phones and cancer, it may be too late.

I'm limiting my own cellphone use to less than an hour a day and using text, speakerphone and landline whenever possible. When I do need to use a cellphone close to my head, I will switch to my off (left) ear or use a headset. In the future, I will only buy cell phones with low emission scores (there is wide variability in the radiation exposure from different phone models). And, most importantly, I will keep my mobile as far away as possible from my 4-year-old daughter's developing brain. By the time she asks for a cellphone of her own, I hope that high-quality, publicly funded research has settled the matter.

Monday, August 31, 2009

It Will Take More Than a Band-Aid to Fix Health Care (Marin IJ)

Last month, we had a disastrous family discussion on health care reform. Our pre-school-aged participant clutched a box of princess Band-Aids and suggested she had the solution. When I told her that we might need to ration those Band-Aids, she asked me if I was a “social-er-list.” Another participant, aged six months, tried to eat my insurance card and then, when I took it away, wailed incessantly. I was discouraged, because what I had hoped would be a thoughtful exploration of how we might keep health care costs from bankrupting our children, turned into a cacophony of distraction.

This scenario, as you might have guessed, was imagined rather than real. But on the national stage the distraction is all too real and it’s threatening to turn an important discussion into a circus. So, in the interest of informing the debate, I’d like to offer several (general) observations from the point of view of an emergency physician.

*Reform, in some form, is necessary. Our current health care expenditures are out of control and are a major economic threat. Even if you are satisfied with your own medical coverage, the bloated health system still puts you at risk in myriad ways. These risks include retiring into a bankrupt Medicare system, across-the-board cuts in social services, and a sluggish economy with sluggish 401Ks. Most people, on all sides of the debate, understand this.

*There is fat to be trimmed. Emergency care is an excellent example – when patients come to the emergency department (ED) for health conditions that could otherwise be treated in a clinic (medical office), the care that they receive is expensive and sometimes unnecessary. When a non-emergency is treated in the ED, there is rarely additional benefit to the patient, just additional cost (to the patient and the system). In my own research into over a million Northern California ED visits, my co-investigators and I found that 48% of ED visits were for conditions that clinic docs could have seen at lower cost, and with less waiting time. As a whole, there may be at least 30% fat (i.e. unnecessary or excessive costs) in the current system.

*All citizens should have access to health care, but also should be active participants in their health and the public health. Residents of Marin County are, generally speaking, knowledgeable about their medical histories and I cannot over-emphasize how this improves their care when they need to come to the ED. Citizens elsewhere are less familiar with theirs – and this is a problem – for them and the system. As for public health, by definition we are all in this together and there are simple things you can do to contribute; practice good hygiene, limit how much you pollute and (as scary as it might be to some), get your children vaccinated.

*Insuring more people will not, in and of itself, decrease the strain on EDs. Research shows that recipients of public insurance are significantly more likely to use EDs than those with no insurance – in the case of Medicaid, nearly four times more likely. This means that we can expect that any reform that insures more patients will most likely also result in more ED visits. This should give policy makers pause – especially given that the nation has seen the closure of over 1,000 EDs in the last fifteen years while visits have increased by over 20% (to 119.2 million in 2006). Already, our community EDs are strained with overcrowding and poorly equipped to handle a public health crisis – like a potential swine flu epidemic. If we add more coverage to patients, we can expect more unnecessary ED visits and further overcrowding. Unless, that is, there is both: 1) a concerted effort to improve access to primary care providers and 2) the inclusion of some incentives that encourage people to choose clinic care over ED care for non-emergent conditions.

*Some sort of tort (medical malpractice) reform is a must. Overuse of medical testing and so called “defensive medicine” may not be as big a part of the problem as some would lead you to believe, but it is definitely part of the problem. Health reform which purports to control costs but doesn’t control torts is not honest health reform. In California, we have a law that caps pain and suffering damages in malpractice suits – such legislation should be in place nationwide. Otherwise, the trend, evident in states such as Florida, wherein certain specialists, like obstetricians, refuse to take call due to risk of litigation will just worsen.

Regardless of what happens this month or next, the health reform discussion is not going away anytime soon. If a bill gets passed, its success or failure will likely lie in the details of implementation. If it doesn’t get passed, we will just be putting this issue off for another four to eight years. Either way, I for one am rooting for a substantive discussion. And maybe a princess Band-Aid too.

*Dr. Dustin Ballard is an emergency physician practicing in Marin County and the author of "The Bullet's Yaw: Reflections on Violence, Healing and an Unforgettable Stranger." His Medically Clear column appears every other Monday. The opinions expressed in this column are his and do not necessarily reflect the views of affiliated organizations or funding agencies.

Friday, August 21, 2009

Step off the ladder, before you get hurt (Marin IJ)

When I visit a house that I’ve never been to before, I can’t help but notice its danger zones. I guess my morbid awareness of hazards is a byproduct of the years I’ve spent working in the Emergency Department (ED). Walking up a sloped driveway (such as my own), I envision an elderly woman falling as she attempts to roll the garbage bin to the curb. Climbing a stairway that lacks a handrail, I imagine how a small misstep could result in a ten-step somersault. Entering a foyer with a glass coffee table, I remember a patient who sat on such a table while sleepwalking – and ended up with a foot-long triangle of glass lodged in her bottom. In the kitchen, I look suspiciously at the cheese slicer, bagel knife and garbage disposal. Out back, I cringe at the power tools – a nail gun, skill saw, and metal grinder. It’s not that I am paranoid, it is just that I have seen too many home projects gone awry – hands nail-gunned to 2x4s, fingers precisely amputated by skill saws, and bits of metal wedged in eyeballs by projectile-inducing grinders. But, danger lurks everywhere and we can’t live our lives afraid of everything. As Johann von Goethe once wrote, "the dangers of life are infinite, and among them is safety."

So while it is not instructive to excessively preach about prevention, there is one common backyard tool that really gives me the shivers, and this I must share with you. The ladder. Ladders are simple and useful objects in most situations, but they are also disasters waiting to happen. Nationwide, based on data from the United States Consumer Product Safety Commission (CPSC), there are approximately 170,000 ladder-related visits to EDs each year, including over 150 deaths. Based on a statistical analysis of the CPSC data published in the American Journal of Preventive Medicine, the rate of ladder injuries has increased by fifty percent since 1990. Here are a few things about ladder-related injuries that may not surprise you; they usually occur at home (a non-occupational setting), they are frequently related to improper positioning or support and/or over-extension of the ladder, they most frequently involve men, and their severity increases dramatically with the increasing age of the victim and the height of the fall. With this in mind, there are some folks who just shouldn’t be using ladders – elderly folks taking the medication Coumadin (warfarin), drunk or otherwise intoxicated people, and anyone with balance or equilibrium problems. For the rest of us, I have some simple advice.

These are common sense tidbits from the CPSC:

*Straight and extension ladders should be set up at about a 75-degree angle and should extend at least 3 feet over the roofline/working surface.

*Make sure the weight supported by your ladder does not exceed its maximum load rating (this includes you and your materials).

*Metal ladders conduct electricity so you should use a wooden or fiberglass ladder when working in the vicinity of power lines or electrical equipment.

*Be sure all locks on extension ladders are fully engaged.

*Keep your body centered between the rails of the ladder at all times and avoid leaning over to one side or the other.

*Do not use a ladder for any purpose other than that for which it was intended (i.e., ladders should not be used as a play structure for little Jimmy).

And, from my own clinical experience, I’d like to add the following helpful hints:

*If you are going to climb a ladder, leave the chainsaw behind. Unless you are a professional, chainsaws and ladders just don’t mix. I treated one 80-year-old gentleman who was on a ladder, trimming some branches, when he lost his balance and fell. Either on the way down or on impact, I’m not sure which, his chainsaw collided with his neck, dissecting it like an anatomy lesson. Remarkably, he survived (albeit with significant disfigurement) but if the chainsaw had cut another centimeter or so deeper his major blood vessels would have been severed…I do hope that he subsequently retired both his chainsaw and his ladder.

*Placing a mattress 15 feet below your ladder is not adequate protection from a fall – especially if you are 85-years-old. A colleague of mine has a neighbor who liked to clean the gutters on his two-story house and felt entirely safe doing so because of the mattress he placed on the ground beneath him. Apparently, this gentleman carefully considered the direction in which he was most likely to fall and placed the mattress accordingly. Luckily, he retired the ladder before he had a serious fall; that mattress would not have prevented a broken hip or cracked skull.

So, next time you pull out the ladder for a weekend project, take a moment to consider if you will be using it safely and, perhaps more importantly, whether you should be using it at all.

Monday, August 10, 2009

Parental Deception that Goes too Far (Marin IJ)

History is ripe with foolish medical therapies. Bloodletting, mesmerism, and “colonic irrigation” enemas are just a few of the well-intentioned but potentially harmful treatments that have lost both favor and credibility. Unfortunately, new ones are always there to take their place. Take, for instance, a product launched last year named Obecalp – a pill designed to deceive children. Now, as the father of an opinionated four-year-old, I know that creativity is a crucial part of parenting. When my daughter squawks at the idea of walking to pre-school, I ask her to be Dora the Explorer on an important mission. Or, if the living room floor is completely covered with crayons and Groovy Girls, I tell her about the “messy monster,” who absconds with toys that are not neatly put away. Fibbing to children is an ancient technique perfected by generations of parents who have explained “There is no more ice cream,” “Yes, sweetie, someday you can have a pony,” and “Of course Santa Claus can fit down the chimney.” But while I am not above the occasional white lie that prevents an 8.0 trembler on the meltdown scale, I (and many others) draw the line at Obecalp. Last May, the New York Times reported that a chewable, cherry-flavored dextrose (sugar) tablet would be marketed to parents as a placebo treatment for children. A placebo is an inactive drug that works based on a patient's belief that it will make him or her better and Obecalp, as you may have noticed, is the word “placebo” spelled backwards. The idea behind Obecalp was to market a chemically inert alternative to painkillers such as Tylenol (acetaminophen) and Motrin (ibuprofen). Bottles of 50 tablets were to sell for $5.95 and because they didn’t contain active ingredients they could be sold as over-the-counter dietary supplements. The concept, according to inventor and mother of three, Jennifer Buettner, was to design a pill with “the texture and taste of actual medicine so it will trick kids into thinking that they’re taking something. Then, their brain takes over, and they say, ‘Oh, I feel better.’” A useful trick, perhaps, and with a website tagline of “Invented by a Mommy!” some financier must have thought Obecalp was going to be a sure bestseller. Actually, it was just a bad idea. Even in a highly medicated society like ours, a fake drug for children was a line most parents were not willing to cross. Now, let’s be clear; the placebo effect does exist and it can be powerful. There are certain situations where, after parents and a physician discuss it, a trial of placebo treatment makes sense. For example, some pediatricians recommend that the parents of a child with ADHD try a week or two of placebo before starting a potentially harmful medication like Ritalin. But, we already live in a pill-for-every-problem culture. Remember when many obese Americans opted for Fen-phen rather than diet modification and exercise? Some of them ended up with pulmonary hypertension rather than skinny jeans. By encouraging our children to a pop an Obecalp for every sniffly nose, tickly throat, or bruised ego, we would be reinforcing this mindset. And even worse, we would be substituting a pill for parental creativity and attention. When I was a boy, my mother turned me into a vegetable and fruit-chopping machine through a simple technique – extreme flattery. I was led to believe that I, and only I, was capable of delicately slicing pineapple. If we left it to someone else, our fruit salad might not make it to the table. When I finally realized that I’d been duped for years, I was somewhat perturbed, but mainly impressed – my mother had found an effective way to keep me out of trouble and save herself some time. The lesson was duly noted for later use. A year later, the Obecalp website is still active, but the product has not found its way to the local drug store. My inquiries to the “Invented by a Mommy!” e-mail address were met with cyber silence. Thank goodness. The idea of substituting a sugar pill for ingenuity wasn’t going to do our children any good in the long run. Just thinking about it leaves a bad taste in my mouth.

Tuesday, July 21, 2009

Risky Business (Marin IJ)

In the midst of the national discussion about health care reform, much has been made of dynamics that encourage “over utilization” of medical resources. If the phrase “over utilization” doesn’t outrage you, think of it as medicalese for unnecessary care – such as the excess use of diagnostic tests and overly aggressive treatments. Some of the commonly cited instigators of over utilization are: the litigious nature of our society, the millions of uninsured patients who defer primary care and seek (more expensive and usually last minute) treatment in the Emergency Department (ED) and fee-for-service re-imbursement structures that reward doctors who provide more care (whether it’s needed or not) rather than less. If you haven’t read it, Atul Gawande’s recent piece “The Cost Conundrum” in the New Yorker is an excellent examination of this topic. But, there is one variable Gawande fails to discuss and it is an important one: personality. Specifically, I am talking about the risk-tolerance of individual doctors. Risk-tolerance? This phrase is commonly associated with the diversification of 401K portfolios and jumping out of airplanes, but it actually plays a bigger role in medical decision-making than you might realize.
Consider a study from the University of Pennsylvania (UPenn) published last month in the American Journal of Emergency Medicine. Dr. Jesse Pines and his colleagues examined the use of abdominal cat scans (CTs) in the ED and correlated the ordering trends of individual physicians with their responses to a standard risk-taking survey. The UPenn study catalogued 838 adult patients with new-onset belly pain (excluding those who were pregnant or had suffered an injury) and reviewed their records to see if they received an abdominal CT or other imaging studies. The abdominal CT was by far the most commonly used imaging test and in this respect the UPenn study captured a microcosm of the national debate on over utilization. The abdominal CT is an expensive test (costs vary, but a typical bill is at least several thousand dollars) and involves some risk to the patient (in the form of radiation exposure and potential harm to the kidneys). Belly pain can, however, be caused by a lot of different things and CTs are a very reliable way to rule-out most of the concerning diagnoses (such as appendicitis or metastatic cancer). Thus, the UPenn team hypothesized that “risk-tolerant” physicians (i.e. those more willing to take risks) would order fewer abdominal CTs (foregoing them in low risk situations) than risk-averse ones. To distinguish between the two types of doctors, the researchers used a subscale of a standardized personality test (the Jackson Personality Index) that asks respondents to indicate how much they agree with statements such as “I try to avoid situations that have uncertain outcomes,” and “Taking risks doesn’t bother me if the gains involved are high.” When they crunched the numbers and adjusted for other variables (such as gender, age, and the specific location of the patient’s belly pain), they found that their hunch was correct; the most risk-tolerant physicians were 15% less likely to order an abdominal CT. Interestingly, when they searched for two other predictors of increased use of CT – fear of malpractice and stress scores in uncertain situations – there were no associations. So, based on this study, the risk-taking nature of physicians, rather than their fear of being sued or their reaction to stressful situations, is a key determinant of how they practice medicine. Other studies, involving chest pain patients and those with strep throat symptoms also demonstrate that risk-taking doctors have different practice patterns than risk-averse ones.
Now, before we start testing all prospective medical students for risk-taking preferences (if you want to see where you fall on the spectrum, check out, let’s take a step back and ask what these findings mean.
Do doctors who order fewer abdominal CTs provide less-than-optimal patient care? The UPenn study didn’t address this question, but I’d venture to say that more CTs do not necessarily mean better care. In fact, physicians who order more CTs may expose their patients to unnecessary risks. As Johann von Goethe once wrote "the dangers of life are infinite, and among them is safety." And do the results of this study mean that physicians who agitate about the high costs of runaway medical malpractice claims are blowing smoke – because it may be that their personalities are more to blame than the lawyers? Once again, not necessarily – there are a number of other studies that have found an association between fear of being sued and over treatment and it may be that this connection only applies in certain clinical situations. I know plenty of physicians (and would include myself in this group) who sometimes make decisions in the treatment room that are aimed at avoiding a date in the courtroom.
Finally, this is a single study, involving a relatively small group of physicians and performed in a setting (a university medical center) that functions differently than most “normal” community EDs. Nonetheless, this study is further proof that from one physician to the next, there can be significant differences in how medicine is practiced. At the risk of being called a socialist, I contend that individual variations in care, while inevitable and necessary, should be constrained within reasonable limits. For example, risk-taking physicians should be encouraged to consider the worst-case scenario when they decide to minimize care, and risk-averse physicians should remember that over-testing not only costs money, but can lead to further unnecessary testing and procedures. Many physicians have grumbled that practice guidelines and comparative effectiveness research unduly limit their autonomy, but I see these things as tools to help modulate the inherent human attributes that contribute to doctoring, whether they be experience, empathy, or tolerance of risk.
Consumers of medical care may want to consider not only the risk-tolerance of their physicians (perhaps risk-averse patients are well served by having a risk-tolerant physician) but also the risks associated with their own lifestyle habits. But, this is a topic for another day. Now, I am off for an afternoon of bungee jumping and drag car racing.

Monday, July 13, 2009

Pain Kills (Marin IJ)

Michael Jackson had pain, unbearable pain. Not just the chronic physical ailments of a middle-aged performer, but also the unique pain of being Michael Jackson; the pain of stardom too early, of being uncomfortable in his own skin, of multiple failed marriages, of a damaging lawsuit, and of a never-ending parade of rumors and innuendo.

As we found out last week, Michael Jackson was treating his pain aggressively with prescription drugs. Reportedly, one of these drugs was Demerol, a painkiller so addictive and dangerous that it has been banned from many Emergency Departments. Another was Oxycontin, a drug that if chewed or crushed rather than swallowed whole causes a heroin-like high. A third may have been Diprivan; a powerful anesthetic that should only be used in carefully monitored settings because it suppresses the drive to breathe. Regardless of whether some or all of these drugs played a role in his death (and my guess is that they did), it is pretty clear that Michael Jackson was an abuser of prescription drugs. And in this, he was certainly not alone.

Prescription drug abuse is a big problem in this country, and one that is getting bigger by the day. A 2006 national survey estimated that 5.2 million Americans take prescription painkillers for non-medical reasons each month – that’s more people abusing prescription drugs than cocaine, hallucinogens and methamphetamine combined. And this number does not include those people who have been diagnosed with chronic pain, a group who are known to suffer from a high incidence of untreated depression and other psychiatric problems. Among the tens of millions of prescription painkiller users, thousands die each year from unintentional overdoses – in 2004 alone 7,500 deaths were attributed to narcotic painkillers (synthetic opiates such as Oxycontin). This, from a numerical standpoint, makes prescription narcotics far more lethal than either cocaine or heroin.

So, as Michael Jackson’s sad demise illustrates, we have a prescription painkiller problem, and I, for one, wonder if we are over-treating pain. Have we, in the process of attempting to ensure the comfort of the gravely and terminally ill, created a morass of prescription drug addicts? Of codeine collectors, Percocet poppers, VicoHeads and Dilaudid darlings? I see these people every day; because while Michael Jackson had his own Dr. Feelgood, many prescription drug abusers rely on their local emergency physician to get them a fix. Some of these “patients” are in their twenties and have no clear medical reason to be hooked on 360 pain pills per month. Of course, I’ll admit that pain is a difficult thing to measure, and I am sure that the majority of my patients have real pain. But some of them are just plain junkies. And junkies will say or do just about anything to get high. They will give fake names (which is a criminal offense) and construct elaborate stories. One patient recently told me that his house had burned down, taking with it a six-month supply of Vicodin and Xanax, and demanded that I refill the medications immediately, as he was due to catch a flight to Costa Rica in a few hours. Upon further investigation, the fire department had no record of such a fire and his flight to Costa Rica was merely theoretical. Prescription drug addicts will even cause themselves physical harm in order to get a prescription – a colleague of mine once caught a patient trying to fake a painful kidney stone attack by scratching at his urethra with a paper clip.

In an Oregon study tracking 30 drug-seeking patients over the course of a year, these patients had more than 12 pain-related ED visits annually, visited an average of 4 different hospitals and used 2.2 aliases. Sadly, if healthcare providers at one facility refused to give unnecessary narcotics, the patients were usually able to obtain them elsewhere (over 90% of the time). Two of the 30 Oregon patients died of drug overdose. They weren’t named Michael Jackson, so their deaths didn’t garner much attention. But they should have, because they were preventable.

It’s time to recognize that not all pain is equal and that we need a structured means to cut off the supply lines to abusers and funnel them into treatment programs. Some addicts may be beyond help, but we must stop facilitating the habits of those who can be rehabilitated. And, friends, family and physicians need to confront people who appear to be entering a cycle of narcotic dependence lest they themselves become ‘the man in the morgue.’

Monday, June 29, 2009

Why I became a doctor (Marin IJ)

Years ago, when I was applying to medical schools, I was frequently asked, “Why do you want to be a doctor?” In response, I regurgitated a series of bland justifications: I wanted to help people and make a difference in their lives; I was inspired by the challenge of diagnosing and fighting disease; I came from a medical family and had seen, firsthand, how satisfied my parents were with their careers. At the time, I was convinced that these were not only sincere answers, but ones that served my application well. Upon reflection, a decade and a half later, I chuckle at my responses. Not only did they lack originality, but they left out the seminal inspiration for my medical career: bones. Actually, Bones, as in Dr. Leonard “Bones” McCoy, chief medical officer of the USS Enterprise.
Dr. McCoy was my favorite character on my favorite childhood television show, Star Trek. Throughout much of grade school, my brother and I settled down daily to watch an hour of exploration of space’s final frontier. We didn’t care if it was a beautiful day outside or if there was homework to be done; Star Trek could not be missed. We never went so far as to attend a Star Trek convention, but I do recall owning (and even wearing) a blue Starfleet uniform.
There were lots of great characters on Star Trek: the charismatic Captain James Kirk, the intellectual Spock and the inflective Scotty. But Dr. McCoy was the most marvelous of all: passionate, principled, intuitive and as cantankerous as a cactus. He was also a peerless physician who made the job look exceedingly easy. Walking up to a patient in the sick bay of the Enterprise, Bones need only wave his medical tricorder—a saltshaker with lights and a hum—and he’d have the diagnosis. Then he’d aerate the patient with a puff or two of noninvasive hypospray, and voila, the ailment was cured. No needles, no blood, no pain, no stink, no discernible liability, absolutely nothing but easily applied medical technology. To boot, Bones could play the “doctor card” to get out of other tasks, punctuating the cop-out with lines like “Dammit Jim, I’m a doctor, not an engineer,” or “Dammit Jim, I’m a doctor, not a bricklayer,” or “Dammit Jim, I’m a doctor, not a coal miner.”
Who, I wondered, wouldn’t want to emulate Dr. McCoy?

Sadly, medical practice in the 21st century is not as easy for me as it was for Dr. McCoy in the fictional 23rd century. A diagnosis isn’t always apparent, and most serious complaints require invasive testing. Treatment is rarely as simple as a nasal spray, and everything I do is shrouded by the specter of medical-legal ramifications. Nonetheless, as I reflect on my fictional mentor, it becomes apparent how current medical practice is moving, perhaps inexorably, toward a Dr. McCoy-like future.
More and more, physicians rely on noninvasive testing for important information: X-rays, CT scans, EKGs, MRIs. And treatments have evolved—we now have a nasal flu vaccine, and pain medication can be given via a skin patch. Surgeries can be performed by inserting cameras through tiny incisions and in some cases by using pulses of sound waves or lasers. Recently, I read about “proton beam therapy,” a developing technology that involves zapping tumors with a beam of high-speed protons that deliver DNA-warping radiation to a malignancy without damaging the surrounding tissues. Someday soon, writes William Hanson, MD, author of The Edge of Medicine: The Technology That Will Change Our Lives, proton beam therapy will emerge as a “medical tour de force, in which the patient walks into a room, lies down on a bed, and, for the minutes he’s there all of this magical stuff happens around him and to him, painlessly and silently, perhaps while he listens to his iPod.”
Such technology, while amazing, also highlights a fundamental transformation in the practice of medicine. Nowadays, the doctor-patient relationship is more about interpreting laboratory or radiographic tests and explaining the risks and benefits of treatment, and much less about hands-on artistry. Test-based medicine is more scientific and has less variation in quality, but its practice blurs the essence of what being a doctor used to mean.
Dr. McCoy made doctoring look easy, perhaps too easy. Surely, any lowly officer on the Enterprise could have been taught how to use the tricorder and the hypospray? Was there really anything to it? I encounter many patients who have a similar attitude towards modern medicine. I occasionally have patients come into the Emergency Department and declare, “I am here for an MRI,” or ask “Doctor, don’t you think I need a CT?” Sometimes these statements are justified, but sometimes I feel like boldly beaming these people to the land of reality checks.
Often, I feel like a secretary as well as a physician: ordering tests, filling out forms, reconciling medications, and documenting the hell out of all of it. This physician focus on bookkeeping will likely only increase in the future. And while I’ll admit that on the macro level this amounts to “progress,” it does make me reconsider some of those answers I gave to the medical school admissions officers years ago.

*This column was adapted from a piece that recently appeared in Marin Medicine, the magazine of the Marin Medical Society

Henry VIII (Marin IJ)

Dr. Dustin Ballard: Genetic testing - crystal ball for parents?

Dr. Dustin Ballard

Henry VIII, the 16th-century British monarch, was plagued for years by a vexing reproductive problem. By the time he was on his third wife (out of six) and numerous conceived pregnancies, Henry had yet to father a living male heir. In 1536, not long before arranging the beheading of Queen Ann Boleyn, the dismayed Henry is said to have exclaimed, "I see God will not give me male children." Back in his day, this type of misfortune was blamed on God or, as in Henry's case, the wives. Henry (who is thought to have been clinically depressed and/or paranoid schizophrenic,) certainly didn't seem to blame himself. Several hundred years later, however, there is now evidence that perhaps Henry's problem was caused by his own DNA; it seems that some men are genetically predisposed toward fathering girls.

Last year, a Newcastle University study found evidence of just this type of link. A team led by Corry Gellatly examined nearly a 1,000 family trees dating back to 1600 - tracing the lineage of brothers and sisters. They found that men inherit a tendency to father girls or boys from their parents. Thus, a man with four sisters is more likely to father girls of his own than a man with two brothers (Henry VIII had two brothers and three sisters).

This would seem to explain the well-documented phenomenon of increased rates of male births in war-torn countries; men with multiple sons are more likely to have a son (or sons) survive and these sons have a genetic tendency to conceive

more male children. Based on Gellatly's work, it is likely that a yet undiscovered gene controls the composition of a man's sperm - in some cases directing greater production of X sperm (daughter sperm) than Y sperm (son sperm) and in some cases directing an even or Y-dominant distribution.

Now that we have evolutionary evidence, I imagine it won't be long before geneticists locate this specific "gender gene." And once they do, an inquisitive fella with a few greenbacks to burn will be able to discover his own gender gene via "direct to consumer" genetic testing. Perhaps you've heard of these Web-based companies such as 23andMe and Navigenics that allow you (for $1,000 and up) to "search and explore your genome;" providing a breakdown of nearly 100 genetic tendencies, ranging from the likelihood of developing diabetes or breast cancer to the risk of sticky earwax.

This technology has seemingly blossomed overnight. In the not too distant past, it took 13 years and $3 billion to sequence the entire human genome and now Knome Technologies ("Know Thyself") will sequence yours in a few months for the tidy price of $350,000. But, as with any explosion in medical technology, there are some valid concerns. First, some worry if there are enough protections in place to keep employers and health plans from discriminating on the basis of genetic information (a federal nondiscrimination law was passed last year, but it is too early to say how effective it will be). Second, as addressed in a recent editorial in the New England Journal of Medicine, many gene-disease risk associations are rather weak and likely to be revised with further study. Thus, personal genetic-testing in its current form is much like the nutritional supplement industry: ripe with hype and subject to manipulation. Consider, which advertises, based on immunity-related genetic compatibility evidence, the ability to genetically match couples and fill the world with better sex, more orgasms and healthier children.

Many medical providers wonder whether it is wise to obtain and interpret genetic information without a physician's involvement and counsel. And to what degree do we really want to genetically "know ourselves"? If we are talking about a screenable and treatable disease, such as breast cancer, it makes sense to look for genes (such as BRCA 1&2) that significantly increase risk. But too much risk-awareness about less clear-cut associations could lead to paranoia. Predisposition to earwax? Not sure I need to know about that.

As for the gender of one's unborn children, this can be one of life's great surprises. Some people choose to learn early on in a pregnancy, and others wait until the delivery room. No matter which, it is impossible to predict, before you experience the moment, what it feels like to hear the words "It's a boy" or "It's a girl." It would be a shame if genetic knowledge led someone to decide not to have children, based on whether they thought they were likely to have girls or boys. It is worth remembering that some of life's great accomplishments can stem from circumstances clouded by ambivalence.

Consider Henry VIII; his eventual male heir Edward VI, died a sickly lad of 15 while his daughter Elizabeth ruled the kingdom during a period of 45 years of enlightenment. If Henry had known the type of queen Elizabeth would become, he might not have blamed God, but instead thanked his DNA.

Dr. Dustin W. Ballard is an emergency physician at Kaiser Permanente San Rafael and the author of "The Bullet's Yaw: Reflections on Violence, Healing and an Unforgettable Stranger." His Medically Clear column will return July 6.