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.

Makes No Scents

Several months ago, a good friend asked me for some bar-side medical advice. Why, he wondered, had his sense of smell deserted him. The problem, he said, began with a bout of nasal congestion, but weeks later and snot-free, he was still sniff-impaired. If he leaned over a bowl of onions or buried his face in a lilac, he could pick up the smell, but just faintly. I was somewhat perplexed, but not too concerned – probably the lingering effects of the cold, I told him, and his sense of smell should return eventually.

Weeks later, my friend’s problem persisted. At best, he could smell 15 or 20 percent of normal, and if he got the least bit congested, then he went back to zero. Now concerned, I considered the day-to-day ramifications of his condition (the medical term for which is anosmia); 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 a working sense of smell can warn of imminent danger; the decayed cabbage of propane, the garlic odor of toxic organophosphate chemicals or the bitter almond of cyanide gas.

As I was just beginning to appreciate the extent of my friend’s loss, I saw a yahoo news headline that offered a clue to its cause: “FDA says Zicam Nasal Spray can cause loss of smell.” The Food and Drug Administration (FDA), based on 130 different complaints, had advised 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. He recalled it clearly in fact, because the product had caused an intense burning sensation in his nose. Thus, he was not surprised when I informed him of the FDA’s notice – he had long suspected that his loss of smell was due to Zicam. But, he was frustrated; Zicam is 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 (including Dr Elliott’s column in this paper last week) 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 are using alternative therapies. This is not surprising; a recent CDC survey study of 32,000 Americans (including 9,400 children) found that 38% of adults and 12% of children had used some sort of alternative medical therapy in the previous year. Rarely, do I see people who seem to 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 a woman with a devastating vertebral artery dissection after a chiropractic adjustment or a young man with severe gastrointestinal bleeding caused by a Chinese herbal medicine. And I am also aware that most alternative treatments are of no proven benefit. In fact, recent well done studies have rebuffed the therapeutic clams of St. John's Wort, Vitamin E, Selenium and Gingko Biloba. Combine this with the barrage of disingenuous marketing on packaging and T.V. and I’ve become inclined to view with suspicion anything "alternative," "natural," or "homeopathic." On a recent trip 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).

Traditional medicine is not without its faults, and I have, in sum, seen far more complications from conventional treatments than from alternative therapies. Nonetheless, the basic process by which mainstream medical therapies are evaluated is much more rigorous and safety-consciousness than that of complementary 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 (NIH) 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 keep growing and entrepreneurs will have to scramble to develop "all natural" treatments to fill the void. And, there will be some treatments added to the now short list of effective alternative therapies – which include fish oil, red yeast rice and melatonin.

So, far be it from me to tell people not to use alternative treatments – for some people these therapies help. What I advise, however, if that before you use a new homeopathic product picked off the shelves of your favorite natural food store is to do some 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. If not, be prepared to contact your friendly product liability lawyer. Speaking of which, if anyone can recommend one, I have a friend in need.