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