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 http://testyourself.psychtests.com), 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.
Tuesday, July 21, 2009
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.’
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
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?
Posted: 06/07/2009 06:30:08 PM PDT
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 ScientificMatch.com, 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 (http://www.quackwatch.com/) and the NNCAM site (http://nccam.nih.gov/). 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.
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 (http://www.quackwatch.com/) and the NNCAM site (http://nccam.nih.gov/). 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.
Monday, April 13, 2009
A Smoldering Issue (Marin IJ)
Nearly two years ago, Seung-Hui Cho, a senior at Virginia Tech University, committed the deadliest act of gun violence in recorded U.S. history. For days afterward, the story was inescapable and dense with horrific images; students in locked classrooms, being picked off by shots fired from 9 mm semiautomatic pistols; people leaping from second-story windows; a professor holding the door to a room shut so that his students could escape, absorbing fatal gunshots in the process; one boy protected from the assailant's bullets by a classmate's dead body; evidence of more than 200 rounds of hollow-point ammunition; still photos of the killer, a young man with drawn lips and hollow eyes and chilling pre-recorded video footage.
In all, Cho felled 32, injured 25 and re-ignited the smoldering issue of gun violence in America.
The press wondered how a person who had previously been declared "mentally defective," could easily obtain semi-automatic weapons. Others obsessed about campus security's slow response. Politicians spun the events to fit their ideologies and bolster their polls. The state of Virginia closed the loophole that had allowed (the mentally unstable) Cho to legally obtain firearms. Later in 2007, Congress beefed up the existing National Instant Criminal Background Check System (NICS), making it somewhat more difficult, nationwide, for the mentally ill to purchase guns. And after that, well, it was quickly back to the status quo.
The status quo in this country is disturbing; eight dead in a mall in Omaha in 2007, nine in a home in Covina in 2008, 13 slain two weeks ago in Binghamton, N.Y., and an annual toll of more than 4 million gunshots, 400,000 gun-related crimes and 11,000 firearm homicides. And consider the booming and mostly unregulated gun show industry, which makes it remarkably easy to purchase firearms, including excessively deadly ones (like the TAC-50 sniper rifle - which has a kill range of nearly two miles).
Gun shows thrive despite evidence that regulating them (as California has done) decreases illegal sales and despite the knowledge that Mexican drug cartels are buying thousands of powerful weapons at U.S. gun shows. In the political arena, it's status quo, too. Many Democrats still blame their 2000 presidential loss on the gun issue and are afraid to re-consider the assault weapon ban (which lapsed in 2004). Congress' Tiahrt amendment, which limits the disclosure and use of gun sales data, still exists, despite widespread opposition by police and law enforcement agencies.
For those who hoped that the Virginia Tech massacre might have made us safer and smarter about gun violence, the situation looks gloomy. "We, sadly, have become accustomed to a high level of gun violence, such as the events that occurred at Columbine and Virginia Tech," says Dr. Garen Wintemute, director of the violence prevention research program at UC Davis Medical Center. "These tragedies have had very little impact on efforts to lessen gun violence in the country. It is clear what we could do; we are just not willing to do it."
Now, you may be wondering why I am writing a medical column about firearms. The simple answer is that I believe gun violence should be considered a public health issue rather than a political one. Wintemute and other experts in the field have long argued that bullets should be viewed as pathogens - like bacteria or tumors. If one views the problem through this lens, targeted restrictions on firearms are preventive medicine, rather than an affront on personal liberty. Forty years ago, at a time when the nation's roadways were unregulated death traps, many voiced concerns that improvements in highway safety were unnecessary impingements on freedom. But, over time, we have come to appreciate that speed limits, traffic safety signs, seat belts and airbags all save lives. In the case of gunshot wounds, the issue of prevention is paramount. It is a simple observation, but no one dies from a bullet that isn't fired. The vast majority of gun deaths happen at the scene - these victims have catastrophic injuries that cannot be treated. Contrast this to some other disease processes, such as heart attacks or blood infections that can often be successfully treated, even in critical cases. Thus, from a public health standpoint, the bullet is a pathogen that, more than just about any other, needs to be prevented rather than treated after the fact.
So, what does gun violence prevention mean? It means keeping guns out of the hands of violent criminals and the severely mentally ill. It should also mean recognizing that a preponderance of scientific evidence demonstrates that owning guns does not make us safer - that you are more likely to kill or be killed with your own gun than you are to peacefully prevent a crime. And it means making bullets less destructive, making enforcement of gun crimes tighter, cracking down on those who sell crime guns, regulating gun shows and stopping the flow of American guns to Mexican drug dealers. This is what we could do, but don't have the will to do.
My (rather conservative) British father-in-law was visiting recently around the time that four Oakland police officers were killed by gunfire. Watching the news coverage, he said to me, "I just don't understand America's obsession with guns." I considered telling him about the Wild West of yesteryear and John Wayne and Clint Eastwood and of the perceived sanctity of the Second Amendment. But, then I thought about it as a father and as a physician and replied simply, "I don't either."
In all, Cho felled 32, injured 25 and re-ignited the smoldering issue of gun violence in America.
The press wondered how a person who had previously been declared "mentally defective," could easily obtain semi-automatic weapons. Others obsessed about campus security's slow response. Politicians spun the events to fit their ideologies and bolster their polls. The state of Virginia closed the loophole that had allowed (the mentally unstable) Cho to legally obtain firearms. Later in 2007, Congress beefed up the existing National Instant Criminal Background Check System (NICS), making it somewhat more difficult, nationwide, for the mentally ill to purchase guns. And after that, well, it was quickly back to the status quo.
The status quo in this country is disturbing; eight dead in a mall in Omaha in 2007, nine in a home in Covina in 2008, 13 slain two weeks ago in Binghamton, N.Y., and an annual toll of more than 4 million gunshots, 400,000 gun-related crimes and 11,000 firearm homicides. And consider the booming and mostly unregulated gun show industry, which makes it remarkably easy to purchase firearms, including excessively deadly ones (like the TAC-50 sniper rifle - which has a kill range of nearly two miles).
Gun shows thrive despite evidence that regulating them (as California has done) decreases illegal sales and despite the knowledge that Mexican drug cartels are buying thousands of powerful weapons at U.S. gun shows. In the political arena, it's status quo, too. Many Democrats still blame their 2000 presidential loss on the gun issue and are afraid to re-consider the assault weapon ban (which lapsed in 2004). Congress' Tiahrt amendment, which limits the disclosure and use of gun sales data, still exists, despite widespread opposition by police and law enforcement agencies.
For those who hoped that the Virginia Tech massacre might have made us safer and smarter about gun violence, the situation looks gloomy. "We, sadly, have become accustomed to a high level of gun violence, such as the events that occurred at Columbine and Virginia Tech," says Dr. Garen Wintemute, director of the violence prevention research program at UC Davis Medical Center. "These tragedies have had very little impact on efforts to lessen gun violence in the country. It is clear what we could do; we are just not willing to do it."
Now, you may be wondering why I am writing a medical column about firearms. The simple answer is that I believe gun violence should be considered a public health issue rather than a political one. Wintemute and other experts in the field have long argued that bullets should be viewed as pathogens - like bacteria or tumors. If one views the problem through this lens, targeted restrictions on firearms are preventive medicine, rather than an affront on personal liberty. Forty years ago, at a time when the nation's roadways were unregulated death traps, many voiced concerns that improvements in highway safety were unnecessary impingements on freedom. But, over time, we have come to appreciate that speed limits, traffic safety signs, seat belts and airbags all save lives. In the case of gunshot wounds, the issue of prevention is paramount. It is a simple observation, but no one dies from a bullet that isn't fired. The vast majority of gun deaths happen at the scene - these victims have catastrophic injuries that cannot be treated. Contrast this to some other disease processes, such as heart attacks or blood infections that can often be successfully treated, even in critical cases. Thus, from a public health standpoint, the bullet is a pathogen that, more than just about any other, needs to be prevented rather than treated after the fact.
So, what does gun violence prevention mean? It means keeping guns out of the hands of violent criminals and the severely mentally ill. It should also mean recognizing that a preponderance of scientific evidence demonstrates that owning guns does not make us safer - that you are more likely to kill or be killed with your own gun than you are to peacefully prevent a crime. And it means making bullets less destructive, making enforcement of gun crimes tighter, cracking down on those who sell crime guns, regulating gun shows and stopping the flow of American guns to Mexican drug dealers. This is what we could do, but don't have the will to do.
My (rather conservative) British father-in-law was visiting recently around the time that four Oakland police officers were killed by gunfire. Watching the news coverage, he said to me, "I just don't understand America's obsession with guns." I considered telling him about the Wild West of yesteryear and John Wayne and Clint Eastwood and of the perceived sanctity of the Second Amendment. But, then I thought about it as a father and as a physician and replied simply, "I don't either."
Monday, March 30, 2009
What's the right price for a kidney? (Marin IJ)
EVERYONE HAS a price, or so it has been said. Circumstances or incentives can drive people to do just about anything - take a job they despise, live in a place they detest, support a cause they don't believe in or eat a bowl of rotting monkey brains. A monetary incentive might even entice us to give up a bodily organ.
For instance, how much cash would it take for you to sell a kidney? Keep in mind that you have two kidneys, but can do just fine with one, so long as it is functioning well. Of course, if you give up a kidney and the remaining one is later damaged (because of trauma, infection or diabetic complications) things will no longer be just fine.
I should also mention that removing a kidney is not a trivial process: it requires surgery and general anesthesia, and there's the possibility of surgical complications including death (less than 1 percent of the time). Consider also that the selling of organs is deemed unethical by most bioethicists and organ transplant organizations and that it is illegal in the United States and other Western countries. But even knowing all this, I bet if you ponder it long enough, you have a price. So, what is it? A comfortable retirement? Your daughter's college education? Twenty minutes alone with Bernie Madoff?
Before you decide, you might be interested in the going price for one working kidney elsewhere in the world. In Iran, where organ sales are legal, it is $5,000 to $6,000. According to the parliament of Singapore, which is considering legalization of organ sales, the proposed ceiling price for a kidney would be $33,000. In India, where organ sales used to be legal and a black market now flourishes, compensation averages around $1,250. That's according to the San Francisco Chronicle, which ran a piece last year describing India's illicit organ trade, a trade that pivots on the practice of buying organs for cheap from India's working poor and selling them for much more to wait-listed foreigners.
In San Diego County, the kidney of a healthy 22 year-old "nondrinker" was recently offered on craigslist for "$100K obo, plus any medical expenses." But, that may be overly optimistic. In 2003, Nobel Laureate economist Gary S. Becker performed a market analysis that predicted a U.S. commodity price of significantly less than that - $45,000.
It doesn't seem quite right to discuss what the market price of a kidney might or should be, but we've reached the point where, no matter how unpleasant, the topic needs to be addressed. Worldwide, the demand for viable organs continues to increase, and in the United States it's estimated that 17 people die each day while waiting for a donor.
Various strategies, such as public relations efforts and state drivers license advance permissions, have failed to significantly improve cadaveric donor rates.
Internationally, success rates are somewhat better because of presumed consent (opt-out) and mandated choice (yea or nay required) organ donation laws that streamline the consent process. And, like it or not, the Chinese have successfully harvested organs from tens of thousands of executed criminals.
But yet, nefarious black markets in India and elsewhere thrive. Desperate kidney purchasers, according to the late Israeli transplant nephrologist Michael Friedlander, are "exposed to unscrupulous treatment by uncontrolled free enterprise." And for the paid donors, the treatment is not much better. According to news reports, kidneys sold in India come from laborers such as P. Guna, a 38-year-old rickshaw driver with a fourth-grade education. For Guna, $1,250 is certainly a lot of money, but considering that his kidney was sold for more than $25,000, it sure seems like he was taken advantage of.
As with other illicit trades (such as recreational drugs and prostitution), one could argue that legalization of organ buying and selling would allow for regulation, and regulation could protect the sick as well as the poor and disadvantaged. In Iran, for instance, the legalization of organ selling has eliminated the waiting list for kidney transplants, and it is certainly possible that a similar policy could do the same here. Ultimately, though, this issue will remain a sticky one as long as the demand for organs outstrips the supply from cadavers or until we are able to grow new kidneys in a laboratory.
So, my question is not merely of hypothetical interest, it is also of practical public health policy interest. What is your price? What is a fair market price? What should have Guna's price been?
For instance, how much cash would it take for you to sell a kidney? Keep in mind that you have two kidneys, but can do just fine with one, so long as it is functioning well. Of course, if you give up a kidney and the remaining one is later damaged (because of trauma, infection or diabetic complications) things will no longer be just fine.
I should also mention that removing a kidney is not a trivial process: it requires surgery and general anesthesia, and there's the possibility of surgical complications including death (less than 1 percent of the time). Consider also that the selling of organs is deemed unethical by most bioethicists and organ transplant organizations and that it is illegal in the United States and other Western countries. But even knowing all this, I bet if you ponder it long enough, you have a price. So, what is it? A comfortable retirement? Your daughter's college education? Twenty minutes alone with Bernie Madoff?
Before you decide, you might be interested in the going price for one working kidney elsewhere in the world. In Iran, where organ sales are legal, it is $5,000 to $6,000. According to the parliament of Singapore, which is considering legalization of organ sales, the proposed ceiling price for a kidney would be $33,000. In India, where organ sales used to be legal and a black market now flourishes, compensation averages around $1,250. That's according to the San Francisco Chronicle, which ran a piece last year describing India's illicit organ trade, a trade that pivots on the practice of buying organs for cheap from India's working poor and selling them for much more to wait-listed foreigners.
In San Diego County, the kidney of a healthy 22 year-old "nondrinker" was recently offered on craigslist for "$100K obo, plus any medical expenses." But, that may be overly optimistic. In 2003, Nobel Laureate economist Gary S. Becker performed a market analysis that predicted a U.S. commodity price of significantly less than that - $45,000.
It doesn't seem quite right to discuss what the market price of a kidney might or should be, but we've reached the point where, no matter how unpleasant, the topic needs to be addressed. Worldwide, the demand for viable organs continues to increase, and in the United States it's estimated that 17 people die each day while waiting for a donor.
Various strategies, such as public relations efforts and state drivers license advance permissions, have failed to significantly improve cadaveric donor rates.
Internationally, success rates are somewhat better because of presumed consent (opt-out) and mandated choice (yea or nay required) organ donation laws that streamline the consent process. And, like it or not, the Chinese have successfully harvested organs from tens of thousands of executed criminals.
But yet, nefarious black markets in India and elsewhere thrive. Desperate kidney purchasers, according to the late Israeli transplant nephrologist Michael Friedlander, are "exposed to unscrupulous treatment by uncontrolled free enterprise." And for the paid donors, the treatment is not much better. According to news reports, kidneys sold in India come from laborers such as P. Guna, a 38-year-old rickshaw driver with a fourth-grade education. For Guna, $1,250 is certainly a lot of money, but considering that his kidney was sold for more than $25,000, it sure seems like he was taken advantage of.
As with other illicit trades (such as recreational drugs and prostitution), one could argue that legalization of organ buying and selling would allow for regulation, and regulation could protect the sick as well as the poor and disadvantaged. In Iran, for instance, the legalization of organ selling has eliminated the waiting list for kidney transplants, and it is certainly possible that a similar policy could do the same here. Ultimately, though, this issue will remain a sticky one as long as the demand for organs outstrips the supply from cadavers or until we are able to grow new kidneys in a laboratory.
So, my question is not merely of hypothetical interest, it is also of practical public health policy interest. What is your price? What is a fair market price? What should have Guna's price been?
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