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

Handy Information (Marin IJ)

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

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

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

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

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

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

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

Do your homework before using alternative treatments (Marin IJ)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Priorities (Marin IJ)

September 30th, 2009

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

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

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

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

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

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

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

October 12th, 2009

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

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

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

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

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

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

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

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

Malignant Mobiles? (Marin IJ)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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


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


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