Archive for July, 2007

Policy on Comments

Friday, July 27th, 2007

We welcome appropriate comments, all of which must include your e-mail address. Back links masquerading as comments will not be published.

Sports Doping: A Modest Proposal

Friday, July 27th, 2007

The wheels keep coming off the Tour de France, as juiced up cyclists are unmasked with increasing frequency just before the tour reaches its climax. Michael Rasmussen, the Dane who won the 16th stage, was dismissed by his team, Rabobank, for misleading his bosses that he was training in Mexico, while actually training in Italy, a hotbed of “blood doping,” (use of the hormone erythropoieten, EPO, to artificially raise the oxygen-carrying capacity of the blood.) Rasmussen was not alone. Patrik Sinkewitz was dismissed from the T-mobile team after he failed a blood test in June. The Astana team, sponsored by companies from Kazakhstan pulled out after one of its stars tested positive for blood doping, and the Italian team Codis withdrew after one of its riders, tested positive for testosterone. For cycling there is a long history of doping. Tyler Hamilton, an Olympic champion Gold Medalist was fired from his team in 2004, and Floyd Landis, last year’s Tour winner is currently in official limbo for doping violations. Even Lance Armstrong is still under suspicion, at least in France, because people wonder how a cyclist can win 7 Tours after recovering from cancer. His case still has not been “finalized,” according to some. This is just the tip of the sports “iceberg.” There’s the still unfinished story of baseball’s home run “king,” Barry Bonds.

And don’t forget the NFL. Three of the five starting offensive linemen from the Charlotte, North Carolina Panthers’ 2004 Super Bowl team were in a report used by prosecutors in the case against Dr. James Shortt, who was sentenced to prison after pleading guilty to illegally distributing steroids and human growth hormone (HGH).

I could go on, but there’s not enough room here to document the widespread use of performance-enhancing drugs in professional and college sports for several decades. There is a good discussion of the issue at this site.

I tend to agree with sports lawyer Michelle Gallen that the pursuit of doping athletes has turned into a modern day witch hunt. New laws are being passed by the states and the Federal Government every other month to criminalize enhancing drug use in professional, even amateur sports. (Alcohol and caffeine, by the way, are legal). Certainly use of anabolic and androgenic steroid hormones, blood transfusions, EPO, and a spectrum of pharmaceuticals carries severe short and long-term risks for athletes who are willing to sacrifice their health, if not their very lives on the altar of competitive success. Winning is equivalent to fame and money, the bottom line in sportsdom.

The dangerous game of using performance enhancing drugs in sports competition lead us into a philosophical and ethical morass. But is there indeed some way to achieve competitive fairness without making cheating athletes into criminals?

Here is a modest proposal, serious enough to ponder at least: Would it be feasible to have a two tier level of sports competition, one for the performance enhanced, the dopers, the other for the “straights” who reject drug use? Obviously, there would be logistics problems; you’d have to test everybody, but how frequently? How many negative tests would get you into the “straights”? One advantage for the athletes would be achieving competitive fairness, and no pressure to risk life and liver for fear of losing fame and paycheck.

And think of the enormous economic and social benefits. Two NFL’s, two, NBA’s, two NHL’s, six baseball divisions, even two world Olympics, two Wimbledons, etc. Multiply All the games in All the sports by two, and what do you have: Twice as much ad and other revenue, twice the athletes, double the number of fans, not to speak of amplified media coverage, and double the number of TV sports channels. The possibilities are staggering.

Patient Privacy:Delusions and Dangers

Tuesday, July 24th, 2007

If you like alphabet soup, take a spoonful of professional codes of conduct, decreed by our lawmakers, FERPA and HIPAA. These two confusing laws have caused enormous confusion despite their good intentions. The first, the Family Educational Rights and Privacy Act, the college confidentiality law passed in 1974 is often misinterpreted as prohibiting faculty or staff from sharing student information with one another or family members. Yet according to Peter Lake of Stetson University quoted in the New England Journal of Medicine, (NEJM 357;2:109, July12,2007) FERPA restricts only discussion of a student’s academic record, Not information about strange behavior or illness.

A recent tragic example is the mass murders at Virginia Tech. Two female students, complained to campus police that he was stalking them, an English Professor threatened to quit, and some students found him so menacing they refused to attend class with him. Yet Virginia Tech, like other colleges trying to help emotionally troubled students, thought they had little power to report Cho to the police or force him off campus and into therapy.

College counseling centers as well as experts are confused and some claim they are prevented by HIPAA, the Health Insurance Portability and Accountability Act of 2003, from sharing information about a student without his permission. What about doctors, even hospitals and ER’s, in their confusion over the complexities of the law, who fear sharing your medical information without your signed consent in a medical emergency? Did you hear the story about the patient who died in the ER because his doctor refused to give essential information about the results of a cardiac cath over the phone? How unbelievably complex it is to legislate patient privacy without allowing exceptions for treatment, billing, charting, record keeping, quality assessment, even marketing. No wonder healthcare workers, let alone patients, -even the judiciary-are confused.

The Philadelphia Inquirer reported that Judge Theodore A. McKee of the U.S. Court of Appeals scratched his head in frustration and asked the government’s lawyer to explain again who, exactly, is entitled to see a patient’s private medical records under federal law? The U.S. Department of Justice lawyer, hesitated for a second and McKee pounced: “If you’re not sure what the rights of patients are, how is Miss Williams down the street, at age 89, supposed to know.”

Both patient and privacy advocates, describe HIPAA as forcing Americans to choose between access to medical care or control of personal medical information. But when it comes to secrecy in the Internet Age allowing us access to unlimited information world wide can we even taste the solitude of the past when all we had were libraries and telephone books? Was it one of the founders of Netscape who wondered if true privacy still existed?

I’m not against HIPAA, but have one question for the legal experts: When your medical chart can be examined by anyone who arrives on your hospital floor or doctor’s office, including but not limited to doctors, nurses, dietitians, transporters, orderlies, housecleaning, and visitors, where’s the beef?

On Being a Smart Patient

Friday, July 20th, 2007

There are many obvious and not-so-obvious questions you should ask yourself as well as your doctor when you consult her:

1. Is it difficult to get an appointment or reach my doctor in an emergency? Does the office have a convoluted automated call system, does my doctor return calls or do I hear from the office nurse or secretary? Is it difficult to get prescriptions re-filled?

2. When I have a physical complaint like back, muscle, or chest pain, does he/she examine me? If I have abdominal pain does she examine my abdomen while I’m lying recumbent on an examining table-and with my belly exposed. With new or unexplained abdominal pain, does she do a rectal or pelvic examination. (Which reminds me of a long-ignored surgical adage from my old friend, Dr. Goodman: “Put your finger in it before you put your foot in it.”)

3. Does my doctor encourage specialty consultation in serious, chronic, or unexplained illness, or am I reluctant or embarrassed to ask for an outside opinion?

As I have previously pointed out, it has long been accepted knowledge that an office visit generally concludes in one of three ways: the patient receives a prescription, an order for some tests-or both. With a new or chronic complaint, does the doctor rattle off a list of possible diagnoses. Beware the Rule-Out doctor. Patients, laboring under a sense of entitlement because they pay so much for health care, often are only too willing to collaborate in this clinical farce. One of our friends once remarked, “Why not get all the tests possible, check everything out, go for broke? It’s already paid for.” (By whom, I might I add? She was a nurse too.)

The idea that generally the more tests the better is a supreme example of deeply flawed thinking or clinical inexperience. Misguided, excessive medical investigation often discloses an innocent abnormality which far too often catalyzes an uncontrollable series of unforeseen events leading to clinical catastrophe, the so-called “cascade effect” (about which more later.) Moreover, unnecessary and redundant medical testing is one of the principal reasons our healthcare system is lurching into bankruptcy.

A critical consideration in ALL medical testing: Will the results of this test change my treatment? No medical test or procedure should be performed as a fishing expedition or for mere curiosity, but only for the purpose of changing the management of the patient. This is especially important with invasive testing, such as endoscopic studies or cardiac catheterization, all of which carry minute but measureable risks of misadventure.

The Vitamin C Hangover

Tuesday, July 17th, 2007

 

 

Linus Pauling, Nobel Laureate in Chemistry, is ranked in a list of the 20 greatest scientists of all time by the British magazine New Scientist, along with Albert Einstein and Newton. His previous insights about the structure of DNA led to its discovery by Watson and Crick. He is considered a founding father of quantum chemistry and molecular biology. Anticipating over 50 years ago the dangers of air pollution from automobile exhaust, he even built an early electric car!

 

In his late 60’s, Pauling, influenced by the biochemist, Irwin Stone, began taking vitamin C in huge doses, 1000mg.-3000mg every day to prevent and abort colds. Excited by the results, he published “Vitamin C and the Common Cold” in 1970. He then began a long collaboration with the British cancer surgeon, Ewan Cameron in 1971 on the use of vitamin C as cancer therapy for terminal patients. Cameron and Pauling wrote a popular book, “Cancer and Vitamin C.” Pauling’s work on vitamin C generated controversy and was quickly regarded by some adversaries in the field of medicine as outright quackery. Three prospective, randomized, placebo-controlled trials were conducted at the Mayo Clinic; all three failed to prove a benefit for megadoses of vitamin C in cancer patients. Further studies during the following decades convincingly showed that megadoses of vitamin C did not prevent or abort colds, and did nothing for cancer.

With overwhelming medical evidence to the contrary, millions of people still believe in vitamin C, to the tune of hundreds of million dollars in yearly sales. Despite the recommended daily allowance by the Government of 75mg-90 mg./day for adults, (it used to be 30mg./day) enormous numbers of Americans think nothing of dosing themselves with 1,000mg-5,000mg. a day for the treatment of colds. Some cancer patients still believe in the vitamin. Googling vitamin C gets you 40.6 million hits. For starters there’s a Vitamin C Foundation, a pop singer Vitamin C, and in 2000 Mattel released a Vitamin C Doll.

Vitamin C is plentiful in a wide variety of foods, not only fruits and vegetables, but in meats, and many cereal products. It is largely destroyed by cooking; on the other hand it is not stored by the body. Most people tolerate large doses of vitamin C without difficulty, However, overdosing with over 1,000 mg. of Vitamin C can cause nausea, cramps, and diarrhea, and reduce absorption of vitamin B-12, and even cause iron overload. A recent report blames a worsening of osteoarthritis on large doses of vitamin C. Chronic megadoses of vitamin C in some patients may enhance the development of (oxalate) kidney stones.

Spend your health dollar as you will, but if you’re taking excessive doses note that over 95% or more of ingested vitamin C is excreted in the urine in 24 hours. This is literally a way to flush away your money.

 

 

 

Where’s the 24/7 Rule in Hospitals?

Sunday, July 15th, 2007

Fever and many other symptoms of illness intensify in the later hours of the day. This is a fact of life for the sick, especially those unfortunate enough to be hospitalized, many of whom have been operated during the preceding sunlit hours. As the evening draws on there is fewer staff to attend patients. After dark is prime time for serious, even fatal hospital mistakes. Staff is cut even more on the night shift, let alone weekends and holidays.

The result is that mistakes multiply on the night shift and on weekends and holidays. Unfortunately hospital services, excluding ICU’s and ER’s are run like most businesses, “open” during daylight, and largely “closed” or at least attenuated on weekends and holidays. It is not surprising that more medication errors are made at night, more kids admitted at night were at increased risk, and a recent HealthGrades study showed that almost a quarter of a million patient deaths over a three-year period were preventable in terms of staffing. A 2005 study of 3.3 million births in California found that babies born late at night were 16 percent more likely to die than those born in the daytime. Other research found that patients going into cardiac arrest at night were more likely to die.

No hospital brochure talks about dangers after dark, only too well known to the medical world. There are reasons to feel anxious when entering a hospital, even though some improvements are being made in hospital staffing and services thanks to public outcry. The problems will remain endemic to the American hospital system, however, until thorny issues of resource allocation are solved: weekend and night rotation of non-professionals despite seniority, and round-the clock sharing of coverage by senior professional staff. Improvements cost money, of course, and and translate into higher medical costs for all of us. How much added financial burden is sustainable for an overburdened healthcare system remains a question I will attempt to address in future blogs.

Still, the time should have long passed when one cannot summon the night nurse, or a sleep-deprived intern is in charge until-or unless-his attending or senior resident can make it in for a critical patient. We get electricity and water 24/7, why not medical attention, in (or out of) hospitals?

Seat Belts, Airbags, and the Governor

Thursday, July 12th, 2007

It seems Chris Moltisante of The Sopranos prefigured another New Jersey accident by suffering multiple broken ribs and punctured lungs after not wearing his seat belt on one of the last TV shows of the series.”Typical injury from airbag” someone remarked. From the looks of Chris, blood pouring out of his mouth amid gasps for breath, he probably would have died anyway, but for the sake of the story, got a suffocation assist from Uncle Tony.

On April 12 this year New Jersey Governor Jon Corzine himself almost died of 11 broken ribs, and multiple other fractures when the SUV in which he was riding swerved to avoid another vehicle on the Garden State Parkway and crashed into a guardrail. His car, headed for a meeting with Don Imus and the Rutgers University women’s basketball team, was traveling at 91 mph, but none of the other four passengers, reportedly all wearing seat belts, suffered significant injury. Corzine was on a respirator and virtual life support for over a week, but miraculously survived. It should be noted that the Governor, in one story suggested he almost never used seat belts, even though failing to do so is against the law in most states, including New Jersey, which has one of the highest rates of seat belt use.

After his recovery, Mr. Corzine made a public apology along with a plea for the use of seat belts. “I’m New Jersey Governor Jon Corzine and I should be dead….I have to live with my mistake. You don’t. Buckle up.”

Let me pose a question: if you could only have one or the other, would you go for the seat belt or the air bag? The answer is easy. Don’t depend on air bags. Steven Levitt, co-author of Freakonomics, and Jack Porter, a professor at Wisconsin, wrote an article six years ago that compares the effectiveness of seat belts and air bags for adults. They found that “…wearing a seat belt reduced the chance of death by 60-70 percent across all crashes. We estimated that air bags reduce the death rate by 15 percent in frontal crashes, but did not help in partial frontal, side, or rear crashes. ” Previous research studies found benefits for adults even higher with seat belts, and lower than air bags! No one but a fool, who knows the data would prefer an airbag to a seat belt if it was an either/or choice. By their estimates to save a life with a seat belt costs $30,000; to save a life with an air bag costs $1.8 mm. See here.

Levitt suggested that one thing left out of the statistics is that airbags reduce the number of suicide attempts from running into trees and bridge abutments, “especially suicide attempts by people who want their deaths to appear to be accidents, for insurance purposes.”

Why Another Medical Blog?

Wednesday, July 11th, 2007

As my medical newsletter, Second Opinions, became more and more popular, it occurred to me that a blog might stimulate more frequent Internet postings, not only by me, but hopefully by readers as well.

Not that we are short of medical information or sources thereof. Just Google “chest pain” for over 3 million URL’s (or “Yahoo” Yahoo for over 16 million.) But information, is not always the equivalent of knowledge any more than widely-shared beliefs necessarily represent wisdom, let alone “truth. ”

That’s why second or third opinions may often be a reasonable approach, to be sought equally by the troubled patient as well as exhausted Internet searchers. If you want bland medical consensus, stop here. If you like medical news, filtered and unfiltered, and comments with a seasoning of controversy or criticism, read on. As Santayana once said, “Skepticism is the chastity of the mind; do not surrender it to the first comer.”