Vol. 209 March 15, 2019, Jargon Update

March 15, 2019

Jargon: “special words or expressions that are used by a particular profession or group and are difficult for others to understand.”

PIV
“Penis In Vagina” intercourse.  Researchers into the sexual activities of people over 65 yo. are using this term to more accurately define a specific sexual act . . .  because they are documenting a wide variety of sexual practices without penile insertion in this age group.

Elderly” is OUT
This term is currently way out of favor. Few “older adults” want to be considered elderly. “Seniors” is acceptable, even though it implies that those under 65 are “juniors”. It may be the association of that word with “discount” that keeps it current. “Perennials”, suggested as a response to the “millennials”, has the connotation that one has to be replanted every spring so it’s failing to stick. “Olders”, “gerontos”, and “third-agers” are distant possibilities. “Older adults” has been adopted by the American Geriatric Society. The American Association of Retired Persons began referring to itself simply as AARP in the late 1990’s . . . about the time it started sending membership invitations to 50 year olds. The Boston Commission on Affairs of the Elderly just changed its name to the Age Strong Commission. (The best candidate for “Best New Politically Correct Term of the Year” award.)

GM/GF
Genetically engineered wheat that contains far less gluten for gluten-free bread that tastes and feels more like real bread has been created using CRISPR gene modifying technology. When it does reach the marketplace it will undoubtedly cause a real purchasing dilemma for a select group of tree huggers.

“Organic”, “natural”, “healthy”
All still remain relatively undefined by the U.S.  Department of Agricultural so any company can put those labels on almost any food. The USDA and the National Organic Standards Board have opposite opinions on the “organic-ness” of carrageenan, a seaweed derived thickening agent. The USDA Organic label does indicate no synthetic pesticides and fertilizers, no genetically modified crops, no chemical processing aids, and no artificial ingredients. A proposed Food Labeling Modernization Act hopes to set uniform, definitive standards in the U.S.

Computer vision
A growing domain of artificial intelligence using “deep learning”, a “type of machine learning that uses multilayered neural networks whose hierarchical computational design is partly inspired by a biologic neuron’s structure.” (1) (Took the words right out of my mouth.) Computer vision can analyze medical images like pictures of skin lesions as well as the work flow in operating rooms or the progression of patient mobility in the ICU.

Moral injury
This is a substitute term for “burn out” in describing what is happening to our physicians.  “The increasingly complex web of medical providers’ highly conflicted allegiances. . . results in the moral injury . . . of not being able to provide high-quality care and healing in the context of health care. . . . Electronic health records track productivity and business metrics, but significantly reduce face-to-face interactions.” (2)

Cisgender
Having a gender identity that is aligned with one’s sex assigned at birth. The opposite of transgender. . . usually, but some transgender persons identify with both genders or neither! (on to the next jargon item.)

Nonbinary
Identifying as neither male or female, having multiple gender identities, or having none; “a more expansive concept of gender.”

Sexual orientation
“Who you go to bed with. Gender is who you go to bed as.”

High-end lobster
Offered by a Maine seafood restaurant that pumped marijuana smoke through the tank water to sedate lobsters before throwing them into the pot. The practice was stopped by order of the state Department of Health for “dispensing of marijuana without a license.”

Standing desks are OUT
A deeper look into the 2015 research of the health benefits of standing vs. sitting while working at a desk indicates that there is little actual health benefit to standing. “Workers should not fool themselves into thinking that standing is a form of exercise.”

Pasture-raised chicken
“Cage-free” chickens may still be raised in packed buildings with no outside access. “Free-range” chickens have outside access but there is no government standard for amount of available space. “Organic” chickens are cage-free, are fed only organic feed, and have outdoor access, but it may be just a small concrete porch. “Pasture-raised” chicken require 108 square feet per bird of outdoor space to earn that label as well as the “Certified Humane” label. (3)

Geroscience
This emerging field of scientific research of longevity hopes to gain the Federal Drug Administration’s attention for reviewing drugs to retard the aging process, which recognizes aging as a natural process (outside their purview) not as a disease (within their jurisdiction for review of new drugs).  A newly formed Boston-based Academy for Health and Lifespan Research will lobby various governments world-wide to support development of drugs and other age-slowing therapies.

“Safe-school officer”
Former combat veterans wearing body armor while carrying a 9mm Glock handgun and a sawed-off automatic rifle hired to roam the halls of the Manatee School for the Arts in Palmetto, Florida. The principal hired the combat veterans because “I don’t want this to be the first time they’ve had someone shooting at them.”

References:
1. NEJM 378;14 April 5, 2018
2. Drs. Talbot and Dean, Boston Globe 8/15/18
3. Consumer Reports On Health, February 2019

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Vol. 154 September 15, 2016 READER BEWARE, Take a Grain of Salt With Media Hype About Medical Advances

September 15, 2016

Hub thumbnail 2015Headlines that tout a new drug or a new procedure which is “much better” than the old one are very common in our media. Some of them are true. Some of them are misleading. Most of them depend on the definition of “better” in the research study or clinical trial. A recent issue of the New England Journal of Medicine reviewed the “changing face of clinical trials” and outlined in detailed, technical language what their readers (physicians and other health professionals) should look for in published studies and clinical trials to confirm that the simplified “positive outcome reported” is significant and relevant. (1)

It inspired me to give similar “heads-ups” to my more general readers so they might be better evaluators of media announcements and commercials about medical advances.

Be skeptical about percentages
“Drug A has 50% less side effects than Drug B” or “Drug A is 50% more effective than Drug B.”
If 2 out 100 patients had a side effect with Drug A and Drug B side effects happened in 4 of 100 patients, that is a 50% reduction of a very low occurrence event, and it is probably not relevant.

“Antibiotics reduced the time out of work (or out of school, or days of fever) by 50%”.
This could mean “time absent” went from 2 days to 1 day, not all that significant considering the cost and potential side effects of antibiotics.

For those of you who want to dig deeper you should ask for the P value of the positive outcome. A statistical P value of 0.05 means that the difference between the two treatments is not enough to say that one was better than the other. The difference is “not significant”. In medical studies the test of a true difference is a P value of less than 0.001; written as P<0.001. That difference is “significant”. Looking at P values is an easy way to avoid the illusionary trap of percentages.

“Dementia Incidence is Decreasing!”
This was the February 2016 “headline”, admittedly in the back pages or side bars, in several newspapers and magazines. It was based on data from the ongoing, well-respected Framingham Heart Study that has been studying the same people since 1975. The article listed declines of 22%, 38%, and 44% each epoch (an epoch is about 15 years) from 1975 to 2010 in 5205 persons over 60 years old.
Looks impressive!
Again the percentages.
The actual incidence went from 2.8 per 100 persons demonstrating dementia to 2.0 per 100. These numbers seem a bit less dramatic to me. To top it all off, the risk reduction was observed in ONLY those who had at least a high school diploma. I’m glad that I am in that population subgroup, but that suggests an issue about the relevance of study results to the general population.

Is the positive outcome of the study clinically relevant?
Tests of some new drugs treating diabetes have shown a much better control of blood sugars, but NO reduction in cardiovascular events and even a HIGHER mortality rate.

Certain cancer tests may be shown to find cancers earlier, but there is no reduction in patient morbidity and mortality. The PAS test for prostate cancer “found” a lot more cases of prostate cancer, but did not result in any reduction of deaths from prostatic cancer. Later studies even showed that the PAS test often resulted in unnecessary further tests and treatment, so the age criteria recommendations for obtaining a PAS were changed in 2012.

Multiple studies of ICU patients have shown “better” physiological or laboratory value resulting from selected treatments, but NO change in length of stay or mortality rates in those patients receiving the new treatment.

Is the study large enough to be reliable?
This can be tricky. The study should involve enough patients to be statistically sound (there’s the old P<0.001 value again), but big numbers are not a guarantee. A recent article on the effectiveness of CPAP (continuous positive airway pressure) treatment for Obstructive Sleep Apnea (OSA) was based on studying close to 2500 patients. Sounds big to me, but look how they got to that number.

15,325 patients were assessed for eligibility in the study.
.        
9481 declined to participate or were excluded for other reasons
leaving 5844 that met the study’s diagnostic criteria
.         2598 were then excluded for having too mild symptoms
leaving 3246 who entered a one-week trial period
.          
529 were then excluded for poor compliance or other reasons
leaving 2717 patients that were randomized into the study
.            
30 were then excluded from the analysis for a variety of reasons
leaving 1346 receiving the new treatment and 1341 receiving standard treatment
.            62 receiving the new treatment discontinued
            85 receiving the standard treatment discontinued.
Resulting in 1284 analyzed for the new treatment and 1256 analyzed for the standard treatment.

Besides suggesting how difficult the logistics of a clinical study can be, a markedly descending number of study participants like this can raise concerns about a selection bias of patients, or as they say, “There’s many a slip twixt the cup and the lip.”

Oh, yeh, the results of the study?
“CPAP treatment significantly (P<0.001 again) reduced snoring and daytime sleepiness, but did not prevent cardiovascular events (P values 0.96 to 0.07)”.


Also there were so many variables in this complex study like “duration of use” (3.3 hrs. a night average) , “degrees of compliance” with protocols, different “severity of symptoms”, etc. that the NEJM felt compelled to publish in the same issue an editorial suggesting caution about the impact of this study on current clinical practice (see comments about clinical relevance above).

Conclusion:
More often than not the new procedure or the new drug is more expensive than the “old” one. That adds another reason to ask your doctor if it is really better than the previous one. Remembering that “if it happens to me it’s 100%”, what is the patient  supposed to do? How can we evaluate this bombardment of new advances?

“Ultimately, physicians at the point of care bear the final responsibility for accurately interpreting clinical trial results and for integrating regulatory and guideline recommendations to make the best treatment decisions for each patient in their care” (1)

References:
1. “The Primary Outcome is Positive – Is That Enough?”, New England Journal of Medicine, Sept. 8, 2016, 375;10 p.371


Vol. 149 June 1, 2016 Jargon Update, Placebo Prices May Count, and Visual Acuity in Kids and Baseball Players

June 1, 2016

Hub thumbnail 2015Jargon Update

Babylag” : the sleep deprivation symptoms experienced by 50% (gender not identified) of new parents; worse than jet lag because they can be cumulative.

“Brobats” : Robots, six times the size of human sperm cells, that move and turn by wriggling their tails; aka MagnetoSperm; may eventually be used to deliver drugs through the bloodstream.

Connectomics” : the study of “connectopathies” like Alzheimer’s, schizophrenia, depression, and autism spectrum disorders; spurred by the increasing use of functional MRIs (fMRI) as a non-invasive brain imaging.

Placebome” (pronounced Pla-SE-bom): the network of 10 genes that predisposes people to respond to a placebo; moving forward on personalized medicine is a long-standing goal of he Human Genome Project.

Placebos believed to be expensive may work better than those believed to be cheaper.

One or two of those 10 genes may be associated with what’s in your wallet.   The Washington Post (1/29/16, Bernstein) “To Your Health” blog reports that investigators “found that the patients performed better on motor skills tests when they believed they were on the expensive drug, an effect that increased when they were given the expensive placebo first.” The Los Angeles Times (1/29/16, Kaplan) “Science Now” blog reports that investigators “also used functional MRI scans to assess the patients’ brain activity and found that the ‘cheap’ placebo prompted more action than the ‘expensive’ one.” The blog adds that “to the researchers, this was a sign that the patients expected less from the placebo they believed cost less, so their brains responded by doing more work.” (Huh ???) There is much more to the placebo story; a story too complex to tell in a single paragraph or understand from a single study..

Outdoor activity for prevention of myopia in children (at least in Chinese children)

The prevalence of myopia (nearsightedness) increases throughout childhood, particularly during and after puberty. Myopia often progresses as children grow older and high levels of myopia are associated with an increased risk of sight-threatening complications later in life (eg, myopic macular degeneration and retinal detachment). In a study published in JAMA; 314, October 2015 , 1913 school children in China were randomized (by school) to an additional daily 40-minute outdoor class or usual activity . The cumulative incidence rate of myopia over three years was lower in the intervention group compared with the control group (30 versus 40 percent). This is the first study to suggest an effective preventative strategy.

Increasing the amount of time children spend outdoors is a simple intervention and could be a strategy to reduce the risk of developing myopia and/or slow its progression. The effect was related to just being outdoors and had nothing to do with sports or activity.This is yet another good reason to reinstitute recess periods in elementary schools. The mechanism of the preventative effect of being outdoors is unclear. Some think that lack of exposure to sunlight for long periods is associated with myopia. Myopia is more common in high-income regions of the world presumably because those people spend less time outdoors.  “Myopia, once believed to be almost totally genetic, is in fact a socially determined disease,” and is increasing in prevalence. (SciAm June 2016, p.80)

Speaking of outdoor eyesight

Wade Boggs, whose number was just retired by the Boston Red Sox, shared “better than normal” visual acuity with fellow Baseball Hall of Famer Ted Williams. “Normal vision” (20/20) is being able to see at 20 feet what most people see at 20 feet. As the letter size increases going up the Snellen chart (designed in 1862) the denominator number increases. If you have 20/100 vision you can see clearly at 20 feet what most others can see at 100 feet. Wade Boggs’ visual acuity during his baseball career was 20/12. He could see the blue dot of the MLB logo on the ball as it rotated toward him! That and several other factors apparently accounted for his superb hitting. (Wade’s favorite game as a child was the early video “Pong” which was one of several hand-eye-coordination games that he played.)

Ted Williams, the other fantastic Red Sox hitter, had 20/15 vision. He could see the stitches on the hurtling baseball. The two had very different batting stances and styles, but were good friends. After several attempts by Ted to “correct” young Wade’s stance and swing they resolved to mostly talk about fishing.

Speaking of video games

PCs are apparently passé to babies. Most are using smartphones or tablets. In a 2013 survey of nearly 1500 U.S. parents 40% of children UNDER 2 years of age used a mobile device, an increase from 10% in 2011. (66% watched TV – no increase since 2011) Most of this was probably due to the rapid increase in smartphones in those families. Smartphone use of educational media for children up to 8 yo. in lower-income families tripled between 2011 and 2013 while PC use decreased. The same study revealed that 28% of parents felt that children’s device use decreased the time they spent with their kids while 12% felt it increased their time with them.

A study of over a thousand 13-17 year olds by the same Common Sense Media organization revealed that in 2012 the  vast majority of teenagers had their own cell phone (82%) including 41% who say they have a “smart” phone, meaning they can use it to “check email, download apps, or go online.”  Cell phone ownership varied by age (74% of 13 to 14-year olds, compared to 87% of 15 to 17-year-olds), and by income (74% of lower-income youth, compared to 84% and 86% of middle- and upper-income youth). There were no significant differences in cell phone ownership by race or by parent education. Surprisingly, the teenagers who were surveyed preferred face-to-face communication (49%) over texting (33%), but other studies have shown that the fear of being “left out” seems to compel the use of social networking via devices.

Read the rest of this entry »


Vol. 135 November 1, 2015 “He, She, or It?”

November 2, 2015

Hub thumbnail 2015

People tend to confuse sexuality and identity, and often want to conflate these things, but being transgender has nothing to do with sexuality.

— Norman Spack, Director Emeritus and Founder of the GeMS Program, Boston Children’s Hospital

Last week one of our five-man book-and-lunch club started our monthly gathering with, “Before we start can you tell me if an infant with unclear genitalia is called transgender?” It quickly became clear during the ensuing conversation that most of us not only knew someone with gender identity issues, but also that we (all over 60 y.o) had blurry, often overlapping, and quite different understandings of gender definitions and terms.  I suspected that we might not be the only ones confused, and thought that researching a blog on the subject might be clarifying for me and others.

What’s the difference between“transsexual”  and “transgender”?
“Transsexual” was coined by a German surgeon in the 1930’s for people (usually males) who wished to have sexual reassignment surgery (SRS) and change from male to female (M2F, MTF). “Transgender” was coined in the 1960’s, was much more about who the person thought they should be rather than about sexual orientation, and was not usually associated with the desire for SRS. In 1979 Christine Jorgensen rejected “transsexual” and insisted on “transgender” (even though he/she underwent SRS). Transgender seems to be the most PC term today, and transsexual, still implying an interest in SRS, is considered to be a subset of transgender. There is a World Professional Association for Transgender Health  as well as a blue/pink/white striped Transgender Pride flag that “will always be correct, no matter which way you fly it.”Screen Shot 2015-11-01 at 5.17.07 PM

A over-simplified, and not always correct, way to remember the differences is:
“Transsexual usually implies sexual orientation, ‘who you go to bed WITH’.
Transgender usually implies gender orientation, “who you go to bed AS?’ ” (1)

An excellent illustration of the complex interplay of these two terms is the Amazon Prime video “Transparent” for which Jeff Tambour won a 2015 Emmy for Lead Actor (a term, by the way, that is now often used for both male and female). In the series of 12 episodes we met several transgender characters, some of whom appeared to have had SRS and hormone therapy and some who have not.

What’s the difference between cross-dressers, drag queens, and transvestites?
Transvestites  are people who like to dress and act like those of the opposite sex. In the 1970‘s “cross dressers” was coined by such people who disliked the implications of fetishism or homosexuality in being called “transvestite”. Cross dressers can be private and have any kind of sexual orientation (J. Edgar Hoover?). Drag queens are theatrical cross dressers who are mostly male homosexuals with great pride in their flamboyant entertainment value.

Is a hermaphrodite the same as an infant with ambiguous genitalia?
Rarely an infant may be born with genitalia that appears to be neither clearly male or female (now called “intersex”). It is important for physicians and family to quickly forge ahead in checking chromosomes, internal anatomy, external physical appearance, parental wishes, and other factors to decide quickly which sex the child shall be raised as. Surgically, it is much easier to create a functional female than a male, but many factors are involved. Even rarer is the hermaphrodite who is born with both male and female genitalia. Unlike lesser species, these human hermaphrodites can not self-impregnate, but can apparently have a future career in adult porn.

In recent years our recognition of and services for gender identity confusion in children has increased. In 2007 Boston Childrens Hospital started a Disorders of Sexual Development and Gender Management Service (GeMS). Since then that multi-disciplinary team of 12 professionals have evaluated and treated over 160 pre-pubertal teen agers for gender identity confusion; 75% of whom lived within 150 miles of Boston. (1)  GeMS considers gender identity confusion as potentially life-threatening because of the higher than expected suicide rate among those adolescents not treated. Evaluations are initiated in “gender non-conforming” children  as soon as 10 or 11 years of age. Puberty is delayed by hormonal therapy, and later the child’s gender appearance can be changed to match the child’s mental gender identity through hormones and surgery.

Even a cursory review of these terms, what they used to mean and what they mean today, suggests many PC/sensitivity potholes dotting the road of their practical use. One Boston suburb middle school teacher started the first day of school this fall with a request to her class to indicate “by which pronoun each wished to be called”.  In addition to the grammatically traditional gender neutral terms like “it”, “one”, and “they”, invented gender neutral pronouns exist and include “zhe” and “zher” and “zhem”. (2000). The medical term “gender identity disorder”, disliked by many because it implies a disease condition, is being replaced with “gender dysphoria”.

References: 1. Norman Spack, MD TED talk


Vol. 109 September 1, 2014 Today’s Buzzword is “HARM REDUCTION”

September 1, 2014

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Harm reduction is a policy of encouraging and supporting an individual
to take incremental actions to reduce the potential harm of high-risk behaviors
which a person can’t or won’t stop.

 

 

The American Heart Association (AHA) last week reiterated its concern about the negative health effects of e-cigarettes (electronic cigarettes that deliver vaporized nicotine only), but cautiously noted that it considered e-cigarettes as an acceptable “last resort” for those who can’t stop smoking after using nicotine patches and other medications . This is the most recent example of a “harm reduction” strategy.

Aruni Bhatnagar, Professor of Medicine at the University of Louisville in Kentucky and the lead author of the AHA’s statement, wrote: “If someone refuses to quit, we’re not opposed to them switching from conventional to e-cigarettes…Don’t use them indefinitely. Set a quit date for quitting conventional, e-cigarettes and everything else.”

There is scant evidence that using e-cigarettes help people to stop smoking, but e-cigarettes do not deliver tars and other carcinogenic chemicals to the lungs. Hence, smoking an e-cigarette can reduce harm. The American Cancer Society jury is still out.

The “harm reduction” strategy, identified in the 1980‘s, began to really be promoted as an alternative to abstinence around 2000. It was initially focussed on psychoactive drug abuse, but was later expanded to include alcohol and all substance abuse. Its strategies are also incorporated into adolescent sex education, HIV prevention, and homeless health programs. Tactics include school-based distribution of condoms, community needle exchange programs, methadone maintenance, housing without sobriety for the homeless, and, in some countries, heroin dispensing clinics and clean injection facilities.

The DARE (Drug Abuse Resistance Education), or “just say no”, program was that was based on a zero tolerance principle, and it was not effective in reducing drug abuse.

Critics of the harm reduction strategy claim that such an approach can “normalize” the risky behavior that society wants to change. They think harm reduction policy can raise an expectation that such risky behavior is acceptable and even “expected”, particularly for adolescents.

Proponents of harm reduction quote extensive literature that shows that it is “inexpensive, evidence-based, and effective” . The designated driver awareness policy is an excellent example of a successful harm reduction tactic. It is one factor in the reduction of teen age car accidents and deaths. A few years ago the homeless health center with which I am associated stopped requiring alcohol abstinence, sobriety, on the part of a client prior to being placed in transitional housing. Its rates for successful stable housing, subsequent employment, and duration of sobriety increased among those clients.

 MYTH
Harm reduction is opposed to abstinence and therefore conflicts with traditional substance abuse treatment.
Harm reduction encourages drug use.
Harm reduction permits harmful behavior and maintains an “anything goes” attitude.

FACT
Harm reduction is not at odds with abstinence; instead, it includes it as one possible goal across a continuum of possibilities.
Harm reduction is neither for nor against drug use. It does not seek to stop drug use, unless individuals make that their goal.
Harm reduction focuses on supporting people’s efforts to reduce the harms created by drug use or other risky behaviors.
Harm reduction neither condones nor condemns any behavior. Instead, it evaluates the consequences of behaviors and tries to reduce the harms that those behaviors        pose for individuals, families and communities.

Despite all the scientific evidence, it is sometimes hard to fully embrace the concept of “harm reduction” emotionally. I sometimes feel that small moral tug of “whatever happened to right and wrong”. After all, the Ten Commandments say “Thou shall not commit adultery”; not “Try very hard not to commit adultery and, at least, don’t cause an unwanted pregnancy”. But, many studies  show that harm reduction strategies can benefit the individual, the family, and the community. We will be hearing a lot more about it, so we should get used to it.


Vol. 106 February 1, 2014 Do You Know Where Your Medical Data Is?

February 1, 2014

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The price of freedom is eternal vigilance.

                                                                                  –Thomas Jefferson…or Thomas Paine, Abraham Lincoln,
Dr. Thomas Sowell,  and John Philpot Curran.

The federal government is giving money to doctors and hospitals to computerize their medical records ( “EMR” = electronic medical records). To get paid the medical providers have to show “meaningful use” of EMR by, among other things, writing and sending a certain percentage of their prescriptions to pharmacies by computer , by creating interactive websites (“Patient Portals”) to improve patient access to their medical information , and by entering much more of their patient’s personal data into their computers. The improved coordination of care, collaboration of medical providers, and reduced costs of care through the meaningful use of EMR by Accountable Care Organizations (ACO) is a cherished hope of Obamacare (ACA) supporters.

Recently, another arm of the federal government (NSA = National Security Agency) has been shown to be collecting, and maybe analyzing, huge reams of personal data from our telephones, social network sites, and credit card companies. Facebook, Google, and Verizon have all been put on the defensive and are scrambling to show that they weren’t helping, at least “knowingly helping”, the government do this. Wired magazine recently reviewed how this conflict between the government’s promises of security and the internet giants’ promises of privacy is eroding the public trust in both.

So at a time that our government is aggressively incentivizing medical providers to put more and more patients’ personal data into cyberspace, the public’s faith and trust that such data will be safe and not be misused is weakening.

What’s the worry? How bad could it get? Since a picture is worth a thousand words, I direct you to this 3 minute video on how to order a pizza in 2015. Whether you find it believable or not,  or whether you think that 2025 is a more realistic date, you may rest assured that the NSA will know that you clicked on and viewed it.

Reference:
1. “How the NSA Almost Killed the Internet”, Wired, January 2014
2. http://www.youtube.com/watch?v=Q2DY6jWT2a4  “How to Order a Pizza in 2015”


Vol. 88 April 15, 2013 How Do You Feed a Baby in a Patient-Centered World?

April 14, 2013

hub “Patient-centered medicine” is one of the new buzz words in health care reform. It is second only to “medical home”; the label for the multi-disciplinary team incentivized by governmental reimbursement to use electronic technology to provide the coordinated, individualized primary care that the family doctor used to provide by himself (yes, it was usually a “he” back then).

“Patient-centered medicine” champions joint decision-making between physician and patient. Most illustrative examples of patient-centered medicine given are high cost, high drama events like alternative cancer treatments, cardiac interventions, and even DNR or “keep plugging” choices. The central tenet is that the patient knows best his or her needs, desires, and feelings and medical decisions should consider those as paramount.

  • Pediatricians recommend breast feeding exclusively for at least 6 months, ideally for 12 months. (1)
  • Nearly half of mothers started solids at age 4 months to 6 months so the infant would sleep through the night and/or they would spend less on expensive formula. (2)

How might “patient-centered medicine” sound when it comes to “feeding baby”?
We pick up the conversation near the end of a routine well-baby visit:

PHYSICIAN SITS CLICKING ON A LAPTOP BACK TO BACK WITH THE PARENT WHO IS DIAPERING AND DRESSING HER INFANT ON THE EXAM TABLE.

PHYSICIAN: Leonard is 4 months old so he’s due for his second round of immunizations today. Before we give those, do you have any other questions?

PARENT: He’s not sleeping through the night. I want to start some solid food. Is there any food I should avoid?

PHYSICIAN: Are you still breast feeding?

PARENT: Well…sort of. I went back to work when he was 2 1/2 months old. He gets formula at daycare, and I breast feed him at bedtime.

PHYSICIAN SWIVELS AROUND ON STOOL TO FACE MOTHER.

PHYSICIAN: As I am sure you know, we recommend breast feeding for the first year.

PARENT: R-i-g-ht… well I had to go back to work. Doesn’t breast feeding make him plumper and more likely to be fat as he gets older?

PHYSICIAN: Breast feed babies sometimes look plumper than formula babies, but we think breast feeding actually protects them from adult obesity.

PARENT: Really? I heard on Fox News last month that breast feeding didn’t actually do that. (3)

PHYSICIAN: Yes, that was a recent single study done in Europe. The NY Times and Time magazine also carried it. (4)

PARENT: Emma certainly isn’t fat. I remember I breast fed her for close to a year because I wasn’t working at the time. You told me not to start her on solids until after 6 months.

PHYSICIAN: Just a second. Let me look up Emma’s record. …

PHYSICIAN SWIVELS AROUND ON STOOL TO TYPE ON THE LAPTOP.

PHYSICIAN: What’s her birthdate?…our new computerized medical record keeps records only as individual patients, not families. I can’t find Emma’s record.

PARENT She’s eleven now, from my first marriage, her last name is different.

PHYSICIAN: Ah, yes, here she is. …Looks like we were concerned about your family’s history of food allergies, so we cautioned you about not starting foods until she was over 6 months old.

PARENT: Emma is doing great without any allergies. I’d like to start solids on Leonard because he is so fussy at night and seems hungry when he wakes up.

PHYSICIAN: A new recommendation is to start potentially allergic foods earlier rather than later . Small portions of those foods started as early as 2 months of age may actually reduce future allergic reactions. (5)

BEEP…BEEP…BEEP

PARENT: What’s that?

PHYSICIAN SWIVELS AGAIN TO FACE PARENT.

PHYSICIAN: Oh, that’s just my laptop letting me know that this visit is reaching 95% of the usual duration of a well baby visit.

PARENT: So, I should breast feed Leonard for a whole year, but could have started solid foods two months ago? Most of my friends swear that giving food makes their babies sleep longer at night.

PHYSICIAN: Exclusive breast feeding for 6 months has lots of advantages for the infant. There is no evidence that giving solid foods makes the infant sleep longer at night, but there is probably no harm in starting him on cereal now.

PARENT: Any particular kind of cereal?

PHYSICIAN: A 1994 Swedish study showed that introducing wheat before 6 months of age caused a big spike in gluten allergies and celiac disease, but a recent one there showed that giving wheat to breast fed babies at 4 months actually decreased the later occurrence of celiac disease and gluten allergy.

PARENT: So, wheat cereal could be either good or bad at his age? This is very confusing.

PHYSICIAN: Science can be confusing. It often changes its mind as new data is gathered.

PARENT: When I switch to all formula is there any one that is best? Should I start with soy? When I switch to milk, should it be whole milk? … or 2%? … or 1%? What about peanuts?

BAHUGGA!…BAHUGGA!…BAHUGGA!

PARENT: What’s THAT?!

PHYSICIAN: That’s a notice for me that the average duration of a well baby visit has been exceeded by 20%. I really must go on to the next patient. Please go to our practice website where we answer those questions and provide several nutritional advice sites for further information.
Your baby is doing fine.  We’ll see you again in two months.

PHYSICIAN EXITS THE EXAM ROOM AND PARENT STICKS HER HEAD OUT INTO THE HALLWAY TO DIRECT ONE MORE QUESTION TO HER RETREATING BACK.

PARENT: Oh, doctor….do I need a password for the website?

References:
1. American Academy of Pediatrics, AAP.org
2. Journal of Pediatrics, March 30, 2013
3. Fox News March 13, 2013 reporting on JAMA article March 12, 2013
4. NY Times March 14, 2013
5. American Academy of Allergy, Asthma, & Immunology, January 2013


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