Vol. 143 March 1, 2016 What’s In A Name?

March 1, 2016

Hub thumbnail 2015

 

Few Americans recognize the contributions of IMGs (international medical graduates), or more broadly all foreign-born physicians, to U.S. healthcare.

 

Physicians born anytime in the 1930s – 1950s are more likely to have the surname Smith, but starting in the 1960s the U.S. saw an uptick in diversity, and in both the 1970s and 1980s, Patel topped this list as the most common last name among all physicians. Patel is now officially the last name most frequently preceded by “Dr.”

Rank 1930‑39 1940‑49 1950‑59 1960‑69 1970‑79 1980‑89
1 Smith Smith Smith Lee Patel Patel
2 Lee Lee Johnson Smith Lee Shah
3 Miller Miller Miller Johnson Kim Lee
4 Johnson Johnson Brown Patel Smith Smith
5 Kim Patel Williams Kim Nguyen Nguyen

This trend is likely to continue. Since the 1980s, the number of Asian American med school graduates has increased from almost none to making up approximately a fifth of all graduates . According to the 2014 census, foreign-born doctors now make up approximately 25 percent of all physicians practicing in the U.S.

Current medical student enrollment statistics reflect a similar mix.
Of 86,746 medical students in U.S. medical schools in 2015:

46,108 were men       (53%)
40,634 were women  (47%)
All: 54% white
.      20% Asian
.      8% multiple ethnicity
.      6% African-American/Black
      5% Hispanic
Only 2% of U.S medical students are “Non-U.S. Citizen or Non-Permanent Resident”

These figures confirm that most of the 25% practicing physicians that are “foreign-born” have come to the U.S. after non-U.S. medical school graduation for residency training and have stayed to practice. Foreign born physicians require a J-1 visa from the U.S. government to participate in our residency training programs. In 2011 65% of physicians with a J1 visa (foreign-born) were practicing primary care (internal medicine, pediatrics, and family medicine) compared to 28% of U.S. medical graduates.

The AMA has estimated that once the Obamacare “access to care” elements are fully implemented and as our older age demographic increases we will be about 90,000 physicians short of those needed to maintain optimal physician/population ratios. Much of that “physician shortage” will be in primary care. Interestingly the two most popular specialities for IMGs are Anesthesia and Psychiatry. One specialty does not require a lot of talking to patients. They are asleep most of the time. The other requires nothing but talking! Of course, the highest percentage of IMGs (20%) are from English-speaking India.


Vol. 130 August 1, 2015 Medical Diagnosing Websites

July 31, 2015

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Have you ever gone on the internet
to seek a diagnosis for your symptoms?

 

Fifty million people did so on iTriage last year. Healthline.com

gets 6.5 million visits a month. WebMD’s “symptom tracker” gets 4 million visits a month.

Are they any good at making a diagnosis for you? Do they give good triage advice?

A recent study by Harvard Medical School faculty says “not too bad”, BUT “seeker beware”. (1)
There is significant accuracy variability between the websites. The authors identified 143 websites offering diagnoses in response to symptoms entered by the user. They submitted 45 standard sets of symptoms from “patients looking for a diagnosis” (entered by non-professionals) to each of the 43 websites directed at general medicine/primary care “symptom tracking”. The “patient’s” symptoms entered were in one of three categories (unlabeled and unknown to the website): 1) symptoms require urgent medical evaluation, 2) symptoms should be evaluated by a medical professional by appointment, and 3) self-care without medical evaluation is all that is recommended (the classic medical triage decision tree).

On average, half of the websites listed the correct diagnosis first. 58% listed the correct diagnosis in the top three. However, the range of correct number of #1 diagnoses varied from 5% to 50% between websites. Not unlike a medical professional’s diagnostic decision-making, the software on these websites correctly identified common diseases more frequently than uncommon ones. (The old medical student saw is true: “When you hear hoofbeats think of horses, not zebras.”)

A more comforting result of the study was that 80% of the symptoms needing urgent evaluation and care were identified correctly. The flip side was that two-thirds of the patients that could have been served well by self-care alone were instructed to seek a medical evaluation. As one web-designer physician remarked, “We try to neither unduly alarm nor inappropriately reassurance users.” The software behind the triage advice on these websites (“should I see a doctor or not”) is highly risk-adverse in suggesting so many medical evaluations for minor symptoms. This may not prove so useful to people using the websites to avoid a visit and the payment of a deductible.

The triage accuracy was comparable to that found in studies of nurse practitioner telephone triage which ran about 60-70% compliant with physician in-person recommendations. Of course, the symptom tracking websites do lack perceptions of patient anxiety, tone of voice, urgency of speech, and other subtle, but important clues (especially to pediatricians), of the nature of the situation. Perhaps as a practicing pediatrician I put too much stock in those kind of clues in assessing a patient by telephone, but I suspect that they do improve the person-to-person triage decision-making. At least, the symptom tracking websites were better than just entering symptoms into a Google.

Which symptom tracking website was the best? DocResponse.com got the highest score, but offers no pediatric content. Healthychildren.com by the American Academy of Pediatrics is the site to go to for that. MEDoctor had the worst results. e-Patient Dave, a respected non-medical patient care advocate, recommends trying 2 or 3 websites with the same symptoms.

The traffic to these kind of websites and their popularity with patients may spawn a new word in the lexicon of medical practice; “cyberchondriac”

Reference:
1. BMJ 2015:351, July 8, 2015


Vol. 118 January 15, 2015 It Ain’t Just Vaccines That People Decline

January 15, 2015

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Half of U.S. patients don’t take their medicines as prescribed by their physicians.(1,2)

We use to call such patients “non-compliant.” As “patient-centered care” became the mantra for contemporary medicine that “passive, judgmental” term of “non-compliant” was banished and replaced by “non-adherent”, a presumably less derogatory term implying a partnership of patient and physician. (3)

A cardiologist, struck by the number of her patients that did not comply with adhere to their heart medicine prescriptions, asked 20 of them who had survived a heart attack why they didn’t adhere to medications that had proven benefits of secondary prevention of a next event, an event that could cause death. (4) Their comments (listed first below)  were surprisingly similar to feelings expressed to me by parents who decline immunizations for their children (typed in bold italics ).

1. Risk Aversion
“Why take medicine that could wreak havoc on your body.”
In people with negative emotional reactions even a small risk of side-effects seemed to overpower any positive feeling about the proven benefits of a drug. Their perception of risk is greater than their perception of benefit. They are “far more sensitive to possibility than to probability”.(5)
Despite numerous studies showing that there is no probability of an association between measles vaccination and childhood autism some parents still feel that there is always the possibility. Arguing relative probabilities of vaccine side effects versus disease effects with them is not productive.

2.Naturalism
“Medications are chemicals and should not be in your body on a regular basis”.
Vitamins, herbs, and other health supplements of all kinds are often turned to because they are not “chemicals”.
“I don’t want to have any foreign proteins injected into my child”. Natural immunity, of course, depends on our body recognizing and reacting to foreign proteins so that symptoms resolve and our next exposure to the same foreign protein doesn’t make us sick again. “It is the additive proteins that we don’t want” is often the next statement from the parents. Pointing out that there are 315 “foreign proteins” in today’s vaccines  rather than the thousand’s in the vaccines before the 90’s does not reassure them.

3.Denial
“Men don’t like taking medicine because to do so they are admitting that they are not strong. Most people like to think that they are strong and mighty. …Their very sense of well-being after surviving a heart attack and quickly resuming healthy lives may convince them that medications are not necessary.”
Some parents feel that their unimmunized children are safe from disease because the rest of the children are immunized, the “herd immunity protection” argument. Pointing out that herd immunity is effective only when the community reaches the currently unachievable high percentage of immunity (a 94% threshold in measles and whopping cough) has no effect. You would think that the possibility of measles in their unimmunized child in a partially immunized community would override the small probability of side effects from the vaccine. It doesn’t with some parents.

4. Avoidance of Sick Identity
“Has having a heart attack become too easy?” People can spend more time being sick from flu than having a therapeutic cardiac cath within 90 minutes of arriving at the ER and walking out of the hospital 24 hours later.
Has the absence of children dying or being crippled by measles, polio, diphtheria, or croup dulled our ability to imagine our children in such a sick state? Sporadic epidemics of whooping-cough and croup in certain states have been successful in raising immunization rates a bit. If there were an Ebola vaccine, I wonder how the vaccination  non- adherent parents would have juggled that possibility/probability calculation for their children.

5. Difficulty Visualizing Benefits
“The benefits of cardiac medications may be imperceptible and the absence of perceived benefit is a well-documented reason for non-adherence”. Adherence to anti-platelet medications (“blood thinners”) is higher than other cardiac meds perhaps because the patient can easily visualize the “thinned” blood flowing smoothly through an unclogged pipe. That the medication is actually “doing something” is reaffirmed by the prolonged bleeding from a razor nick.
Maybe we pediatricians should develop an app and FitBit that could non-invasively measure antibody levels and send an alert to the child (via his/her own smart phone, of course): “Your antibodies against [insert tetanus, diphtheria, or whatever disease name here] have been declining for years and are now at a level that no longer protects you. Go immediately to your nearest [insert sponsoring drug/ convenience/department store name here] and get vaccinated.”

6. Avoiding Dependency
“Relying on cardiac medications is another form of addiction. I brought on this heart attack by my life style and it is my responsibility to avoid another by changing my life style.” Taking medications may be viewed as a loss of control, as “following orders” , as “being told what to do”.
This rejection of authority rings true in my experience with some parents who decline immunization for their children. It also may explain why pockets of unimmunized children who are not in poor families are sometimes clustered within tree-hugging, organic food eating, aging-hippy communities. Frustrating as this rejection of authority is to the physician, repeatedly battering the head and shoulders of these parents with all the scientific facts proving that vaccinating their child is safer than having them contract the disease is counter-productive.

The discussion with parents who decline immunizations for their children is hardly ever a rational one. Some beliefs and feelings seem impervious to facts. Certainly a parent’s personal knowledge of some child, usually a cousin or a nephew/niece, who had a vaccination and then had a seizure or who “has never been the same since” is a real conversation stopper. That personal experience can generate such deep feelings that I no longer even try to talk them out of that hole. We don’t experience that same depth of feelings if an older adult we know survives a heart attack only to die of a second one months or years later. We often feel, not knowing all the details, that “C’est la vie”.

References:
1. NEJM 2005;353:487-97 Adherence to Medication
2. J Gen Intern Med 2008;23:115-21 Secondary Prevention After MI
3. Ann Pharmacotherapy 2004;38:161-2 Adherence or Compliance?
4. NEJM 2014;372;2:184-7 Beyond Belief
5. Psych Bull 2001;127:267-86 Risk as Feelings


Vol.111 October 1, 2014 ; How Does Your Doctor Rate?

October 1, 2014

hubI think this is actually a trick question. I know very few people who have only one doctor. They have several, spanning different specialities.

 “Doctor Rating” sems to be  a thriving business. Consumer Reports Magazine (October 2014) lists six websites that present some sort of doctor ratings that go beyond the basic info provided by the AMA, Medicare, and state Boards of Registration in Medicine and state medical societies.

I examined these websites to see what I could learn how each one rated some primary care doctors that I know in my own vicinity. What I found was not particularly helpful nor illuminating for a variety of reasons.

The websites usually used two sets of criteria for ratings, one for the office (“ease of making appointment, friendly reception, etc.”) and one for the physician (“bedside manner, waiting time, clarity of discussion”,etc.”). Most used a rating of 1-5 stars, but one used “A-F”. Physician groups were rated, but to learn about individual doctors within the groups I had to scroll through individual patient text comments.  All of the websites had errors such as listing physicians who were dead, retired, back in India, or now in New Zealand.

I searched under “internists” and often also got dentists, obstetricians, cardiologists, oncologists, and even “lice doctors”. There seemed to be no rhyme nor reason to the sequence in which doctors were listed, except for the one website that highlighted the “Top 10” (apparently “patient satisfaction” was the sole criteria). Some websites forced me to scroll through all the names alphabetically to find the one name I was looking for. Some allowed me to search by individual name. Despite entering my zip code as a clue I got lists of doctors from many miles away. Some websites listed nurse-practitioners (NP) in the list which is not bad, might even be helpful, but it was not always clear with which physician(s) the NP was affiliated.

In the instances that I was able to find physicians about whom I had my own rating opinion, I did find that the website ratings generally matched my own bias. In the few instances that I could find the same physicians on different websites, the website ratings agreed.

Here are comments on my experience with specific websites:

Angieslist.com    “A to F”    Access to doctors’ rating for a year costs you $20.($16 if you use PayPal)
Gives number of reviews used to decide the rating (usually single digits); Have to click and scroll individual patient comments to identify individual physician rating in a group; three“A” reviews plus one “F” review created a “B” rating (4 reviews).

Healthgrades.com      1-5 Stars   Free Listed
177 internists near me, but listed only alphabetically; the first dozen or so listed would fit my “marginal” category; gives number of reviews used to decide the rating, but no patient comments/reviews presented; also included cardiologists and ophthalmologists.

Vitals.com    “Where doctors are examined.” 1-4 Stars   Free
136 internists near me, but the highest number of dead, moved, or wrong specialty doctors; had search “filters” to help me narrow my list, and the “patients’ choice” was the most helpful; you can choose a video that presents the ratings in a pleasing, non-revealing, fourth-grade-educational-level cartoon.

RateMDs.com     1-5 Stars     Free
Can search by name or “find a doctor by locale”; lists a “top 10” presumably based on patient satisfaction, but my doctor was NOT listed even though he is “the BEST doctor in the world” because no patients had submitted reviews.

Yelp.com   1-5 Stars   Free
The worst mix of wrong specialities and very few physicians listed; I suspect that doctors have to enter their own offices to this website or even pay for a listing, but I am not certain.

CastleConnolly.com   “Lists America’s Top Doctors”  An annual List and Book
Doctors are nominated, reviewed, and screened by a professional staff for this list founded by two men (neither one a physician) on the Board of Trustees of NYU Medical School; list is heavily weighted to academics in the NY metropolitan area.

Whosmydoctor.com    A work in progress; “not yet ready for prime time”
Leana Wen, MD, Rhodes Scholar, Director of patient-centered research at George Washington University, and a recent TEDMED presenter surveyed patients about what they wanted to know about their doctors. Almost everyone wanted to know that their doctors were competent, certified, and free to make evidenced-based medical decisions uninfluenced by whom they were paid. No surprise there. BUT, she also found that patients wanted to know something about the doctor’s values; what the doctors held dear to their heart!

“One after another, our respondents told us that the doctor-patient relationship is a very intimate one, that to show their doctors their bodies and share their deepest secrets, they want to first understand their doctor’s values.”

Dr. Wen set up a website “Who is My Doctor?” in which doctors could voluntarily state their feelings about reproductive medicine, alternative medicine, and end-of-life-decisions. This information, obviously beyond competency and source of compensation information, would be accessible to all patients and potential patients in an effort toward “total transparency”. The website and Dr. Wen apparently ran into a hailstorm of resistance from some physicians who did not believe that “total transparency” was a good thing. The website is currently just collecting signatures of those who support the concept, 387 to date.

Bottom line:
Doctor rating lists are not very helpful if you are blindly doctor-shopping in your area. If you do the usual thing and get some names of “good docs” from your friends and neighbors, then the rating websites could help you check out the opinions of other patients. None of these websites are as illuminating nor as complete as Trip Advisor…yet.


Vol. 104 January 1, 2014 Hubslist’s Blogs of 2013

January 1, 2014

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“Happiness is Not a Warm Gun” – Jan 1, 2013
In half of my lifetime our culture has moved from arguing that sometimes it was “better to not wear a seat belt in case there was a car fire” to having my grandchildren remind me that I shouldn’t start the car until MY seat belt is buckled. No ONE law accomplished that, and it happened despite critics and opposition from big time lobbyists. Why can’t we do the same for gun control?

Ten Ways To Improve Your Health – Jan 15, 2013
 This list, “backed by scientific research”, was complied by AARP.
1.  Throw a Party – Social connections help you live longer.
2.  Adopt a Pet – Exercise it (and you) and count it as another social connection.
3.  Choose Dark Chocolate – An ounce a day keeps the doctor away.
4.  Savor Your Coffee –  Three cups a day keeps Alzheimer’s away.
5. Have a glass of wine or beer – “Guinness is Good For You” One glass a day for women, two for men!
6. Have Sex – There is nothing bad about releasing endorphins. It also counts as aerobic exercise.
7. Listen to Your Favorite Music – A song a day keeps the heart pumping away.
8. Take a Nap –  A nap a day keeps the brain hoarder at bay.
9. Go Outdoors – Go look at the greens, don’t just eat them.
10. Use Soap. regular soap – Antibacterial soaps with triclosan aren’t worth the cost and may not be safe.

The MYTH of Antioxidants – Feb. 1, 2013
A 2007 systematic review of 68 clinical trials concluded that antioxidants do not reduce the risk of death. Certain antioxidants were linked to a 5%  INCREASED risk of death. The American Heart Association and the American Diabetes Association now advise “that people should not take antioxidant supplements except to treat a diagnosed vitamin deficiency”. “The literature is providing growing evidence that these supplements – in particular at high doses –  do not necessarily have the beneficial effects that they have been thought to…We’ve become acutely aware of potential downsides.”

The ATF has no ammunition – Feb. 15, 2013
The Tiahrt Amendment, passed by Congress in 2006, permits gun dealers to destroy gun registration applications within 24 hours of completion so as “to avoid any inadvertent errors from being promulgated” . It placed these prohibitions on the ATF;  the federal agency overseeing firearms

prohibited from establishing a registry of gun owners (imagine no one keeping a registry of car owners)
prohibited from requiring gun dealers to maintain inventories of their wares
prohibited from inspecting any gun dealer’s records more than once a year
prohibited from revealing firearms trace data to anyone other than law enforcement personnel (firearm tracing is done for  firearms used in crimes. One study showed that 57% of guns used in crimes in one state were traced to only 1% of gun dealers.)
prohibited from requiring gun dealers to respond to police inquiries.

 So we may not need any more laws or regulations for gun safety. We could just repeal the one “Tiahrt Amendment”, and let the ATF begin to do its job.

Take a Pill – March 1, 2013
“Something like a third of consumers who’ve seen a drug ad have talked to their doctor about it,” says Julie Donohue, a professor of public health at the University of Pittsburgh who is considered a leading expert on this subject.”About two-thirds of those have asked for a prescription. And the majority of people who ask for a prescription have that request honored.”  Our mantra continues:
“Hey, Doc,
Forget the Mediterranean Diet.
I’m an American.
Give me a pill.”

The New Pope – March 15, 2013
The medical question I have not been able to answer despite my extensive, exhaustive research (at least an hour on Google) is:  Which Pope had the ulnar nerve palsy? The classic hand gesture of the “Papal Blessing” or “Papal Benediction”, despite erudite analysis by reverent writers on the religious symbolism of his hand and fingers, is, in fact, the result of a nerve palsy of the hand. Even the Vatican tourist guides know this.popesign1The Italian bishops were surprised that the Bishop of Milan, Angelo Scola, was not elected, and much to their embarrassment they prematurely released a report that he had been. I, too, was disappointed that Angelo Scola did not get elected. We all could have called him Pope Scola.

Pope Francis Bails Out Obamacare – April 1, 2013
In a solemn Easter Mass Pope Francis dramatically offered the help of the Roman Catholic Church in funding universal health care in the U.S. He noted that because the U.S. is the only civilized Western country without universal health care and is currently having financial problems, it is the Christian thing to do. “Since neither disease nor money is restricted by national boundaries, it makes good sense to protect the rest of the world from the health problems of  the beleaguered U.S. ” The Pope’s plan was immediately dubbed, “Francincare” (pronounced  as “Frankincare” with the Italian hard “c”). At the end of the press conference Pope Francis returned briefly, showed the persistent Papal nerve palsy to the gathering, and closed with a benediction in Italian: “Felice Aprile Ingannare Giorno”, in Spanish: “Felize Abril Enganar Dia”, and finally in English: Happy April Fools Day”.

Patient Centered Medicine – April 15, 2013
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 more 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.

Lessons Learned from the Development of Polio Vaccines – May 1, 2013
1. Even in science, what you know is important, but WHO you know can be also.
2. Yesterdays “field trial” is today’s mass immunization campaign, and NOBODY tests drugs or vaccines, whether from mice brains or monkey kidneys, on themselves and their family members anymore!
3. The history of testing vaccines and drugs on impaired or incarcerated populations reminds us again of the necessity for “informed consent”.
4. As more academic institutions seek joint contracts with big pharma to replace reduced NIH support of research (MGH and Sanofi, AztraZenenca, etc.) accusations of being a “commercial scientist” seem moot.
5. Some immigrants can be very smart, focussed, and hard-working, and they can contribute immensely to our country’s health and wealth.
6. Science keeps gathering data and testing hypotheses, so we should not be surprised when its recommendations change.

Medical Marijuana – May 15, 2013
1. Marijuana use before the age of 20 does have structural and functional effects on brain development, primarily but not limited to the frontal lobe. (“The frontal lobe, responsible for impulse control, is the last to develop and the first to go.”)
2. After the age of 20 there is little current evidence that MJ causes any permanent effect on brain function or structure.
3. There are  currently no predictors that will identify an occasional user of MJ as one who will become dependent or addicted to MJ (daily use), but the earlier one starts using marijuana (13 yo.) the more likely brain function will be effected.
4. Despite the “trustworthy karma” of medical marijuana, marijuana prescriptions will result in the dispensing of varied, complex, and inconsistent products.
5.Access to marijuana by middle and high school students in 2013 is now so easy according to both students and researchers that medical marijuana dispensaries will provide little increased access to adolescents.

The three drugs of adolescent choice today, tobacco, alcohol, and marijuana, do share a common denominator in that those who use one of the three drugs by age 13, will use one or more of the others before 18 yr. There is NO evidence that one is the “gateway” to another. In fact, one researcher remarked that the concept of a gateway is more of a myth than a reality. He called development of addiction to one or the other substance as a “shared vulnerability”.

Sunscreen SPF Ratings Escalation – June 1, 2013
This year Consumer Reports states that the according to their tests the maximum effective SPF is now 40. Paying for anything above that is wasted money. Two years ago Consumer Reports tests showed that any sunscreen with a SPF (Sun Protection Factor) over 30 gave no more protection than a 30. They also recommended that year-old sunscreen might have lost some of its effectiveness, so new sunscreen should be bought each year. New FDA regulations require the sunscreen to be labeled with a three-year expiration date.

What Massachusetts Docs Think About Medical Marijuana – June 15, 2013  Common threads in the  118 comments posted were:
1. Does marijuana even belong in the purview of physicians? “Just legalize it and let patients decide whether to use it or not”
2. Most physicians who supported its medical use would do so “in certain circumstances”; implying strongly that physician control over use was assumed by supporters.
3. All camps called for more research to move toward a stronger basis of evidence.

Do You Have Obesity or Are You Just Fat?- July 1, 2013
The House of Delegates of the AMA just voted to designate obesity as a disease. This means that you will no longer “be fat”. You will “have obesity” like you “have diabetes”.  The AMA Scientific Council recommended to retain obesity as “a condition”. A spirited debate about the consequences has begun. I suspect that much of the controversy  is about money. Medicalizing a societal condition will cause more money to be spent on surgery and drugs.  “Insurers will pay more.” The upside of that could be more provider reimbursement for prevention and life style counseling by primary care providers, but surgery and big pharma are usually first in line. Two new anti-obesity drugs (Belvig and Qsymia) came on the market this past year. More than one-third of Americans will instantly be labeled as “ill” and therefore eligible for more medical services.

Sunscreens Are Poisonous? – July 15, 2013
The culprit is oxybenzone  and other similar chemicals in chemical sunscreens first described as “endocrine disruptors”, a code word for “estrogen effect” which directly connects it emotionally to breast cancer, particularly by Dr. Oz.   Oxybenzone is such a common ingredient in skin products that a CDC survey of Americans in 2003 detected it in 97% of urine samples. The link to breast cancer in humans has not been proven. One reassuring fact is that hormones, like all chemicals and unlike radiation, have to reach a certain blood or tissue level to have any significant effect.  An average woman would have to apply 1 and 1/2 quarts of sunscreen to 25% of her body (arms, legs, and face) each year for 277 years to attain the levels of oxybenzone that had uterine effects in lab rats!

Too Much Sun in Vermont?! – August 1  , 2013
I am in a hammock in Vermont reading, much to my surprise, that Vermont, the land of a severely short summer, has one of the highest melanoma rates in the country.  About 29 people per 100,000 in Vermont get diagnosed with melanoma as compared to the national average of 19 per 100,000. Bennington County has the HIGHEST rate of melanoma of any county in the nation, 179% above the national average!

Somezhiemer’s – Sept. 1, 2013
News releases and internet blogs this week are full of buzz about a protein that apparently is related to the memory loss of aging; something I call Somezhiemer’s as opposed to Allzhiemer’s (sic).  In this Columbia University School of Medicine study a deficiency of the protein RbAp48 in a specific part of the brain in both older mice and 8 older humans (both postmortem) was correlated with memory loss ; at least the ability of the mice to remember a water maze pathway.
The good news is that one specific biological cause of memory loss has been discovered, as contrasted with speculation about aluminum, cooper, mercury, zinc, and other environmental agents.The bad news is that us older people will probably not, in our lifetime, be able to take a “RbAp48 pill” each morning, so we don’t misplace our car keys, glasses or …. forget to write an August 15 blog.

Fear of Fever – Sept. 15, 2013
Many parents think that a temperature over 98.6 F is a fever. Most pediatricians consider a temperature of 101 F or higher as a fever, except in infants under 3 months where we pay attention to temperatures over 100 F. Any pediatric practice worth its salt has a handout or a website page describing fever as one of nature’s way to fight infection. Fevers are usually caused by common viruses for which antibiotics are no help, and discomfort from them is relieved easily by simple medicines.
We desire zero risk level in our lives, and a fever, no matter how small or how short in duration, indicates that something may be wrong. Speaking of risks, how can we accept that everyone must remove their shoes at the airport because one person had a bomb in a shoe, but we don’t register gun owners and accept the much greater risks of our kids being shot?

 Obamacare Begins – October 1, 2013
Like the Bible, Obamacare is open to interpretation. Your view of it may depend on your political party rather than your religion. Both are vulnerable to quoting out of context in support of opposing viewpoints. Both have overall, encompassing goals which can often be lost, or at least obscured, by minute details of excess verbiage. Both have, and will continue to have, “unintended consequences” (like the Inquisition and the Crusades) that we mere mortals have to deal with.
Everyone certainly agrees that Obamacare is NOT divinely inspired. Congress has clearly rejected the idea of a central authority (like the Pope, or Donald Berwick, MD as “Czar” of CMS). The Bible is no longer chained in the dark in the back of the church.  Obamacare is now out in public, out in the market place. We shall eventually see how well it meets the needs of our citizens for affordable health care.
By the time the Republicans win the presidency Obamacare will have so many beneficiaries (voters) that they won’t dare to kill it, and they’ll have to rename it. I wonder WWJD?

Flu Vaccination – October 16, 2013
The trivalent vaccine is the most readily available (at both your physician’s office or a retail store) and there is no compelling reason to seek out the quadrivalent vaccine. The vaccine’s effectiveness in preventing the flu depends on which flu strain is circulating in your area. Effectiveness may be as high as 80% in young adults, but is almost always lower in the elderly. A high dose vaccine that allegedly delivers four times the usual prod to your immune system is being marketed for the over 65ers , but it is not recommended since there is no independent study of its success.
In Massachusetts last year there were 5 flu deaths in children under 17 yo.  None of the five had been adequately vaccinated. Two of the five had no pre-existing health problems. Nationally there were 146 pediatric deaths from the flu last year compared to 34 the previous year.  40% of those deaths were in children who were otherwise very healthy.  90% of them were unvaccinated.

Paranoia – Nov. 1, 2013
Former Vice President Dick Cheney recently said during a “60 Minute” interview that he had his cardiologist turn off the wireless function in his implanted pacemaker “in case a terrorist tried to send his heart a fatal shock.” Years later, he saw that scenario played out in an “Homeland” episode. We knew that his DC residency was pixellated in the Google satellite view, and we wondered if he was on the NASA phone surveillance list.  But then, we remembered that he had ordered it.
Polls taken in Boston after the Marathon bombings indicate that more people think that “such attacks are likelier, but fewer live in dread of them.”.”In the United States since 9/11 Islamic terrorism has resulted in the deaths of 37 people. During that same period, ten thousand times that many have been killed by guns wielded by their countrymen or themselves.”

Is It a Strep Throat or Just a Virus Cold? – Nov. 15, 2013
A team of Boston research physicians have recently come up with a potential APP for that! These physicians combined two clinical findings that the patient could recognize with real-time data about the occurrence of positive strep tests in the community in the past 14 days to generate a “Home Score” to tell you if you really need a strep throat test.
There may soon be a home kit for that! Other physician researchers in Boston are ready to test a home-based, patient-administered Rapid Strep Test. A positive home-based RST would be enough to initiate treatment and prevent complications.

The Myth of Multi-Tasking – Dec. 1, 2013
“Multitaskers are terrible at every aspect of multitasking…When we talk to multitaskers they seem to think that they’re great at it and seem totally unfazed and totally able to do more and more and more.” Actually, those who did it the least, did it the best. “We are worried that multitasking may be creating people who are unable to think well or clearly.”
Recent work involved study of the erosion of social and emotional development by the increasing use of social media. “We have to get back to that saying, ‘Look at me when I talk to you’”.

Aspergers or Autism – Dec. 15, 2013
Confusion about these syndromes  increased in the 2000’s as screening tools improved and awareness of the syndromes grew.  The authors of the 2013 Diagnostic and Statistical Manual of Mental Disorders (DSM-5) , the bible of insurance company reimbursement, has attempted to simplify and clarify the situation by lumping all the diagnostic names into one billing code, “Autism Spectrum Disorder” (ASD).
The attempt has not succeeded according to its critics and many practicing physicians.
Parents of Asperger children could lose insurance benefits now tied to that diagnosis. Grant-supported educational and enrichment programs for Asperger’s may dry up. Asperger’s has always been a less terrifying diagnosis than autism.  People with Asperger’s, and probably more important, their parents, don’t want to be labeled with the stigmata of “autistic”. Dan Akroyd and Daryl Hannah  self-proclaimed their Asperger’s in 2013.


Vol. 101 November 15, 2013 Sore Throat: Strep or Not ?!

November 15, 2013

hub“What’s the difference between a cold and a strep throat?”
“About $75.”

A strep throat diagnosis has always required an office visit and a swab of the throat because clinical features alone can not reliably distinguish between group A strep and a viral sore throat.

For decades physician researchers have been seeking a way to make the correct diagnosis of strep pharyngitis vs a viral cold based on clinical findings only. During my training in the 60’s a pediatric group practice in Rochester, N.Y. compared their strep throat culture results to each physicians’ prediction based on clinical findings only (fever,  absent cough, tonsil appearance, etc.). They batted about 50% at best, with errors in both directions, false positives and false negatives.

That may change soon.

A team of Boston research physicians have recently come up with a potential APP for that!

These physicians combined two clinical findings that the patient could recognize with real-time data about the occurrence of positive strep tests in the community in the past 14 days to generate a “Home Score”.(1)  The addition of this community prevalence data, “real-time biosurveillance data”, according to the authors, increases the reliability of the prediction of “strep or no strep” for patients over 15 years old. One with a low-risk “home score” could safely skip going to the doctor. In the U.S. 12 million people a year visit a clinician for a sore throat, and the authors speculate that a “home score” could reduce those visits by 230,000 to 780,000. Of course, electronic “real-time biosurveillance data” is not available in most places. In the office where I work our “real-time biosurveillance” is distinctly less high tech and consists of a question to our nurse, “Joan, have we had a lot of positive streps this week?”

Why all the fuss about strep? Multiple studies show that treatment of strep throat with penicillin merely shortens the duration of symptoms by only about 24 hours in most cases compared to treatment with just increased fluids, temperature control, and rest. But, in people over 3 years of age (some say 6 yrs.) a strep infection can cause some people to develop complications of kidney (glomerulonephritis) or heart (rheumatic fever) inflammation . That is the reason we treat step throats with antibiotics. Children under 6 yrs. rarely develop those complications.

The American Academy of Pediatrics recommends strongly that anyone under 15 yo. be examined and have a strep test done. That strep test is now a Rapid Strep Test (RST) rather than a culture. It detects the presence of the bacteria by antigen reactions, not culture growth, and gives a result in 5 minutes. A throat culture for strep takes 18 to 48 hours. A small percentage of the RSTs may be falsely negative, so the AAP recommends that negative RSTs be double-checked with a back-up strep culture.

There may soon be a home kit for that!

Improvements in RST have reduced false negatives to a very small number. So small, that other physician researchers in Boston are ready to test a home-based, patient-administered RST. A positive home-based RST would be enough to initiate treatment and prevent complications. Such a reliable home-based test could greatly reduce visits to the pediatrician, ER, or urgent care setting, but communication with a health care provider would still be necessary to start appropriate antibiotic treatment.

So, in the near future you might be able to self-diagnose a “non-strep” sore throat using a smart phone APP (if over 15 years old) or a strep throat with a home-based RST kit and get timely, appropriate treatment without a visit to a health care provider.

I assume the APP will be free or $1.99 at most. I wonder what the home RST test kit will cost?

Of course, nothing in medicine is 100%, even death and taxes now-a-days.* About 12% of people who have a strep throat and are treated with penicillin will still carry the strep asymptomatically for a long time, not develop complications, and will have a positive RST with just a viral cold or even when healthy.

* The Obamacare penalty for not being insured was determined to be a tax by a 5 to 4 vote of the Supreme Court. Past ethical controversy about “brain death” has been superseded by equally lively discussions of “heart death”.

References:
1.  Ann Intern Med. 2013;159:577-583, 5 Nov


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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