The Evidence Gap

The New York Times has a nice series of articles looking at "evidence-based" medicine, that is, comparing what is practiced in medicine with what we know from trials and studies about that practice.

Our Infatuation with Med Tech: New Heart Scans All the Rage but Benefits Unproven

Our health care system is heading towards insolvency. The reasons are multifactorial, but one which many policy wonks and responsible physicians agree is characteristic of the high cost of care in the US is early, eager adoption of technology before thorough cost-benefit analyses. Professional organizations should be arguing more strongly in favor of evidence-based standards for the adoption of new technologies; but our fee-for-service systems and single-minded specialist fifedoms prevent this. Our central government (medicaid and medicare) could also play a key role in determining what technologies should be reimbursed from the pockets of taxpayers. But repeatedly the government has caved in to lobbying interests.

A new study in the New England Journal of Medicine regarding the use of a new CT technology to image the heart for narrowed coronary arteries address just this issue. The new scans are a prime example of this heady infatuation for new technologies regardless if it has shown to improve outcomes. Many doctors - primarily cardiologists and radiologists - who stand to benefit from the tests have been promoting CT angiography as a non-invasive alternative to conventional angiography. Sound good in principle, but that's not good enough when lives and billions of dollars on the line. We need sound, impartial judgment and objective evidence. Here is a brief comment on the same. The New York Times ran a good front page article on this issue a while back.

Why Aren't Cardiologists Doing Their Homework?

Here's an interesting study this week from the Journal of the American Medical Association that looks at how often patients underwent a stress test prior to getting angioplasty. In turns out that less than 50% of the time! And so why is this a big deal?

Angioplasty is where a small balloon is used to open up a coronary artery to relieve a blockage, followed sometimes by the placement of a stent to keep the vessel open. It is much less riskier and invasive than open heart surgery and is well known to save lives in people having heart attacks and in those with unstable coronary disease. However, we know that in people with stable coronary disease angioplasty has no more benefit over medical therapy (nitro, blood pressure, and cholesterol meds). The difference between stable and unstable CAD is basically how and when you get symptoms of reduced blood flow to the heart (chest pain, shortness of breath, and so on). In stable CAD you only get these symptoms when your heart is stressed, say when you are climbing the bleachers at the football game, arguing with your spouse, or watching our fine President make an ass of himself on television. So according to our best medical evidence, if you fall into that category you're most likely to be best off with just taking your medicines following your doctor's good advice to exercise and eat your veggies, and staying the hell away from the cardiologist.

Naturally, it is never easy in medicine to separate people nicely into one group or the other. Several professional societies such as the American Heart Association have published guidelines stating that for any non-emergent (elective) angioplasty a patient should have a stress test first to demonstrate myocardial ischemia, that is, insufficient blood flow to your heart muscle. There are lots of types of stress tests, but the principles are the same: make the heart work harder (running on a treadmill) and measure function of the muscle (EKG, echocardiography, nuclear perfusion scans). The tests help sort out if there is ischemia (not all patients with poor blood flow will have symptoms, typically women) and if there is chest pain if it is due to an angry, blood-starved heart or not.

It seems intuitive that just ballooning open vessels with plaques is a good idea. Strangely, we know the probability of having a heart attack is not easy to predict from the degree of vessel narrowing alone. What determines your heart attack risk are based on several factors, and many people with narrowed coronaries or stable CAD never have a heart attack. So its seems it is not simply a structural problem. Hence, the need for the stress test, which allows the doctors to identify the functional nature of the vessel. Incidentally there is trendy new use of CT scans (CT angiography) that takes thin slice, high-resolution images of just your coronaries and is able to actually image individual plaques. The 3-D reconstructions are pretty amazing to say the least. But, the utility of the scans are controversial because they don't tell you which plaques are likely to be trouble makers, which is what we really want to know. Nevertheless, lots of doctors are totally into the scans and convince their patients they need to have them, and so in some places every middle aged man with a history of chest discomfort is getting this expensive trip to the CT scanner. This is a great example of how our medical system readily embraces new technology that seems promising before evaluating the evidence behind its efficacy.

Okay, back to angioplasty. So why the hell are so many people - more than 50% - getting ballooned and stented before verifying that they have a functional vessel problem? That's the question this study raises. A generous explanation is that doctors either intentionally or unintentionally ignore the guideline recommendations, relying instead on personal experience and local practice standards. Call me a pinko Francophilic Obama-loving Terrorist, but my own opinion is that this is just another example of how the fee-for-service system incentivizes doctors and hospitals to provide care that may not actually benefit patient. But to be fair there are other non-financial aspects of medicine that muddy the waters: our professional ethics urge us to provide the best care regardless of cost and over-treatment serves as a bet-hedging maneuver in the paranoia of malpractice claims.

A Few Thoughts on the ICU

I'm finishing my rotation in the ICU. It is an immensely interesting place to work, but frustrating as well. To my surprise, I do not find the degree of suffering and high mortality depressing. I am sort of happy - relieved - when patients expire (the medical term for die) because most of what we do in the ICU is prolong death, and by extension, pain and suffering.

The moral conundrum encountered daily in the ICU is that we have advanced technology to keep people alive even when a disease process is inevitably leading to death and is medically irremediable. Family members, staff, physicians, and even patients themselves who are still lucid, often conflate the benefits of life support therapy with medical progress. The fact that a ventilator and blood pressure medicines keep dad from dying is interpreted as possibility that things may turn around. In these stressful times people listen to what they want to hear. They cling desperately and hopefully, to small, but medically trivial, "positive" changes in body function - such as blood pressure - from one day to the next.

Family members often want to know "the numbers" - the results from lab tests, vitals signs, and so on. I am learning, however, it is often counterproductive to discuss this data in much detail. A 1-point increase in hematocrit (red blood cell concentration) will be taken as a sign that dad's still hanging on, when in the context of all the other data, it may very well be meaningless. Sure, you tell the family that, "well, the overall trend is such and such, and that number does not necessarily mean so and so" but like I said, people hear what they want.

In other areas of medicine I am very much a proponent of transparent communication. Tell the patient the data, give him a sense of what they mean (to my best medical opinion), elicit questions and then let him decide what to do.

So why is that a problem in the ICU? Most lay people with a loved one dying in the ICU grossly underestimate the severity of the disease process at hand, while at the same time they overestimate the ability of modern medicine to reverse that process. Also, many people dying in the ICU have several organ systems failing, and putting the whole picture together can be very complicated, even for someone who's medically trained. Most people can easily understand the prognosis of a back sprain or even a heart attack, but that of a critically ill patient is altogether different.

For me the most frustrating thing about the ICU is that we are often too focused on preserving life at all costs and loose sight of what the patient might want, what is the likely outcome for the patient even if they do survive, and their pain as we keep them alive. There is a lot of guilt that drives decision making in the ICU, both among family members and doctors. We forget that it is the disease that kills a patient, not the withdrawing of life support. Even people who feel it is a Christian duty to preserve the sanctity of life at all costs seem to forget that it was God who inflicted the disease on this patient in the first place, and that all our life preserving interventions just obstruct the natural process he has willed into existence.

The ICU, as many people may guess, is incredibly expensive. Nowhere in medicine have I seen such exorbitant, egregious use of health care resources. It sounds heartless to insinuate that every patient comes in with a price on their life. But honestly, who ends up paying for a 2-week stay in the ICU with several very expensive medications, CT scans, MRI scans, and so on? Some of the debt is carried by the family, others by the insurance company or hospital, which is to say, the rest of us in the form of higher premiums. One patient I admitted for fulminant alcoholic liver failure recently died after 3 weeks in the ICU. At $3500/day that's over $70,000 just for the room. I think this is a fair price to pay for someone who has a reasonable chance to survive the disease (this guy's pre-hospital mortality was 60% within 3 months) and a reasonable chance of returning to be a functional member of society.

I know that's not a warm-and-furry approach to life; but then again I didn't invent alcoholic liver disease; that's just reality of life and death. Of course most situations are gray and drawing the line between a good and poor prognosis is notoriously difficult and inaccurate. However, there is no doubt that a more open cultural attitude about death and socialized medical system in which health care budgets were fixed, would allow us to more clearly mark that line without guilt. And that I think would be better for all of us, including dad.

Thoughts on Medical School Burnout

Lost month in the Annals of Internal Medicine a study on medical student burnout and suicidal thinking, and then a commentary in Slate.com. I hear a lot these days in the press, blogs, at work among colleagues, about how stressful the medical profession has become.

Having had a previous career prior to medicine, I can say for myself at least that there is more stress in medicine than the tech industry, but it is not because of long hours as many people think. I think it is primarily because of the type of stress - the responsibility of managing people with complex medical conditions, the pressure of high-patient turnover, and the legal implications of medical decision-making. These all make medicine more emotionally charged than in other professions. On top of that is the type of work schedule. Many people in other professions work 80 hour weeks. But only in medicine is it typical to work extremely long periods 30 or 48 hours, or be on call when you have to be available around the clock. That's difficult because it messes up routine, your sleep, it become impossible to plan anything. An 80 hour workweek is heavy, but it makes a big difference if those hours are predictable and separated with periods of recovery.

The stress of being a medical student is also unique. Commonly voiced complaints are the ridiculous cost of medical education ($100-150K) and the endless training (min of 7 years after college). These feed into each other since indebtedness leads people to seek more training in higher paid specialties.

For me "burnout" in medical school has not been about working long hours or dealing with unpleasant patients. It is about the pressure of getting good evaluations in a environment where expectations of my roles and responsibilities are poorly defined, combined with a sense of ennui because I am not given any responsibility for patient care.

There are high expectations of you to know a lot that you don't really know, often times before you've ever been trained. Expectations are constantly shifting and are totally dependent on the team you are working with that week. And just as you get the hang of something, you switch clerkships and possibly hospitals sites as well. This is like starting a new job every 4-6 weeks; new nurses and staff you don't know, a new space where you don't know where anything is, new residents and attendings - your bosses essentially - with their own way of doing things. And all along you get evaluated by every resident and attending you work with, even if it is for a few days.

But beyond all that, the worst part about the clerkship years for me was that I was totally useless. As a student you can't write medical orders, so your role is limited to glorified shadowing - following your team around and observing. At OHSU, a large academic medical institution where there are many residents and other students, there is considerable competition for patients. Residents and interns have priority in managing patients and doing procedures; the student is last to know new test results, handle a scope, or peak into a wound. Yes, you do your own exams and write your own notes, but these are meaningless to the patient's care because the resident and attending also do this as well (nothing done by a student can be billed to the patient). I was told by one attending that I needed to act as if the patients were my patients, that is, take ownership of them. This was really frustrating, especially for someone like myself with a previous career with managerial responsibility, because the system is not designed to allow a student to do that in any meaningful sense.

Most student's motivation during clerkship is to get a good grade, and that's done by convincing your team that your a good student. But how do you do that? Attendings and residents rarely, if ever, observe your exams or interviews. Often times they don't really read your note in any detail. So your evaluations hinge largely on your presentations, those few precious minutes during the day when all eyes and ears are turned to you. Presenting a patient is a vital skill in medicine and doing it well is an art; this kind of emphasis in medical school clerkship is corrupting.

And here why: If I had an hour to see and prepare a progress note for my attending, I would best be served by spending as little time as possible seeing the patient - get in, get out - and the rest looking up new literature or reading up on the disease. Indeed, knowing your literature is crucial to being a competent doctor. But shouldn't bedside care also be? Sadly, bedside care is actually one of the ways in which a student can "add value" to the care delivered to a patient. Our system does not reward the student who takes bedside care seriously. Patients never evaluate students; and attendings only evaluate what they see: the fruit of diligent study appearant in an impressive assessment and plan.

Sure, I've learned a lot the last 18 months during my clerkships, but I am eager to move on and actually do work, to have some responsibility and feel accountable.

Radiohead, Liars at White River Amphitheatre | Photos from seattlepi.com

I saw the greatest rock band in existence last week. No, seriously. Anyone who says differently doesn't understand music. And I would say that Radiohead is the perhaps the best rock band since the Beatles.

Radiohead, Liars at White River Amphitheatre | Photos from seattlepi.com

When to give pills to a drug seeker

I saw a 31 year-old in the ED last week who came in complaining of wrist pain after falling from his skateboard. The triage nurse did not find his story compelling (acute) enough for immediate transfer back to the ED. He was upset then told the nurse that he also had abdominal pain as well.

Once in a room back in the ED I looked at his hand. There was not the least sign of a fall: no abrasion, no redness, no swelling, no deformities, no numbness, no cold hand, no painful movement. When I pressed on his hand bones he vaguely retracted his arm as if to show me that he was in pain. He made no facial grimace when I asked him to gasp my fingers as hard as he could. It was pathetic acting. People really in pain wince when you push in a tender place or ask them to use a part that hurts. They do not look at you stone-faced. They do not invite you mash around on a sore body part, as this guy seemed to do, with "push there, it really hurts, yeah, right there, and it hurts here too, push there."

As part of a routine exam I asked him if he had any underlying medical conditions. He leaned forward and said in a suspicious voice, "this is just between me and you - you can't tell anyone - but I have 4 herniated disks in my back and so I take a lot of Percosets. You see, I need a lot more pills than usual to help my pain." Percoset is one of the many prescription pain pills. It is a narcotic, a relative of morphine, opium, and herion. He gave me some bogus excuse for this secrecy as needing to protect his health information from his insurance company, which would drop him if it discovered he had an expensive medical condition like 4 herniated disks. The story was absurd, obviously. Having such a debilitating back condition like that at such a young age would be a perfectly good reason to have insurance. And why the hell was he riding a skateboard anyway? And why was he telling me medically relevant information if he didn't want it in his medical record?

As I stood up to leave the room I excused myself by saying that I would discuss the case with my supervising physician, as I always say to every patient. He jumped up from the exam table and closed the door in front of me. "You promised you would not tell anyone, who are you going to tell now?" he exclaimed somewhat desperately. I brushed him aside and immediately left the room. This was clearly a sign of aggression.

If there was ever a "slam-dunk" case of a drug-seeking patient, this was him. I have no doubt that this guy made up story of falling on to his wrist as an excuse to get narcotics from the ED. Every ED doc in a urban center will see someone like this on every shift. It is aggravatingly common. I offered ibuprofen and ice, which is exactly what I would have given my own friend or child, but he insisted that his pain was just too bad that he needed something more.

What makes treating pain so tough is that one can never know how much pain a patient is in. Sure, clinical experience gets you a long way, but ultimately it is based on the patient's report, and even then one and the same type of condition may very well be more painful to one person than another. However this case was straight-forward, and it I admit I content to know confidently that his claim of pain was false and his visit to the ED was a ploy to get drugs. A young healthy guy falling off his skateboard with absolutely no evidence of injury (wrist x ray was negative) will not be the sort of pain that warrants narcotics.

There are many ED docs who would have just given him a few days of pills and sent him home. That's the easy way. You get the patient out of your ED and free up your bed for someone else. No arguing with the patient, no explaining why you are "so mean and heartless" for not understanding what the patient says they are going through.

In reality, most cases of pain management in the ED are not so black and white. Many involve people with chronic pain conditions (back pain is classic), who really do have pain and really do need pain relief, but have become dependent on narcotics. And the dependence is not only physical. Actually the psychological dependence is perhaps more common and destructive. So many people I see on chronic narcotics have come to refashion their identity around their disability and see narcotic use as the one way they can be functional. It is a rationalization, just as with any drug abuse behavior. Ironically people on long-term narcotics are notoriously non-functional. The pills dumb you down, they're sedating. Sure, they make you don't care about your pain, but they also make it less likely for you address that pain in a positive way. Motivated people with chronic back pain are usually able to manage it with changes to their lifestyle, such as loosing weight and exercise. But pills, as our culture has increasingly come to believe, are the easy answer.

It behooves me to develop my own personal policy about narcotics since I will be working in the ED. I think the Japanese have a great approach. In Japan prescriptions for narcotics are illegal except in a few cases or known, documented chronic pain, such as cancer. This makes a hell of a lot of sense. In the hospital or clinic the patient is there under your supervision. They are not going to over dose or abuse the medication. They are not going to sell it on the street. I think liberal use of narcotics when indicated while in the ED is totally justified. But sending home people with narcotics who do not have a convincing reason for needing them, I think, is bordering on unethical. Sending this guy home with just 3 days worth of pain pills - say 20 - can fetch $200 on the street. That's not bad money from sitting in the ED for 3 hours.

There are now more deaths from prescription narcotics (Vicodin, oxycodone, codeine, Percoset, Dilaudid) that from street narcotics (heroin, opium). By following our Hippocratic oath to do everything in our power for the "good of the patient" we have inadvertently created a epidemic of physician-mediated narcotic abuse. Getting these millions of people of these meds will be a huge challenge to come. Especially since the association of chronic narcotic use and mental illness, such as depression, is alarmingly, if not surprisingly, strong.

An even larger challenge will be reversing the cultural attitude in this country that one is entitled to live free of pain. We need to look to other cultures and to our own ancestors who suffer and suffered from just as much pain as we do and yet did not dependend on narcotics. Pain is very much moderated by emotion and context and how much significance one bestows on it. It is a fact of life, of aging, of disease. It hurts and it's inconvenient, but perhaps in the greater scheme of things there's a reason for that: pain forces us to be aware of our bodies' frailty and vulnerability.

Seven Reasons Why Americans Spend a Crap Load on Health Care

In the June 18 issue of the Journal of the American Medical Association there is a nice opinion piece that summarizes some key points about why health care is so expensive and ineffective in the US compared to other industrialized nations. Check out the stats in the table above.

In brief there are 7 points why health care is so expensive in the US:

1. A physician culture that privileges meticulousness over effectiveness.
   The Hippocratic oath, ingrained in every doctor and medical education system, values thoroughness of medical investigation regardless of cost. I am trained to order as many tests as necessary to eliminate every diagnosis possible, regardless of how likely they are. A patient with a "slam-dunk" bedside diagnosis of appendicitis will still get a $1500 CT scan in most hospitals to confirm what what was already known.
   
2. Fee-for-service system that provides economic incentive for providing care.
   As long as doctors have practices that are run like businesses (most are) this will always present a potential conflict of interest. In reality many doctors rationalize care that may not be necessary by the above principle of "meticulousness." Doctors need to be compensated for results not just for providing care. A very good article in the New York Times on CT angiograms is an excellent example. Economic incentive further hurts our system by irrationally over-compensating procedures compared to non-procedural cognitive aspects of medicine, resulting in a flood of doctors toward specialties and a brain drain away from primary care.
   
3. Pharmaceutical & medical device marketing to physicians.
   The medical world is awash in information that is impossible even for the most recluse speed reader of medical journals. Anything that gives busy doctors a summary or this information and how it may change their practices is very attractive, and this is precisely the role that marketing reps from the industry fill. The problem is that this information is crafted to buoy sales.
   
4. Fear of being sued.
   There is some debate over how much malpractice lawsuits actually increase health care costs. Doctors point to this as a major factor, but it is likely exaggerated. Nevertheless, I see doctors making "cover my ass" decisions to do a test all the time. And these are rarely for the patient's benefit, although many patients think they're getting better care, and they always add more costs.
   
5. Patient preference for new fangled technology regardless of proven efficacy.
   Americans are addicted to technology, especially when it presents an easy way - or the illusion of one - to solve a problem that is really behavioral or cultural in nature. My favorite example is narcotic pain pills for chronic pain. And doctors feed this desire with enthusiasm. It is a pathetic co-dependent relationship.
   
6. Direct-to-consumer marketing.
   The drug industry has been very successful at convincing people that if anything stands in the way between their right to total joyous bliss every second of their lives then there is a pill. Aging has become a disease. Suffering has become a disease. Not getting a hard on and the snap of one's fingers, has also become a disease. It is becoming commonplace that the patient comes to the doctor asking for a drug for a problem they think they have because of a commercial.
   
7. Shielding the true cost of care from patients.
   Few people understand what anything really costs in medicine, including doctors. When it comes to our health our attitude is, like the Mastercard commerical, "priceless." Over fifty percent of the health care resources a typical patient consumes is in the last 1-2 years of life. That's a whole lot of money spent on keeping very sick, frail people on the cusp of death from dying. Personally, I think a lot of this has to do with our Christian values, which have been perverted by contemporary politics, selfishness of the aging babyboomer generation, and over-confidence in medicine. We have a very poor understanding of death as a culture. We don't accept it, much like our attitude towards debt (thanks again to Mastercard). The thinking from "life is sacrosanct" easily leads to "life at all costs" and then to "death is a failure of morality."
   

Pediatric Vital Signs

Pediatric Vital Signs

Typical vital signs in the pediatric population

Extracted from: Jorden RC: "Multiple Trauma" in Emergency Medicine - Concepts and Clinical Practice 3rd ed.; Rosen P, Barkin R et al. (eds). 1982 Mosby-Year Book, Inc. p281-282

Search PubMed

AGE WEIGHT (Kg) PULSE RESP SYST BP DIAST BP Premature 1 145 <> 42 +/- 10 21 +/- 8 Premature 1-2 135 50 +/- 10 28 +/- 8 Newborn 2-3 125 60 +/- 10 37 +/- 8 1 mo 4 120 24-35 80 +/- 16 46 +/- 16 6 mo 7 130 89 +/- 29 60 +/- 10 1 yr 10 120 20-30 96 +/- 30 66 +/- 25 2-3 yr 12-14 115 99 +/- 25 64 +/- 25 4-5 yr 16-18 100 99 +/- 20 65 +/- 20 6-9 yr 20-26 100 12-25 100 +/- 20 65 +/- 15 10-12 yr 32-42 75 112 +/- 20 68 +/- 15 Over 14 yr > 50 70 12-18 120 +/- 20 75 +/- 15

Evil in South Dakota: State Forces MDs to Lie.

South Dakota's unbelievable new abortion law. - By Emily Bazelon - Slate Magazine

Satan is alive and kicking in South Dakota, if you use deception, lies and trickery as a marker of evil - as I would. Doctors providing abortions in SD will soon be forced by the state to say things they know to be false, like "the fetus you are carrying is an unique, separate human being" and just downright misleading like describing adverse effects of abortions like "increased risk of psychiatric stress and suicidal thinking."

First the "unique, separate human being" part. A fetus is a sort of parasite. The fetus lives in a symbiotic relationship with its host, the mother, in which it derives a long-term one-way benefit of nutrition, growth, and protection. I have no idea how any doctor will be able in good faith to say that a fetus is "separate" since it is unlikely to be viable until at least 24 weeks of gestation (at 28 weeks it is considered viable). So what does "separate" supposed to mean? Potentially separate? Separate in terms of DNA? Separate in terms a "soul," that is a central nervous system (I'm partial to a neuroscientific explanation of the soul!)? Perhaps the SD constitution will allow MDs to fill in what this "separate" is supposed to mean - I certainly hope so, otherwise this is a patently false statement.

Calling a fetus a human being doesn't particularly bother me, unless the intention to do so is to persuade a parent-to-be that having an abortion is just like killing a living child (this is different than calling a fetus a person, which has a distinct legal meaning). And that is the whole point of the SD requirement.

Abortion and homicide are as legally and sociologically different as night is to day. Abortion is private and only affects a few individuals. Homicide is deeply disrupting to the community at large. I might not agree with daughter or friend having an abortion, but it doesn't threaten my sense of security or freedom to pursue happiness and prosperity. Having a killer next door does. Hence, the irrefutable and objective need to legislate one type of killing - that of people.

So here' s my pitch to Christians who oppose abortion: indeed, God may not see the difference between killing people and fetuses important - but that is an issue between him and mother (or parents). Frankly, everyone else's views are irrelevant to that very personal relationship a mother has between her fetus and God. Let a woman make her choice and take the issue up with God.

Permitting abortion is a win-win if you think about it. We can protect constitutional rights and preserve freedom without rebuking God's disdain for abortion! If God doesn't like the mother's decision to have an abortion, she will get her punishment, right? And isn't this how free will is supposed to work? Didn't he endowed us with free will so that we could choose between good and bad, and learn from the consequences?

Physician Assists Death of Non-sick Old Lady in Germany

Here's an interesting story from Germany about physician-assisted suicide. Except in this case, unlike those in which Jack Kevorkian was involved, or those cases which are legal in Oregon, the woman who killed herself was not suffering from a terminal illness. Where do we draw the line? Or should we?

How Mental is My Chest Pain?

Recently I evaluated a 50 year-old Somalian immigrant in the ED for chest pain and shortness of breath. She had a soft, but emaciated expression that was a uneasy mixture of worry and fatigue. The woman was fairly well known to the ED - she had been in multiple times with this complaint. Every time she was given an EKG, a chest xray, and her blood was tested for cardiac enzymes that show if a heart attack had occurred. These had always been negative. She had a cardiac stress test done as an outpatient some months back that also showed no cardiac disease. Yet, still it is hard to ignore chest pain that seems to cripple a patient.

Three of her children were present when I saw her, two grown ups and an adolescent. Her eldest son, around 30 years-old was professionally dressed in a collared shirt and spoke English very well. It was clear he was educated and was her main health care decision maker, as she spoke no English. Everyone asked me over and over, almost out of desperation, what had been causing her pain. It was clear from this questioning that in their many unfortunate encounters with the American health care system, no doctor had provided a very good - or very understandable - explanation. The son told me that his mother was upset at him because he was not able to find an explanation - or find a doctor who could give an explanation. He was at his wit's end, exhausted and frustrated.

It was clear to me that there was more to the story than heart or lung disease. On my psychiatry rotation last month I spent a day each week at a volunteer psychiatric clinic for immigrants - especially those from war-torn areas such as Africa, Vietnam, the Balkans - and learned a great deal there about how psychosocial context for people in this unique situation can exacerbate medical illnesses.

It turned that this woman's chest pain episodes started six years ago when she came to the US. Her son said that she had always been somewhat of an anxious person, but that it never led to inexorable chest pain that required emergency care in Somalia. She was also living in a broken family that caused her considerable grief: her youngest son, only 10 years-old, was still in Somalia with her husband.

A lot of symptoms that doctors cannot explain get chalked up to anxiety, depression, and stress. And many patients resent this. They feel their doctors are telling them that their symptoms are all somaticized, "between their ears," made-up fake symptoms that are not worth testing, treating, or even empathy. And many doctors dislike patients with somaticized symptoms because they have a strong suspicion that tests will not reveal a diagnosis. And so they are reluctant to treat pain that they feel has no "organic," that is anatomical or physiological, basis. To an extent this is understandable: treating chronic back pain, for instance, that is largely aggravated by anxiety and poor living habits with a narcotic runs a significant risk of dependence. Long term use of narcotics will address chronic pain (and anxiety) very well but at the expense of reducing that person's overall functionality - their ability to work, parent, etc. So in the end the doctor has addressed one problem by creating a larger one. This happens all the time because chronic pain is so damn elusive.

OK, back to my Somalian woman in the ED. She has chronic pain. She has no identifiable (at least by our diagnostic tools) biological cause for that pain. She is that difficult patient many MDs loathe to treat because the direction and outcome of a treatment are not clear. This is because the cause of her pain is anxiety and depression from being uprooted from her traditional community and living in a fragmented family. On top of that, she has very limited resources to turn to here in Portland, Maine. There are no traditional Somalian healers. There are no Somali (and possibly no Arabic) speaking MDs. There is no free psychiatric clinic for refugees. There is no pill or surgery or test or procedure that will fix any of this. The English-speaking American MD has very little to offer this woman because her needs are not medical in nature. And yet, her suffering manifests itself as a medical condition.

I spoke at length with the family in the ED (a privilege I have as a medical student unbound by the obligations of high patient turn-over) and explained to them what I thought was the cause of her recurring chest pain. In a nutshell I told them it was in fact "between her ears," which I believe is true, but in such a way as to not dismiss the fact that she really did have chest pain, that her symptoms were not just illusory manifestations of her broken psychosocial context. I urged the family to understand the relationship of this pain to her social circumstances, that it was not unlike having a headache caused by poor sleep due to stress. I also apologized to the family for the fact that there was nothing I could offer them except a pill - a benzodiazapine which is essentially a martini in pill form, a very effective medication for anxiety. I recommended that she follow up with a family doctor and consider getting a prescription so she could have this medicine around when the pain gets really bad. Most likely it would keep from coming back to the ED, getting all those senseless tests done over again by a doctor who probably will not have the time to talk to her like I had.

In the end it seemed the family was satisfied with this explanation, although the son was reluctant to have his mom start popping pills. He preferred she do yoga or meditate, both of which I readily encouraged, although, I explained, these methods are better thought of as prophylactics and would unlikely help in a severe, acute situation.

As I enter my last year of medical school I am more and more convinced that nearly every medical condition has an underlying psychiatric one. This story is an obvious example, but in many cases the relationship is subtle and indirect. It is convenient and simple to think of so-called "adult-onset" diabetes (type 2, associated with obesity) as just a medical problem, which is, the condition in which the body's tissues lose their ability to respond to insulin, resulting in an elevation of blood sugar. Yet, nearly every patient with type 2 diabetes is overweight, eats poorly, and does not exercise. Obesity is itself is an interesting phenomenon in this country - indeed all post-industrial societies - and my gut instinct is that there are a handful of anomalous psychiatric states underlying these lifestyles that are so self-destructive, such as depression and addiction.

Tachyarrhythmias

Paroxysmal Tachycardias 150-250 bpm

• Paroxysmal Atrial Tachycardia
• An irritable atrial focus produces a normal wave sequence, if P' waves are visible.
• P.A.T. with block
• Same as P.A.T. but only every second (or more) P' wave produces a QRS.
• Paroxysmal Junctional Tachycardia
• AV Junctional focus produces a rapid sequence of QRS-T cycles.
• QRS may be slightly widened.
• Paroxysmal Ventricular Tachycardia
• Ventricular focus produces a rapid sequence of (PVC-like)
• Wide ventricular complexes.

Flutter (250-350 bpm)

• Atrial Flutter
• Continuous (“saw tooth”) rapid sequence of atrial complexes from a single rapid-firing atrial focus. Many flutter waves needed to produce a ventricular response.
• Ventricular Flutter / Torsades
• A rapid series of smooth sine waves from a single rapid-firing ventricular focus; usually in a short burst leading to Ventricular Fibrillation.
• Torsades de Pointes if amplitude of wave varies like a ribbon.

Fibrillation (350-450 bpm)

• Erratic (multifocal) rapid discharges
• Atrial Fibrillation
• Multiple atrial foci rapidly discharging produce a jagged baseline of tiny spikes.
• Ventricular (QRS) response is irregular.
• Ventricular Fibrillation
• Multiple ventricular foci rapidly discharging produce a totally erratic ventricular rhythm
• without identifiable waves.
• Needs immediate treatment.

Conduction Blocks

Sinus (SA) Block

• An unhealthy Sinus (SA) Node misses one or more cycles.
• The SA Node usually resumes pacing, but the pause may evoke an “escape” response from an automaticity focus.

AV Block

• 1° AV Block: PR interval greater than .2 s.
• 2° AV Block: some P waves without QRS response
• Wenckebach - PR gradually lengthens with each series does not produce a QRS.
• Mobitz - some P waves don’t produce a QRS response. More advanced Mobitz block may produce a 3:1 (AV) pattern or even higher AV ratio.
• 3° AV Block: no P wave produces a QRS response
• P waves—SA Node origin.
• Rate of QRS determined by AV node (40-60 bpm) or ventricles (20-40 bpm)

Bundle Branch Block

• QRS greater than 0.12 sec.
• Right BBB: R and R' in V1 or V2
• Left BBB: R and R' in V5 or V6
• With Bundle Branch Block the criteria for ventricular hypertrophy are unreliable
• With Left BBB infarction is difficult to determine on EKG.

Arrythmias

Sinus Arrhythmia

• Irregular rhythm that varies with respiration.
• All P waves are identical.
• Considered normal.

Wandering Pacemaker

• Irregular rhythm. P waves change shape as pacemaker location varies.
• Rate less than 100/min.

Multifocal Atrial Tachycardia

• Same as wandering pacemaker but rate is great than 100/min.

Atrial Fibrillation

• Irregular ventricular rhythm.
• Erratic atrial spikes (no P waves) from multiple atrial automaticity foci.

Escape Rhythms and Beats

• Automaticity focus escapes overdrive suppression to pace at it inherent rate (rhythm) or to emit transient beat.
• Due to loss of upstream pacing (e.g. sinus arrest) or conduction block
• Atrial foci paces at 60-80 bpm (non-SA node source)
• AV nodal foci paces at 40-60 bpm (may cause retrograde atrial depolarization)
• Ventricular foci paces at 20-40 bpm (Stokes-Adams Syndrome)

Premature Beats

• Irritable focus that spontaneously fires a beat.
• Atrial & AV node foci
• Epinephrine
• Increased sympathetic stimulation
• Stimulants: caffeine, amphetamines, cocaine, beta1-receptor agonists
• Digitalis
• Hyperthyroidism
• Stretch
• Ventricular foci
• Hypoxia
• Hypokalemia
• Mitral valve prolapse, myocardis

EKG Interpretation

RATE

• 300, 150, 100, 75, 60, 50
• For bradycardia & irregular rhythms: rate = cycles/6 sec. strip ✕ 10

RHYTHM (arrhythmias, tachyarrhythmias, conduction blocks)

• P before each QRS.
• QRS after each P.
• PR intervals (for AV Blocks).
• QRS interval (for BBB).
• If Axis Deviation, rule out Hemiblock.

AXIS

• QRS above or below baseline for Axis Quadrant (for Normal vs. R. or L. Axis Deviation).
• For Axis in degrees, find isoelectric QRS in a limb lead of Axis Quadrant using the “Axis in Degrees” chart.
• Axis rotation in the horizontal plane: (chest leads) find “transitional” (isoelectric) QRS.

HYPERTROPHY

• In V1
• P wave for atrial hypertrophy.
• R wave for Right Ventricular Hypertrophy.
• S wave depth in V1…
• + R wave height in V5 for Left Ventricular Hypertrophy.

INFARCTION

• Scan all leads for:
• Q waves
• Inverted T waves
• ST segment elevation or depression
• Find the location of the pathology, and then identify the occluded coronary artery.

Dermatome Map

A Comment about Transparency in Medicine

Original story about crap left in people after surgery: http://www.msnbc.msn.com/id/25120613/

My comment: http://cmolstrom.newsvine.com/

And yet more thoughts! This is not a defence of surgeons as much as an explanation for how things are from their perspective I guess.

In the OR staff joke, "how often is a final count off when the patient leaves the OR?" The answer of course is never, because a patient should never leave the room with an off count and unexplained missing item would be found. The point is that something gets left behind and the count is still correct! Human error, but there are better and better systems with built in redundancy that improve catching errors if they happen, because they will.

One example is putting a small metallic strip in every gauze pad or towel so that it will show up on xray. A normal gauze or even towel will not show up on CT or xray, which could be why some patients need to be re-opened to find the damn thing. Some people do not recover well from abdominal surgery - especially if they have other illnesses - and so a left behind towel is not the first thing to come to mind since that sort of thing is rare. In that case the corrective surgery should not be the responsibility of the patient - probably the surgeon since he or she is ultimately responsible (although the scrubs, etc., are hospital employees).

Not all cases are clear cut though. Certain specialized staple guns that use a ribbon of stables and work by zippering together two pieces of tissue usually shed some extra staples in the process. Going after all those staples would take extra time (more anesthesia risk) and expose risk to organs due to the "fishing around" - the risks are not worth the benefit. The risks theoretically are, I suppose, a perforation of something, but that never happens so I'm told. Just sitting there they will not cause infection because they are sterile just like the other staples that will remain in permanently. It is debatable whether a surgeon should tell every patient about these things that never cause a problem even if they theoretically could. Of course patients want to know everything but in reality doctors filter out information since there is little use in telling a patient about extremely rare 1 in a 100 million risks and complications that do nothing but cause anxiety. Believe it or not many people do not understand statistics. This is a frustrating aspect of the profession.

Example - Last night in the ED I saw a woman with abdominal pain and tingling in her arms and legs that got better after vomiting once. She was totally healthy, 34 years old, no history of any diseases, mother of 2 infants. She was also a very anxious woman, prone to anxiety attacks, corroborated by her husband, and had given a history very suspicious of anxiety-induced abdominal pain: her cousin's son had just been diagnosed with a brain tumor and she had visited the family earlier that day. She has two kids and has been festering on that...what about my children? To an extent this is natural maternal feeling, but the chances of her kids getting are brain tumor are really, really, rare. The chances of her having a heart attack or stroke (what she thought she had) are extremely unlikely. Can't say impossible - you never say never in medicine - but very unlikely. What do I tell her? I say it is very unlikely for reasons x, y, and z that you have a heart problem, and the tests we ran here show that. But should I also say, "but an EKG (heart tracing) is not 100% on the money for heart problems, and so there is still a chance this could be your heart" and send her home an anxious again? Reassurance involves minimizing some information and maximizing other, and some people take that as not being up front with the patient.

Leaving extra staples in is one of those things that surgeons never talk about - not because of denial but because patients are not likely to understand the very low risk of complication and will just make them worry. Hell, every veteran doctor has seen a zillion patients who start to have symptoms only after they are made aware of a disease (which they don't have, but think they might). "I'm having belly pain after my surgery (everyone does) and the doc told me about those staple...I wonder if it could be..." and so that the belly pain gets worse for no physiological reason. This is called somatization.

Another example, just last night! 20 month old girl comes in with 4 very worried family members because she is wheezing. She improves some on medicated oxygen (for asthma) but not back to 100%. Parents are very anxious because they've never seen many infants with asthma. From a physician's view in fact the girl is doing really well overall, her blood oxygen is totally normal, she does not look infected. Half of the treatment involves reassuring the parents. We get a chest x-ray to rule out a foreign body aspiration. Her lungs look great, but she has an unusually shaped aortic arch. X rays are not at all the test of choice to diagnose an aortic problem, plus she was poorly aligned in the machine, so the film is a little cock-eyed. But the shape is unusual nonetheless. We talk to radiology and they did not even feel it was necessary to comment on the aorta in their report. So, of course I am not going to tell the parents, "the xray looks normal, except we thought the aorta was a bit strange - oh, don't worry, it is probably nothing just the way the film was" Worried parents don't hear anything after "don't worry...." It would have been nuts to say anything. There was no explanation for the unusual shape, she clearly had no cardiac problems. Normal anatomic variant? Weird artifact from the film? At any rate should I worry the parents about these details?

Every doctor has their own way of talking to patients about adverse effects, risks, complications, abnormal test results -in my woman above many would just say "it's not a heart problem, don't worry" and leave it at that. I think it is important that patients know our tests and diagnostic skills are not perfect, that there's other possibilities even with someone like this woman. But at the same time I can't dwell on the other possibilities without making her totally freak out. Its a fine line, and every patient is different. The bottom line for me is: when in doubt, talk it out!

Alcohol Withdrawal

Minor withdrawal 6 to 36 hours
Tremulousness, mild anxiety, headache, diaphoresis, palpitations, anorexia, GI upset
Seizures 6 to 48 hours
Generalized, tonic-clonic seizures, status epilepticus (rare)
Alcoholic hallucinosis 12 to 48 hours
Visual, auditory, and/or tactile hallucinations
Delirium tremens 48 to 96 hours
Delirium, tachycardia, hypertension, agitation, fever, diaphoresis

The Omnivore's Dilemma

This is a great book on a timely, important topic. Here are some key points I've gleaned from it.

• Processed food is a supply-driven business but it has to deal with the problem of the "fixed stomach" - that is, food consumption, unlike computers or clothes, is biologically limited by the size of our guts. So, in order to make profits, the industry must either (a) get people to spend more on the same number of calories (the Whole Foods approach) or getting people to eat more (the General Mills and McDonald's approach).
• Super-sizing has been a way to get people to spend more money. However, studies has shown that mammals over-eat when presented with the opportunity because they (we) are evolutionarily designed to feast when food is available to tide through the next famine. We are programmed to respond most readily to high-energy substances like fat and sugar, because fatty, sweet things provided our ancestors with the biggest caloric bang for the hunting or gathering.
• High fructose corn syrup (HFCS) was invented in 1980. It is not found naturally in any food, but its constituents, fructose and glucose are naturally occurring sugars. It is very sweet and a source of highly-dense calories. As such we respond very strongly to it, but our sensory apparatus is not well designed to appreciate the calorie load in HFCS because it is not found in whole food. It teases our taste buds and tricks our guts.
  
• HFCS has found its way into nearly every processed food item. At the same time the average caloric intake in the US has increased 10% (about 200 calories) per day, while calorie expenditure (work and exercise) has remained level or even decreased. Those 200 calories a day end up in fat cells around our waists and hips. We now have an obesity and diabetes epidemic due to consumption of energy-dense processed foods.
  
• A family meal at McDonald's of 4510 calories requires 10 times as many calories to produce (raising the corn, raising the beef, processing the foods, reconstituting them, transportation). That's 1.3 gallons of oil!
  
• Food processing is an irrational use of energy: it involves taking natural whole foods and braking them down into constituent chemicals which are then reassembled into a new products.
  
• There is a 90% loss of energy each move up the food chain, say from grass, to cow, to carnivore. That's why there's a lot more plants than predators in a given ecosystem. In other words only 10% of the calories of grass (or corn) a cow eats go into making tissue (meat) that we eat, while rest goes to keeping the animal alive or is excreted as waste. This inefficiency is why eating meat - especially cows - is environmentally costly. A more sustainable diet is eating (more often) lower on the food chain where we are able to reap the energy from the sun in the most efficient manner - directly from plants.
• Cows have been taken from their natural habitat - a grassland - and placed in cow-cities, feedlots, where they are fed corn (not their natural diet) and wallow in their own excrement. This is the cheapest way to make meat. But overcrowding and an unnatural diet make the cows sick (just like occurs in human slums), so they are routinely treated with large quantities of medicine and hormones which, when excreted, leach into the soil and contaminate nearby water supplies.
• Farmers have always this problem: they make good money during famines because of high prices, and loose money in boom years because of low prices. Unlike consumer products which are driven by demand, agriculture is usually driven by supply: the price of wheat is determined by the bounty rather than the demand for it. To ease the burden of unpredictability in this market, the government provides subsidies so that farmers are guaranteed an income when prices fall below costs. But this just encourages farmers to produce more crop (for greater profits), which results in surplus and even lower market price. The end result is that taxpayers are subsidizing overproduction. The market as found ways of using this surplus: feeding us more and exporting the rest. It is economically irrational.

Food should be protected from capitalist ventures because there is little, if any, room for innovating things that evolution has already mastered.

Eating "organic" food is not as important as eating whole, unprocessed food. A good maxim is: if your grandmother doesn't recognize an ingredient then don't eat it.

Benzodiazepine Half-life

Short Half Life (less 12 hr)
Lormetazepam
Temazepam
(Zopiclone)
Triazolam
Loprazolam

Intermediate Half Life (12-20 hrs)
Lorazepam
Oxazepam

Long Half Life (>20 hrs)
Nitrazepam
Diazepam
Flurazepam
Chlordiazepoxide

Opioid Dosing Equivalents

Drug	Dose		T1/2
Morphine	10 mg I.V.	30 mg p.o.	2-4
Codiene	100 mg I.V	200 mg p.o.
Hydromorphone	1.5 mg I.V.	7.5 mg p.o.	2-3
Hydrocodone		30 mg p.o.
Methadone	10 mg I.V.	20 mg p.o.	15-20
Fentanyl	100 ug = 4 mg I.V. morphine		1-2
Meperidine	75 mg I.V.	300 mg p.o.	2-3
Levorphanol tartrate	2 mg I.V.	4 mg p.o.	12-16
Oxycodone		30 mg p.o.	3-4
Oxymorphone	1 mg I.V.	6 mg p.r.	2-3

DVT - Imaging and Labortory Findings

1. Contrast venography—Although contrast venography remains the gold standard for diagnosing DVT, it has been largely replaced by ultrasonography in most institutions. The advantages of contrast venography include a sensitivity and specificity of nearly 100% and the ability to detect DVTs of the calf, iliac vessels, and inferior vena cava that can be missed by ultrasound. Its primary disadvantages include its invasive nature, use of contrast material, and availability. Additionally, 5-15% of studies performed are technically inadequate.

2. Ultrasonography—Ultrasonography is the most accurate noninvasive study for diagnosing lower-extremity DVT, with a sensitivity of 93-100% and a specificity of 97-100% in detecting proximal DVTs. The limitations of ultrasonography are its ability to detect pelvic and calf DVTs (20% of which will extend into the popliteal vein and thigh).

3. D-Dimer assay—D-dimer is formed when fibrin is degraded by plasmin. The testing for the presence of D-dimer is by latex agglutination (least sensitive), whole blood agglutination (bedside, qualitative), and enzyme-linked immunoassay (ELISA) (most accurate). When combined with ultrasound, the whole blood agglutination and ELISA have an almost 100% negative predictive value.

From Current Diagnosis & Treatment Emergency Medicine - 6th Ed. (2008)

Rochester Criteria for Identifying Febrile Infants at Low Risk for Serious Bacterial Infection

1. Infant appears generally well
2. Infant has been previously healthy:
3. Born at term (>/=37 weeks of gestation)

• No perinatal antimicrobial therapy
• No treatment for unexplained hyperbilirubinemia
• No previous antimicrobial therapy
• No previous hospitalization
• No chronic or underlying illness
• Not hospitalized longer than mother

4. Infant has no evidence of skin, soft tissue, bone, joint or ear infection
5. Infant has these laboratory values:

• White blood cell count of 5,000 to 15,000 per mm3
  
• Absolute band cell count of <=1,500 per mm³
• Ten or fewer white blood cells per high-power field on microscopic examination of urine
• Five or fewer white blood cells per high-power field on microscopic examination of stool in infant with diarrhea

Jaskiewicz JA, McCarthy CA, Richardson AC, White KC, Fisher DJ, Dagan R, Powell KR. Febrile infants at low risk for serious bacterial infection--an appraisal of the Rochester criteria and implications for management. Febrile Infant Collaborative Study Group. Pediatrics. 1994 Sep;94(3):390-6. [Medline]

Canadian C-Spine Rule

For patients with trauma who are alert (as indicated by a score of 15 on the Glasgow Coma Scale) and in stable condition and in whom cervical-spine injury is a concern, the determination of risk factors guides the use of cervical-spine radiography. A dangerous mechanism is considered to be a fall from an elevation 3 ft or 5 stairs; an axial load to the head (e.g., diving); a motor vehicle collision at high speed (>100 km/hr) or with rollover or ejection; a collision involving a motorized recreational vehicle; or a bicycle collision. A simple rear-end motor vehicle collision excludes being pushed into oncoming traffic, being hit by a bus or a large truck, a rollover, and being hit by a high-speed vehicle.

http://content.nejm.org/cgi/content/full/349/26/2510

Canadian CT Head Rule

CT Head Rule is only required for application in patients with minor head injuries who have any one of the following:
High risk (for neurologic intervention)

1. GCS score <15>
2. Suspected open or depressed skull fracture
3. Any sign of basal skull fracture (hemotympanum, "raccoon" eyes, cerebrospinal fluid otorrhoea/rhinorrhea, Battle's sign)
4. Vomiting >=two episodes
5. Age >=65 years

Medium risk (for brain injury on CT)

1. Amnesia before impact >30 minutes
2. Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height >3 feet or five stairs)

NOTE: Minor head injury is defined as witnessed loss of consciousness, definite amnesia or witnessed disorientation in a patient with a GCS score of 13 to 15.

CT = computed tomography; GCS = Glasgow Coma Scale.
From Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et al. The Canadian CT head rule for patients with minor head injury. Lancet 2001;357:1394.

Medice is a Crappy Gig

Doctors know that doctors are increasingly dissatisfied with their profession. The reasons are many, but mostly stem from an ever-increasing amount of non-clinical work that is not reimbursed (dealing with insurance companies, for instance, for payments or pre-authorizations). Combine that with Medicare payments that have not kept up with inflation (and in fact have decreased) and you have a recipe for disaster for both doctor and patient. The end result is that doctors spend less time seeing each individual patient - the 15 minute visit is becoming standard in primary care - because doctors must cram in more patients during the day to keep the clinic afloat. And then there's all the extra work they don't get paid for, which makes for long work days, sleepless nights, and a fast-track to burnout. Furthermore, a litigation-obsessed culture and the rise of the "professional patient"* that make the years of intense, hard-fought training seem trivial.

What do do?

Most of this is a result of doctors' own apathy to take action, to stand up to crappy work conditions. This passivity is also our virtue, since the majority of doctors are willing to put up with exploitation for the sake of patient care. The equivalent to a physician strike has been threatened by many doctors - refusing to take more Medicare patients if the reimbursement system is not repaired - but ultimately doctors feel that this would violate their professional ethics. Plus it would make the profession look bad in the eyes of the public; rarely does our community hold lawyers, politicians, business executives, or even professors, to the same strict standard.

* The patient who demands certain medical care or self-righteously questions physician expertise after a little bit of internet reading that gives an inflated sense of medical understanding.

Motocycle Helmet Laws

I am doing a visiting clerkship at Maine Medical Center in Portland this month. I was shocked to see motocyclists not wearing helmets. This is a law in Oregon since...for a long time I suppose. I also just learned that Pennsylvania repealed their helmet law a few years ago. It is no suprise that the number of motocycle fatalities and hospitalizations increased since that law was repealed in 2003. It is odd indeed that there are several states that still do not have universal helmet laws (requiring helmets for all riders) while many states such as Oregon, New York, and Massachusetts have had such laws for over 30 years. I was told that, at least in Maine, the motocyle lobby is more powerful than the public health lobby.

Decision-making by special interests rather than public interest has become a familiar story of what we accept as democracy in our own government, which is a large reason I think we tolerate rather liberal use of alcohol, tobacco and firearms, all of which are massive threats to public health. Sure, there are cultural reasons too, which was immediately obvious in the absurd public reaction to Obama's comment about guns and poverty while campaigning in Pennsylvania. I cannot pretend to separate out "authentic cultural principles" from a special-interest positions, but I think that lobbying, marketing and public relations more often than not hijack public debate on these very important topics by normalizing one side of the issue in the interest of private gain.

So you want to live longer?

Here is a story on possibly the newest anti-aging fad: resveratrol. It's found in red grapes and other foods. In lab animals it has been shown to switch on a set of enzymes called sirtuins that are associated with anti-inflammatory and anti-neoplastic processes. Sirtuins apparently extend life in worms, flies and rats. The mechanism is thought to be that similar to the calorie-restriction theory of life-prolongation. This theory says that low-grade starvation stimulates the body to switch from reproduction (in which a body's resources are ultimately directed to offspring) to preservation (in which the body's resources are directed at the self). Hence, a longer life, as counterintuitive as it sounds. I should say, however, that there is no evidence in humans that this is the case. The calorie-restriction diet fad and resveratrol supplements have not been around long enough to know if they have any significant effects and a clinical trial measuring longevity would probably take several decades. If you consider the risks minimal compared to the potential benefit, you might just hedge your bet and do it anyway, which is the only rational explanation for why someone would willingly starve themselves. Furthermore, I am not sure if CR would really make a significant difference compared to simply following your doctor's advice, which is, eat lots of fruits and vegetables and get exercise. Only recently with all the media attention around obesity and diabetes has the American mainstream really started to take these doctor's orders to heart. (Incidentally, high gas prices may be the biggest boon to healthy aging as it will discourage dependence on the car).

Calorie-restriction diets are pretty controversial in the medical community. The obvious concern is the risk of malnutrition - but that could be lessened with supplements, if you think that is a good way to get nutrition (I don't). Another concern is that CR is really just anorexia - or possibly some other disorder - in masquerade. CR people, like anorexics, are obsessive about calorie counting; in fact their entire daily routines can revolve around it. Anorexia is a very complex disease that involves psychosocial factors and possibly organic brain disease. Many anorexics are very functional, educated, smart individuals. They can be very good at rationalizing their self-destructive behavior. CR, if a flavor of anorexia, would not simply be a rationalization of chronic self-starvation, it would be a pseudo-medical and pseudo-scientific theory defending anorexia as a healthy lifestyle choice.

Another element I find amusing about the anti-aging community is that it is almost entirely composed of young and youngish people who probably have very little contact with elderly folks. I have quite a bit of contact with older people. One thing that is fairly consistent is that old people don't talk about wanting to live longer. You just don't see 85 year-olds talking to you about the latest and greatest fad to keep them young and healthy. My theory about that is simple: old people get tired of living. And this is hard to foresee when you are fit, healthy, functional, and have life changes to look forward to when you are in your 20s, 30s and 40s.

One thing I enjoy most about my older patients is talking to them about how they view the quality of their lives. If they are happy, then what are their secrets? If they are not, then what when wrong? I hear a lot of the same answers.

The secret to aging well is pretty simple: keeping a good sense of humor; being passionate about something; and having meaningful personal relationships. If an 80 year-old has got those three or just two of three, then chances are, they are pretty happy with their life, regardless of their medical problems. This brings to mind an 81 year-old gentleman I met while in Burns, Oregon that had a smile and energy of someone more than half his age. We like to think that it just genes; but this guy also had the magical trifecta: he was always telling jokes and laughing, he played bluegrass guitar and fiddle very well several times a week, he had a large family close by in town and many friends with whom he played music.

How about those who don't do so well as they age? Invariably these are people who don't have any interests or hobbies (dispassionate); people who are unable to deal with stress well (lack humor); people who have a weak social support system (few nearby friends/family). People think that you are prone to get depressed as you age simply because your body and mind break down. We know quite well, however, that how one perceives pain and disability plays a very large role in the meaning of the pain or disability. In other words, a depressed individual is more likely to attribute more significance to their knee pain than is someone who is not depressed. A person who throws out their back at work as opposed to working in the yard is much more likely to see the doctor for a disability claim, and there is very good data that shows people who claim disability for an injury recover much more slowly than those who do not, regardless of the severity of the disability. So my point is, that we deteriorate as we age, but what that means to us - will it become a disability that impairs our sense of well-being or not - is very much a matter of how many of those protective factors (passion, humor, relations) we have in our lives.

Nevertheless, even the happy 81 year-old I mentioned conceded that life is getting long. He is happy, but life has a very different meaning for him now than it did 50 years ago. Back then he had a series of life-changes to look forward to: graduating from school, perhaps college, getting married, having children, buying a first home, developing a career. But at 81 all the big life-changing events have happened.

The tragic thing about aging is that our mental and physical functioning will decline, at varying rates, as we approach death. Ideally that decline should be short and fast; the worse case perhaps is Alzheimer's dementia, where the decline is insidiously slow and protracted, and involves not simply ending up in wheelchair but in loosing your mind and identity. The goal of simply extending life I think misses the point, and that is not about how long to live, but about how quickly to die. One could be the most devout CR dieter for many decades and eke out another five years of life. But eventually that person will die and it will be the same process as any one else: cancer, infection, heart attack, dementia, and maybe trauma. It maybe swift or interminable, but the death is the same.

Young evangelical Christians are starting to act, well, Christian after all

Well finally some of the guys are actually reading the Bible and thinking about it, literally, like a good Evangelical should. If you were to rewrite the Bible today based on the content of right-wing Christian power brokers all you would find would be anti-abortion this and anti-gay that. Nothing about helping the poor. Nothing about stamping out disease. Nothing about the environment. Nothing about that Godforsaken war. And yet. And yet, the real Bible is exactly the opposite, isn't it?

Done with psychiatry and onto 4th year

I just finished my clerkship in psychiatry. It was pretty fun. It was very interesting. But I'm not sure if I want to be a psychiatrist. Psychiatrists seem to be a pretty happy, low-strung group of people. Psychiatry is really different from the other medical specialities. Only in psychiatry can you treat any illness with the same medication, and the same illness with any medication.

The field is somewhat maligned by the rest of the medical profession. Doctors view psychiatry as a medical field like physicists view sociology as a scientific field. It is soft in terms of method and subjective in terms of evidence. The large majority of doctors dislike mental illnesses, exemplified by diseases like schizophrenia and bipolar disorder. They dislike the diseases because they are poorly explained by modern biomedical paradigms (e.g. molecular and cell biology). They remain resistant to the kinds of physical explanations given to other diseases. We know a whole lot about how the heart works and why heart attacks happen. With our knowledge of that organ we've been able to develop a very accurate mechanical model of physiology and disease. We are far from that stage when it comes to diseases of the mind, although there is no doubt that these diseases are ultimately based on dysfunctional biology too. Psychiatry is a good 200 years behind cardiology. This is not a failing of the field but proof of how extraordinarily complex the brain is.

My attending likes to poke fun of neurologists, the other kind of doctors who study the brain. Actually, neurologists diagnose and treat nerve abnormalities, and to the extent that this involves the brain, that organ too. Neurologists have the same prejudice towards mental illness that is widely found in medicine: they hate it. This must sound odd to someone who does not make a clear distinction between the mind and the brain. Indeed this duality - formalized by Rene Descartes - is largely rejected by neuroscientists, who view the mind has a manifestation of a whole bunch of ultra complicated neuronal connections (synapses). The above-mentioned attending likes to say that neurologists and indeed most of the medical community think of the brain as the motor and sensory strips, the visual cortex, Broca's area (language control) and the basal ganglia, thus excluding most of the brain that constitutes the essence of being human: executive cognition.

Perhaps more than mental illness, most doctors dislike the mentally ill patient. The reasons for this is varied. Many doctors went into medicine because they like the application of biology to making people's bodies work better. To be honest, many doctors (and especially surgeons) are not much different than car mechanics, except the car is very sophisticated and the stakes for success and failure are very different. Sure, a lot of doctors (and especially internists) do like the fact that their patients have personalities, quirks, desires, flaws, and so forth. This guarantees variety and unpredictability to the profession. Personality, however, often becomes an impediment to the doc doing her job. For example, the patient with chronic low back pain who wants an easy fix with a pain killer instead of loosing weight. Or the individual who fails to control his diabetes with proper diet and exercise because he suffers from depression. People find all kinds of excuses to not do what their doctors tell them. To some extent this is normal, we all do it, but for those who are mentally ill, it is more than a matter of making excuses. The reasoning machinery we take for granted is skewed or even grossly flawed in these people. You can't just tell a schizophrenic that he has to take his medicines or he'll go crazy, just like you can't tell a depressed person to cheer up and get on with their life.

Japanese Government Addresses Metabolic syndrome

asahi.com : EDITORIAL: Metabolic syndrome - ENGLISH

The Japanese government has a new health plan for people at risk of acquiring metabolic syndrome, with mandatory visits to a nurse councilor and penalties for insurers which fail to meet certain targets:

In addition, the health ministry requires each health insurance provider to set specific targets concerning the ratio of people covered by its insurance program who take medical checkups, the ratio of those who receive counseling and the reduction in the numbers of people who already have or are likely to develop metabolic syndrome.

This later seems pretty bizaare, although I have to give the government credit for taking early initiate on the problem, I doubt if there were many public health experts and doctors consulted.

2008 Pulitzer Prize

This photo won a Pulitzer Prize this year. The videographer is a Japanese man, Kenji Nagai, who was mortally wounded.

Yangon, Myanmar.
Published September 28, 2007
Adrees Latif of Reuters

One of the family medicine cross-covers I work with last night said "I'm not trained to do efficient medicine, I'm trained to do good medicine - saving money if for the people downstairs (the accountants and administrators)" and then later "I'm not trained to care for populations, I'm trained to take care of individuals."

Postponing death for...who?

I've heard older patients tell me "if I was going to live this long I would have taken better care of myself!" Even if that person had taken better care, then he would still be saying the same thing, only 10 years later. Modern medicine has become very good at postponing ageing-related frailty and disability, which is wonderful if you are enjoying your life and want to postpone death. But I'm seeing that this is actually not the case with many geriatric patients. There seems to be a point at which a person just starts to quit caring about living.

This is hard, if not impossible for us younger ones to understand. At some point it is as if the joy of living another day is simply not worth the effort of enduring the aches, pains, boredom, fatigue, loneliness, slowness, and inconvenience of growing old.

I'm afraid I'm not sure if the medical community really helps matters either. We keep hearts and kidneys working longer and we replace joints when they give out, and in many cases we prolong life for people who are ready to die - maybe not physically, but mentally and spiritually. I'm not sure how much sense this makes, and I am not sure if it is ethical.

As our patients and loved ones grown old and infirm we take away little by little their autonomy to decide the course of their lives by themselves. We do so much to keep the elderly alive that is motivated by our own need to feel like we are helping them; we rarely step back and ask grandpa or grandma what they really want. When we do they often tell us what we want to hear, not what they want to say. And when they tell us what we don't want to hear we think they're being irrational or demented and thus dismiss their desires.