Thursday, December 11, 2008

Diagnosis - Confusing Confusion -

The middle-aged man writhed on the gurney in the E.R. His eyes were squeezed shut. Low moans emerged from his parched lips. His sister and brother — the only members of his large Polynesian family who lived here in Portland, Ore. — tried to comfort him, but worry was etched deeply into their faces. Dr. David Peel, the emergency-room doctor at Providence Portland Medical Center, was also worried. This 53-year-old man had a fever and excruciating pain in his back. One leg was weak and he was confused. But the scariest part of all was that the man had been discharged from this hospital just three days earlier after being treated for the exact same thing.

Peel quickly reviewed the records of that first weeklong stay in the hospital. The patient, a smoker, had a history of diabetes and high blood pressure. He came in confused and with a fever. During that admission, the medical team thought he had an infection in his brain, an encephalitis. His white-blood-cell count was high, which was consistent with an infection, and his spinal fluid was abnormal, suggesting inflammation. In addition, the amount of sodium in his blood — an essential mineral and one that is tightly regulated by the brain and the kidneys — was dangerously low, a condition known as hyponatremia. Infections can cause low sodium. So can severe vomiting and diarrhea. And both the encephalitis and the hyponatremia can cause confusion. The team put the patient on powerful antibiotics and was replacing the missing sodium. Treat both, the doctors thought, and the confusion should improve. But it didn't. His fever went down; his sodium went up. But his confusion remained unchanged. He still didn't know where he was or why he was there.

More ...

Where Have All the Doctors Gone? -

One morning during my medical residency many years ago, one of the senior doctors pulled me aside after rounds, as was his routine, to review the status of patients in the intensive care unit. A few had single-organ failure — their lungs weren't doing well, or their hearts weren't beating efficiently. A few struggled with double-organ failure. But the majority of patients were battling multisystem organ failure, and their prognoses were not good.

"People can survive one organ system failing and even two," the senior doctor said to me after we were finished. "But when that third one goes ..."

He leaned forward and looked me in the eye. "Three strikes, and the game is over."

That remark came to mind recently when I thought about the crisis in primary care and President-elect Barack Obama's plans to make health care accessible to all.

Primary care is delivered in a variety of settings by a variety of professionals, including nurses and physicians' assistances, but it is anchored by family-practice doctors, general internists, pediatricians and, for many women, gynecologists. As the nation's front-line doctors, primary care physicians address everything from chronic diseases, like diabetes, heart disease and high blood pressure, to more acute conditions, like pneumonias, intractable flus and potentially cancerous masses and lumps.

While their initial work in diagnosis often sets the trajectory of care for a patient, they also manage long-term conditions, guard the public's health and advocate preventive care measures. For many patients, too, primary care doctors are invaluable guides through the maze of health care options and specialists.

In the last several months there have been reports in medical journals about an impending shortage of primary care physicians. This spring in the health policy journal Health Affairs, researchers at the University of Missouri-Columbia and the federal Department of Health and Human Services published a study that projected a generalist physician shortage of 35,000 to 44,000 by the year 2025. The researchers based their figures on current physician usage patterns and did not take into account increases that might occur because of rising access to health care.

The news got worse in September, when The Journal of the American Medical Association published a study showing that just 2 percent of graduating medical students are choosing to enter general internal medicine. The students surveyed were concerned in part by what they perceived to be a more difficult personal and professional lifestyle, compared with other fields. They felt that the paperwork and charting required of primary care physicians were more onerous, and they were not eager to care for the chronically ill in a health care system that focuses on acute care.

The potentially devastating public health implications of both of these reports rippled out into the medical community. Last month in an official statement, the American Medical Association vowed to support financial incentives for medical students who choose to go into primary care.

More ...

Orgasms During Childbirth? - Motherlode Blog -

First thing next month (Friday January 2) will be the primetime debut of a film that has been making the "under the radar" rounds of women and film festivals since May. ABC's 20/20 will air the documentary "Orgasmic Birth", by Debra Pascali-Bonaro, a childbirth educator and a doula, which asks the question: What would happen if women were taught to enjoy birth rather than endure it?

Some women will see this film as a declaration of emancipation from the medicalization of childbirth. Others will see it as yet one more way to raise expectations and make new mothers feel inadequate if they do not experience the "ideal" birth.

The message of the film is "that women can journey through labor and birth in all different ways. And there are a lot more options out there, to make this a positive and pleasurable experience," Pascali-Bonaro tells ABC. "I hope women watching and men watching don't feel that what we're saying is every woman should have an orgasmic birth."

But the title certainly catches attention, referring to what Pascali-Bonaro calls "the best kept secret" of child birth – that some women report having an orgasm as the baby exits the birth canal.

Tamra Larter experienced that while Pascali-Bonaro's cameras were rolling. She and her husband, Simon, opted to have their second child in their suburban New Jersey home, and through most of the hours of labor the couple was kissing and caressing.

"The phyical touch and nurturing was just really comforting to me," Larter told ABC. Of the orgasmic birth that resulted she said: "It was happening, and I could hardly breathe, and it was like, 'oh, that feels good.' That's all I could say really."

Christine Northrup, an OB-GYN and author of "Women's Bodies, Women's Wisdom" explains in the film that orgasms during labor are the results of chemistry and anatomy: "When the baby's coming down the birth canal, remember, it's going through the exact same positions as something going in, the penis going into the vagina, to cause an orgasm. And labor itself is associated with a huge hormonal change in the body, way more prolactin, way more oxytocin, way more beta-endorphins — these are the molecules of ecstasy."

And on that note I open up the comments for your thoughts …

New Tests for Down Syndrome Raise Tough Issues -

Beth Allard was recovering from labor, waiting for a hospital photographer to capture her newborn son's first day in the world, when a pediatrician walked into her room and told Allard her life was ruined. Allard might have expected as much from a doctor, given what she'd already heard from others in the previous few months: little Ben, who had tested positive in utero for Down syndrome, would be mute and illiterate, they said; he would spend his life hanging off her, drooling. The pediatrician was harsher: "You should consider putting him up for adoption," she said. "You're going to end up divorced. Don't even bother having any other children. Didn't you have the option to terminate?" Finally, the pediatrician left, and Allard resumed her wait for the photographer. He never came.

Ben Allard is now 9, and it's hard to understand why doctors were convinced he would be such a burden. He's a friendly, witty kid who's happily enrolled in third grade at a regular school. He does, says Beth, "all the things they told us he wouldn't be doing, and more." She shudders when she thinks about how wrong the doctors turned out to be: she almost took their advice and ended her pregnancy.

She would not have been alone in that decision. Life with Down syndrome can be very challenging for both parents and kids, and according to studies, 90 percent of women whose fetuses test positive choose to abort. Now, because of a technological advance, pro-life and disability advocates worry those numbers may rise even higher. Currently, Down syndrome is picked up with blood screens and ultrasounds, then confirmed with invasive tests such as amniocentesis and chorionic villus sampling, which insert needles into the uterus and slightly increase the risk of miscarriage. Some women forgo the tests for that reason. Next year, though, new, noninvasive genetic screens that pose no harm to fetuses or mothers may start arriving in doctors' offices. If they become common, they could result in more diagnoses, more abortions, a dwindling Down population and a drop in support for families who carry to term—what Down activist Patricia Bauer has called "the elimination of an entire class of people." Even now, only 5,000 babies are born with the syndrome each year.

More ...

The Truth About Alternative Medicine -

Is natural better? Apparently, a lot of women think so. A survey released today by the National Institutes of Health found that 42.8 percent of American women use some form of complementary or alternative medicine, compared to 33.5 percent of men. That's similar to the gender difference in use of conventional medicine, says Richard Nahin, of the National Center for Complementary and Alternative Medicine. The most popular alternative remedies were nonvitamin and nonmineral products such as fish oil, omega-3 and glucosamine. Use of mind-body therapies such as deep breathing, meditation and yoga has also climbed since the last such poll in 2002. The report, which uses data from the 2007 National Health Interview Survey, also provides even more specific clues about the most likely consumers of these treatments: 50-somethings who have graduate degrees, are relatively well off financially, live in the West and have quit smoking.

More ...

People paid to lose weight are more successful, study shows --

In a nation struggling with soaring obesity rates, there is no gimmick that Americans haven't tried to lose weight. But what if someone paid you to keep the pounds off? Could it work?

New research from the University of Pennsylvania School of Medicine has found that cash could be the ultimate incentive in weight loss. In a study of 57 people seeking to lose weight over four months, those who were paid to shed pounds lost more than those who were not.

The study, released yesterday in The Journal of the American Medical Association, is based on a well-known premise in psychology: Positive reinforcement can help people change their behavior. Individuals respond best when reinforcement is immediate and when the incentive represents something of value to them.

Changing health habits is tough because it requires people to make sacrifices now that might not benefit them until much later, said Dr. Kevin G. Volpp, associate professor at the University of Pennsylvania School of Medicine and the study's lead investigator.

Simply imploring people to lose weight to improve their health rarely works, he said, but incentives can provide a tangible boost during what can often be a long weight loss journey.

"We know that lowering weight can help diabetes and other health problems, but it's hard to figure out how, in the here and now, does this affect me," he said. "Incentives provide a reinforcement mechanism that helps people to take actions in the short term that are in their long-term best interests."

Investigators split study participants into three groups and challenged them to lose a pound a week.

One group took part in a lottery system, in which participants had the chance to win up to $100 a day for meeting daily weight loss goals.

Another used what researchers called a deposit contract system, in which participants bet their own money - between a penny and $3 per day - that they would meet their goals. If they did, researchers matched their winnings. If they did not, their money was forfeited and put into a pool to reward people who met their goals.

The third, a control group, received no money.

Participants weighed themselves every morning and called in results to researchers. Everyone but the control group then received text messages notifying them of their progress and how much money they could expect. Participants were paid every month.

At the end of 16 weeks, the lottery group lost an average of 13.1 pounds; the deposit group 14 pounds; and those who received no cash 3.9 pounds.

"I think it was as successful as we have hoped it would be," Volpp said. "I think it shows that these types of incentive programs that involve daily feedback are feasible."

But the long-term benefit of the approach is questionable; few participants sustained their weight loss. At a seven-month follow-up, members in each group had gained back some of the weight.

More ...,0,4501560,print.story

The downside of requiring young doctors to get more sleep. - By E.B. Solomont - Slate Magazine

Much to the delight of harried young doctors everywhere, an expert panel recently agreed that medical residents aren't getting enough sleep. Citing evidence that fatigue leads to more medical errors, the Institute of Medicine said last week that doctors in training should not work more than 16 hours without taking a five-hour nap. Though it carries no binding authority, the recommendation of the IOM's report supplements an earlier rule, passed by the Accreditation Council for Graduate Medical Education in 2003, that limited residents to 30-hour shifts and no more than 80 hours of work each week. Surgical residents may someday soon have to prepare themselves to halt an operation and announce that it's nap time.

The American medical establishment has been slow to give up a hazing ritual that assigns grueling schedules to trainees, with supporters of the schedule arguing that the long hours prime young doctors for the rigors of medicine, expose them to many disease scenarios, and promote continuity of care for patients. Other nations have been quicker to jettison that system. New Zealand limits residents to 72 hours of work each week, while France caps the workweek at 52.5 hours. Danish residents work no more than 37 hours a week. (What a breeze!) Elsewhere in Europe, countries are slowly lowering the work hours of "junior doctors" to comply with the European Working Time Directive, which limits hours for all shift workers. By 2009, junior doctors will work no more than 48 hours a week.

Unfortunately, working less comes with a big price tag. Countries that have imposed shorter work hours for residents have faced steep staffing shortages as well as questions about the quality of their medical training.

More ...

Wednesday, December 10, 2008

The Evidence Gap - The Pain May Be Real, but the Scan Is Deceiving -

Cheryl Weinstein's left knee bothered her for years, but when it started clicking and hurting when she straightened it, she told her internist that something was definitely wrong.

It was the start of her medical odyssey, a journey that led her to specialists, physical therapy, Internet searches and, finally, an M.R.I. scan that showed a torn cartilage and convinced her that her only hope for relief was to have surgery to repair it. But in fact, fixing the torn cartilage that was picked up on the scan was not going to solve her problem, which, eventually, she found was caused by arthritis.

Scans — more sensitive and easily available than ever — are increasingly finding abnormalities that may not be the cause of the problem for which they are blamed. It's an issue particularly for the millions of people who go to doctors' offices in pain.

The scans are expensive — Medicare and its beneficiaries pay about $750 to $950 for an M.R.I. scan of a knee or back, for example. Many doctors own their own scanners, which can provide an incentive to offer scans to their patients.

And so, in what is often an irresistible feedback loop, patients who are in pain often demand scans hoping to find out what is wrong, doctors are tempted to offer scans to those patients, and then, once a scan is done, it is common for doctors and patients to assume that any abnormalities found are the reason for the pain.

But in many cases it is just not known whether what is seen on a scan is the cause of the pain. The problem is that all too often, no one knows what is normal.

"A patient comes in because he's in pain," said Dr. Nelda Wray, a senior research scientist at the Methodist Institute for Technology in Houston. "We see something in a scan, and we assume causation. But we have no idea of the prevalence of the abnormality in routine populations."

Now, as more and more people have scans for everything from headaches to foot aches, more are left in a medical lurch, or with unnecessary or sometimes even harmful treatments, including surgery.

More ...

Bedside Advocates

The Bedside Advocacy initiative will recruit retired physicians, nurses, social workers and experienced lay persons to serve as volunteer advocates and facilitators for high-risk patients. Individual bedside advocates will serve only a few patients on a one-on-one basis. Each patient will be followed to all sites where healthcare is delivered, including his or her home. The main idea is to stay in touch and be available at all times, when needed.

Why is the Bedside Advocacy project necessary? Because healthcare in America today is bewildering, anxiety-provoking, fragmented, often inaccessible and, yes, at times, uncaring. All of this despite, almost always, the well-intentioned efforts of physicians, nurses and other staff to the contrary. 

The Bedside Advocacy initiative is designed to put caring back into healthcare and help patients and families cope with these and other problems. With a trained advocate at bedside, or in an ambulatory setting, the fragmentation of care will diminish, patient safety and the quality of care will be enhanced, and the costs of healthcare and hospitalizations will be reduced. Interviews with ordinary people have convinced us that there is enthusiastic public support for this service. Similarly, we believe that healthcare institutions and providers will find significant advantages in their own pursuit of higher levels of patient satisfaction, safety and improved quality of care. To back up these convictions, proper studies embedded in pilot and demonstration projects will be carried out to prove the utility of this project, as well as rigorous evaluations.

Several retired physicians, nurses, social workers, other health professionals and experienced lay persons have expressed interest in serving as volunteer bedside advocates. Phase I will focus on recruitment of a few of these individuals in a pilot project in Eastern Massachusetts. The Bedside Advocate's Creed conveys in a robust way the spirit and role of the advocate.

Many leading specialists in patient safety and the quality of care have helped in refinement of the Bedside Advocacy project. Bedside advocates will not practice medicine. They will, however, get to know those they serve thoroughly and facilitate prompt communication with the healthcare team when asked to do so by the patient or the family. Confidentiality agreements will be binding on all volunteers, in line with current healthcare practice.

More ...



Partners and Prostate Cancer -

Men who live on their own are less likely than those living with a spouse or a partner to be screened for prostate cancer, even if they have a family history of the disease, a new study finds.

Writing in the December issue of Cancer Epidemiology, Biomarkers & Prevention, researchers said the findings might help doctors better reach those men most in need of the screening.

Prostate cancer is a leading cause of cancer deaths among men, and those who have had a close relative with the disease are more than twice as likely to get it. But if it is caught early enough, the odds of beating it are good.

The study did not venture an explanation for why men living with partners sought screening more often. But the lead author, Lauren P. Wallner, a doctoral student at the University of Michigan, said it was possible that their partners encouraged them.

The researchers drew on data from a long-term study of the residents of Olmsted County, Minn. Among other questions about their health, the residents were asked about their attitudes toward prostate cancer. Researchers then looked at how often they had been given rectal exams and blood tests to look for signs of it.

Men with a family history of the disease were more likely to have been screened frequently, the study found.

Unattached men are not the only group who may not be getting screened. Guidelines call for men with a family history of prostate cancer to be tested from age 45. But it was not until after 60 that they began being tested more often than men with no family history of the disease.

Doctors Without Modems? Technology Historian Nathan Ensmenger checks the pulse of the e-health revolution.

Ensmenger found that comprehensively answering the question of why most doctors don't use email produced a sort of case study in thinking about information technologies in a sophisticated way—moving beyond what he describes as the simplistic economic and technological determinism that often dominates discussions about Internet commerce. "We can't talk about email, or the Internet, or computers as if they're one thing," Ensmenger argues. "We have to talk about them in particular business, economic and legal contexts.

According to Ensmenger's research, never in the past decade has the rate of email interaction between physicians and patients increased above six percent, despite the fact that national surveys indicate that as many as 90 percent of respondents would welcome the opportunity to communicate with their doctors via email, with 37 percent stating that they would be willing to pay for such access. The short explanation as to why this demand remains largely unsatisfied comes down to money, but there are pertinent noneconomic factors as well.

"Physicians are rarely reimbursed for Internet-based activities," writes Ensmenger. "This is certainly a powerful disincentive. And yet reimbursement is rarely cited by physicians as their principal reason for avoiding the Internet. Rather, concerns about privacy, liability, and patient safety and well-being are described as being primary."

Even allowing for a degree of calculated disingenuousness, Ensmenger reasons, physicians' collective wariness of Internet-based medicine seems to also stem from significant legal, professional and ethical concerns. "For most people, email is a very casual thing," he says. "But for physicians email cannot be casual. They have to worry about HIPAA regulations, so there has to be an infrastructure for keeping information secure. There are concerns about patient care—doctors asking, Can I adequately diagnose someone without seeing them? Email is also not something that can be easily delegated to a nurse in the same way as certain kinds of tests or paperwork."

More ...