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Sociology and Language of Medicine

Smooth Operator

by Laura McFarland, Communications Director

According to a 2008 survey, operating room staff play music during about two thirds of surgeries, as reported in this year’s British Medical Journal’s Christmas issue, which reviews the history of music in the operating room.

Aside from a more general effect on health, numerous data specifically support music for patients having surgery under local or general anaesthesia. BMJ notes that in a randomised trial of 372 patients having elective surgery, relaxing melodies (60-80 bpm, mimicking the resting heart rate) proved to be superior to midazolam as a pre-anaesthetic anxiolytic. Combined data suggest that this calming effect is maintained before, during (when awake), and after surgery, with music faring better than noise blocking devices alone. For patients requiring further respiratory support postoperatively, music’s ability to reduce anxiety, heart rate, and respiratory rate extends even to ventilated patients in intensive care.

My son, delivered by C-section, was born to the sounds of Loverboy, “Working for the Weekend.” Personally I would have preferred something a little more classical, which is apparently the preferred genre. Its popularity may be in part due to the lack of lyrics, which alas rules out holiday carols. The Journal offers a number of suggestions and some understandable don’ts (REM’s “Everybody Hurts,” for instance) if readers find themselves needing to make a selection.

MCN wishes a joyful holiday season to all of our readers. We will be closed on Thursday, December 25th and Thursday, January 1st. To meet the needs of our clients, MCN is open during regular business hours throughout the rest of the season. Our 26 offices nationwide, including operational centers in Tampa, FL, Long Island, NY, Chicago, IL, and Seattle, WA, are seamlessly connected through one fully integrated database. Whatever the weather, MCN staff are available to answer client questions, receive referrals, and review and deliver reports from 8 am – 8 pm EST.

Medicine still requires the vignette

In an era of systematic clinical research, medicine still requires the vignette, as explored in this opinion piece. The multiple comments are interesting as well, many with strong opinions which provide illumination into why patient stories are (still) so important and how they fit with a sound scientific approach to better treatment:

In addition to reminding us of the real and human part of practicing medicine, stories are great hypothesis generators. Evidence-based medicine is important, but no real evidence can be generated until a testable hypothesis is created. This is where vignettes play an important role. When we see an outcome, especially if it’s unexpected, it forces us to ask questions, which in turn lead to hypotheses.

Your Brain’s Silent Killers?

by Laura McFarland, Communications Director

Turns out my mother might not be so unusual after all. Or at least in one particular way: she’s gluten intolerant, but not celiac. For years she ate crackers to settle her stomach; then she learned that it was the crackers that were upsetting her stomach.

She is joined by nearly 20 million other Americans who regularly experience distress after eating products that contain gluten. About 1% of the population has celiac disease (an autoimmune disorder that can occur in genetically predisposed people where the ingestion of gluten leads to damage in the small intestine). Currently, however, according to this fascinating article in The New Yorker, about a third of American adults, a number well beyond even this 20 million,  say that they are trying to eliminate gluten from their diets.

Given that humans have been eating wheat for about ten thousand years, what’s going on that would suddenly make the numbers of those who experience intolerance increase? The article explores multiple possibilities — a change in wheat’s genetic composition, the modern diet, changes in the bacteria which help us digest food, intolerance of a specific group of carbohydrates (FODMAPs), too much vital wheat gluten — and provides examples of studies.

Multiple opinions are noted, from David Perlmutter, a neurologist and the author of one of the gluten-free movement’s foundational texts, “Grain Brain: The Surprising Truth About Wheat, Carbs, and Sugar — Your Brain’s Silent Killers,” writes “Gluten sensitivity represents one of the greatest and most under-recognized health threats to humanity.’’ Given that 20% of the world’s calories, not to mention the basis for multiple economies, come from wheat, that’s a fairly daunting concept to grapple with.

Then there’s research by Joseph A. Murray, a professor of medicine at the Mayo Clinic and the president of the North American Society for the Study of Celiac Disease. Said Murray, “Everyone is trying to figure out what is going on, but nobody in medicine, at least not in my field, thinks this adds up to anything like the number of people who say they feel better when they take gluten out of their diet. It’s hard to put a number on these things, but I would have to say that at least seventy per cent of it is hype and desire. There is just nothing obviously related to gluten that is wrong with most of these people.’’

So which is the more accurate perception? Perhaps understanding what’s really being removed from one’s diet when they try to give up gluten. As author Michael Specter suggests, “The initial appeal, and potential success, of a gluten-free diet is not hard to understand, particularly for people with genuine stomach ailments. Cutting back on foods that contain gluten often helps people reduce their consumption of refined carbohydrates, bread, beer, and other highly caloric foods. When followed carefully, those restrictions help people lose weight, particularly if they substitute foods like quinoa and lentils for the starches they had been eating. But eliminating gluten is complicated, inconvenient, and costly, and data suggest that most people don’t do it for long. The diet can also be unhealthy.”

A Doctor’s Malaise, and a Profession’s

Brian L. Grant MD

Reading the NY Times Review of this book leaves one with their own sense of malaise, whether they are a doctor or a patient. The anecdotes shared reflect the reality for many physicians and health care workers. This writer recalls a number of years ago, refusing to sign off on routine admit orders for a patient who had no need for $5.00 multivitamin tablets that could be purchased at a drug store for a hundredth the cost (not that they were needed at all from a clinical or nutritional standpoint), I was called in to “meet” with the hospital administrator, a non-clinician, who was clearly irritated with my decision, and the general comment that I was going to do what was clinically appropriate and was not concerned with his cost and profit issues. Thankfully I was not an employee of the hospital, or that may have been my last day.

It is hard to feel sorry for colleagues on an economic basis, as physicians are hardly on the bottom rungs of the US economic ladder. But one is more likely to enjoy a waterfront home as an MBA or entrepreneur than an employed physician. The lack of autonomy driven by a seizing of power by payers, drug companies, and non-medical managers is perhaps what drives physician malaise. Medicine is not your father’s profession any longer. Not only is your doctor more likely than ever to be a mother now, but the economic realities of health care have substantially changed. The smartest people in the health care room are as likely to be the investors and non-medical managers who ably control distribution and access. And as has been discussed before in these pages, the lack of market dynamics in a system where the ultimate consumer – the patient — is generally buying without paying, abets a system where abuses like unneeded treatments, consultations, and tests can take place.

Today the new IPhone comes out to great fanfare. It will be expensive relative to most phones. Some will decide they must have it, but many will stick with what they currently have in their pockets – whether a current IPhone or another brand. If phones were paid for by “phone insurance,” many would decide that this latest version is the only acceptable option and that it is unjust and unfair for their carrier to deny them this phone. And of course Apple would determine that their phone will be priced at a much higher rate reflecting the perceived necessity of it and lack of market constraint and competitive drivers like we see in many a medical device, drug, procedure or study.

The saddest part is that while nobody has ever died or been hurt from too nice a piece of consumer electronics (unless they were mugged to get at it), many a patient has been harmed from unneeded care and medical intervention. And society is harmed from way too much money being spent in the health care sector, driven as much by overconsumption as by high prices.

Thoughtful physicians and health practitioners are saddened and disheartened when they conclude that much of what they do lacks value relative to the cost and actual impact. They realize that they are part of a system driven by excesses and motivated by behaviors on the part of colleagues, hospitals and companies that are less than admirable in many cases; and driven on self-interest rather than the physical and economic well-being of patients and society. The ideals that still drive many to enter health care are challenged regularly, leading to a disconnect between one’s self-identity and reality. This can give way to depression, cynicism, or concession. On the other hand there still remain many in medicine who have found ways to do what they love, while serving others with integrity and pride.

The Happiness Calculation for Smokers

How do you quantify happiness levels? The question has relates to a longstanding requirement — first codified under the Clinton administration — that every set of federal regulations with more than a $100 million effect on the economy needs an analysis to prevent the adoption of regulations with high costs and low benefits.

Now it is being applied to the government’s new tobacco regulations proposed this past April, specifically to a cost-benefit calculation which assumes that the benefits from reducing smoking — fewer early deaths and diseases of the lungs and heart — have to be discounted by 70 percent to offset the loss in pleasure that smokers suffer when they give up their habit.

Is this a problem? Well, yes, according to many, as the proposed regulations could water down the agency’s ability to regulate tobacco products. If the formula for assessing costs and benefits remains unchanged in the final version of the regulations, it could set a dangerous precedent that would constrain public-policy making for years to come.

“This is the single biggest obstacle facing the F.D.A. in executing the job Congress gave it,” said Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, an advocacy group. “There’s no way the F.D.A. can do its job if this is applied.”

An F.D.A. spokeswoman, Jennifer Haliski, said that there was “still a great deal of uncertainty” surrounding the calculation, and that the agency was helping fund research to explore the issue. So far the Food and Drug Administration has received at least 69,000 public comments on the new regulations, some quite high profile. Earlier this month a group of economists, including one Nobel Prize winner, weighed in, asking that the calculation be changed before the ruling takes effect. Read more…

Munchausen by Proxy and Social Media

by Laura McFarland, Communications Director

As the mother of two small children, this is the kind of article I’d prefer to skip over and never have to know about. This past January Garnett-Paul Spears, aged 5, died from sodium poisoning. His mother, Lacey Spears, has been charged with committing depraved murder and manslaughter in the case.

Munchausen by Proxy Syndrome, a disorder wherein caretakers purposely harm children and then bask in the attention and sympathy, has not been specifically mentioned by the prosecutors though “Spears fits the pattern” of such caregivers as noted by some experts.

Dr. Marc Feldman, a psychiatrist and forensic consultant in Birmingham, Alabama, who wrote the book Playing Sick, said he believes the Internet has contributed to the number of Munchausen by proxy cases, with its quick and easy access to a potentially huge, sympathetic audience. One study estimates there are more than 600 cases a year in the U.S. alone. For example, doctors at Seattle Children’s Hospital found three cases of mothers who falsely blogged that their children were near death and were rewarded with support. In a 2011 case in Great Britain, a childless 21-year-old woman joined an Internet forum for parents, claiming to have five children and chronicling her nonexistent baby’s battle with celiac disease and bacterial meningitis. Most cases rarely end in death; when a death occurs, it’s because of a miscalculation, Feldman said. “It would defeat the purpose to kill the child.” Read more…

Trying to Bring Down Oz

Concerned with the public health impact of Dr. Mehmet Oz’s health advice, in 2013 University of Rochester medical student Benjamin Mazur asked state and national medical associations to take action. However, though for over a hundred years the federal government has passed legislation and created agencies to prevent consumers from being deceived or harmed by “bad medicine,” the situation is a complicated one. For instance, though the Federal Trade Commission has the legal authority to prosecute people who mislead and injure consumers, they can’t do anything about Oz since he’s not actually selling the products he talks about.

With regard to his concerns, Mazur noted: “I’m definitely not the only one.”  Sen. Claire McCaskill, for instance, told Dr. Oz during a Capital Hill hearing: “The scientific community is almost monolithic against you in terms of the efficacy of…three products that you called miracles.”

Mazur explains his concerns:

This issue was brought up by a number of physicians I worked with during my family medicine clerkship. We had all of this first-hand experience with patients who really liked his show and trusted him quite a bit. [Dr. Oz] would give advice that was really not great or it had no medical basis. It might sound harmless when you talk about things like herbal pills or supplements. But when the physicians’ advice conflicted with Oz, the patients would believe Oz.

Mazur is not entirely anti-Oz, of course; as he explains, “I would probably say that he does have the health interest of his viewers in mind. But in the long term, undermining good science and the relationship patients have with their current physicians is probably doing much more harm than good. If they’re not going to listen to advice from physicians—who are providing good, evidence-based advice—if they’re going to listen to other doctors on the show, it’s going to do more harm than good.” Read more…

Politicians’ Prescriptions for Marijuana Defy Doctors and Data

Brian L. Grant MD

This is a fascinating article on a number of levels. The comments by readers as well as the article are illuminating. I come to it as a person who came of age in the 70s, trained in psychiatry and reside in Washington State. I also have an interest in medical anthropology which among other issues looks at cross-cultural health care systems and beliefs. Finally, I have a strong interest in medical politics and economics which are major drivers of policy and practice in US Healthcare.

Washington State is one where medical marijuana (cannabis) is legal and recreational marijuana will be legal in July with a rigorous permitting and taxation system. In observing the medical marijuana “industry” and practice in Washington, what has been clear is that it is a parallel system whereby anyone can obtain a prescription for medical marijuana and that a tiny minority have the sorts of diagnoses such as glaucoma, terminal pain, cancer, and the like that were invoked to justify medical marijuana in the first place. Furthermore, given the wide array of symptoms that may be “helped” by medical marijuana, most of which are subjective, such as pain and anxiety – there is not a person reading this post who could not receive authorization if they so choose. The dispensaries that provide pot use nice euphemisms such as “medicine” to describe cannabis, and “donations” as what one pays to receive their medicine. Whether one can obtain marijuana while declining a donation is not clear.

So in my view, medical marijuana at least in principle, if not in practice, is by and large a sham. It makes liars out of decent people who want to get high, have a good time, harm nobody in most cases, and perhaps relieve some real symptoms. Similarly, it promotes disingenuous behavior on the part of practitioners who prescribe it, some of whom are true believers, but all of whom are paid good money to write a script often based upon one visit with someone they will never see again.

Therefore, with reasonable reservations and concerns, one should be pleased to see marijuana become legal for recreational use. Like alcohol, which was touted during prohibition as having medicinal value as a way to access whiskey and other drinks  and more, read here and here), marijuana as a medical substance has by and large been a back door to access by those who want to smoke it for its mood altering attributes.

There are many similarities between alcohol and marijuana. Both are substances that can alter one’s thinking and are psychoactive. Both can be sources of enjoyment and conviviality and both can and do cause harm. One is by and large legal and the other not and therein lies the problem. If we as a society wish to ban all substances and behaviors with potential for harm, the list would be long, not end with alcohol, and would certainly start with tobacco and include excessive caloric consumption and other quite legal and common substances. Unlike alcohol, or increasingly prescribed opiates, marijuana has little propensity for physical addiction and tolerance.

Relatively speaking, the end organ damage and aggressive behaviors that excess or chronic use of alcohol induce significantly outweigh the degree of harm seen in typical marijuana users. The numbers of those who use alcohol abusively with resulting damage to themselves or others is significant. Since marijuana use is generally defined as abuse per se, studies looking at actual damage from the use of marijuana need to focus on objective rather than regulatory criteria. Is marijuana harmless? Of course not. Dosages are imprecise as one smokes something with inconsistent intake and varying amounts of active THC. “Edibles” can be misused or accidentally fall into the hands of children. One can simply lack balance and overuse marijuana in lieu of more productive and useful activities, just as could happen with alcohol consumption. And the impact of smoking marijuana is of unknown concern as at least one study suggests that lung damage from typical use is not an issue.

Neither cannabis nor alcohol belong in the hands or mouths of children and make no mistake – increased access to either creates some collateral damage that non-use would avoid, just like opiates or the 70 MPH speed limit on the highways.

Interesting systemic questions include: What is the role of the health care system in deciding that it owns a portion of the human experience, or that something is a medical issue rather than a component of general life? What are the economics of the system and the impact of a substance like marijuana that can be easily grown and distributed outside of the pharmaceutical industry with no inherent barriers to entry other than access to sun or artificial light, soil, fertilizer, water and seed stock? Could there be an element of those in power wanting to maintain control of an income stream, resulting in criminalization, and restrictive regulations along with false or distorted claims of harm to control distribution and access?

Finally, what damage has flowed from criminality of cannabis? How many have died as a result of criminal and gang drug traffic? How many harmless individuals have been prosecuted and jailed for use or distribution of marijuana? How many of the judges, prosecutors, and jurors sitting in judgment on these defendants can with a straight face deny their own use of cannabis in their own lives at some point? What can we learn from countries like Holland where cannabis has long been legal?

We are about to embark on an experiment in Washington state, already started in Colorado, with legal recreational marijuana. The ultimate results remain to be seen. Whatever one’s personal views on legalization of cannabis, facts and data should inform both personal and government decisions on the policies and use of cannabis and other products. Unfortunately the subject is often polarized by advocates and opponents.

Judge Upholds Policy Barring Unimmunized Students from School during Outbreaks

Brian L. Grant MD

MCNTalk has been following the vaccination refusal controversy for some time. As noted in this recent Times article, a NY court has affirmed the right to deny access to schools by unvaccinated children when another student is ill with a vaccine-preventable disease.

These particular cases are interesting because they illustrate a clash in values between sincerely held beliefs, religious or otherwise, and the public good. It leaves unanswered or at least unresolved the question of whether beliefs may trump good science. Also un-addressed is the practice in place whereby one can invoke religion where convenient, though scriptures are silent on vaccines and many other practices that individuals may choose to invoke religion to justify or excuse behaviors and choices.

Vaccines are a medical miracle that have virtually eliminated smallpox, diphtheria, measles, pertussis, and polio, maladies that have killed and maimed untold millions in the world and which can easily re-emerge when there is a sufficient number of unvaccinated to allow for transmission from person to person, versus current herd immunity that keeps the diseases in check.

Beyond the bad science claiming dangers of vaccinations are the polarizing effect of well-meaning parents and others who have come to believe these claims, clashing with other parents and authorities who do not want to support policies that in turn support the unvaccinated exposing their children and others to preventable risk.

The comments by readers, available along with the article, contain many compelling arguments worth considering on the topic.

How a tattoo can help reconstruct a life

Would you travel around the world for a tattoo? More than 5,000 women have, to visit Little Vinnie’s in Finksburg, Maryland, where proprietor Vinnie Myers specializes in 3-dimensional nipple tattoos, an important final step in breast reconstruction after cancer surgery.

After a woman undergoes a mastectomy and breast reconstruction, the darker, sensitive skin of the nipple and areola is usually removed entirely. Surgical reconstruction is possible, but obtaining a tattoo allows women to forego further surgery and the resultant scar. Mr. Myers has been providing such tattoos since 2001, introducing a new specialization that has helped thousands of women worldwide. Read more…and watch the video.