January 19, 2010 – 11:16 AM
For clearance to participate in sports, The American Academy of Family Physicians recommends the following:
Athletes with a murmur that becomes softer with squatting or louder or longer with standing or during a Valsalva maneuver should be evaluated for hypertrophic cardiomyopathy and mitral valve prolapse.
For clearance to participate in sports, The American Academy of Family Physicians recommends against following:
Routine screening with noninvasive tests, such as echocardiography, exercise stress testing, and electrocardiography is not recommended
If this blog has one mission in life - besides to amuse and entertain - it is to prevent those in the medical profession from doing excess harm. Lord knows, there are plenty of people out there who would have been much better off had they never come in contact with the medical profession. As doctors, we can't always help people. But, at the very least, I think it is incumbent upon us to become proficient at not harming our patients. And, one of the best and easiest ways to prevent harm to our patients is to decline to screen them for things that they don't need to be screened for!
Whether or not we should screen for hypertrophic cardiomyopathy in order to prevent sudden death in young athletes is controversial. Currently, there is no evidence to support it, but more studies need to be done. HOWEVER, if there is no evidence to support routine screening with ECG or echo, then you can be damn well positive that there isn't any evidence to support routine screening with cardiac ascultation!
This happens rather frequently in medicine. I'm thinking particularly about the recent controversy over the new age recommendations for routine mammography. Whenever the evidence points us in a direction contrary to what health care professionals believe to be their beneficent duty, we end up with recommendations that simply don't make sense.
I've got to go to the local high school and do some sports physicals this afternoon.
December 30, 2009 – 11:23 PM
NBC will be airing a new reality show set in Cook County prison in which investigators probe innmates for information. A brief glimpse of prison life reminded of my former job as in OBGYN resident. There's a very real sense in which OBGYN, and most other surgical, residents are actually less free than prisoners. I think Cook County innmates have at least as much control over their day to day activities as I used to. Of course, they can't quit prison the way I quit my former residency program. Let's put it to a vote: assuming you would be finnancially set by the end without having to work another day in your life, would you rather spend 5 years in prison or 5 years in a surgical residency?
November 9, 2009 – 2:46 PM
Thomas Nasca, CEO of the accreditation council for GME published, on October 28, 2009, an open letter to the medical community. It details the findings of a 16 member ACGME task force regarding the effect that limiting resident work hours has had on medical professionalism. Thanks to DB for bringing it to my attention.
My problems with this letter are severalfold, but can mainly be distilled down to the following. Dr. Nasca would seem to suggest that it is ACGME's belief that medical professionals, bound as we are by the oath of Hippocrates and motivated as we are by altruism, should not be held to the same standard as other industries when it comes to safety and work hour regulations.
Thus, while residents must not be forced to remain on duty for excessive periods, they must not be precluded from demonstrating the caring and commitment required of them as altruistic professionals. ACGME's standards, and the expectations of the public of the nature of enforcement of those standards, must match this important principle. It is here, as in other places, that the analogy with the airline industry fails. A pilot, running out of hours, can refuse to fly the plane, and the passengers are no worse off for the decision, other than the delay. The Neurosurgeon, faced with a patient requiring an emergency craniotomy, does not see an option to, nor does he or she want to say no. The patient struck by a car, with multiple trauma, acute rhabdomyolysis with hyperkalemia and acute renal failure, needs dialysis now, not after the Nephrologist has slept for five hours. The patient needs and demands no less, as does our vow of Hippocrates.
I vehemently, though respectfully, disagree, Dr. Nasca. It is here that the analogy to the airline industry is more appropriate than ever. No more is it ok for a pilot - who is responsible for over a hundered lives - to violate his work hour restrictions than it is for a neurosurgeon who has been awake for 14 hours to perform an emergency craniotomy despite the fact that it is only one life that is at stake. Taking care of patient needs in violation of duty hour restrictions is not the hallmark of professionalism. Quite the contrary. Lack of adherence to standards that are put into place for the explicit purpose of protecting patient safety is irresponsible and clearly unprofessional
Within the boundaries of reasonableness, and with a goal of patient safety, residents must demonstrate willingness to sacrifice for their patients' needs, being taught and given the opportunity to demonstrate the practical manifestations of altruism, the core virtue undergirding professionalism.
In this case, Dr. Nasca, I will vehemently and disrespectfully disagree by referring the above quoted text as 'BULLSHIT!' As professionals, it is not our job to "sacrifice" for our patients - unless you're referring to the whole enterprise of being a doctor as "sacrifice." On the contrary, it our mandate as professionals to remove ourselves from situations in which our own well being has the potential to come into conflict with that of our patients - just as any professional in any other industry should recognize when his or her interests come into conflict with the interests of those whom he or she is purported to serve. I don't know about you, but I don't want my doctor to be in any situation in which he may have to choose between my well being and his own.
I think the medical profession is going to continue to struggle with this issue until there is some kind of cultural shift toward a more rational conception of the doctor-patient relationship.
August 28, 2009 – 11:35 PM
Acting on the results of a recent study which suggests that nearly 2/3 of people with gender identity disorder go undiagnosed, the American Psychiatric Association has recommended routine screening for this condition.
Gender identity disorder, or GID, is characterized by strong and persistent cross-gender identification and persistent discomfort about one's assigned sex or a sense of inappropriateness in the gender-role of that sex. These symptoms often cause significant impairment in social functioning and lead to disastrous wardrobe, make-up and hairstyling choices in patients who do not receive proper counseling.
According to Gail Silverman, APA spokesperson and lead author of the study, "We are just now learning that millions of people suffer needlessly due to GID. When there are effective treatments available such as hormone therapy and, ultimately, anatomy-altering surgery, it's simply unconscionable that we allow so many to go undiagnosed." Dr. Silverman also cited lack of reimbursement as a major barrier to individuals with GID getting help. Currently, less than 1 in 10 insurance providers will cover gender identity services and individuals who do receive treatment - which are now believed to represent less than 30% of those affected with the disorder - can incur out-of-pocket expenses reaching tens of thousands of dollars.
The APA will recommend a list of screening questions to identify those who are at risk for GID which can be remembered using the mnemonic "TRANS." It is recommended that all patients screened at routine intervals.
- Thoughts - Have you ever thought about what it would be like to be the opposite gender?
- wRong - Have you ever felt like you were born the wrong gender?
- Anatomy - Are you distressed by your own primary and secondary sexual characteristics?
- Nervous - Does dressing as your assigned gender make you uncomfortable?
- tranS Sexual - Have you ever gone to see Rocky Horror Picture Show?
Opponents of the new guidelines argue that there is not yet enough data to properly evaluate outcomes for individuals receiving treatment. Psychiatrist Harry Seeward today was quoted as saying, "With the enormous technical obstacles we continue face in the phalloplasty procedure, our efforts must first focus on designing a better penis before we can reap the benefits of early diagnosis of GID."
August 20, 2009 – 7:03 PM
You know you reading an excellent book when something you read makes explicit a fact or observation that you didn't even realize you had. This is the case with the current book I'm reading, Michael Pollan's The Omnivore's Dilemma. In specific, at 29 years of age, I still consider myself to be relatively young. Yet, the days when one could easily obtain a mere 12 ounces of soda at one time - common when I was a child - seem to be those of a bygone era. Vending machines now sell soda only in massive 20 ounce packages. Who drinks that much soda at one time? Unfortunately the answer to that question is, more and more people do, thereby contributing to the epidemic of obesity in this country.
The reason why soda companies do this is fairly complicated, but is has to do with the ever falling price of corn. Today, coca cola (or any soda) is made mostly out water and high fructose corn syrup. Since the 1970's, our government has given subsidies to farmers to grow corn thus insentivising them to grow more and more of it. As a result, we have a massive surplus of corn and the price of corn is so low, it sells for less than it costs farmers to grow it. Recall that, after water, corn is the principle ingredient in your coke. What happens if the product you manufacture becomes cheaper to produce? You try and sell it to more and more people. But, we're not talking about cars or computers here. The market for something like soda is what economists call "inelastic." There's a limit to how much humans can drink. But, that hasn't stopped to soda companies from stretching, tugging and inflating the market to a near bursting point. "The price per ounce is as low as ever. Therefore, we're not going to sell you a mere 12 ounces of it. You're going to buy 20 ounces and you'll like it!" And, of course, consumers will buy pretty much whatever is marketed to them.
There's really no reason why anyone should ever drink more than 8-12 ounces of concentrated sugar at a time. In fact, our bodies are exquisitely adapted via the process of evolution to thrive in an environment where no such foodstuff exists. Therefore I propose that, like cigarettes, we add a surgeon general's warning to any concentrated sugar drink that is packaged in quantities greater than 12 ounces. It should read something like this: Consumption of this beverage in one sitting is likely to lead to weight gain, diabetes, loss of teeth, use of poor grammar and impregnation of your mentally challenged girlfriend with your ninth child whom you may name Cletus.
After coming a remarkable third place in this year's Tour de France, Lance Armstrong was gracious enough to answer some questions from Dr. Sanjay Gupta - medical correspondent for CNN. Wait a second, doesn't Lance Armstrong's cycling comeback and amazing result at the Tour de France fall into the category of sports? Why is being interviewed by CNN's medical correspondent? Well, Dr. Gupta may be an excellent neurosurgeon but it he was worth his salt as a reporter, perhaps he might have leveraged some his medical expertise in order to shed some light on the doping allegations that have plagued the all star cyclist. Here is the relevant excerpt from the interview:
GUPTA: One of the things you mention -- you talked a lot about during the whole tour was surprise test for doping. They just come and surprise you.
ARMSTRONG: They're not surprises any more.
GUPTA: Not surprising -- 40, I think over 40 tests.
ARMSTRONG: They're 50 -- they're 50 now.
GUPTA: What do you say to the critics? What do you say to the skeptics now at the end of the tour?
ARMSTRONG: Look, I've done this a long time. And I've been at the highest level now since 1992 until 2009. I've been tested more than anybody else. If I can take four years off and come back at the age of 38 with more controls than anybody else on planet Earth and get third in the hardest sporting event in the world, I think we've answered the questions.
Bravo. That's hard hitting stuff, Dr. Gupta. Why does everyone continue to dance around the core issue, namely, the man takes testosterone? He had testicular cancer. He had his testes removed. He has the unique privilege of being allowed to take testosterone. Dr. Gupta doesn't consider that maybe the general public might be interested in what Lance Armstrong's testosterone level is? What if it turns out to be much higher than average but still within the "normal" range? Should other athletes be allowed to supplement in order to bring their testosterone level up to that of Lance Armstrong's? To be honest, I don't even know if these anti-doping labs even test levels, or if they just test urine for banned substances. Maybe if CNN had sent an actual reporter, he or she may have reported on these things.
Anyway, I think this is just one further example that serves to highlight how futile, Draconian and ultimately ridiculous our policies are with regard to doping in competitive sports. As I've said many times before, decisions regarding taking hormones or any other drug are medical decisions and should be kept between an athlete and his or her doctor. Doping is only considered "cheating" because it is against the rules. Change the rules and it won't be cheating anymore.
The L.A.P.D. searched the office of Michael Jackson's doctor yesterday. According to DEA spokesperson Rusty Payne, whose agency is assisting with the investigation, the search warrant was issued relating to the drug propofol. Propofol is a powerful anesthetic and is almost never used outside of an operating room or ICU setting - certainly not the kind of thing any doctor would ever admit to prescribing on an outpatient basis. So far, there seems to be only speculation as to why authorities suspect Michael Jackson had propofol in his system. According to E! online (I'll have more reliabe sources for you when this blog generates enough revenue to hire a full-time researcher) the preliminary results of a second autopsy turned up lethal amounts of propofol.
Obviously, we need a lot more information before deciding on the gullt of innocence of Michael Jackson's doctor. But, what if he did OD on propofol? Maybe that's what his doctor was using to treat insomnia. I'm only playing devil's advocate here, and I challenge the reader to not so quickly dismiss the above described scenario as malpractice at best, manslaughter at worst. After all, in primary care we give patients drugs to help them sleep all the time. These drugs have risks; people can and do overdose on them. Your response is probably along the lines of, "But propofol for insomnia! This is madness. The risks of giving someone propofol in an unmonitored setting vastly outweigh the benefit of helping them sleep!" Sure, I don't disagree with you. But how does one decide where to invoke one's own values preferentially over patient values? I mean, if the patient truly understands the risks, maybe the risk does outweigh the benefit from his or her perspective.
One solution is, simply always let the patient decide. If he understands the risks and benefits of treatment, prescribe whatever he wants. You're just the expert consultant, the patient is the one directing care.
At other extreme are those who wouldn't subject their patients to any risk whatsoever unless they have clear evidence that treatment will result in decreased for morbidity or mortality. Such a doctor will never treat something like insomnia until someone can prove that people with untreated insomnia die sooner or have some other, quantifiable, adverse outcome and that said outcome is worse than the risks of treatment.
Most of us fall somewhere in the middle. But where? How do you decide? This question is particularly relevant to treating patients with chronic pain. How much pain medication do they need? Who decides? The solution I favor is to legalize all narcotics. Make them widely available so that people can treat themselves taking doctors out of the equation completely. There is no science, after all, to inform us as to how much pain medication is "enough." There is no "optimal" dose aside from 0mg PO q4hrs prn. The less you take the better. You don't need a doctor to tell you that. Of course, that doesn't mean you shouldn't see a doctor. Your doctor may be able to diagnose and fix whatever it is that's causing the pain, obviating the need for pain medication. That would be ideal. Unfortunately, doctors aren't always able to do this. Which puts us in the unenviable position of either prescribing or withholding medications that only increase morbidity and mortality and have only subjective benefit?
