The Case History of Everyman

doctor-visit

Let’s call him John Doe. John is a real patient and this is a real case history; however, this scenario could apply to any man. John came in about eight months ago for a “wellness check-up.” His affect made it clear that he really didn’t want to be there. His mind was on the golf course, or worse yet, on his overwhelmingly stressful job. It was an act of love that his wife made him come in, mentally kicking and screaming the entire way. It was also an act of reciprocal love that he consented to make the journey. After all, what was the big deal? A few extra pounds around the middle is just a part of growing older. OK, he was getting a bit more irritable, but it was certainly the job that was making him so fatigued. He figured that his mild erectile dysfunction was probably due to stress.

Of course it worried him a bit that he had heart disease in the family, and he was starting to accumulate quite a few risk factors himself. As it turned out his “wellness check up- up” revealed that he wasn’t so well after all. In fact he was careening down the road to ruin with a faint vision of an imminent crash in sight in the form of diabetes, heart attack, and/ or stroke. Until we got his labs back, we didn’t fully appreciate how dire things really were.

His triglycerides were through the roof. His cholesterols were elevated with lots of the bad kind. The good kind was barely to be found. His C-reactive protein, a sensitive measure of inflammation and an excellent predictor of heart disease, was also sky high. His testosterone was i n the basement. His vitamin D was tanked with serious implications for his immune function and cardiac function. We tested his overall nutritional function and found numerous other deficiencies. If all this was n’t bad enough, his blood sugar was elevated and he met the criteria for metabolic syndrome, a complex metabolic condition which portends heart disease, diabetes, and stroke.

Fortunately, the labs got his attention when his wife and I had failed. They painted an undeniable picture of pending catastrophe. Life had a bullet with his name on it, heading straight for his heart. He realized that he was at a cross roads in his life. The age old cardinal sins of gluttony and sloth, along with the modern day curse of unrelenting stress were taking its toll. It also didn’t help that he was an unwitting victim of the modern American diet (MAD diet) and ubiquitous environmental toxins. John Doe realized that he had a choice, as most of us do. He could continue on the same path destined to result in misery and premature death, or he could turn his life around and travel down the path of wellness and vibrant living.

The first and most important step in this process is the mindful realization of the problem. Instead, the insidious slippery slope of illness stealthily stalks us day by day. Most of us never see it coming until the heart attack hits us. Men in particular live in a perpetual state of denial. Oh, we might pump a bit of iron to keep the biceps firm, and we might take some Viagra to keep other things firm, but the light bulb of wellness often does not illuminate until it is too late. Fortunately for John Doe, he got it!

The next important step is Intention. That is, intention to make a change. This step is never easy. It means altering a lifetime of bad habits. Habits that we got away with for
so many years i n our youth, but which then come back to haunt us. Fortunately for John Doe, he clearly saw the light and headed toward it full steam ahead. He started an exercise program, heavy on the cardio. He went on a serious diet appropriate for his condition. We corrected his underlying metabolic and hormonal deficiencies. He started a targeted supplementation plan to correct his nutritional deficiencies, and to provide therapeutic relief from some of his conditions. It was an amazing transformation.

When John arrived back in the office for his follow up visit, I could hardly believe my eyes. He had lost more than 20 pounds, as well as four inches from his waist. He was looking fit and trim and full of energy. He announced that he was feeling fantastic. We sat down to go over his labs and i n every instance there was remarkable improvement. His bad cholesterols were significantly down, and his good cholesterols were up. His markers of inflammation were dramatically improved. His metabolic syndrome had gone away. His vitamin levels were robust. In summary, John Doe was like a new man. He felt better than he had felt for years.

As we dedicate this edition of Natural Awakenings to men, I hope that all men will take hope from Joh n Doe. Just as John Doe turned his illness into wellness and will reap a longer more vibrant life, so too everyman holds within him the potential for greater wellness. We have been given precious gifts of mind, body, and spirit. To reach our full potential, we must nourish and grow these gifts with mindful attention.

Take note of the path that you are on. Are you at a crossroad? With steadfast intention, day by day, and step by step, begin your journey down the path of wellness. You and your loved ones will reap immeasurable and priceless rewards for the rest of your life.

This article is meant to educate. It is not intended to diagnose or treat. Anyone with a problem related to the issue discussed in this article should consult a qualified health care provider.

What is Hormone Imbalance? Is it Andropause or Menopause?

andropause

Hormone imbalance is a medical condition that arises when one or more hormones get out of balance with the rest of the hormones. When this occurs in women it is called
menopause. When it occurs in men, it is known as andropause.

The world we live in today is not the same world we had 100 years ago. Today we see many factories producing man-made chemicals at an alarming rate and discharging the waste products into our environment or putting them in our food and water supply. Once these chemicals are in our environment we are then exposed to them via breathing, drinking contaminated water, or eating foods that contain these chemicals, etc.

Many different chemical products that we come in constant contact with can cause the estrogen to increase in the body. This in turn can result in a compromise of the endocrine system which can lead to a hormonal imbalance. Once these chemicals are in our body, they have the opportunity to do considerable damage to whatever they come into contact with or disrupt.

If we are to understand the origins of hormone imbalance, then we must first examine how age affects the body itself. In a natural progression of aging, normal production of testosterone decreases as we grow older, and the percentage of testosterone vs. estrogen is reduced. Combine that with the exposure to harmful substances in our food and environment, and the estrogen levels begin to increase steadily resulting in a hormonal imbalance in men.

The modern world finds us contsantly exposed to a new type of environmental compound known as xenoestrogens. This particular type of estrogen, generally classified as petrochemicals, posess an extremely powerful estrogen-like effect. These xenoestrogens can be found in the air we breathe, plastic materials, clothing, herbicides and pesticides as well as personal care produtcs. As you can see it is not very difficult in today’s times to be exposed to a number of these chemicals.

Sadly, the modern diet is also polluted with hormones. Synthetic estrogens are now commonly found implemented for the production of larger cattle and other meat-producing animals, as well as to boost egg and milk production. Many of us are eating our way into estrogen dominance as many foods now contain small to large amounts of estrogen. Farmers put estrogens in the foods they feed their livestock. Many birth control pills are not biodegradable and can be found in many of our towns and cities water supply. Synthetic hormones have chemical structures that are not compatible with our bodies and therefore tend to interfere with normal body functions.

lowtestosterone

So what does all of this mean to men when they have too much estrogen? It means that they are in the male form of menopause, called andropause. Andropause is similar to menopause in women. The difference is that women begin to have a decrease in estrogen and men tend to have an increase in estrogen or a decrease in testosterone. Testosterone does tend to decline
with advancing age which will cause a change in the ratio  of testosterone to estrogen. Andropause finally takes over when the men have a higher level of estrogen than they do
testosterone.

When this condition occurs it can take the form of many different ailments and conditions. It can produce enlarged prostate, low sex drive, impotence, urinary problems, depression, fatigue, foggy thinking, and an unusually rapid increase in weight. Some medical studies have also linked low testosterone to diabetes as well as an increased risk for having a stroke.

What should any man do that is experiencing any of these conditions? The first step is to make an appointment with a doctor to have your hormone levels checked. This is not quite as easy as it sounds because there are many different ways to check hormones; blood is just one of the ways. Other tests appear to be more accurate than blood; however, sometimes a combination of different tests is what is needed to find the imbalance.

Once this imbalance has been identified, you then need to be treated to reduce your estrogen levels and increase your testosterone levels. Do not make the mistake of simply taking more testosterone! Why? Because taking more testosterone and not finding out why your estrogen is elevated is asking for more problems. This is like putting fuel to the fire because your body can convert the increased testosterone into more estrogen.

For information on all-natural testosterone boosters and finding the best male enhancement supplements, visit MaleHealthReview.com.

Your choice of doctors is certainly your decision, so make a wise choice. At Madison Clinic we work with hormones every day. We have different methods of testing your levels, as well as natural treatments to help reverse the problem.

What is Swine Flu?

swine-flu

Ignorance is truly bliss under many circumstances, but when it comes to a person’s health and well-being, knowledge is definitely power.

A case in point is the recent public health scare occurring in response to the swine flu. With the barrage of media attention, it’s easy to get lost among the flurry of information, creating confusion and, ultimately, panic within the population. To lessen fears, it can be useful to understand exactly what makes the influenza virus, something that already affects many people each year, tick.

An Influenza virus invades the cells of a person’s respiratory system in order to accomplish one goal: to multiply, or make more copies of itself. After gaining entry to a cell, the virus hijacks the machinery contained therein, forcing it to make the components necessary for new viruses. When the task is complete, the newly created virus particles burst out of the cell and search for other healthy cells to invade. Its “life” cycle then begins again.

An influenza virus has two components that are needed to enter and then exit a cell. These proteins are called hemagglutinin and neuraminidase, respectively. The scientific terminology for the swine flu virus, H1N1, actually corresponds to the names of these two proteins, and the numbers correspond to particular variants of these proteins. Hence, H1 is hemagglutinin variant 1 and N1 is neuraminidase variant 1 .

There are 16 varieties of hemagglutinin and 9 varieties of neuraminidase, and the combinations of these two constitute different strains of the virus. Some may remember when the world turned its attention to H5N1, or the “bird flu,” only a few short years ago. The virus’s neuraminidase protein has become an effective target for anti-viral drugs such as Tamiflu. Because a virus needs its neuraminidase to leave the cell it invaded, blocking its ability to function keeps the initial virus and all its new copies bound inside the cell instead of being able to leave and prey upon other cells.

Each year, scientists keep a close watch on influenza outbreaks that occur across the country; based upon the information, a prediction is made about which influenza strains are likely to affect the human population during the upcoming flu season that typically occurs from December to March. Vaccines are then tailored to these predicted strains so that the immune system will be armed with protective molecules to recognize and kill a virus in the event of infection.

Flu vaccines are not effective from year to year, however, because the virus mutates continually in an effort to avoid being noticed by the immune system. Influenza type A viruses, which includes 2009 H1N1, have a high rate of mutation and can affect people of all ages, pigs, and birds. In some cultures, it is common for people to live closely among these species, breathing the same air and creating an opportune environment for the influenza subtype A viruses to be passed between each other. These conditions, combined with the propensity of the virus to mutate, facilitate the evolution of a strain such as H1N1 that is problematic because it spreads easily from person to person, people do not have immunity to it, and there is not yet a vaccine.

You Know You’re a Natural Man If…

natural man

Ok, guys, I know you’re making the shift. You might not notice, but it’s happening – you’re slowly but surely evolving into a more sustainable, mindful, sensitive and peace-ful way of life. It may start as simple as taking your own bags to the grocery store and shopping for local produce or tak- ing a yin yoga class and getting regular massages. I whole- heartedly commend you. But just in case you’re not convinced, here are a few hints to determine if you are indeed embrac- ing the art of natural living.

You Know You’re a Natural Man If…

• You faithfully recycle your organic beer cans
• You go fishing with the guys and try and to save the fish
• You get lost driving and meditate for 5 min. to figure out the directions
• Your boxers and briefs are made from hemp and bamboo
• Your idea of kicking butt is doing T’ai Chi
• Instead of getting road rage when you’re stuck in traffic, you chant “ommmm” until the feeling passes
• You smudge yourself after a bad day at work
• At the first sign of feeling sick, you whip out a bulb of garlic and chew it
up without wincing
• You drum and dance naked under the full moon
• You read Nature Magazine

Live It Up Natural Guys.

Lose Anger, Lose Weight

Office Worker Yelling at Computer

Men who are angry and hostile pack on more pounds over time than women or their less angry, more laid-back peers, suggests a French study, which found that the more hostile a man’s personality, the more his body mass index (BMI) increased during an extended period. The researchers noted that hostility could affect weight in many ways; for example, hostile men may be less likely to follow dietary health guidelines, tend to exercise less and are more likely to be depressed—all factors known to contribute to unhealthy weight gain.

Researchers reviewed data on 6,484 men and women participating in a U.K. study of socioeconomic status and health. Participants ranged in age from 35 to 55 at the study’s outset. Results culled over a 19-year period showed that, while the relationship between BMI and hostility remained constant for women, hostility seemed to accelerate weight gain over time in men.

Source: American Journal of Epidemiology, 2009

Ride For Them 2007 !!

Hi all,

Despite the “I’m Back” post from a couple of months ago, I seem to have fallen off of the blogwagon pretty hard. It’s certainly not for lack of material. Rather, it’s for lack of time. I’ve been working hard in the lab, working hard in the clinic, and more recently, working hard on the bike.

Once again, I’ll be riding in the Pan-Massachusetts Challenge, a 192-mile ride from Sturbridge, MA to Provincetown, MA. All of the money raised by the Pan-Mass Challenge goes to support the Dana-Farber Cancer Institute. I’m very luck in that all of the money that I raise is held in a specific account that my teammates and I can use to directly fund programs to support pediatric oncology patients and their families. Last year I raised over $80,000 and our team raised a total of $135,000. This year we’ve expanded the team and hope to break $150,000.

So for now, I’ll be blogging very sporadically and cycling more regularly. If you could please visit my PMC website, www.rideforthem.com, I’d appreciate it. There you can read the stories of the children that I ride in honor and in memory of. If you are interested in making a gift to this important effort, please click here. Finally, if you have a blog or other website, would you consider posting a little blurb about my effort, and perhaps a link to the Ride For Them website ? I think it would be absolutely terrific if the physician- and nurse-blogging community could help me make a concerted effort this year to spread the word! I appreciate the kind words and the link provided by Kim over at Emergiblog.

Thanks for considering this! I’ll leave you today with a local cable news piece supporting my ride last year. If you go to the Ride For Them website I have a few other interesting videos regarding my ride and the PMC.

I’m back.

clock

As one can tell from scrolling through the sparse entries over the past 6 weeks, I’ve been laying low. It’s actually been a nice little holiday – I find that a break every now and again helps gets the creative juices flowing again. Plus I’ve been working on a couple of other projects, one that I hope to reveal in the next 3-6 months.Given that it is relatively late, and that I’ve had something of the emotional day, I’m going to keep this entry short. Before long, I’m sure that I’ll get back into the swing of things. There are grand rounds to write for and to host. Flea did me the favor of tagging me with the ‘Why Do You Blog?‘ meme (which I’m hoping to respond to). And the lovely Dr. Signout tagged me with the ‘Thinking Blog‘ meme.And since blog memes are always a cheap and easy way to fill blog space, I think that I’ll start one percolating around and see how far it goes. I’m calling it the “$456 billion meme” (which should be pretty easy to track in Technorati).

This meme is inspired by something from my hometown paper, the Boston Globe. They posted a pictorial feature called, “What does $456 billion buy?“:

While there is some disagreement on the idea of troop deadlines for US soldiers in Iraq, all sides seem to be on board with the amount included in the bill to fund the war.

Including the $124.2 billion bill, the total cost of the Iraq war may reach $456 billion in September, according to the National Priorities Project, an organization that tracks public spending.

The amount got us wondering: What would $456 billion buy?

The Globe did a great job of listing some of the obvious places where this money could go: education, environment, global poverty. They also really (in my opinion) stepped in it with this one:

US drivers consume approximately 384.7 million gallons of gasoline a day. Retail prices averaged $2.64 a gallon in 2006. Breaking it down, $456 billion could buy gasoline for everybody in the United States, for about 449 days.

Please. Could that be any more infuriating? And appalling?

Here’s my suggestion: $456 billion could probably buy a cure for cancer. Given that we fund the National Cancer Institute to the tune of about $4.8 billion, and the entire NIH for about $28.85 billion, we could fund the work of the NCI about 100 times over for the money we’ve pissed away in/on Iraq. And the 3376 American soliders killed? We could send all of them to college and graduate school and staff 10 or 20 brand new cancer centers. And pay for the laboratories.

So this is the meme: where would you have spent the $456 billion spent on this miltary action? I hereby tag Flea, Signout, Clark, GruntDoc and Dr. Rob. For those not tagged who have an suggestion, feel free to comment here. Or at the Globe’s website. Or both!

Grab your tissues. This is what Pulitzer Prizes are for.

It’s coming up on 3 years for me as a pediatric oncology fellow. As I’ve discussed earlier in this blog, it take an increasing amount to generate an overt emotional response. I’ve come to the conclusion that this is due to the fact that my emotional range has been severely re-calibrated as a result of my experiences.

Therefore, it is a testament to the power and beauty of the photographs that earned Renee Byer, of The Sacramento Bee the 2007 Pulitzer Prize for Feature reporting that tears welled up in my eyes as I scrolled through the twenty photographs documenting Derek Maden, and his mother Cyndie French, during his 11-month battle against neuroblastoma. I’m certain that you will find these photographs as compelling and heartbreaking as I did. Their honesty and intimacy blew me away. They are by far the most accurate a portrayal of childhood cancer as I have seen in the lay press, and triggered flashbacks of the children that I’ve seen whither away as a result of their disease.

I hope that these photos will motivate you to consider joining the fight against childhood cancer – either by writing your federal representatives to argue for more support for cancer research – or more directly, by making a donation to my 2007 Pan-Mass Challenge effort. A good part of the money that I raise goes directly to helping support children and families during their cancer treatment.

A small donation, no matter what the amount, will help. Please visit my website – Ride For Them – read the stories of the children that I take care of, and consider helping me in this important effort.

Thanks.

[NB: Thanks to Mark Hemingway at MetaFilter for bringing this to my attention.]

Grand Rounds: Volume 3, Issue 26

Welcome to Grand Rounds

amphitheater1
William Osler conducting Grand Rounds
(courtesy of the medical archives at Johns Hopkins University)

Introduction

It is a privilege to host the current issue of the medical blog Grand Rounds. As an afficionado of medical history, it is remarkable to see this latest incarnation of process that has “evolved from centuries-old practices that trained physicians by means of apprenticeships.” (Mueller et al., Mayo Clin Proc 2003 ). Medical grand rounds have morphed from ward-based teaching or using an illustrative case presented in an auditorium (as illustrated above) to a lecture format. In William Osler’s day, grand rounds took place at the bedside and were lead by master clinicians. It is now uncommon for patients to have anything to do with medical grand rounds. Most of the grand rounds that I have attended have been didactic talks delivered by the more senior members of the faculty or occasionally by a guest speaker. More and more, grand rounds appears to be no more than a weekly lecture series. Grand rounds have been poked at in the medical literature, have been critically analyzed with regard to their utility and cost, and have been entirely revamped at one of the oldest hospitals in the country. More recently, some have recommended looking at grand rounds from a “consumers’ perspective“. Clearly, grand rounds will continue to have an important education and social value, but it appears model will continue to evolve over time.

I recommend Dr. Lawrence Altman’s terrific piece on the changes in grand rounds from the 12.12.06 issue of the New York Times. Interestingly, Altman ends his piece with a anecdote about how humor can occasionally crop up in grand rounds. As an in silico experiment I Googled the phrase “grand rounds humor” and was thrilled to see that nearly every one of the first 30 entries linked to an edition of the medical blog grand rounds. I conclude that we are on the forefront of a revolution on grand roundsmanship, one that blends medicine with humor, thoughtfulness, open-mindedness and inclusiveness.With this as an introduction, I present to you the best of the week’s medical blog entries.

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Students

It is unusual to have students present cases at traditional hospital grand rounds, which is exactly why I feel compelled to lead off with the medical student entries this week. Of course, the first entry that I will share with you came to me a good 7-1/2 hours after the deadline. Jeffrey, a medical student at Monash University in Australia, being properly interested in the basics of physiology and neuroscience, contributes an interesting review of a phenomena that I’ve experienced, and I am certain that others have as well: music can motivate you during physical exercise and more importantly, help you build positive associations that will increase your desire to continue exercising in the future. Clearly Apple and Nike have capitalized on electronic positive feedback during exercise.

Jeffrey gets an inadvertant bonus point: while looking for something with which to back a pithy comment about his tardiness, I came across a fascinating and personally relevant study done by Dan Ariely at the Massachusetts Institute of Technology entitled, “Procrastination, Deadlines, and Performance: Self-Control by Precommittment” (click here for .pdf). In this study, the authors, after recognizing that procrastination is a familiar trait and that people sometimes attempt to control their procrastination by setting deadlines for themselves, pose three questions:

(1) Are people willing to self-impose meaningful (i.e., costly) deadlines to overcome procrastination? (2) Are self-imposed deadlines effective in improving task performance? (3) When self-imposing deadlines, do people set them optimally, for maximum performance enhancement? A set of studies examined these issues experimentally, showing that the answer is “yes” to the first two questions, and “no” to the third. People have self-control problems, they recognize them, and they try to control them by self-imposing costly deadlines. These deadlines help people control procrastination, but they are not as effective as some externally imposed deadlines in improving task performance.

Also earning bonus points this week is the remarkable Bertalan Mesko, a medical student at the University of Debrecen, Hungary. I am certain that those of you who read last week’s Grand Rounds, or who regularly read his blog, ScienceRoll, are as impressed as I am with the quality of his writing, the depth of his interest, and his sheer productivity. Clearly, Bertalan has a unique degree of intellectual curiosity and an impressive dedication to genetics. As a result of one of his blog entries on newborn genetic screening, he had the chance to make contact with the mother of a child with medium chain acyl CoA dehydrogenase defect. He shares what he learned of the newborn screening system in the United States.

We received another international medical student entry courtesy of Mexico Medical Student, who studies in one of my favorite places in Mexico, Guadalajara. Enrico is a 2nd year student who has been blogging on-and-off since 2000 and has submitted the fascinating “5/4“. I’ve encountered a couple of physicians in my life who enjoy integrating mathematics into medicine (pun well intended). Enrico’s blending of music, math and medicine deserves recognition for creativity and insight.

Patients and Families

The inclusion of families at grand rounds is probably less common than that of medical students or patients. A Medline search for the phrase “parents AND grand rounds” turned up only three papers, including this fascinating speech given by parents of a NICU child to an audience of physicians at teaching hospital.

This week I was fortunate to receive a number of entries from both patients and families, including one from Moreena, the mother of a child awaiting a 3rd liver transplant. At her blog, The Wait and the Wonder, she writes about the public nature of illness, in particular the isolation in plain sight that occurs when a clearly ill child is out in a public place. She also has written a thoughtful piece in response to some of this blog’s musings about privacy issues in medicine in the age of Google and webcams. Moreena brings up the boundary issues in medicine, but not as the idiom used by physicians and nurses refer to professional boundaries. Instead, Moreena thoughtfully discusses the public/private boundaries with regard to illness:

Trying to figure out how much to reveal, and where to draw the line between the personal and the private in the medical world, is still a delicate subject. I’m guessing that many doctors and nurses have a stronger sense of that boundary, since the nature of their jobs thrusts them into the private world of so many people, and with so little ado. (”Hello. My name is Dr. X. And now it is time to feel up your liver!”) Certainly, I would agree that videotaping the comings and goings of hospital personnel without their permission shouldn’t be allowed, especially since so much that was previously private is now broadcast with little thought.But, in trying to protect privacy and the legal interests of the hospital, I hope that doctors and nurses will remember that the medical life, the details that may seem so squicky and intimate to them, are also just part of everyday life for their patients.

Speaking of “squicky and intimate” details, I received an eyebrow-raising entry from Amy Tenderich who writes Diabetes Mine. Her entry entitled, “Too Sexy for My … Pod?” reminds us that patients who live with internal and external devices still need to get undressed in front of their spouses as part of “every day life”. I’ve been fortunate to not really have to consider whether or not my patients consider their port-a-caths to be “not sexy”. Very fortunate. But clearly for a woman with a wireless, continuous glucose monitor attached to her lower abdomen, this may be an issue.

For more on new technologies in diabetes care, I refer you to Dr. Rima Bishara’s entry on insulin pumps. Dr. Bishara is a relatively new blogger with 15 years under her belt as an internest, and we should welcome her into the fold.

Nurses, Dieticians and Pharmacists

It is much more common, in today’s large medical centers, to see specialized versions of grand rounds, including Nursing Grand Rounds (from my residency alma mater), Palliative Care Grand Rounds, and Pharmacy Grand Rounds, among others. Rather than have all of these exist as separate forum, I’m pleased to use thus edition of the medical blog Grand Rounds as a means to include other health care providers.

In doing so, I want to start with an entry from n=1’s Universal Health blog, which is entitled, “Docs On Nurses: CME is a Must. As the husband of a nurse, I found his/her perspective to be both refreshing and enlightening as well as important and extremely well expressed. N=1 makes an important observation that I have, of course, witnessed and been guilty of but had not, until now,appreciated in this manner:

At any given time, in any given healthcare patient setting, nurses are routinely interrupted more than once per minute. This includes while they are administering medications, while they are validating orders, while they are planning care, while they are teaching, while they are comforting a grieving family, while they are discharge planning, while they are in the middle of a sterile procedure – any time, anywhere. This multitasking capability is difficult and complex to learn and to use on a continual basis.Physicians wouldn’t tolerate that routine interruption to that degree and on that basis. But nurses do, and that’s considered the norm of clinical practice.

N=1 reminds physicians (and everyone else) that nurses are not in pace to be “bacon savers” – an attribute that I’ve ascribed to many a nurse who has kept me from making a mistake – but are equals in the healthcare team. This view is probably more common to my generation of physician than, say, my father’s generation, but is still not universally accepted. I want to highlight this post for both the importance topic and the excellence of the writing. My stethoscope is off to you, N=1.

Nurse Ratched, among others, has been set upon both by JCAHO and by her hospital’s attempt to create new revenue streams. Her post entitled “Bottom Line Therapy” sheds light onto the seemingly endless upward spiral of new programs, metrics, and technologies implemented as the health care system evolves away from simply caring for patients.

In honor of March being National Nutrition Month, Andrea Giancoli who writes The Family Fork, brings us some useful tips for helping patients to evaluate claims made by many of the fad diets that have been popular for the past 30 or 40 years.

On the pharmacy front, the prolific and thought-provoking David E. Williams takes on last week’s Wall Street Journal piece on disparities in the pricing of generic medicines.

Physicians

Finally, we come to the physicians who have, as usual, provided a wealth of thought provoking entries. Dr. Elmer at Parallel Universes provides what will undoubtedly be one of the first in a slew of posts stimulated by Dr. Jerome Groopman’s latest book, How Doctors Think. Dr. Elmer’s recounting of his colleague’s ‘thinking error’ leads him to opine that we should focus more of our medical education efforts on teaching students how to think as well as what to think about. For those interested in one view of the ‘thinking’ behind medical decision making, I strongly recommend Edmond A. Murphy’s The Logic of Medicine.

RayGunGirl, an intern headed for a career in radiation oncology, shares an extraordinarily personal story that links nicely to Jerome Groopman’s work. One of the problems that Groopman believes leads physicians down the wrong path in their thinking are their biases against certain patients or types of patient. In her entry entitled “Toys in the Attic” she realizes what many seasoned physicians have learned: we all have a lot more in common with our patients that we realize – we just need to be willing to find, admit, or recognize it. Making these types of connections facilitates the empathy that makes for the best physician-patient (or nurse-, pharmacist-, etc.) relationships.

Speaking of interns, surely all of you know that last Thursday was Match Day for nearly 22,000 medical students. For most, it was a fine day, including the author of pumpkin doodle – a fourth year student who matched to her first choice last week, and who I file under “doctors” today on the occasion of her impending graduation and the fact that this is her very first Grand Rounds post. Despite pumpkin doodle’s joy, it should be recognized that there were nearly 28,000 applicants for only 22,000 positions, making for 6,000 unhappy individuals. Dr. Bard Parker at A Chance to Cut is a Chance to Cure reviews the match statistics for the 2007. He finds that family medicine continues to be in decline from the standpoint of filling residency slots with US medical graduates, while radiology and surgery did well. To my surprise, given the stress on the nation’s emergency medicine system, Bard reports Emergency Medicine was this year’s “big winner” according to this one metric.

While the match numbers for internal medicine may be flat, Dr. Val Jones, who writes Dr. Val & The Voice of Reason, has seen interns with the compassion, drive, and determination needed to be tireless advocates for their patients. She describes one such intern in her entry entitled, “Do The Right Thing“:

The next day during ICU rounds the attending physician asked for the name of the intern who had insisted on the admission. After hearing the name, he simply replied with a wry smile, “remind me never to f [mess] with her.”

Dr. Kenneth Trofatte writes the amusingly titled Fruit of the Womb. His two posts this week on early pregnancy loss (part one and part two) shed light on the far less amusing side of obstetrics and gynecology. It wasn’t until I read Dr. Trofatter’s post that I realized that he has given, and will continue to give, far more bad news about the loss of a child that either I or most pediatric oncologists will. I particuarly appreciated this quote:

The MD after my name means that I am the one responsible for the Morbid Discussion that has to take place to inform a couple that they have a pregnancy that didn’t make it through the first trimester.

We have a couple of other great perspectives on discussions with patients. Representing frustrated this week is Artemis who writes (naturally) The Thoughts of Artemis where she vents her frustration with getting her patients to answer questions:

Why is it so difficult to put together a history? It’s not just patients with memory issues who have a hard time compiling a list — so-called “normal” folks have as much difficulty as well. [I]t’s frustrating to have to spend so much time trying to put together the ‘back story’ when it should be as readily supplied as the list of medications that (some) patients put together.

Representing wistful is the always eloquent Signout, who expresses her regret at missing the opportunity to answer a question for her patient:

“I’m a sick, sad old man,” he said, and was quiet for a while. Through the stethoscope, his silence sounded like the inside of a seashell. Then, foggily, as if from inside the earth, he said, “Is this worth it?”I didn’t know how to answer his question. Looking back, I cheerily ignored it.

Keagirl (who I guess chose her name as a play on Kegel), our friendly urologist who writes Urostream, sounded neither frustrated nor wistful following her encounter with a surly and inappropriate Emergency Department physician. I hope that Dr. Bard (above) is correct because it sounds like Emergency Medicine could use the extra help in order to keep their physicians from acting this poorly to the consulting specialists.

We actually heard from two urologists this week, one of whom works on the cutting edge of surgical technology. In his blog, Thoughts from a Robotic Surgeon, Dr. Domenico Savatta shares some of his practice data with regard to robotic prostatectomies and, in my opinion, correctly implores his fellow surgeons to collect and report accurate data to their patients in order to avoid “guesstimating” and in order to help patients make their own informed decisions.

A number of the physician bloggers took on items in the news this week. Of note is an entry from Dr. Philip Gordon’s Tales from the Womb on the use of recombinant human erythropoietin in cancer patients. Once again we find ourselves in a situation where the marketing, and in this case the strong direct-to-consumer (DTC) marketing, has gotten far ahead of the efficacy data for a drug. As one who has used erythropoietin in some non-malignant hematologic disorders as well as in post-stem cell transplant patients, it is interesting and concerning to read his description of the increasing use of rhEpo in neonatology in the absence of clinical trial data in this population. I also agree with his harsh criticism of DTC ads for these remarkably expensive and specialized drugs. It’s one thing to consider the general populations ability to critically assess their need for a drug like sildenafil. It’s another to expect them to be able to critically assess the utility of recombinant hematopoietic growth factors such as erythropoietin or PEG-filgrastim (Neulasta).

In a similar vein, Grunt Doc addresses the recent FDA warnings regarding the reports of bizarre behavioral effects of the prescription sleep medications and shares a case he observed. I strongly recommend reading through the comments to this post, which are nearly as fascinating and entertaining.

Dr. Anonymous, apparently more concerned with staying awake than going to sleep, reports on the news that the “pick me up” people feel when drinking that first cup of coffee in the morning may have more to do with stopping withdrawal symptoms than with the stimulant effects of caffeine.

Over at the superbly produced and extremely well-written Aetiology we have Dr. Tara Smith’s entry on antibiotic resistant bacteria in the non-human members of the primate order. Her entry was inspired by the recent news, and subsequent blog entries, regarding the use of the 4th-generation cephalosporin cefquinome in cattle. We often think about antibiotic resistance from the point-of-view of humans or domestic animals intended for human consumption. Dr. Smith opens our eyes to the potential for spread of resistant organisms to the farthest corners of the planet. Slipping into the juvenile, I must take a minute to say that her line, “I told you you could learn a lot from studying an animal’s ass!” is will surely share with my gastroenterology colleagues in the future.

The international use of antibiotics was also discussed by Dr. Paul Auerbach, who a surgeon with an appointment in Emergency Medicine at Stanford, who specializes in Wilderness Medicine. I envy Dr. Auerbach’s travels to Everest Base Camp in Nepal. He returns with some good advice on the antibiotics that he would recommend taking with for international travel.

While I prefer to share essays in Grand Rounds, I feel compelled to add Dr. Jon Inarritu’s contribution from his blog, Unbounded Medicine. Dr. Inarritu sends us this video of a public service annoucment regarding anorexia, bulimia, and body dysmorphic disorder.

I want to close with two entries from a source that I would not have discovered had it not been for my hosting this issue of Grand Rounds. Reading these reinforces my believe that we are truly privileged, not just to have our remarkable medical blogging community to share our thoughts with, but that we are also very lucky to be able to do what we do in the field of medicine. Susan Palwick is a volunteer emergency room chaplain who has been constructing a series of sonnets based on her experiences. She sends us The Ed Sonnets: Room 6.2 which is beautiful in both its construction and message. To have this alone would have been enough. But read ing through her blog, Rickety Contrivances of Doing Good, I came across this remarkable entry entitled ‘Chaplain Stress’ in which she provides yet another unique perspective and set of observations on circumstances that I have missed due to the desensitization that accompanies frequent exposure. I can’t pull out any one quote because the entire post should be read. I strongly encourage you to visit this and share in the rich subtext that physicians and nurses can sometimes overlook in the stuggle to handle our busy workloads.

Conclusion

That’s all for this issue of medical blog Grand Rounds. It was a treat to assemble Grand Rounds and I hope that you take away as much from reading it as I did from writing it. My thanks to the bloggers whose entries have been used, and to the bloggers who entries there was enough room for. The next issue will be hosted at Medviews on Tueday, March 27th. My thanks also go out to the talented Dr. Nick Genes for keeping this remarkable tradition alive.

Pediatric Grand Rounds: Volume 1, Issue 24

©2003 Derek Dudek

Welcome to Pediatric Grand Rounds, Volume 1, Issue 24!

It seems that many of the pediatricians are swamped with patient care duties. It could be the tail-end of RSV season, the onset of rotavirus season (depending on where you are), or the ongoing norovirus outbreaks. Whatever the case, this week’s call for grand round submission resulted in more entries from the recipients of pediatric care than from the providers. As always, because the purpose of grand rounds is to broaden one’s perspective, I’ve included equal number of both and also purposefully created the artificial divide of physicians and patients to allow one to compare and contrast the perspectives.

Pediatricians

I’ve come to expect discussions regarding immunization to come from my friend Flea. However this week it seems that Dr. Rob at Musings of a Distractible Mind is going to carry that particular torch. In his entry, “I Hate Immunizations” he discusses the non-medical aspects of this fundamental work done by our specialty. His inclusion of the very busy 2007 Recommended Immunization Schedule reminds me of the challenges faced by pediatricians who have so much important work to fit into a 15 minute office visit.

The ever-entertaining Flea offers us “More Notes from the Lunatic Fringe”. Flea must have some special radar for finding people with odd credentials weighing in on subjects such as immunization and shaken-baby syndrome because he manages to bring us the story of Viera Scheibner, a retired micropaleontologist from Bratislava, Slovakia, who fancies herself an expert on vaccines despite the fact that she’s neither a pediatrician, a physician, an immunologist, nor even a biologist. After reading his post and the Wikipedia entry on “Dr.” Scheibner, I think that I agree with Flea’s description of her occupying a place far out on the fringe. I am wondering if Flea’s subscription to the New Yorker is up-to-date. If so, he must have loved the story in this week’s issue on HIV and AIDS deniers and the devastating impact they’re having on the lives of HIV-infected people in South Africa.

In a similar vein, Orac’s post, “The Depths of Antivaccination Lunacy” goes into greater detail about people on the fringes of reality trying to link vaccinations to shaken baby syndrome. Orac’s blog, Respectful Insolence has long been one of my favorites, both for the quality of his writing, the depth of the content, and the “prickliness” with which he takes on the pseudoscience frauds who prey on the fears of others.

The always-resourceful Shinga has introduced to me the pediatrician blogger David Blake, who writes the interestingly-named Mavistown 3.0. Shinga volunteered David’s accounting of a parental malapropism for this week’s grand rounds. Happy that I pulled the correct grammatical term out of some dusty 6th-grade synapse, I googled ‘medical malapropism’ to see what else I could find and came up with a couple of cute cartoons courtesy of Twosheep, a knitting blog. Of note, Twosheep is clearly a science nerd. Intrigued, I dug a little deeper and found a bona fide article from The Journal of Family Practice, entitled (appropriately) “Children’s medical malapropisms”. You can get the radiologists (markedly less funny) perspective on medical malapropisms here (note: links to .pdf file).

Sandy, at Junkfood Science, submitted a number of entries, from which I’ve selected her essay on the safety of cow’s milk and the occasional hysteria around recombinant bovine growth hormone (rBGH). While I’m likely to agree with Sandy on the safety of milk, and her assertion, “… that milk is … a perfectly safe, wholesome and nutritious food for growing children and those who choose to enjoy it,” I am, of late, less convinced that cow’s milk is the best food, or even necessary, for human children, as I’ve detailed in my post, “Not Milk?“. This short piece was inspired by new genetic evidence showing that the lactase gene is the egg, and not the chicken (how’s that for mixed metaphors!) when it comes to digesting lactose.

On the NICU front, Neonatal Doc elicited a whopping 38 comments on his post entitled, “Village” where he discusses one of the core dilemmas in neonatology: who does, or should, shoulder the work of caring for the severely impaired children that are the product of our resuscitating younger and younger pre-term infants? In doing so, he raises important and difficult questions about the ethics of “saving” these remarkably premature newborns.

Clearly, though, there are miraculous saves that take place in the NICU. A couple of weeks ago the major news outlets trumpeted the survival of a 22 week old preemie. Laura, at Adventures in Juggling celebrates the healthy checkup of her ex-24-weeker (and the child’s vaccination experience) in her post entitled, “Doing Shots Mean Mommy Style”.

Shinga sent me well over a dozen different selections this week, and I was a little worried that she had failed to include her own entry. Sure enough, tucked at the bottom of a long e-mail I found a link to her post entitled, “Vaccination versus Faith in Vitamins” Touching, But Insufficient Evidence“. It seems like she’s taken her lumps in the fight that we pediatricians wage to prevent illness in children:

This week, I was told that my stance on vaccinations is proof that I am a fool and a pharma shill which is par for the course. I was informed that it has been proved both that healthy children don’t get childhood illnesses and that if they do, those illnesses strengthen their immune systems.

I’m surprised that she didn’t mention the recent JAMA paper which last week provided additional evidence to support the assertion that the multi-billion dollar vitamin and dietary supplement industry is a drain on world-wide healthcare resources. It never ceases to amaze me how people will gulp down expensive handfuls of vitamins and anti-oxidants for which there is little scientific proof but balk at vaccines for which there is both extensive high-quality scientific evidence and decades of experience. In fact, as this analysis states, there seems to be evidence that consumption of certain anti-oxidant vitamins may actually increase mortality!

On the child advocacy front, Lourdes de Asis, over at Allergy and Asthma Source, takes a break from allergies and asthma to bring us a detailed public service message on household poisons.

Signout, who is three-quarters of the way through her internship year (hang in there, Signout!), hasn’t seen a pediatric patient in a while, but shares with us an experience from a couple of months ago on the pediatric oncology service in her post entitled, “The New Black“. She makes an interesting observation:

Talking about death and dying is the new black–it’s all over medical school curricula, residency program workshops, and newspaper science sections.

I agree – it seems that we are now, finally, talking more about death and dying, and as hard as it is to do so with children, I heartily endorse it. Her use of the phrase “[phenomenon] is the new black” reminds me to share with you an interesting project that documents every instance of the phrase ‘is the new’ encountered from various sources in 2005 (courtesy of MetaFilter).

A pediatric grand rounds wouldn’t be the same without some mention of poop. Thankfully, Clark Bartram, who writes Unintelligent Design, shares with us a Code Brown, and a case of Hirschprung disease in a newborn in his post entitled, “The Not So Normal Newborn Nursery: Poop There It Is …“.

And finally, from the housestaff front comes Vitamin K, MD and her blog, Peds. Not Just for Those With a Foot Fetish. Her entry, “… how do I handle this …?” details her reaching the point in her training where she’s learned enough medicine and science to realize that there are too many instances where things are done to patients despite the evidence. Vitamin K – we feel your pain (for which, the evidence now shows, you should use ibuprofen instead of acetaminophen, courtesy of Medpundit).

Parents

This episode of Pediatric Grand Rounds also brings a host of emotions from parents: disappointment, frustration, hopelesslessness. Hmm. Sounds like things have been a lot harder for the parents this week than for the pediatricians.

On the parent side, frustration is the theme for Purple Kangaroo who grapples out loud with the differences between food allergy and dietary intolerance and provides a real-world example of the aphorism, “Ask 12 specialists, get 13 different opinions.” Her heartfelt essay highlights an important phenomena in medicine: the disconnect between physicians, who are experienced in dealing with not-well-understood phenomena, and parents, who find such phenomena disconcerting when they happen to their children.

Moreena, at The Wait and Wonder, highlights the sense of helplessness that parents of critically ill children experience. She does a wonderful job of showing me an entirely different perspective on the advice that I’ve often given to the parents of my patients. I have told the parents of children who have successfully completed their cancer therapy, and who are consumed with worry about relapse, that it is not possible to predict or control relapse. I tell them, from my relatively safe position, that life is full of unknowns. I tell them that I cross the street between the building with my lab and the hospital a half-dozen times a day and never think about the fact that on any one of those occasions, I could be run over by the hospital shuttle. It’s certainly possible, but I’m not going to stop crossing the street just because of the possiblity.

Moreena points out a perspective that I’d not considered:

People with the best intentions have pointed out to me that something bad could happen to any of us, at any time. The idea is that we never know, and usually have no control over bad stuff happening, anyway, so therefore I should just let go of all my constant worrying … Honestly, there is just no way that is ever going to happen …We just don’t worry as much about theoretical dangers. But once we can name the danger; once we know what it looks like, once it takes up space in our lives as a realistic and constantly present concern, then it’s hard not to let the worry take over and taint everything we do.

Thanks, Moreena, for the terrific post and the valuable perspective. You are, without a doubt, my pick for the best of the entries this rounds. Your essay reminded me to also share with everyone a post that I came across from the mother of a young boy with neuroblastoma who writes the blog How Can I Keep From Singing. Her post, “Untitled“, was one of the most heart-wrenching and thoughtful pieces written by a parent I’ve read in a long time. These two posts highlight for me the value of medical blogs – both physician- and patient-authored. What I’ve learned from Moreena and Susan reading these will surely help me to better understand my patient’s parents, and that’s a pretty valuable gift to receive, especially from disembodied words on the internet.

The industrious Shinga forwarded me an entry entitled, “Early days 3” from Whitterer on Autism. Mcewen writes 3 different blogs and in this entry discusses the disappointment of having realized that there were no magic therapies for her child’s speech delay.

On a lighter note, Jen, who writes Unique But Not Alone, a blog that discusses her experience with her daughters’ alpha-1 antitrypsin deficiency, shares some “kid logic” in her post entitled “Ginormous”. This reminded me to share with you an episode of the wonderful radio program This American Life also entitled, “Kid Logic” (note: links to .mp3 file).

Also on a somewhat lighter note (at least I hope it was meant as light), Awesome Mom’s son, in anticipation of getting a shot, decided to induce his own respiratory arrest in the physician’s office. She managed to capture on of her son’s breath holding spells an shares it with us in a post entitled, “How to Surprise Your Pediatrician“. Having done the respiratory arrest thing one this week in the ED, I thank Awesome Mom for pushing my post-traumatic stress button.

Ami Chopine responded to my essay on co-sleeping with her thoughts in favor of co-sleeping.

When I first read Do’C’s post from his blog Autism Street, I truly thought he was a physician or scientist (no offense, Do’C). He writes with the same degree of skepticism and critical thinking that I attribute to Orac and Flea. His entry, “A Hot Cup of Jack Squat” written with fellow blogger Not Mercury dissects yet another pseudoscience essay purporting to link mercury to autism written by an author who is a chemist at the Wisconsin State Laboratory of Hygiene and just so happens to have an autistic child.

Well, that just about wraps up another episode of Pediatric Grand Rounds. I want to thank everyone for their contributions, including those whose couldn’t fit into the current issue. I learned great deal from putting this issue together, and I hope that everyone takes at least one or two pearls away with them. The next issue of Pediatric Grand Rounds is being hosted by Rob over at Musings of a Distractible Mind two weeks from now.

And if you enjoyed this issue of PGR, please return on March 20th as I attempt to take on the original blog Grand Rounds.

Finally, be sure to take a moment and let your fellow bloggers know that the current issue of PGR has been posted so that everyone’s hard work and thoughtful comments can be disseminated along the Internets!