Making Sense of Medicine

I remember an obstetrician friend of mine telling me about a tough decision a patient of hers had to make. She had told her pregnant patient that the tests looked like the baby she was carrying would be born with Down syndrome. The patient and her husband got further confirmation, and talked several times with my friend. It looked like they were going to allow the baby to be born, which really encouraged my friend. Apparently most parents choose to have an abortion, these days. The couple researched lots of information, and seemed ready to face the challenges ahead. But one day the phone calls stopped, and my friend was crushed to learn she’d had an abortion. She never learned what changed her mind.

I wish that patient had been able to hear the results of three surveys from Children’s Hospital Boston which were just published in the American Journal of Medical Genetics. The first survey was sent to parents of a child with Down syndrome. The results?

·      99 percent loved their child

·      79 percent felt their “outlook on life was more positive because of their child”.

·      5 percent felt embarrassed by their child.

·      4 percent regretted having their child.

Previous surveys have revealed that expectant parents of children with Down syndrome are often given a negative description of what life will be like. Parents report they are told about dire medical complications – though most children with Down syndrome live healthy lives.

And what are the feelings of the siblings of the Down syndrome kids? That was the subject of the second survey. Of siblings over 12 years old:

·      94 percent felt proud of their sibling.

·      88 percent felt they were better people because of their sibling.

·      7 percent felt embarrassed by their sibling.

·      4 percent would “trade their sibling in” for another.

And for siblings ages 9-11:

·      97 percent said they loved their sibling.

·      90 percent said their friends are comfortable around their sibling.

So adding a child with Down syndrome to a family is not uniformly tragic and stressful. The opposite seems to be the case.

But how do the people with Down syndrome, themselves, feel? Do they consider their lives worth living? That was the subject of the third study. They surveyed 284 people, average age 23. The results:

·      99 percent said they were happy with their lives.

·      97 percent liked who they are.

·      96 percent liked how they look

·      86 percent said they could make friends easily.

·      4 percent expressed sadness about their life.

Having the perspective of people who are living with Down syndrome, either as themselves or as a family member, is valuable. This needs to be communicated with parents whose unborn baby has just been diagnosed. People with Down syndrome have hopes and dreams. They have friends, and go to school, and get jobs. They have goals and they achieve them. Isn’t that what life is all about for all of us?

The last thing Americans need is a reason to NOT eat fruit. We are a nation that eats more than its share of processed foods. More fruits and veggies need to be consumed, not less. Yet the new outbreak of listeria in cantaloupe gives me pause. Should we all give up cantaloupe? The quick answer: No. But we shouldn’t eat the cantaloupe from Jensen Farms in Colorado, which is the source of all of the infections in the recent outbreak.

I feel bad for Jensen Farms, which is a smallish family farm, but I feel worse for the people who have gotten ill from listeria. Listeria is a bacteria that can grow even in the refrigerator. It’s one of the bugs that causes “food poisoning” – that is, the miserable cramping and diarrhea that happens after eating contaminated food. It also causes fever, headache, body aches, nausea and vomiting. It’s uncommon – 1600 cases a year in the U.S. That’s good, because it is a nasty little bug that can pass through the walls of the gut into the bloodstream and cause infection there, or in the brain (meningitis). 

Most people who get listeriosis have a couple of days of misery and then get over it. The people who tend to get in trouble are the more vulnerable among us – people older than 65, cancer patients, people with kidney failure, unborn babies, newborns, and those whose immune systems aren’t fully functional. A simple, cheap antibiotic kills listeria. The good news is that otherwise healthy people almost always get over it without needing antibiotics. The bad news is that it can be deadly for the vulnerable. One out of three of these die – around 250 people yearly in the U.S.

So if 250 people are dying every year, why haven’t you heard about this before? Because most infections are “sporadic” – that is, they occur here and there, and nobody ever knows the source. Outbreaks, such as is happening now, are rare.

So that brings us back to cantaloupes (a fruit I love, by the way). How did they get contaminated? Listeria grows primarily in soil and decaying plants, but it’s also been found in dust, water, animals and humans (who carry it without symptoms), and processed foods. In fact, an outbreak is far more likely to occur in processed foods, such as hot dogs, luncheon meats, soft cheeses, smoked seafood and meat spreads, than in fresh produce. It would be the height of irony if we all abandoned cantaloupes, after this, and ate more processed foods.

This is a good reminder to us all to rinse produce thoroughly before eating. I admit that I have never washed cantaloupe before, though I am starting now. If something bad is on the outer surface, cutting it with a knife will bring it to the inner flesh. The FDA website (http://www.fda.gov/Food/FoodSafety/CORENetwork/ucm272372.htm) says that the inner fruit could also be contaminated. If you happen to have a Jensen cantaloupe, throw it away. No cases have occurred in Louisiana, but 72 people in 18 other states have become ill, and 13 people have died (http://www.cdc.gov/listeria/outbreaks/cantaloupes-jensen-farms/092711/index.html ).

So don’t give up on cantaloupes. Just be careful – and sanitary.

But now a study appearing in the medical journal Lancet shows that Weight Watchers works even when the people get the meetings for free. The study was actually comparing Weight Watchers with the weight-loss counseling in primary care doctors’ offices, but the fact that Weight Watchers beat the doctors hands down didn’t surprise me one bit. I urge my overweight and obese patients to lose weight, but how much can I do in a few minutes, when I have to take care of all of their other medical problems?

The study was done in Australia, Germany and the United Kingdom, so maybe doctors there are better counselors, but I seldom see much weight loss unless my patients become personally motivated, and a lot of times that means shelling out the weekly fee for Weight Watchers meetings. But these 377 patients studied got the meetings for free and still lost weight.

After 12 months, the Weight Watchers group lost twice as much weight as the similarly-overweight group who were counseled by their doctors. How much weight did they lose? If they completed all 12 months, then on average,14 pounds for the Weight Watchers, versus 7 pounds for the doctor group.

I just rented a car and, though I had made a reservation online for the cheapest option – a subcompact – at the counter the agent tried her best to sell me a big upgrade, then a smaller upgrade, then various insurances that I don’t need because I’m already covered, then a full tank of gas at an inflated price, then a GPS and finally XM Radio. And though I knew I’d be offered these things, and I had steeled myself to say no to everything, I wasn’t prepared for the force of her persuasiveness. She was a salesman. 

First she charmed me with her interest in why I was in town. She was warm and funny. After a minute of chit-chat she glanced at her screen and her face brightened. A big upgrade was available at only $15 extra a day. No, thank you. Her brows furrowed as she expressed concern about my need for more legroom and then studied her screen. Her face lit up again and she offered another car that would provide this need for only $10 extra a day. No, thank you.

As she moved into the offers for insurance, and I declined each one, her tone was increasingly disapproving. I’d be responsible for all expenses in case of damage. Guilt washed over me and I felt myself wavering, but managed to hoarsely croak: No, thank you.

You’d think she would give have given up on me at that point, but I guess not, because she somehow made the gas, the GPS, and the XM Radio seem like amazing deals. But in my heart I knew they weren’t, and again said: No, thank you.

As I drove off the lot in my Chevy Aveo (which, by the way, has plenty of legroom) I thought about her methods of persuasion. I use some of those methods, myself, though my intent is not to sell my patients anything, but to try to convince them to exercise, or to stop smoking, or to take their medicines as prescribed. I tailor my approach to the individual. What “works” with one person will be different than with another. With most people I try to use humor to make a connection and lighten the mood. With a few I’m deadly serious.

I guess I am trying to sell something – health. I want my patients to live long and thrive. I want to be the best salesman of a healthy lifestyle that I can possibly be. For what I want for my patients, ultimately, is exactly what they want for themselves – a full and vigorous life. 

The study I’m referring to was published in Health Affairs and covered an educational campaign in the pediatric intensive care unit (PICU) of the University of North Carolina. Basically it encouraged, cajoled, and reminded the health care workers to do what they should have been doing all along – washing their hands or using alcohol gel hand sanitizer before and after each patient encounter, careful cleaning of the mouths of patients on ventilators, and meticulous central intravenous line care.

The study lasted three years, and then the researchers compared costs from “before” and “after”. The results showed kids stayed in the hospital 2.3 days fewer, and their average stay cost $12,136 less. And here’s the best part – fewer kids died. The mortality rate was 2.3 percent less after this simple system of cleaning was insisted upon.

Washing hands led to more kids leaving the hospital and getting a chance to grow up. Now, that’s a reason to keep my hands clean. You, too?

A new campaign, named “Million Hearts”, has been launched by the US Department of Health and Human Services to try to prevent one million heart attacks and strokes over the next five years. It uses the four letters “ABCS” to help us all remember key ways to safeguard our blood vessels, particularly the blood vessels that feed our hearts and brains.

“A” is for Aspirin. Million Hearts urges all those at high risk for a heart attack or stroke to take some amount of aspirin – usually a “baby aspirin”, which is 81 milligrams. The tricky thing is to figure out who is at high risk, though there are ways to calculate this if you know your blood pressure and cholesterol levels. If your 10-year risk of heart attack is over 10 percent, aspirin is recommended. The American Heart Association has a calculator you can do online at: https://www.heart.org/gglRisk/locale/en_US/index.html?gtype=health

“B” is for Blood Pressure. Many people are walking around with high blood pressure. This is risky for their blood vessels, which are stressed with each heart beat when the pressure within them is high. People may know they have high blood pressure (also known as “hypertension”), but their medicines aren’t working well, or maybe they aren’t taking them. Many more folks don’t know their blood pressure is high – they’ve never been diagnosed. What are the numbers to shoot for? The top number – systolic – should be below 140, and the bottom number – diastolic – should be below 90.

“C” is for Cholesterol. When I check my patients’ “cholesterol” level, I’m actually checking for several lipids (total, HDL, LDL-C, and triglycerides). The Million Hearts campaign is focusing on the LDL-C level, which is what I call the “really bad cholesterol”. (Hey, I try to make things understandable to my patients!) Everyone should have an LDL-C level below 160, and people at high risk for a heart attack or a stroke should keep it below 100. If eating well (low fat diet) doesn’t get a person to these levels, then cholesterol-lowering medications are necessary.

“S” is for Smoking. Regular readers of my blog know that I harp on the value of stopping smoking. If you’re a smoker, the number one Healthiest Thing you can do is stop smoking. I saw a patient this week who was very anxious – almost frantic, really – about the possibility that he might have cancer. He smokes. I said, “There’s a disconnect here. If you’re so worried about getting cancer, why are you still smoking?” He said he would try to quit. I sighed. I hope he does it. He won’t just be decreasing his risk for cancer, but also his risk for heart attack or stroke. 

May the Million Hearts campaign be successful!

People ask me how to avoid catching the common cold. “Wash your hands.” Why do I get so many sinus infections? “How often do you wash your hands?” How did I get this staph infection on my skin? “Do you keep your hands washed?”

It seems so simple. Maybe it’s too simple to be believed.

At least we understand how bacteria spreads from person to person. In the early 19^th century, “germ theory” was unknown. Being a doctor who suspected that fellow doctors were spreading infections from patient to patient was the kiss of death for a career. And, unfortunately for one such pioneer doctor, it led to his own death, also.

Ignaz Semmelweis was a Hungarian obstetrician who practiced in Vienna, Austria. (A note to future mothers: as wonderful as Semmelweis was, please do not name your sons “Ignaz”.) If you could afford it, at that time, you would have your baby at home. Hospitals were places where many women died. Semmelweis noted that of the two hospitals available for poor women, the hospital which trained midwives had a 4 percent death rate from “childbed fever”, whereas women who gave birth in the hospital that trained doctors died over 10 percent of the time.

Semmelweis scrutinized what differed between the hospitals. The only difference was that the doctors in training had access to the morgue, and frequently performed autopsies prior to attending a woman in labor. Immediately he insisted that anyone who had been to the morgue wash their hands in a bleach-like solution. Death rates plummeted to 2 percent.

You would think the medical establishment would rejoice – lives are being saved! You would think wrong. His theory was rejected and ridiculed, and he lost his job and had to move to Hungary. Now it doesn’t help that he seemed to be lacking in people skills. When putting forth a ground-breaking discovery to the scientific community, it’s always helpful to be able to charm your critics in a winsome manner.

Being charming wasn’t a high priority for Semmelweis. He blasted cynical obstetricians in a series of letters from Hungary, and didn’t mince his words. At the same time, his personal life was increasingly erratic – he was drinking heavily and visiting prostitutes despite being married and a father. A fellow doctor, supposedly a friend, lured him to “visit” a mental institution in Vienna. When he figured out what was going on and tried to leave, he was beaten severely by the guards and put in a straitjacket. He died, ironically, of a blood infection. He was 47 years old.

“Two planes, Amy,” he said. Two planes? Then it wasn’t just a terrible mistake by a pilot. And then he said, “It was terrorists. Osama bin Laden, I would guess.”

I recount this conversation to give you a sense of how intimately my upbringing was connected to global events. (Thanks, Dad.) Within minutes of the first plane crash, my father knew it was terrorism, and strongly suspected who was the terrorist. 

The contrast with the world of my patients came a few minutes later. I work at a clinic in an indigent care hospital, and many of my patients are poor. There’s a television in the waiting area, and we doctors and nurses would dash out there to see what was going on in New York, and later Washington, D.C., in between seeing patients. Our mood was sober. When one nurse reported the first tower had collapsed, I felt like I couldn’t get a deep breath. After seeing my next patient, I was washed in nausea as I watched live coverage of the second tower’s collapse.

The implications seemed enormous to me, to the other doctors and nurses, and to several of the patients I saw that day. But I also saw patients who were unruffled. I tried to engage each patient on the subject, knowing that they had been watching the events on the television and may have been disturbed by what they saw. But these calm patients didn’t seem to understand what they had seen. New York City was a world away, and two buildings being destroyed there was far less important than discussing their arthritis, or their diabetes, or their thyroid medication. 

And they were right. The business at hand was their arthritis, and their diabetes, and their thyroid medication.

I remember driving home that day with an expanded heart for the poor. When you’re wondering if you have enough gas to drive home, or whether you’re going to finish up in time to catch the last bus, or how on earth you’re going to get your prescription filled – what happens in the rest of America, or in the world, fades into nothingness. 

My life, with its advantages, allows me to think beyond what I’m going to eat, where I’m going to live, and what I’m going to wear. I can think beyond mere survival, and I know that that is a great privilege.

The study, published in the Journal of Clinical Oncology, followed terminally-ill cancer patients at the Dana-Farber Cancer Institute in Boston. First they assessed how much the patients leaned on their personal religious beliefs to cope with the stress of their illnesses. Those who scored highly in that assessment were the “positive religious coping” group.

There are decisions to be made at the end of life, such as whether to be intubated (a tube placed in the lungs) if breathing becomes too shallow to sustain life. As a doctor, it’s never easy to decide whether to intubate someone who is approaching the end of life, mostly because there’s usually no clear sign that death is inevitable. Getting intubated is one form of “aggressive” medical care. Basically, a doctor intubating a patient is applying advanced medical care with the implicit hope that the person will be able to be extubated (the tube taken out) and to be able to live some amount of meaningful life afterwards.

Sometimes the doctor knows the patient is dying and that intubation isn’t going to provide a meaningful extension of life. Yet if the family is insisting on it, I assure you the doctor will do it, unless the patient has made his or her wishes known in an “Advanced Directive”, asking not to have aggressive medical care given if it looks like death is looming.

So now – back to “positive religious coping” and facing death: The Dana-Farber study showed that “positive religious copers” who reported that their spiritual needs were being met by the hospital staff (both by the medical team and by pastoral care visits) were less likely to use aggressive end-of-life treatments, such as intubation. They were also more likely to use hospice, whose philosophy is to support and care for a person at the end of life, treating pain but not seeking to cure.

Also, everyone in the study who reported having their spiritual needs “largely or completely supported by the medical team”, whether they were “positive” religious copers or not, were found to have a higher quality of life as they approached death. 

The key for dying people is having their spiritual needs – whatever they are – satisfied. It sounds like Dana-Farber encourages their medical personnel to be sensitive to these needs, and that there are chaplains available. This combination is not present in every hospital (an understatement). The end of life – when we know it is coming – is generally a time of deep spiritual reflection. It only makes sense for hospitals, since they are places where people frequently die, to support people when they are asking the ultimate questions.

I say I’m wondering, but I’m really not. As I wrote yesterday, abortion is a highly politicized topic in America. That politicization (I guess that is a word) extends into the hallways of academic medicine. I don’t know whether Priscilla Coleman, PhD, the author of the paper, tried to get it published in America before she sent it to Britain, but I highly suspect she tried, and tried hard.

The British Journal of Psychiatry is a highly respected medical journal, worldwide, and, before a paper can get published in it, “peer reviewers” must read it and make sure the science is reliable. The same is true of the best journals in America, but unfortunately these peer reviewers can act as gate-keepers, keeping out good science that doesn’t fit with their philosophical bent. 

But it’s timely that Dr. Coleman’s study was published in Britain just now. Hotly debated in Parliament is a proposal to require a woman seeking an abortion to receive independent counseling first. You would think abortion providers would be happy to have women receive counsel on the risks and benefits of abortion beforehand, but you would think wrong. The member of Parliament who proposed it, Nadine Dorries, apparently has been receiving “constant vilification and near-daily death threats” over her stance on abortion. There is something seriously wrong, here.

If most abortions are performed, as I believe they are, to avoid emotional distress, then the news that they do not needs to be made public, and needs to be widely discussed.