Albert Provocateur

Sunday, December 13, 2009

Green Teen

Teens will be teens! While parents seem to understand this, the motivation behind adolescent action is dubious. In fact, it is not the raging hormones that make teenagers do what they do, but rather the teen brain itself. The issue becomes of paramount importance when focus is directed at teen driving and the influence of alcohol, substance abuse, and cellular telephone usage on its performance and dangers. Biology and physiology don’t lie, and brain scans indicate that the adolescent brain undergoes a thinning of the gray matter or thinking part of the brain around puberty. While motor and sensory areas of the teen brain, as well as reward centers, mature early, the areas of a teenager’s brain controlling plans, decision-making, and impulses and emotions remain immature until the middle 20s. Voilà, parents, educators, and the general public at large are faced with a potential recipe for disaster when the immaturity of the teenage brain, a propensity for high-risk behaviors and potential substance abuse, and the inexperience of adolescent drivers are all combined. So, how does this all translate? The KISS (“Keep it simple, Stupid!”) principle, in this particular case, leaves no room for misinterpretation when it states that teen brain changes can result in high-risk behaviors, substance abuse, and mental illness, that control over high-risk behaviors is still maturing during the teenage years, and that over 2.7 million children and adolescents suffer from behavioral or emotional ills.

The statistics are sobering! Each year 5,000 teens die in automobile accidents, and 400,000 are seriously injured. Teenagers are only 10% of the U.S. population, but account for 12% of all fatal car crashes. It is as if Russian roulette is being played on our roads, with 16-19-year-olds four times more likely than others to “crash and burn,” and with risk of a car crash highest during the first year of driving. Teenagers cost society 30% or $26 billion in annual automobile costs. This fact must be impressed upon them, and the only way to do so and put the financial downside in perspective is by comparison with something teens know and love dearly, namely the cost of a Microsoft Xbox® or a Sony PlayStation®.

Machismo and machines don’t mix, but try telling that to a teenager. If he or she gives you the time of day, you can explain that teenage drivers are more likely to speed, tailgate, and drive hazardously. Will teens listen, however? There seems to be a gender difference also, with teen male drivers 1.5 times more likely than teen females to die in automobile accidents. In these days of “super-sizing” and everything being bigger in Texas, teens are as likely to run into the jaws of life as they are to jaw a quarter-pounder in a fast-food joint. It is a well-known fact that adolescents have the lowest rate of seatbelt use. Statistics demonstrate that of 15-20-year-old male drivers killed in auto accidents, 38% were speeding and 24% were drinking and driving. Male teen “co-pilots” who egg the young driver on make matters no easier!

We are faced with what might be called the “booze blues,” although this is no light matter, by any means. The numbers bear this out. Seventy percent of high school seniors have been found to use alcohol in the previous year. Twenty-three percent of 15-20-year-old drivers who die in car crashes have blood alcohol contents greater than or equal to 0.08, which is comparable to four drinks. Of teen drivers killed in auto crashes after drinking and driving, 74% did not wear seatbelts. And if all this were not bad enough, 33% of teenagers report riding with teen drivers who drink, and 10% drive themselves while drinking. That will certainly give mothers and fathers out there something to think about!

We’ve all heard the expression that a brain is a terrible thing to waste, and nowhere is this idiom more applicable than in consideration of the wasted potential of the teenage brain. Studies show that the adolescent brain is particularly vulnerable to the negative effects of alcohol and other drugs and to addiction later in life, and more so than the brains of people not using such substances before age 21. We can only say “holey smoke” at this, as we learn that large amounts of alcohol close up blood vessels in the brain, causing brain cells to die in decision-making areas and resulting in “dead spots,” craters, or holes. Future shock is a terrible thing, and getting an early jump on the future is not always a good idea, especially when it comes to the devastating effects of alcohol consumption. Teenage binge drinking causes the brain to become inflamed and lose cells, with massive brain shrinkage and behavioral problems arising later in life, as a result. Even the gladiators and charioteers of Ancient Rome knew better than to drink “vino” before battle or high-speed races, which is more than can be said for their modern-day counterparts!

And lest we forget the “green, green grass of home” and the almighty cellular, we are once again confronted with a brick wall. Cars are the second most popular place for smoking marijuana, and more than 2.9 million driving-age teens have reported lifetime use of marijuana. In 2005, more than 750,000 16-17-year-olds reported driving under the influence of illicit drugs, with 1 in 6 teens (15%) reporting driving under the influence of marijuana, and 16% under the influence of alcohol. Driving and talking on a cell phone is still another major distraction and possible cause of car crashes, no less serious than substance abuse. Drivers who use a wireless telephone while driving can lose situational awareness and experience inattention blindness. Parents who give their teens cellulars and teenagers themselves must come to grips with the fact that automobile accidents are the leading cause of death in 15-20-year-olds. Drastic steps, measures, and laws are, indeed, warranted!

If parents and teenagers cannot police themselves, then local, state, and federal authorities must intervene to administer acute and chronic remedies that go far beyond provision of a symbolic Band-Aid®. Current proposals have run the gamut from graduated driver licensing laws and nighttime restrictions, comprehensive underage drinking and driving laws, and restrictions on the number of teen passengers traveling with young novice drivers to restrictions on the use of cell phones, education of parents on the impairment of concentration, coordination, perception, and reaction time for up to 24 hours with marijuana, and national anti-drug media campaigns referring specifically to drugged driving.

Teens are “green,” but the brutal reality of the matter is that we’d rather have them green with envy than green and six feet under!

Bleep Sleep

I have a problem, a problem that is probably going to take years off my life, as well as contribute to my descent into what is called the “grouchy old man” syndrome. I don’t sleep at night. The years of stress, trials and tribulations, utter rancor and dissatisfaction with my station in life, and bitter taste in the mouth from one too many battles lost have taken their toll on my sleep-wake cycle. I have been known to literally pass out in the middle of a conversation, fall sound asleep after eating an average-sized meal in the early evening, nod off at the wheel of my car on the highway on my daily drive home from work, and start to full wakefulness at 2:00 a.m. when average Joes and Josephines are at rest under warm blankets, souls of the departed find repose and sustenance in communal camaraderie, and not a creature is stirring, not even a mouse. In short, I have “bleeped sleep,” and do what I will, I cannot reverse the tide of chronic fatigue I feel and the vicious circle I have created. Simple daily survival has become my mantra, as I no longer take pleasure in the little things in life, and I subsist solely on the caffeine or battery of other stimulants that buttress a circadian rhythm gone awry. I find myself thinking that if I can only get from the “vampire hours” to the early evening, then my day is complete, and I can surrender completely to the narcolepsy and little brother catalepsy that medical science, in all its infinite wisdom, is just now beginning to understand.

I think time would be well spent here explaining and understanding the simple workings of normal sleep, in order to arrive at a solution to my, and possibly your, problem. It is a well-known fact that insomnia, whether it be trouble falling asleep or staying asleep, affects one third of American adults. Wow! To make matters worse, insomnia can result in excessive daytime sleeping, increased appetite, reduced mental abilities, a diminished immune system, growing frustration, and a decline in daytime productivity. Now, while the amount of sleep a person requires is relative, there is a general consensus that seven to eight hours a night is needed to feel fully alert during the day. No one in this life is without worries, and an occasional bout with sleeplessness is normal. When sleep problems persist, however, beyond a few weeks, it becomes necessary to call in the heavy artillery, namely, one’s family doctor. The latter, if a lack of drowsiness on one’s part permits an understanding of the knowledge imparted, can explain the difference between the two states of a normal sleep cycle, and that is that REM (rapid eye movement) sleep is the period in which dreams occur, as opposed to deeper non-REM sleep. The number 65 is something to remember, for at that age the sleep-wake cycle begins to function inefficiently, sleeping for long periods of time occurs less frequently, and illness, pain, medicines, or a frequent urge to urinate take their toll on ZZZZs and prolong the counting of sheep.

While I understand the problem at hand, there must be some reason why I find it hard to sleep. I refuse to believe that the motive is hidden and mysterious. Whatever the latter may be, there are things I can do to combat the utter desolation of tossing and turning, as the rest of the world regenerates its corporeal fuel cells for the coming day. An attempt at inner calmness on my part breeds a game plan from which I must deviate little. First and foremost, a bedtime routine is called for, in which I do the same thing every night before going to sleep. A quiet and dark bedroom helps and, if my inner demons don’t allow my repose in a reasonable amount of time, say 30 minutes, then a brief trip to another room before returning to bed may help. A light snack, such as warm milk or some crackers, before going to bed may be just what the doctor ordered, but knowing myself and my tendency to do everything in excess, I must remain vigilant against eating too much. A “worry wart” I am, so if I can just leave my problems outside the bedroom, and use the latter for sleeping and sex (and a lot of that!), not eating, talking on the phone, or watching television in bed, then I can become a worthy adversary to insomnia. That’s not all, however. Exercising a little each day, at the expense of daytime naps longer than 30 minutes, and avoiding alcohol, caffeine, and nicotine in the evening can’t hurt. Finally, and perhaps most importantly, I must learn to retrain my body to sleep at night. What does that mean? It means that if I can go to bed and wake up at the same time every day, then maybe this Count Dracula can transform himself into an innocuous Rip Van Winkle.

If none of the above measures bring somniferous satisfaction, then “oneth by land and twoeth by sea” sleep studies are warranted to discriminate between periodic limb movement disorder (PLMD) in which legs are kicked many times during sleep, sleep apnea with repeated breathing cessation during sleep, and narcolepsy with its sudden “sleep attacks” without warning, as well as to determine the source of insomnia, snoring, or teeth grinding. I’ve been told that thorough sleep clinic monitoring of my brain activity, body temperature, breathing rates, and muscle movements during sleep can help get to the bottom of this mess I find myself in.

I’ll keep you posted as to my daily daytime quest to uncensor my “bleep sleep,” that is, if I can stay awake long enough.

Weight-less

Why do we hate fat people? Why do we look at them with disdain, with holier than thou attitudes? We are all guilty of their perceived sin, and, to boot, when blinds are drawn and monitor screens glow, we are the first to type “diet” into search engines of choice. Food companies spend millions of annual dollars hawking the latest miracle aliments promising to lower LDL (“bad”) cholesterol, raise HDL (“good”) cholesterol, and increase energy, libido, and everything short of our bank accounts. The high-fat, high-protein, low-carbohydrate (HPLC) diet of yesteryear has been touted from its throne on high for years, until recent research demonstrated its hand in promoting plaque buildup in the highways and byways of our bodies, otherwise known as arteries. While it is obvious that becoming “weight-less” is difficult at best, it certainly isn’t brain surgery. If the solution to the obesity epidemic, however, is as simple as eating more healthily and being more active, then how do we explain the plethora of unsuccessful fad diets and even crash dives into unnatural decreased calorie intake that can leave our bodies in physiologic starvation modes, eat away at healthy muscle, burden our minds with fatigue, grouchiness, and irritability, and disfigure waistlines with that all-too-common B-word, “binge” eating?

We all know the problem. We’ve been victims of it time and time again. What can we do about it? In this case, we are not talking about an ounce of prevention. Pounds are the name of the game, with a new lease on life coming at as simple a cost as a change in eating habits, albeit a small change at first. Let this short piece serve as both a primer to our initial foray into the realms of salubrious diet and healthy weight, and as a rematch between ourselves and past New Years’ resolutions kicked to the curb. While any good change in diet and eating habits begins with our family doctor, we must realize that the men and women in white simply do not have the time to completely overhaul our current lifestyles. They are underpaid, overworked, and, in many cases, more concerned with drugs and “pharmacologic surgery” of the problem than preventive medicine and patient education. We must become creative ourselves, and look to our own proactivity.

First and foremost, we must examine the good, the bad, and the downright ugly. In other words, we must make a concerted effort to assess our own dietary strong and weak points. Are we eating five to seven servings of fruits and vegetables every single day? Is calcium part of our diet and a plan to preempt brittle bones? Do regular whole-grain, high-fiber foods bring up the rear (no pun intended!), contributing to our regularity and preventing unwelcome house guests such as colon cancer, diverticulosis, and something as inconsequential, yet troublesome, as chronic constipation? Will we never learn that too much sugar, salt, and saturated fat is just plain no good? We’ve heard ad nauseam that fatty meats, cakes, cookies, potato chips, biscuits, and sweets not only increase calorie counts, obesity, and weight, but also lead to high cholesterol and heart disease. Nonetheless, we desist from limiting them in our diets and making those small changes, such as adding fresh fruit or vegetables to every meal, or getting more fiber in our diets, that would make hospital emergency rooms, cardiologists, and funeral directors quite unhappy. While keeping food diaries to that end is an exercise in persistence and healthy obsession that many of us do not possess, something as simple as a kindly reminding refrigerator magnet can reap untold economic and quality of life-preserving windfalls.

Lest we forget portion size and the gentle admonishments of our parents who cajoled the benefits of cleaning one’s plate, we may have taken this too far. Current statistics bear this out, and they’re not pretty. The American Institute for Cancer Research has reminded us of what we already know to be true, and that being that more Americans than ever are making Jack Sprat proud, by “licking their platters clean.” Were that not enough, the public is grossly unaware that we unconsciously consume 56% more calories when we are served larger portions, and that more than 78% of Americans are deluded into thinking that the specific food they eat is more important in losing weight than the amount they ingest. God help us!

With Christmas and New Year’s Eve on the horizon, and a change in waistline in the cards unless we act now, here are some “no-brainers” and food swaps that may not trim food expenses in the short term, but will most certainly balance the future medical budget, both personally and nationally speaking. Substituting low-fat, whole breads for white breads, English muffins for doughnuts, baked potatoes for French fries, turkey dogs for regular hot dogs, low-fat cheese for Cheddar, and non-fat for regular mayonnaise may not entirely please the palate, but will certainly keep us around long enough to see our loved ones grow and prosper. And we’ve saved the best for last, as we urge blind obedience to the eight commandments of clever food choice, and those being: have a healthy side dish with meals; go easy on the butter or margarine; avoid high-fat sauces and gravies; serve fresh fruit with the skin on; eat more fresh fish than beef or chicken; consume five or more portions of fruit and vegetables daily; bake, broil, roast, or steam instead of frying; and, finally, substitute dry beans, peas, or lentils as often as possible for red meat in favorite recipes. Impossible, you say! Start slowly, and build up to a crescendo.

Do as we say, and not as we’ve done in the past, and we can liberate the term “weight-less” from the exclusive lexicon of NASA.

Sunday, November 29, 2009

Turkey Trot - Home Alone for the Holidays

You’ve lost your last friend, you’re down in the dumps, the planets are not aligned correctly, the holidays are fast approaching, and you’re home alone. There is nothing more depressing than the sense of utter helplessness one feels at the hands of a perceived abandonment forcibly endured during the festivities of Thanksgiving and Christmas. This is especially true when financial figures dip into the red, when family members are far away, when loved ones are no longer with us, and when television, magazines, the Internet, and other forms of mass communication show us those cozy fireplaces, warm and loving households, and smiling faces that we’d just love to punch in. While it can be normal to feel somewhat subdued and sad during the holidays, when those feelings become tantamount to downright depression, then we have problems. It is usually the elderly that bear the brunt of those “Thanksgiving turnarounds” or “Christmas crises,” due to a plethora of real or imagined factors ranging from financial limitations and being home alone to a loss of independence, eyesight, or mobility. No one is immune, however, and even the young can feel blue, as chestnuts roast on an open fire and mistletoe catalyzes self-embrace, for lack of a suitable partner to share a touching of lips. We know the problem, or do we? We have all felt it at one time or another, what with parties, shopping, baking, cleaning, and entertaining during the holidays taking their toll on sleep, exercise, and self-love. So, I guess my gift to you this holiday season is to come up with a primer or set of instructions for halting, or at least making bearable, that annual mad dash or stampede that leaves us feeling drained and devoid of healthy cheer between that last Thursday of November and the first of the New Year.

Our so-called quest to tame the turkey trot could not begin if we were unable to state categorically that before a cure can be prescribed, an accurate diagnosis must be made. What is it that actually causes us to wallow in self-pity during the most joyous time of the year? Are doldrums a normal sign of aging or are the social obligations, mad hatter shopping, financial difficulties, work-related angst, and sleeplessness of the holidays something greater than the sum of their parts but much less than incurable? Three things are certain at this crossroads of the year, that family can be a burden as well as a blessing, that overspending can mean financial worries for months to come, and that exhaustion, lack of sleep, and exercise deprivation increase stress in a vicious cycle from which it is difficult to extricate oneself. And let’s not forget those vodka spiked eggnogs, peppermint hot chocolates, or Christmas martinis that do little to raise low spirits, rather they have an opposite effect. Adding alcohol to imposed social obligations is a recipe for self-flagellation, when saying “no” to liquid amenities or social outings without pangs of guilt or a need to explain becomes an exercise in willpower that many of us are ill-equipped to muster.

While we have accurately presented this annual rite of remorse, which is new to no one and further complicated by “selection psychosis,” with incapacity to choose the right gifts for family and friends, and “tradition tampering,” with failure to duplicate the conscious and unconscious holiday ceremonies of a happier past, we have done nothing to solve the problem. The good doctor will now make amends, and give you his take on the remedies, which, by the way, are free of charge. The premise here is that we have all gone through this, and, rather than reinventing the wheel, we must adopt what is tried and true. While we cannot force ourselves to be happy during the holiday season, we can certainly reach out to the individuals and community organizations around us. The holidays don’t have to be perfect to be enjoyed, and new friends and traditions can provide an excitement lacking from the usual seasonal rigamarrow. Now, the name of the game is to also set aside family grievances for peace of mind, stick to a realistic shopping budget for obvious reasons, and plan ahead. Running around like chickens without heads was not something envisioned by the inhabitants of Bethlehem many moons ago, and, what was good for the founders, is most certainly good for the rest of us. Learning to say “no” to social activities that can leave us resentful and overwhelmed follows suit, or perhaps attending them only briefly to make an appearance or a surgical “hit-and-run.” Sound realizable? Then let’s put the finishing touches on this work in progress. Don’t forget to get plenty of sleep and physical activity during this holiest time of the year, as well as direct greater attention to stuffing the turkey instead of oneself. Alcohol, sweets, and cheese are fine, but everything in moderation, and, remember, “breathers,” in the form of moonlit walks, stargazing, or soothing music are good. Finally, when all else fails, irritability, hopelessness, and insomnia may warrant a trip to your doctor or mental health professional. There is no shame in asking for help. A perceived loss of face in no way compares with a loss of mind.

Cheers! Things could be worse. I could have mentioned that turkey not only contains more cholesterol than ham, but that it has also been known on occasion to give one the “trots.”

Funeral Fandango

While my medical pieces have heretofore addressed a slew of maladies ranging from acne to zoster, as well as the collective human spirit to preserve life and fight any incursion into our bodies’ inner sanctum, sometimes a final number is called in destiny’s 50-90-year-old bingo game. When taxes no longer disturb the slumber of a hapless victim, the deceased’s family and friends are often left with a reminder of the high cost of dying, in the form of an average funeral bill of $7,323. Then, as the band engages in a badly timed “funeral fandango,” especially in these times of high unemployment, rising medical costs, dashed retirement savings, and freefalling home values, we are left to wrestle with the dilemma of where to find the money to bury loved ones. The Grim Reaper knows no black ink, and the 700 bodies lying unclaimed in the Los Angeles County morgue last July attest to the unsettling reality of sticker shock of the numerous families who can ill-afford to pay runaway funeral costs.

With the price of an average funeral outstripping the cost of living and with funeral directors nonetheless claiming their services a bargain, some good old-fashioned truth is warranted when false prophets, vacillating editorial points of view, and general disbelief in the printed page envisioned by Gutenberg to honestly inform reign. So, let’s call a spade a spade. Here are the facts. In 1984, the Federal Trade Commission (FTC) issued the so-called “funeral rule,” requiring all funeral homes to provide a general price list of all goods and services and permitting consumers to choose individual items instead of a complete package. Notwithstanding this mandate, in 2004 funeral directors continued to argue that the intensive services they provide accounted for their misunderstood prices, and that most people pay far more for weddings, cars, or one year’s college tuition than the average funeral. Obviously, they were steadfast in their convictions when, in 2008, FTC undercover investigators found that a fourth of the funeral homes they visited significantly violated the funeral rule. Hello! We can’t even rest in peace. We feel the pinch even in death!

Aside from a basic services fee, charged by all funeral homes and which there is no getting around, price negotiations can be conducted on a vast assortment of related items ranging from the funeral service and public viewing to embalming and the casket itself. The name of the game is to neither be pressured nor “guilt tripped” by funeral directors who prey on frayed emotions by referring, for example, to less expensive coffins as “welfare caskets” or “morgue boxes.” A little homework goes a long way, and the Funeral Consumers Alliance, which many of us would be hesitant to join as regular card-carrying members (due to the unpleasantness of its connotation), advises family discussion of funeral plans in advance, in much the same way that weddings, vacations, home purchases, and college tuition are hashed and rehashed in the living room or around the dinner table. Who knows, perhaps participants can arrive at alternatives to the traditional funeral home experience.

Unpleasant, you say, and how dare that man broach such melancholia at this joyous time of Thanksgiving and Christmas merriment! Perhaps you’re right, but death is a constant companion that gets no vacation time or annual leave for the holidays. Death of a loved one, while never acceptable, can at least be defused financially if cremation and services at $1,350, do-it-yourself home funerals at $250, or “green” funerals are opted for, instead of the simplest of funeral rites at $5,000 and a grave marker of $3,000, not to mention the cost of a funeral plot. The facts bear this out. While fifty years ago, cremation accounted for only about 4 percent of funerals, that figure rose to 35 percent in 2007 and is projected to increase to 59 percent in 2025, if we live that long to see it.

No one is implying that family members of the deceased, with the help of a death midwife, should bathe, dress, lay out the body, and preserve it with dry ice in the home for three days, in order to save a few bucks and defray the costs of chemical embalming and a traditional funeral service. That possibility does exist, however. Nor is anyone advocating “green” funerals, with burials in open fields, grave markers made from local rock, and even employment of GPS coordinates instead of the markers themselves. Nevertheless, a failure to reel in funeral costs can turn a funeral fandango into a dance with the devil.

Al Capone was a Capricorn

For some time now, animated and often hostile debate has raged over a proposed connection between astrology and medicine, or what is called astro-medicine. Even Al Capone weighed in on the subject, and there were those, critics and curiosity seekers alike, who linked his fateful demise in prison from neurosyphilis to a not-so-casual alignment of his stars in Capricorn. Going back still further, it has come to light that the ancient Babylonians and Egyptians, who were far from ignorant and who gave the world horticultural marvels, a magnificent library, monuments in stone that still stand and awe today, recorded history in the form of hieroglyphics, and willow bark, or aspirin, for rheumatism and pain, were students of medicinal astrology and a perceived influence of stars and planets on health. Their “captive audience” of Jews also kept a knowledge of astrology among their confidential doctrines. It didn’t end there, either. The Middle Ages was a particularly florid period for “star power,” with faculties of astrology springing up in such diverse Spanish cities as Cordoba and Toledo, and with kings, Popes, aristocrats like Catherine de’ Medici, and even a famous doctor-astrologer and bubonic plague authority or two such as Michel Nostredame, better known today as Nostradamus, plying their wares in the heavenly-body arena of the early and middle 1500s. It was thought that a star disharmony between physician and patient would lead inevitably to incomplete recovery from physical malady or no recovery at all. Physician promulgators of astral alignment familiarized themselves with the horoscopes of their patients, and, when that was not the case, patients took it upon themselves to investigate those of their healers. Furthermore, a common conception, or misconception, whichever you prefer, arose that the way the planets were arranged at the moment of a child’s birth dictated a later predisposition to disease.

So, that is all well and dandy, but where does the field of astro-medicine stand today, if it can be considered a field at all? Before that question is answered, some startling revelations bear denouement to incredulous minds. One of them is the fact that two-thirds of the world’s population seek health care from sources other than conventional biomedicine, otherwise known as allopathy. Closer to home, 42% of American households have tried complementary and alternative medicine in recent years, and the staid and somber National Institutes of Health (NIH) has supported no less than 50 investigations into the usefulness of various alternative therapies, of which astro-medicine is no stranger. Demand for attractive, affordable, alternative medicine approaches to chronic disease has grown exponentially, especially on the preventive and public health care stage. In mysterious India, where truths are often hidden and minds open, allopathy rides shotgun to yoga, massage, prayers, spiritual healing, tantra/mantra, gem therapy, hypnosis, acupuncture, magnet therapy, and that old acquaintance, astro-medicine. Can we dismiss the swelling legions of astro-medical warriors and a hungering public so lightly?

Perhaps there is more to the story than mere superstitious invention of a medical system that renders various parts of the body, diseases, and drugs subservient to the influence of the sun, moon, and planets. Perhaps the celestial-corporeal association is real, and the instrumentation and investigative methods currently available are too primitive to prove validity beyond allopathic doubt. Can so many people be wrong? Are the purveyors of allopathy so presumptuous as to think that their medical dominion and carte blanche of the last 400 years trumps the collective wisdom of the prior 60 centuries?

Medical astrologers study the anatomical-astrological birth charts of their clients or patients, in order to give advice about the areas of the body most likely to experience trouble. Farfetched and outlandish, you say? Perhaps, but condemning astro-medicine does not mitigate the fact that scores of patients with chronic diseases such as cancer, AIDS, arthritis, asthma, diabetes, and epilepsy, to name a few, have derived solace, comfort, and a measure of symptom control, if not out-and-out cure, from other alternative medical methods. Those remarkable gains, with survival of up to five years in some cancer patients, warrant a closer look at the “attractive nuisance” posed by complementary therapies so easily discarded by undiscerning allopathic eyes. As Shakespeare put it, in Julius Caesar, “The fault, Dear Brutus, is not in our stars, but in ourselves, that we are underlings.” He might have said, instead, to paraphrase, “Open minds breed sound bodies.”

In astrology, there is a dictum that states, “Stars assume, but do not force,” meaning that the influence of the stars and planets on the health of a person can always be weakened by self-discipline, a healthy diet, and benevolent thoughts. Nowhere is this more evident than in the case of Al Capone. The stars reveal that as a Capricorn his knees, joints, and skeletal system should have done him in. As it was, another “bone” brought about his demise, for he lived, loved, and died by the sword.

Sorcerer's Soup

As ghouls and goblins descend upon us in this Halloween season, the annual question of whether one can be scared to death, or “scared stiff,” whichever you prefer, must once again be posed. The sorcerer’s cauldron froths and boils over, rendering its soup no more toxic than the so-called brain-heart connection. In fact, there is a physiologic basis for strong emotions causing death, when the nervous system becomes so jump-started by serious threat that it can cause heart attack and consequent exitus. Animal studies bear this out. There are also historical precedents to the lethal brain-heart connection, with a Roman emperor, a 13^th century pontiff, and American patriots all succumbing to the mortal blows of anger, grief, and elation, respectively.

Both disruptive life events and the chills of Bela Lugosi, Christopher Lee, or Freddie Kruger movie house madness can lead to an inevitable downward spiral in life’s course. The palpitations, heartache, and anxiety wrought by Hollywood make believe can easily parallel similar repercussions of real-life calamities such as the death of someone dear, the threat of death to someone close, the anticipation of a difficult examination, the embarrassing loss of self-respect or self-esteem, the unpleasant memories exhumed during an anniversary memorial service, or the threat of imminent harm or injury in battle. Even the jolt of a happy ending can end miserably, with the strength of the emotions elicited weighing heavily on an “animus et corpus” worn down by neuronal, hormonal, and psychic bombardment.

We have all experienced anxiety at some point in our lives. The adolescent on a first date with an unsightly pimple that just sprang up, the college student about to take a first set of final examinations after pulling an “all-nighter,” the hapless groom about to say “I do,” the postmenopausal woman awaiting biopsy results after a suspicious mammogram, the second-string athlete about to get his chance in the big game, the employee suddenly called in to the boss’s office after rampant rumors of pink slips and company lay-offs, and the list goes on and on, indicating that being human entails a certain amount of heart palpitations, taut nerves, queasy stomachs, cold hands, and downright urges to roll up into the fetal position until the all-clear has been sounded. Until now, however, the latter had been considered nonlethal, par for the course, and attributed to simply living life. Now we know that they can kill you! A study of 3,015 70-79-year-olds, in fact, has demonstrated that not only “the good die young,” as the saying goes, but the anxious also. The more anxious one is, the more he or she is likely to die, with the added twist that anxiety is a greater predictor of death in blacks than in whites.

And what of the million-dollar shrink’s term, “catatonia,” theme of horror movies and idle cocktail chatter? Catatonia is a paralysis that has no apparent physical cause and little physiologically concrete to refer to, except that it may be provoked by fear. On any given day, any one of us can become its victim with no advanced notice, and a study conducted in 2004 suggests that it was originally rooted in our collective DNA to protect our species from being eaten by other animals. Unfortunately, we now know that other kinds of fear, anxiety, or feelings of imminent doom, real or imagined, can lead to catatonia.

Passing from a sorcerer’s soufflé of Ouija boards, tarot cards, horoscopes, pinned effigies, amulets, potions, elixirs, bloodied chicken corpses, and Santeria, we subsequently navigate the singularly turbid waters of Cupid’s domain, where we pose the question of whether one can, indeed, die of a broken heart. Been there, done that, and lived to tell the tale, you say. Perhaps. But consider yourselves fortunate, as failed romance may be just stressful and acute enough to cause heart failure. While people under stress may already have heart disease, who’s to say that the stress of unrequited love is insufficient to cause fatal heart failure? After all, acute stress cardiomyopathy, which resembles a heart attack without actually being one, occurs in non-cardiac patients hospitalized after acute physical or emotional trauma, such as grief for the loss of a loved one or fear resulting from an act of criminal violence or involvement in an automobile accident.

Our account of mind over matter would be found deficient, if we were not to contrapose the concrete to the sublime. Why worry about what we don’t know killing us, when even the innocuousness of castor oil, rhubarb pie, sunflower seeds, and cherry, plum, and peach stones, to mention a few, can put our short time on earth to an even shorter test? Perhaps we should devote our energies and turn our sights toward what can actually kill us, instead of a witch hunt for sensationalism and magic bullets to fell the monsters inhabiting our psyches since the beginning of our time. Wouldn’t resources be better directed at automobile accidents, murder, other accidents, suicide, and cancer in the 15-24-year-old group, cancer, heart disease, and accidents in the 25-45-year-old group, and heart disease, cerebrovascular disease, chronic lung disease, Alzheimer’s, pneumonia, diabetes, and accidents in individuals 65 and older than at shadows, figments, and sounds that go “bump” in the night?

Sorcerer’s, shamans, medicine men, charlatans, and traveling snake-oil vendors are everywhere, now, at Halloween, and whenever. Calling their bluffs, however, in these times of increased evidence of the brain-heart connection, leaves this writer scared stiff!

Monday, September 07, 2009

Unkind Swine

The so-called plague is upon us. As some run for the hills, and others to their favorite apothecaries or foibles in white, we are besieged by incessant calls to action and a sense of urgency. We are told to vaccinate ourselves, our children, our loved ones, and our friends, lest we fall prey to a swine virus ever so unkind. As is usually the case when heart and emotions dictate to the mind, we jump on bandwagons, follow the Joneses, and are led by the blind, all the while ruminating in self-doubt and our abilities to make the right decisions. All we want to do is what is just and healthy. With little thought for our own well-being, all we aspire to, individually and collectively, is a safe environment for our children, first and foremost (if we want to be selfish, at the least), and for the rest of our nation and the world, when we are feeling especially magnanimous. No easy task when navigating through a morass of scientific information, pharmaceutical hustling over the airwaves, and a press more bent on sensationalism and selling copy than getting accurate information out to the public in a timely fashion. So, briefly, let’s debunk the hype, and with cooler heads take a look at this thing they call the swine flu, with a predominant eye turned more toward prevention with vaccination, than damage control after Pandora’s Box has been opened.

It is designated the 2009 H1N1 flu, and never before has the old adage that “an ounce of prevention is worth a pound of cure” been more apropos. After all, a fever of over 100 degrees, cough, body chills, congestion, diarrhea, and vomiting don’t make anyone’s day. In fact, they can be downright dangerous in pregnant women, people of any age with heart disease, asthma, diabetes, and other chronic maladies, children under 2 years of age, and people over 65. To make matters worse, fever is not always present, and that can lead to a dubious diagnosis between swine flu and the common cold. So, let the buyer beware! A short course of the new swine flu vaccine, whether that be one dose or two, depending on an as yet to be made pronouncement by the Centers for Disease Control (CDC) and experts in the field, along with the regular flu vaccine, may be just what the doctor ordered. While a maximum of three doses, with the two swine flu doses in one arm and the single regular flu dose in the other, may not be the pleasantest of experiences, it sure beats the hell out of the shortness of breath, chest pain and pressure, confusion or seizures, persistent vomiting or inability to hold down liquids, and bluish lips that mandate a high-speed cruise down to the emergency room. The problem is that while health authorities expect the swine flu to peak in October, affecting up to 50 percent of the U.S. population, most vaccine doses are not expected to arrive until November or December. So, what good is vigilance and proactivity, you ask? Not much, sometimes. All we can do is wait, hope, and keep our fingers crossed. Impotence in the face of possible imminent disaster is the stuff of horror movies and Halloween, and not what we’ve come to expect from a health care system that propones to be at the acme on the world scene.

Family physicians, internists, and pediatricians would much rather receive “preemptive” calls from their high-risk patients, than cries for help after the swine flu has already set in. Care should be taken by parents and teachers alike to watch the activity levels of children and, at the first sign of lethargy or listlessness in their charges, call in the cavalry. Anti-flu medications prescribed by the men and women in white, whether they be Tamiflu® or Relenza®, stand their best chance of working if they are administered within the first 48 hours of flu symptoms. A task made no easier by still another fork in the road, and, namely, the $100-price tag of the anti-flu drugs, which many uninsured Americans can ill-afford to pay. Those fathers, mothers, young children, and extended families are precisely the foci of prospective or actual infection that need to be targeted, too! Realizing this, the federal government has gotten off its duff, for once, and shipped millions of doses of the medications to the states, with Texas taking the lead to allocate a good portion of its ration to those most wanting economically. New York has also placed its best foot forward, offering free swine flu vaccinations to its over one million schoolchildren.

The stage is now set for the unkind swine flu to materialize, with its 1-3-day incubation period for symptoms to appear after exposure to the virus. Before high tech kicks in, Mom’s age-old remedies for the flu make good sense, and should stave off or at least ameliorate its onslaught. At first sign or symptom, stay at home and rest, limit your contact with people, drink plenty of fluids, practice good cough and sneeze hygiene, and wash your hands and the surfaces you come in contact with frequently. Only then can we envision a kinder, gentler swine flu.

Appendiceal Appeal

They say it’s no good to anybody. They say it serves no useful purpose. But it’s hard to believe it would exist in the first place were it not for the divine plan of a deity, evolution, or some heretofore unknown life force. Is it a mere vestige of something far greater in our ancestry, or is it the key to wonders cloaked in mystery behind still another locked genomic door? It might just be a simple fellow, and yet it is part of us all and, as such, merits a closer look. What are we talking about here? Why, that enigmatic body part known as the appendix. Darwin himself was fully aware of its existence, and, yet, the conventional wisdom of his time led him to believe that it was a mere vestigial organ, a useless sac embedded in the lower right quadrant of the body, between the small and large intestines. And he knew that it was not limited to Homo sapiens, but ran the gamut of numerous animal species, including flying squirrels, to boot. Now we know, through the advances of modern technology and medical science that the appendix dates back 80 million years, and we are learning that it may be a “magic bullet” of some sort, aiding the human body in its defense against disease by releasing a flotilla of good bacteria into our guts and white blood cells into our bloodstreams when our immune systems are most in need. Yes, the appendix may be appealing, after all.

We often hear that someone we know has had an appendix removed, due to the sudden fever and excruciating lower right abdominal pain of an appendicitis attack. In fact, 1 in 20 people has an appendix taken out, with no dire consequences. That alone has given the medical community license to declare that the slimy dead-end sac known as the appendix is of little or no need to us all. Wrong! Recently, it has been suggested that the appendix is a storehouse, a Big Wal-Mart, if you will, of good bacteria. When a subject’s colon is devastated by the ravages and diarrhea subsequent to a severe case of food poisoning or any number of acute and chronic gastrointestinal maladies, the “good-for-nothing little engine that could,” otherwise known as the vermiform appendix, comes to the rescue, releasing good bacteria or normal flora into our guts to repopulate the healthy bacterial lining that forms an integral part of our gastrointestinal systems and that is often the first to go after a nasty diarrheal attack. But the job of our newfound friend, the appendix, doesn’t end there. Recent studies indicate that it may, indeed, even make, direct, and train white blood cells, which, as you may or may not know, are key to our bodies’ defenses. So, perhaps we should reevaluate the little fella we were so anxious to write off, without giving the benefit of the doubt, a proper chance, or a respite for all the medical data to come in.

Now we must determine what actually causes appendicitis, or that potentially deadly inflammation of the appendix. In reality, the prevailing opinion of experts no longer inculpates a faulty appendix as its cause. You may, in fact, be surprised at whom the finger has been pointed. It now appears that cultural changes due to an industrialized society and improved sanitation are the culprits. The appendix, as a storehouse of what had been good and healthy for our guts and immune systems, was rendered useless and obsolete by the very advances that contributed to our clinical and public health betterment as a society, those being widespread use of sewer systems and clean drinking water. With infection of the gut on the decline due to the latter, there was really no further need of an arsenal of good bacteria and white blood cells to defend us. Why maintain a large standing army when there are no wars to fight? So, the appendix was wrongly relegated to the ranks of a mere vestige. Now, all that has changed. With what has recently come to light on the normal function of our “long-lost friend,” we must look at the question of what can be done to prevent appendicitis, to the chagrin and reduced bank ledgers of general surgeons. If we can find the means to instigate the appendix in much the same way as in the past, and consequently incite our immune systems, through release by the former of good bacteria and white blood scavenger cells, then allergies, autoimmune diseases, and even appendicitis may go the route of imminent extinction. Wishful thinking? Perhaps. But then, again, it certainly is appealing. Darwin would be pleased.

Don't Bug Me!

Make no bones about it, superbugs will inherit the earth, or at least our hospitals, for the time being. There is no escaping them. Go into the hospital for one thing, and come out with something entirely different, if not in a pine box. So, those hallowed halls of healing are slowly but surely becoming more known for what ails them, than for what ails us. Methicillin-resistant Staphylococcus aureus (MRSA), an antibiotic-resistant bacterium, has passed from the exception to the rule in the 1970s to a predominant “mover and shaker” on the Ten Most Wanted list of our nation’s hospitals. The organism lives harmlessly on the skin, but just grant it access to and safe passage through a portal into our bodies, and all hell breaks loose. Its close companion and fellow hit man, Clostridium difficile, an intestinal bacterium, is no less troublesome, and is a force to be reckoned with that even that age-old “bug slayer,” alcohol, cannot neutralize.

There you have it. It’s bad enough that the out-of-the-ordinary causes your hospitalization, without being further insulted by a totally unexpected bug brigade. Unexpected is a poor choice of words, however, as each year 90,000 Americans pick up hospital-acquired infections that kill them, and many more suffer the ravages of diarrhea and other unpleasantries so severe that even Montezuma’s heirs would most likely disown them. It has been estimated that in 2008, on an average day, 7,200 hospitalized patients or 13 of every 1,000 were colonized or infected with Clostridium difficile, and 300 did not survive it. Add those numbers to the toll of MRSA infections in patients with weakened immune systems, or those requiring catheters, intravenous lines, or ventilators, and we become witness to a mathematician’s worst nightmare, that being the formula for a lethal one-two punch.

And to think, in many cases we brought this on ourselves! While the young and very old are often the first and foremost to be “bugged” in the hospital setting, whoever dreamed that the very antibiotics conceived of and developed to thwart any number of serious infectious maladies might boomerang, strip our guts of friendly, protective organisms, and, as a consequence, fertilize the terrain for florid Clostridium difficile growth and proliferation thereafter. MRSA, on the other hand, being a normal inhabitant of the skin, has a tendency to congregate around cuts and scrapes, where it is held in check by a healthy immune system. Impairment of the latter is an open invitation to bloodstream incursion, with resulting sepsis a formidable foe to even the most heavily reinforced arsenal of antibiotics and antimicrobials. The death toll and morbidity rates generated by MRSA and Clostridium difficile come at a stiff price in greenbacks also, to the tune of an estimated $250 billion a year.

The story doesn’t end there, however. The profuse diarrhea incited by Clostridium difficile is the vehicle of a riot or a wildfire, if you’ll allow for literary license, facilitating spread of the bacterium onto hands, bed rails, sheets, IV poles, and uniforms. Person-to-person transmission, from patients or medical equipment to the hands of health care workers and then onwards to other unsuspecting souls, is the name of the game. In short, the bug is spread everywhere. MRSA, for its part, while far removed in its mechanism of action from a potential enrollment in a “defecatory duo” spearheaded by Clostridium difficile, is nonetheless anything but innocuous. In fact, about 250,000 Americans a year receive a nasty surprise when catheters inserted into their large veins to provide fluids or medications become the sources of bloodstream infection with MRSA. One in four of these unlucky souls meets his or her Maker, and just for having been in the wrong place at the wrong time.

So, what’s the solution? How do we stop superbugs in their tracks? What measures can be taken against an MRSA adversary resistant to penicillin and other antibiotics? Is diarrhea lasting longer than 24 hours and accompanied by weakness, a racing heart, or blood in the stool a sign of something as sinister as Clostridium difficile infection or just symbolic of a bad night on the town and a cheap Chinese restaurant? Frequent hand washing, limited use of antibiotics to only cases absolutely necessary, the wearing of sterile gloves and gowns by medical personnel, the use of antiseptics and sterile drapes and dressings to protect patients, and even a probiotic, helpful yeast called Saccharomyces boulardii (or commonly Florastor®) taken orally can go far to checking the advance, if not exterminating entirely, the superbugs. Government and state oversight, public scrutiny, and state laws requiring hospitals to report infection rates to the public can also be strong deterrents to harmful laissez-faire attitudes on the part of health facilities. Case in point, preventives measures, both voluntary and imposed, were instrumental in reducing the rate of MRSA bloodstream infections by about 50 percent from 1997 to 2007.

Superbugs may one day inherit the earth, but not on our watch, as long as actions speak louder than our collective “Don’t bug me!”

Sunday, August 09, 2009

Of Mammograms and Telegrams

The ritual of the yearly mammogram screening has reached epic proportions, with vast numbers of our “over-50-ish” fairer sex trudging down to their family care providers, gynecologists, or radiologists religiously, in order to receive peace of mind for another 365 days. Mammograms were originally conceived of to preclude nasty surprises and their subsequent urgent telephone calls and telegrams. But are they foolproof? Does being a “good girl” and getting one’s annual mammogram avert a worst-case scenario, namely, advanced-stage breast cancer with little chance of cure? Lo and behold, we now learn that no two breasts are exactly alike, and that mammography can detect only about half of all breast cancers in women with dense breast tissue. And how, for that matter, is a woman to know if her breasts are dense? We need to throw some light and accurate medical information on a subject that directly or indirectly affects us all. As products of a mother’s milk, we would be remiss to do otherwise.

Breast tumors are dense and, when coupled with dense breast tissue, make for a difficult game of hide-and-seek, with anatomical camouflage making discovery difficult, at best. To make matters worse, dense breasts are not the exception to the rule and, actually, are quite frequent. The medical literature indicates that half of women under age 50 and one-third over 50 have this density dilemma, if we may call it that. The younger a woman is, the more likely she is to have dense breasts. If that were not all, even if a woman were to be aware of her individual density issue, chances are that she would be blatantly unaware of the fact that her annual mammogram might actually miss its intended target. Were radiologists to inform their patients of this particular, not only would mammograms drop below radar screens and get scratched off shopping lists, but women might protest en masse and further embarrass a health care system already reeling from assaults by Congress, local politicians, the elderly, the poor, and the downright fed-up.

So, in simple terms, one might say that the question is whether or not screening mammograms are worth their weight in biological gold. Do they, indeed, reduce a woman’s chances of dying from breast cancer? If not, why is there so much ado about nothing? In that case, we might be better served by simply moving on to another form of detection, more sensitive and specific than pressing one’s upper torso against a plate. The fact is that mammograms reduce women’s chances of dying from breast cancer by 22% when they are aged 50 and over, and by 15% in those in their 40s. No small numbers, especially when female friends and family members are set adrift in the choppy waters of cancer fear, doubts, and medical misinformation, and cling to the only life preserver and communication beacon heretofore available, namely, the screening X-ray. However, when breast density is thrown into the mix, any attempt at treading water becomes problematic, to say the least. Enter our hero, the breast ultrasound.

While screening ultrasound adds little to the diagnostic picture in women with category 1 (fatty) and category 2 (somewhat fatty) breasts, in whom screening mammography is 98% and 80%, respectively, effective in detecting breast tumors, it can nonetheless commute a death sentence in women with category 3 and 4 (dense) breasts. The latter have only a 50% chance of having their breast tumors detected on a mammogram before they become palpable on physical examination, and ultrasound excels at individuating these silent killers in dense breast tissue. It is not a panacea, however, and with the good comes the bad, and sometimes even the ugly. Ultrasound pinpoints abnormal breast findings 10% of the time that turn out to be benign, when subsequent breast biopsy is done. Not only that, but it is unavailable in many radiology centers and, at a miserly $87 dollars a pop for 20-30 minutes of work, few radiologists are ready, willing, and able to perform it. After all, time is money! Who knows that better than radiologists, who further state that the combination of magnetic resonance imaging (MRI) and mammography is almost twice as effective as ultrasound and mammography at detecting tumors in women with very high breast cancer risks. Those “roentgen masters” are just itching to employ MRI more widely, and being held back only by its $1,000 per test price tag. And when all is said and done, we save the ugly for last. Even were ultrasound to be employed on a large scale, there is no data as yet to tie improved tumor detection with ultrasound to a reduction in deaths from breast cancer. So, currently, an end justifies the means argument cannot be made.

Cancers come, and most often do not go. Until now, their early detection has been the name of the game to improve survival statistics. But what about those lazy, indolent tumors that are so slow-growing that early detection makes little difference, and similar, acceptable survival results can be achieved without a precipitous “jump on the horse,” expensive technology with little financial remuneration for its purveyors, and a rush to judgement? We must ask ourselves whether mammograms, ultrasound, and expensive MRIs influence the survival equation in a meaningful way, or whether cheaper, more patient friendly, and perhaps more delayed detection procedures and devices can achieve equivalent reduction of those fateful telephone calls, letters, and telegrams.

Friday, July 31, 2009

Vaccinator

Fathers, protect your daughters from the onslaught of that perverter of all that is right, good, pure, and just, namely, the HPV vaccine! The call to arms has been sounded from belfries across the nation, to the despair of health care providers who witness another arm in their arsenal against cervical cancer cast to the wayside. The feeling of utter impotence on their parts is both frustrating and devastating, in the face of an ever-mounting body of data that appears to indicate the resounding efficacy of a vaccine that is a relentless adversary in the fight against cervical cancer, when it is unleashed in a timely fashion. Getting down to the brass tacks of the matter, perhaps you, the reader, will become convinced, and lend your daughters to the safe haven and caring hands of those who would stop a virus, the human papilloma virus (HPV), and its progression to something far more sinister dead in their tracks.

Cervical cancer is the second most frequent cancer among women, and it has been associated with HPV. The general public has not been adequately schooled on that score, and remains ignorant as to just how diffuse HPV infection is. The statistics are staggering, and go something like this. Twenty-five percent of persons between 14 and 19 years of age and 45% of those between 20 and 24 years are infected with genital HPV, with more than 80% of both men and women in the United States infected at some point in their lives. Surprised? Read on. HPV is usually acquired within months after the first sexual intercourse, and is usually asymptomatic. If the infection is not prevented, if screening with a Pap smear for precancerous lesions owed to HPV is not conducted due to health information shortfalls or a sense of physical impunity, or if treatment of HPV’s legitimate heirs, anogenital warts and cervical disease, is not instituted thoroughly and immediately, the death knoll will be sounded and direct medical costs stemming from HPV will add insult to fiscal injury. As it stands right now, each year 490,000 of this planet’s women receive a diagnosis of cervical cancer and 270,000 die from it. In 2008, 11,000 U.S. women received such sad tidings and 3,900 were as a result summoned by the Grim Reaper, at a cost of $4.0 billion in health care dollars. A good portion of these victims, and, if not them, future generations might be spared if reliance were to be placed on the “Vaccinator,” a full series of the HPV vaccine, costing $375 dollars and a whole lot less blood, sweat, and tears.

The hero of the moment, called the “Vaccinator,” for purposes of literary color and license, but commonly known as the HPV vaccine, has received a great deal of bad press, with the public continuing to be misinformed in many cases. So, the record must be set straight here, and then, perhaps, heads of households will be more inclined to offer their daughters on its preventive altar in exchange for a welcomed and precipitous reduction in the body count. The HPV vaccine has been marketed by Merck & Co., Inc. since June 2006 under the name Gardasil^®, and it is effective against the four high-risk types of HPV. Women between the ages of 9 and 26 years of age are targeted for vaccination in order to prevent genital warts and cervical, vulvar, and vaginal cancer. They should be vaccinated before their first sexual intercourse, because it is a sad, but true, “fact of life” that HPV infection is usually acquired within months after first sexual intercourse. While the vaccine is effective in immunocompromised women, the same cannot be said for pregnant women. A silver lining is the fact that women with cervical disease from one high-risk HPV type may be vaccinated against the other high-risk types. Gardasil is administered intramuscularly at 0, 2, and 6 months, and the vaccine series does not have to be restarted in its entirety if, girls being girls, a dose is missed. Let the buyer beware, however! Fainting spells may occur in adolescents immediately after vaccination. So, the rule of thumb is for the physician to observe the “vaccinee” for 15 minutes after vaccination. Wow, that was a lot of information! Exclusion of still another piece of stark reality could be construed as criminal, so it needs be said that abstinence from intercourse until marriage is no substitute for the HPV vaccine, as sexual abuse or an infected marriage partner make having been a “good girl” bad.

As the Vaccinator waits in the wings for the raging debate over whether to vaccinate preadolescents or not to play itself out, parents of young women should take no comfort in biding their time with a less is better mentality. Even with the jury out, some verdicts are forgone conclusions.

Sunday, July 05, 2009

Temples to the Gods

What’s a house call, you ask? For those of us old enough to remember, a cough, a fever, an upset stomach, a runny nose, a child’s pinworms, or any manner of body wake-up call left us concerned, but never troubled, for we knew that we could depend upon our trusted physician in white armor to ride to our doorstep on four-wheeled steed. Something has been lost in translation, however, as that friendly domestic cup of tea shared by doctor and patient has been transformed into a mad dash to the emergency room and a rush to judgment, as we chastise a past hero who now reminds us that time is money. So, are the healers of today, with all their bells and whistles, airs of superiority, and self-built clinical temples, better at their art and science than their good-old, bespectacled ancestors, who bore little black bags instead of handheld computers? Is technology mightier than compassion? Are robot-guided catheters and probes more efficacious in the long term than the touch and comfort of a healing hand? Can some suitable compromise be reached? Those and other questions need to be answered, before we embark on that expensive overhaul of the health care system we call universal health insurance.
Medicine has become a business, like many other noble endeavors, and its proprietors seek growing clienteles through self-promotion, whether that be media advertisement or construction of palatial offices and clinics that provide a semblance of professional success to new generations raised on material excess. After all, a doctor in rags, driving a jalopy, certainly does not project or warrant trust, in much the same way as a down and out real estate agent or practitioner of the bar. Furthermore, a “mine is bigger than yours” attitude drives a competition for numbers, both in terms of patients and consequent hard cash, as physicians vie for their piece of the American dream by drawing patients across their thresholds and then treating them with production-line efficiency. Damn feelings and close interpersonal contact, as terse replies to questions and directives to consult the nurse engender little satisfaction, growing hostility, and a sense of loss and abandonment in those seeking solace and perhaps even a cure from the men and women in white.
Those venerable statistics we like to quote have shown big-clinic medicine is a drain on pocketbooks, resulting in 60 percent of all bankruptcies in the United States in 2007 being owed to runaway health care costs. Seeing a different patient every 15 minutes does little to reel in costs or improve patient satisfaction. It is high time for a new paradigm, called “patient centered” practices, that incorporates both increased time with patients and an emphasis on prevention and education to keep them healthy, so that incessant and expensive referrals to specialists become a thing of the past. Not an easy task, you say. You’re absolutely right. To streamline procedures, processes, and administrative costs, with consequent reduction in the health care deficit, all eyes will once again have to turn to that often-touted cure all for everything costly, namely, technology, in the form of online appointment scheduling, electronic medical records, prescription of medications by computer, and virtual office visits by telephone and e-mail. As impersonal as it may seem, and as uncomfortable as we may feel about it, technology can, indeed, raise the bar of primary health care and even personalize it, when placed in the hands of practitioners in the trenches who are unafraid to try something new to safeguard a nation’s health on the verge of financial chaos.
Technology is not for everyone, however, and it will not solve all of this country’s health care issues. The high priests, keepers, and gods themselves in the temples warn that electronic patient records can be hacked, computer downtime can make patient records inaccessible for hours, small primary care clinics are not the answer for patients with multiple health issues, and small practices do not provide safe haven for practitioners who lack technical or business skills or who fear private fees versus salaries in these times of economic uncertainty. Reducing daily patient loads from 25 to 10-12, with longer patient appointments of 30 to 60 minutes, may not be the answer either, as primary care physicians watch impotently as their salary dollars undergo erosion. That, in part, is the reason why primary care remains the most unattractive field of medicine, with practitioner numbers dwindling due to the lowest compensation of any medical specialty. In 2008, the average annual salary of a primary care physician was $201,555, versus $356,166 for a general surgeon and $614,536 for a neurological surgeon. Poor babies! Lest they recall the hordes of unemployed currently walking the bread lines!
All this discussion points to a need for something to be done, and immediately. When general practitioners are scheduled to see 25 or more patients per day in large clinics or temples, whichever you prefer, sufficient time for thorough examinations, adequate discussions, and proper preventive care goes out the window, and the end result becomes the needless ordering of superfluous tests and unnecessary referrals to specialists, all at the expense of national health care ledgers that are rapidly approaching the bottom line. And heaven forbid that we discuss the unquantifiable toll on patients’ psyches of noisy and crowded waiting rooms, and the status quo, for lack of a better word, of getting in and out without wasting the doctor’s time with questions. Ignorance not being bliss in this case!
Is technology the answer? Perhaps not, in all cases. However, it can streamline processes and make small primary care practices financially viable in the current health care market, reducing their costs to half, from 60 percent of income down to 30 percent. That translates into better patient care, with physicians able to see fewer patients without sacrificing their almighty incomes. Tearing down the temples in favor of small storefront clinics with advanced technology may be a return to the future, and the name of the game. Perhaps little black bags can even be made big enough to hold laptop computers.

© 2009, Albert M. Balesh, M.D. All rights reserved.

Saturday, May 23, 2009

Half-Hearted

I have chosen an issue here very dear to me, and one that I will not address with my usually flippant writing style. As a physician, the pathophysiology of the heart has always interested me, and all the more so because my brother-in-law died of a massive heart attack a little over a year ago, at the ripe old age of 50 years. A lifetime of smoking was the major contributing risk factor to his demise. The short stick of smoking served no useful purpose than to exact a heavy toll on the heart and lungs of the guest of honor at a premature burial.
A patient’s insistence on smoking cigarettes is a behavior that can eventually lead to a forgone conclusion. Early exposure to what is called a well-conducted elicitation process, however, may avert that end. So, let me describe a tentative and prospective elicitation process that might have saved my brother-in-law’s life had it been implemented sooner.
Had my brother-in-law, who had smoked heavily for the last 30 years, been one of a small group of habitual smokers enrolled in an elicitation interview process, the positive (in his eyes) and negative attributes of smoking would certainly have been elicited from him, as well as a description of influential individuals in his life who would have either been for or against the importance of his behavior. A series of questions of the following nature, destined to elicit the positive or negative attributes of smoking, might have been asked of him. Does smoking make you feel and look more important? Does smoking relax your nerves and make you feel less anxious? Does smoking make coffee taste better in the morning? Does smoking help you to socialize and break the ice? Do you know that smoking is a major contributing risk factor to serious illness? Do you smoke to lose weight or curb your appetite? Have you ever tried to quit smoking? Is smoking an addictive habit or can you quit anytime? Is smoking expensive? Do you like the taste of tobacco?
The interrogation would not have ended there, either, as the social referents who might have influenced my brother-in-law’s decision to smoke would have been flushed out of the bush. Without pointing fingers, rekindling guilt, or eliciting an “I told you so,” those influential mouthpieces might have been my sister and his wife, who was a smoker also; I myself, who was vehemently opposed to smoking; my brother-in-law’s peers and football drinking buddies, who were known to “hoist and puff” a few; my brother-in-law’s personal physician, who knew that congenital heart disease and heart attacks ran in his family; my bother-in-law’s blue-collar coworkers, who fought boredom on the job via a convivial smoke; my brother-in-law’s favorite rock musician, who was both transgressive and a habitual smoker; and, finally, my mother, an ex-smoker, who frequently warned of the evils of smoking.
With my brother-in-law’s behavioral beliefs and subjective beliefs thus individuated, attention would have been turned next to control beliefs, or the environmental factors that might have made it easy or difficult for him to quit smoking. They were all too pervasive, and a direct frontal assault on the negative influences might have been warranted. To name a few of both the positives and negatives, they might have been listed as being surrounded by family and friends who smoke; radio, television, and newspaper antismoking campaigns; Hollywood movies portraying smoking as “cool;” and antismoking billboards, restaurant signs, and lighted written cues on airplanes.
My brother-in-law was nonetheless obstinate and hard-headed, and, while the elicitation interview and its discussion would have most certainly elicited some resistance in him, I cannot help but believe that in the long run, a significant amount of behavior modification would have occurred to open his eyes to the root causes of his smoking behavior and give him a fighting chance to live a long, productive life. As it was, he lived by the burning stick and died by the burning stick! His life was gone on February 1, 2008 in a puff of smoke, and, instead of cajoling the excesses of Memorial Day barbecues, I must shake my head and gaze at an empty place at the picnic table.

© 2009, Albert M. Balesh, M.D. All rights reserved.
In memoriam of Joseph Conway.

Thursday, May 07, 2009

Hands Off Our Health!

In this age of loss of personal freedoms and intrusions on our privacy by Uncle Sam, credit card companies, the IRS, law enforcement agencies, health insurance companies, banks, and the Internet, it is any wonder that looking over our shoulders has become as reflex as a knee jerk! Inherent in the U.S. Constitution and Bill of Rights, whether stated implicitly, explicitly, or even with duplicity, is the notion that we are free to choose how we live our lives and under what circumstances we wish to live our lives. For far too long now, big government and big business have teamed up, whether consciously or unconsciously, to gradually erode a long series of our basic and civil liberties. The right to adequate and guaranteed health care for all citizens, regardless of race, creed, national origin, or socioeconomic status (SES), however, must remain immutable and untouched. It is the cornerstone of any democracy, and a gauge by which we judge the health of a nation and its collective sanity. There is no debate on the principle of horizontal equity of health care, as any rational citizen of any country worth its weight in this world would most likely agree that “equal treatment for equal need” is a sine qua non, before any discussion of city, state, or federal implementation of health care policy can even begin. Once a decision has been made to incorporate all SES facets of a particular population in the discussion of, and under the umbrella of, a national health care policy, then free wills and open minds must prevail to determine the extent to which a community, a city, a state, or the federal government exercises control over the mental and physical destinies of its inhabitants. That is no easy matter, as private insurance companies and hospitals vie with local public and national authorities for precious health care dollars and the lucrative “baby boomer” and government welfare trades. Competition is intense in this market, and without some form of regulation and uniformity, whether it be local, state, or federal, there is the incessant danger that what one sees on paper will not be what one gets when receiving the “cold shower” resulting from close review of that first hospital or doctor’s bill after recovery. Furthermore, we, as a society, are not getting any younger, and it becomes more and more difficult to decipher the fine print and riders that have become standard fare in most health insurance statement of benefits. Not a day goes by without our parents, who for the most part are senior citizens, receiving some form of printed Medicare propaganda in the mail from nameless and faceless individuals, representing the ever-increasing cadre of private health insurance companies, hawking the pros of their companies while diminishing or excluding the cons. It never fails that such leaflets, fliers, letters, or brochures trigger a litany of questions from our elderly parents that, to be frank, we cannot answer. We would most likely need advanced degrees in law and health management to do so. Therefore, the question arises as to who guarantees the correct design, development, implementation, and communication of health care programs and health care policy. Is it the job of the city? The state? The federal government?
Developed nations like the U.S. and Switzerland have sought answers to these questions for quite some time now. With health care financed by a combination of private and supplementary insurance, out-of-pocket payments, taxes, donations, and city, state, and federal social programs, the “push and pull” for control of health care at all levels of society and governmental bureaucracy has become never-ending. Consumer-driven health care continues to reign in the U.S. and Switzerland, but those trends are destined to decline in favor of increased governmental control, as world economies “cool down” and immigration of the poor from underdeveloped nations to those more technologically and economically advanced increases exponentially. With government subsidies and tax revenues to finance hospitals outpacing local support, governments are demanding more and more “say” in how health resources are dispersed, what health resources are dispersed, and in what measure. While federal tax breaks for hospitals and institutions that strictly adhere to governmental mandates do not guarantee standard of care, they do extend a disproportionate degree of control over our lives to top-heavy agencies that may take financial bottom lines more to heart than social equity and welfare. So, we do have a dilemma here, and we are hard pressed to render unbiased, objective opinions on the matter. What we can say, however, with a certain amount of certitude, is that without U.S. government intervention, programs like Medicare, Medicaid, SCHIP, WIC, and Social Security would be “dead in the water.” Nonetheless, the efficiency of those programs in the long term remains in doubt, especially in the current economic climate. Also, while government may, indeed, control the purse strings, tailored community approaches to health care may be more efficient (both financially and logistically) to address specific local needs, and to develop and implement specific local interventions.
Hands off our health! Then, again, we’re not ticklish.

© 2009, Albert M. Balesh, M.D. All rights reserved.

Tuesday, May 05, 2009

Lions and Tigers and Bears, Oh My!

“The sky is falling, the sky is falling!” How many times have we heard that doomsday cry of apocalypse? We are now using a similar tone to address sexually transmitted diseases (STDs) or sexually transmitted infections (STIs) in teenagers, whichever term you prefer. Trust, solidarity, cohesion, inclusion, and social capital are currently the weapons in the preventive armament against those maladies that are increasing in both incidence and prevalence at alarming rates in the adolescent population. Now, while education and confidentiality are of paramount importance in stemming the tide of uninformed, free sexuality, there are numerous issues involved here, all of which form part of an intricate puzzle. Intervening in only some of those pieces will effect minor change, at best. Unless all facets of the big picture, from peer pressure and safe sex practices to HPV vaccines and parental detachment, are scrutinized and addressed, no long-term, consistent policy will be formulated, and disparities will continue to exist between the rich and poor, affluent suburbia and urban inner city. Experts contend that education is the single most important concept to look at. However, who is ultimately responsible for the sexual education of teens? The schools? Parents? Local public health officials? The federal government? The states? Experience teaches us that education is but a “drop in the bucket,” in many cases.
The relationship between teenagers and their parents has come to the fore recently, as single working mothers and two-parent breadwinner households continue to grow. Parents can no longer take the time to “school” their teens in sex education and safe sex practices when they are more concerned with the day-to-day dilemma of making ends meet and putting food on the table. This situation is destined to deteriorate even further, as the U.S. economy continues to cool down. Furthermore, with cuts in education and public school systems throughout the U.S., parents who think the schools are competent surrogate instruction platforms for their own failings at sexual education of their teens are in for a grim awakening. Welfare rolls are also stagnant, as government resources are limited, and cost cutting has threatened programs such as WIC, SCHIP, and Leave No Child Behind. If that were not enough, while federal, state, and local public health officials continue to sing the praises of safe sex and condom use in television spots, those sound bites compete with the “machismo” and “party like a rock star” mentality of the numerous beer advertisements plastered all over billboards, popular magazine pages, and cathode-ray tubes in our homes. It has become romantic to hoist a beer and take a damsel. You’re a wimp if you stay at home, listen to your parents, dress conservatively, and don’t succumb to peer pressure.
Transportation is another issue. Even if teens are willing and able to seek professional care, they are often “paralyzed” by an inability to reach the resources they so desperately need. In surveys taken among teens and young mothers for the reasons why they have sought prenatal care so late in their pregnancies, transportation difficulties have been found to be in first or second place consistently. That means that prenatal vitamins like folic acid are, indeed, being prescribed when it may already be too late to prevent neural birth defects in their developing fetuses.
Confidentiality is also an exceedingly large issue. Young women and teenagers are often adamant about the fact that they do not want either their parents or their significant others to know they are “victims” of an unwanted pregnancy. Those are just the young women who come forward to be seen and heard, too! It has been estimated that there are many more who decline prenatal care and family planning, to remain in the shadows, only because their fear of parental and social repercussions are enormous. With the spread of HIV/AIDS also slowly but surely dropping off the radar screens of urgent public awareness, young teens are additionally being exposed in record numbers to another “can of worms” that will eventually weigh heavily on a U.S. health care system that may already be crippled financially beyond repair.
So, we have a major conundrum here on our hands, and earth-shattering answers to the questions raised are certainly not immediately forthcoming. The social capital that binds us as people and communities, and enables us to take cooperative action through trust, mutual understanding, and shared values and behaviors, has broken down and not been adequately handed down to our future generation of political, social, moral, and scientific leaders. Furthermore, social capital has taken a backseat to the more pressing issues of financial capital and economic degradation, as provision of food and shelter to our young precludes sex education in the quest for survival hierarchy.
Perhaps we need to start looking beyond “lions, tigers, bears, and bulls.”

© 2009, Albert M. Balesh, M.D. All rights reserved.

Sunday, April 19, 2009

Making the Grade

For those of us who are baby-boomers and old enough to remember, taking a bad report card home engendered a great deal of fear and trepidation, during what seemed an endless walk or school bus ride home. Perhaps that is the way hospital CEOs currently look at the issue of transparency and public disclosure, as they closely guard their respective institutions’ financial and clinical secrets, and damn or withhold any revelation destined to transform stockholders into what amounts to angry parents.
Healthcare consumers, the U.S. federal government, and third-party payers, however, demand the highest standard of care from our nation’s hospitals, as well as reliable performance measures to assure quality. Furthermore, such measures must be applicable to all hospitals, whether they reside in the high-tier or low-tier category. There is much evidence to support the contention that hospital report cards, based on objective performance measures, improve the overall healthcare of patients.
The Hospital Quality Alliance (HQA), based on provisions in the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 and instituted by the U.S. Department of Health and Human Services (HHS), was, indeed, initiated precisely to that end. By collecting data on key measures of hospitals’ management and quality of care (for example, the care provided, the resources consumed, the total costs of care, and the resulting outcomes), the HQA can tabulate report cards to motivate change and hopefully improve overall patient healthcare. Also, the recently proposed Deficit Reduction Act (DRA) of 2005, by instituting financial incentives to entice our nation’s hospitals to “make the grade” by adhering to established measures of performance, and expanding them when necessary, serves as an additional built-in safeguard to our nation’s health.
High performance scores on HQA performance indicators have been associated with up to 15 percent reductions in the odds of death for common clinical conditions such as acute myocardial infarction, congestive heart failure, and pneumonia. So, the initial results are in, and perhaps only a bit of tweaking and several more performance indicators are required before hospital report cards become a diffuse functioning reality.
Who would have ever thought that the long bus ride home would be good for one’s health!

Sunday, April 12, 2009

Trojan Horse: What Lies within a Hospital's Report Card could Spell Trouble

No one likes examinations, let alone report cards, but the stakes are just too high to let our nation’s hospitals continue with business as usual, with no form of grading system in place to hold them accountable. U.S. public health agencies and the federal government must retain the right to impose guidelines, parameters, or benchmarks, whatever one wishes to call them, on hospitals in order to ensure a standard of care that lowers in-hospital mortality rates and guarantees citizens (and illegal immigrants, too) the same level of care, whether they are admitted to high-tier or low-tier hospitals. The petty bickering of hospital CEOs must be put aside, and objective transparency must win the day, both in terms of financial ledgers and healthcare morbidity and mortality data. Without an objective set of rules and regulations to go by, if you will, and grades (based on accurate scientific data) to indicate performance and compliance, measurement of our nation’s hospitals’ standard of care and delivery will be based on quackery, hearsay, sensationalism, and the subjective. That is exactly what is occurring at this precise moment. But, wait just one minute! Perhaps we are being a bit too hasty here. Human nature being what it is, perhaps we will never truly reach our goal of objective measurement of hospital quality of care. Perhaps a hospital’s closely guarded secrets, whether they be financial or clinical, run countercurrent to the dictates of hospital quality assurance, and must, indeed, remain in the private domain. Perhaps our energies should be directed at what is realistic and what we can actually do, and that is develop subjective criteria that parallel and confirm the results of objective measurement of hospital performance.
The latter, in fact, is just what has occurred. As consumers, the U.S. federal government, and third-party payers continue to not only demand the highest standard of care in our nation’s hospitals, but also reliable and valid performance measures to guarantee that standard, the subjective perceptions of hospital executives have been compared to objective criteria used. Lo and behold, what has come to light is surprising, and that is that subjective perceptions of hospital CEOs on the organizational performance of their institutions, with particular attention being paid to subjective perceptions of financial measures such as return on total assets (ROA) and operating margin, correlate strongly with how those institutions actually perform. So, perhaps there is, indeed, some room, after all, for the subjective in the accurate assessment of a hospital’s performance and standard of care.
But that can’t be it in a nutshell, and we cannot rely solely on the subjective. We must look closer, for a cursory, subjective look at our nation’s healthcare system and its protective arsenal of hospitals is tantamount to a Trojan stamp of approval, with subsequent dire consequences when what lurks within translates into the higher mortality rates seen only by those with specialized training to view the writing on the wall. Hospital quality assurance must be based on a standardized set of objective criteria or measures, applicable to all hospitals. A step in the right direction has been the Hospital Quality Alliance (HQA), based on provisions in the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 and instituted by the U.S. Department of Health and Human Services (HHS), which has collected and continues to collect data on key measures of hospitals’ management. Not only that, but the recently proposed Deficit Reduction Act (DRA) of 2005 has also added extra “punch,” and provided the financial incentives for our nation’s hospitals to adhere to established measures of performance, to report compliance with those measures to the HHS, and to expand those measures when the HHS Secretary deems it necessary, to safeguard the nation’s health.
To date, the HQA has developed ten performance indicators for three of the most common maladies seen in a general hospital environment, namely acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. Without going into specific details, summary scores, i.e., performance scores, were calculated per each of 3,720 U.S hospitals surveyed by the HQA on the basis of the sum total of the results reported for each of the ten performance indicators. It was found that high performance scores on the ten HQA performance indicators was associated with a 7-15 percent reduction in the odds of death for each of the three clinical conditions listed above. So, higher performance on the HQA objective indicators correlated nicely with lower hospital mortality rates for the three clinical conditions.
Perhaps there is hope, after all, that hospital mortality rates can be lowered without the divulging of “trade secrets” by hospital CEOs. If that is the case, then there is little need to expose what lies within a hospital’s “Trojan horse.”

© 2009, Albert M. Balesh, M.D. All rights reserved.

Sunday, March 15, 2009

Making the Grade

Return of the Scarlet Letter

Nathaniel Hawthorne is alive and well, and currently residing in the State of South Dakota, where his “Scarlet Letter,” “A,” now represents abortion, not adultery. In July 2008, under the laws of South Dakota, physicians there were henceforth required to tell prospective candidates that abortion is the termination of a living human being’s life, to give women a description of the risks of abortion, to provide them with the age and state of development of the fetus, to answer all women’s abortion questions in writing, and to certify in writing that the women mentioned received and understood all the above information. Failure on the physicians’ parts to comply with the statute might result in medical license suspension or revocation, as well as the possibility of being charged with a class 2 misdemeanor. The South Dakota law had been heretofore suspended by a federal injunction, successfully sought by Planned Parenthood, that was lifted on June 27, 2008 (Planned Parenthood Minnesota v. Rounds). That, and the recent U.S. Supreme Court case of Gonzales v. Carhart in 2007, in which it was noted that some women had come to regret their choice of abortion, and might not have chosen abortion, had they been better informed, paved the way for the implementation of the South Dakota abortion law, with its contained informed-consent requirements.
The South Dakota statute, however, will have repercussions far beyond its state borders, as it rallies dormant state legislatures to continue where they left off, enacting laws and seeking legal means to restrict abortions, in the wake of a series of Planned Parenthood setbacks. Physicians, patients, and believers in the sanctity of the physician-patient relationship should, indeed, be worried. The posture taken by South Dakota violates physicians’ First Amendment rights, not only by forcing them to be the couriers of the state’s anti-abortion message, but also by making them part of that message, via a certification process that, in essence, relegates them to the position of guarantors of their patients comprehension of the state’s law. Some legal scholars have gone so far as to conclude that the South Dakota abortion law, and similar legislation drafted by other states, employ “informed consent” as a means to eliminate abortions.
Were that not enough, the controversy surrounding the South Dakota statute has led to some hard questions regarding violation of the constitutional rights of the aborted fetus, punishment of women who do so, and prosecution of physicians “unable” to explain the multivariegated codicils of the statute. Furthermore, some of the scientific information contained in the South Dakota abortion law is inaccurate, at best, and has not been confirmed by the medical literature in regard. To force physicians to dispense such information, without allowing them enough “wiggle room” to provide alternative, more accurate, or perhaps even contradictory scientific material on abortion to their patients is to violate the Hippocratic oath, informed consent, and the physician-patient relationship.
The subject is complex and emotional, and no resolution will be forthcoming soon. Pro-choice, however, is walking a proverbial tightrope, with no safety net below, and its proponents might as well wear large “Scarlet A’s” on their chests, for their redemption is not at hand.

Saturday, March 14, 2009

"I'm so Hungry, I'm Fat!"

Food insecurity, or “the unlimited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire foods in socially acceptable ways,” is the exclusive domain of the poor, and it affects 12.6 million U.S. households, with obvious repercussions on young and old alike. It is a “no-brainer” to deduce that hunger, or “a prolonged, involuntary lack of food, that results in discomfort, illness, weakness, or pain that goes beyond the usual uneasy sensation,” is an obvious consequence of food insecurity. And if that were not all, food insecurity and food insufficiency have been found to contribute to increasing incidences of psychosocial and cognitive difficulties, suicidal symptoms, and depressive disorders.
So, we are left with the dilemma of not only how to feed the poor, but of how to provide them with healthy foods that reverse the startling trend toward obesity in that population, and in the greater part of the U.S. middle and upper classes, for that matter. The latter two facets of the U.S. population, however, are not burdened by the heavy anchor of food procurement around their necks. The socially and economically indigent must employ a series of strategies to obtain food, any food, and those procurement methods run the gamut from the legal to the illegal, namely, food stamps, WIC program, shoplifting, selling food stamps, using coupons, pawning personal items, selling plasma, scavenging from dumpsters, and asking friends and strangers for food. We must ask the question, therefore, of how it is possible for the poor, with all the hardship inherent in their individuation, purchase, and procurement of food, to become obese? In fact, studies have shown that the highest obesity rates occur in poor communities, that food-insufficient older females have a higher risk of being overweight than food-sufficient females, and that high body mass indices (BMI) are common among low-income adults and youth. How do we account for this counterintuitive hunger-obesity paradigm? Why do we see such numerous examples every single day of stereotyped, racially profiled individuals (known by deprecatory terms such as “white trash,” “trailer trash,” “beaners,” “niggers,” and a slew of others), of lower socioeconomic status (SES), who give credence to the saying, “I’m so hungry, I’m fat?” There appears to be a disconnect. How can hunger possibly be associated with obesity? While the question is intriguing, the answer is not so exotic. Increased portion sizes, diets based on fast food, and food insecurity, or the memory of it, are strong inducements to the indigent and socially emarginated to overeat tasty food, or any food, for that matter, when it becomes available.
The question of whether or not to tax high-fat foods, in order to make healthier foods, the fruits and vegetables, more attractive to limited pocketbooks, is a controversial one. While the issue is difficult to address, and leaving questions of civil liberties aside, there are some of us who feel that the taxing of unhealthy foods might place undue hardship on indigent, obese populations (of low SES) already hit hard by a failing U.S. economy and financial hard times. In that light, it might not be a realistic road to follow. On the other hand, although increased taxing of high-fat foods might, in the short term, pose financial hardship for the indigent and trigger subsequent increased government spending to sustain nutritional programs and financial solvency for them, in the long haul increased spending might be more than compensated for by the savings incurred by U.S. taxpayers as a whole consequent to the reduced incidence and prevalence of psychosocial, cognitive, depressive, and suicidal symptoms and disorders tied to food insecurity and hunger in the poor.
While questions abound and results may not be immediately forthcoming in this extremely important issue, there is no doubt that intervention at the societal and community level must begin in childhood, possibly through the school system, as a history of food insecurity in the young has a way of “snowballing” into obesity in adults.

Friday, March 13, 2009

Primum Non Nocere, Secundum Treat Patients Not Diseases

There is a battle raging behind the scenes over how to address the shortage of primary care physicians in the current climate of diminishing revenues, increased patient loads, and lack of universal health care coverage. Enticing recent graduates of U.S. medical schools to enter the field of primary care has become an exercise in futility, as the amount of student loan debt accrued by newly trained physicians warrants entrance into more lucrative fields of specialization, such as those which are procedure-oriented and provide substantial reimbursement for instrumental and invasive therapies. While primary care is, indeed, a rewarding arena of endeavor, the current number of board certified primary care practitioners is hardly sufficient to buttress even the “tip of the iceberg,” which is beginning to topple, as older physicians leave the field for retirement and other pursuits, and as the few remaining go home on a nightly basis worried to death that they’ve made mistakes or not completed their work. If that were not enough, the increasing amount of paperwork inherent in the profession, the growing number of therapeutic options and new drugs available, and the added responsibility of providing continuous preventive care to patients whose socioeconomic backgrounds often pose additional limitations to an already complex patient management scenario often render job satisfaction a non sequitur. And for those of you out there who say that, “It’s all about the Benjamins” (Franklins, that is, and money, in short), there is much more to this story than financial remuneration. It has been found, for example, that when payments to primary care physicians are increased, they work no harder, and, in fact, reduce the number of patients they see. So, perhaps there are things more influential than money as motivators to primary care physicians to do a better job, and to neophyte physicians to enter the field of primary care. They might be, namely, a sane life, more leisure time, and the value of a job well done. For those who have truly dedicated their lives to the study and practice of medicine, no price tag can be placed on the latter.
We know the problem. Where does it all fit in the public health arena, and what can we, the public, policymakers, legislators, medical school faculty, state medical boards, and the Department of Health and Human Services do to increase the allure of primary care medicine, or to “conscript” new physicians into the ranks, perhaps in exchange for student loan debt forgiveness or other inducements? What we already know is this, that the current U.S. health care system is chaotic and in utter disarray, and that unless we, both the public health and clinical professionals “in the trenches,” come up with suitable and workable solutions to the primary care shortfall, provision of first-line health care is destined to worsen.
Solutions have not been immediately forthcoming, and the call to arms has been hampered by the sheer enormity of the undertaking and statistics showing that, in many cases, patients are cut off and interrupted by their physicians due to time concerns after an average of only 23 seconds of explaining their problems, that 50 percent of patients leave office visits not understanding what the physician has told them, and that it would take 18 hours per typical workday for primary care physicians to provide all the preventive and chronic cares services needed by their patients. Recently, two solutions have come to the fore, and perhaps it would be wise to look at them closely. One idea proposed has been to reduce daily patient load for primary care physicians to 10 patients per day. That would allow them more time per patient, but would most likely aggravate the already acute shortage of primary care physicians. The second solution, which appears more sage, would be to adopt a team approach to primary care. As a medical degree is not needed to perform all the daily tasks of a primary care physician, the latter might be delegated to ancillary staff. Physicians would become team leaders, seeing fewer patients per day, consulting with team members, handling telephone and electronic encounters requiring a physician, and ordering medication changes. All other duties currently managed by primary care physicians would be transferred to “health coaches” on the team, and their tasks would run the gamut from contacting patients and explaining changes made by the physician to their treatment regimens to listening to patients’ concerns and following up on patient compliance to treatment plans.
The solutions mentioned here are in their experimental stages, and nothing is written in stone. However, without serious attention turned to the monumental problem of primary care, the numbers of those physicians will most likely continue to dwindle, with obvious repercussions on the concern for hurt (nocere) inflicted on patients and with the little physician involvement available for patient care directed at numbers and diseases, not at living, breathing human beings and the plethora of interactive elements composing their well being as a whole.

Albert Provocateur

Sunday, December 13, 2009

Green Teen

Bleep Sleep

Weight-less

Sunday, November 29, 2009

Turkey Trot - Home Alone for the Holidays

Funeral Fandango

Al Capone was a Capricorn

Sorcerer's Soup

Monday, September 07, 2009

Unkind Swine

Appendiceal Appeal

Don't Bug Me!

Sunday, August 09, 2009

Of Mammograms and Telegrams

Friday, July 31, 2009

Vaccinator

Sunday, July 05, 2009

Temples to the Gods

Saturday, May 23, 2009

Half-Hearted

Thursday, May 07, 2009

Hands Off Our Health!

Tuesday, May 05, 2009

Lions and Tigers and Bears, Oh My!

Sunday, April 19, 2009

Making the Grade

Sunday, April 12, 2009

Trojan Horse: What Lies within a Hospital's Report Card could Spell Trouble

Sunday, March 15, 2009

Making the Grade

Return of the Scarlet Letter

Saturday, March 14, 2009

"I'm so Hungry, I'm Fat!"

Friday, March 13, 2009

Primum Non Nocere, Secundum Treat Patients Not Diseases

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