MLLTD: Medical Learned Lesson of The Day

Today, I am going to begin something that will hopefully bring this on-death's-door blog back to life. (You can blame intern year of residency on the deathward spiral.) I am launching a new series that will primarily occur on Twitter, but will be integrated into the blog.

Everyday, I am going to post to my Twitter account at least one thing I learned from my experience in the hospital that day. I will prelude the post with the acronym in the title of this post, MLLTD.

Then, at the end of every week I will gather all of those wonderful tweets (or some might think of them as treats), and post them to the blog.

Hopefully, these posts will inspire me to get back to integrating research, and helping explain how the day-to-day occurrences of an internal medicine resident can help improve your health and the health care you receive.

So, here goes nothing ...

First MLLTD!

POV: Importance of CPR Education Classes

Last week, in preparation of the beginning of my residency training as a new MD, I had to get re-certified in BLS (Basic Life Support) and ACLS (Advanced Cardiovascular Life Support). For the lay people out there, these classes have to be taken by physicians and nurses every two years so they are deemed proficient to take care of patients when they need CPR and administer advanced therapies involved in CPR situations if needed. You may ask: Do doctors and nurses really not know CPR and need to be trained in it every two years? I know I was asking that when I was sitting at the beginning of the class.

The importance of knowing what to do in these critical situations, when patients are most susceptible to die, cannot be stressed enough. The research has proven over and over again that fast and appropriate action saves lives. An article released early last year in the New England Journal of Medicine showed that in patients needing defibrillation, if the patient was defibrillated later than two minutes after an in-hospital cardiac arrest, they were 48% less likely to survive to be released from the hospital.

Along with some of my fellow graduating medical students, the classes I was taking were attended by cardiologists out of training, cardiologists in training, other specialty residents, and nurses. When it came time to test our proficiency in basic CPR, one-by-one we each had to perform the appropriate steps, including being able to use an automated external defibrillator (AED), which are the defibrillators found in malls, on planes, etc. Surprisingly, the cardiologists out of training had the most trouble with the appropriate steps. They did not ask for help, check to see if the dummy was breathing, or use the AED correctly. This was probably due to a couple of understandable reasons: they don't usually use AEDs in the hospital and the steps guidelined by the instructor were probably different than when they first learned CPR.

In general, I think it is safe to say (or at least I hope it is) that when cardiac arrest occurs in the hospital, patients and their families can be assured that good care is provided. And I, personally, have been involved in only a couple handfuls of cardiac arrest situations, but I cannot ever point to one moment of mistake in any of them. However, seeing those cardiologists flounder was important to my future training. It really made me realize that no matter how much I will learn and how much experience I gain over the years, it is always important to put forth my best effort and keep myself on top of my game.

Medical Blogosphere Weekly

I know that most of the people that follow me on Twitter have blogs, and are probably familiar with Grand Rounds, but I believe that the majority of my blog readers might not be familiar with it.

Grand Rounds started four and a half years ago and is a weekly collection of blog entries around the web that different medical blogs host. It's purpose is to introduce a wider audience to the expanding array of talented doctors, nurses, techs and students writing online today. Bloggers have to submit stories each week for that week's edition of Grand Rounds. Sometimes there is a theme for week, but most of the time there is none. But that does not discount the quality posts every week that are submitted.

I did not know about it until I started following bloggers on Twitter, but now I make it a weekly read. And I think you should too. Here is a link to the upcoming schedule of hosts, and a link to next week's host, Kerri Sparling, and her blog Six Until Me.

Checking Smokers Urine for Lung Cancer

Some interesting news has come out of the Annual Meeting of the members of the American Association for Cancer Research this week. Some researchers, led by Jian-Min Yuan, MD, at the University of Minnesota presented their findings on development of a laboratory test for two chemicals in urine that are elevated in persons that go on to develop lung cancer. The two chemicals are NNAL, a byproduct of one of the most carcinogenic compounds from tobacco, and cotinine, a byproduct of nicotine.

Their research showed that people with a mid-range level of NNAL had a 43% increased risk of lung cancer, and smokers with the highest levels of NNAL and cotinine had an 8.5-fold increase in the risk of lung cancer. Now, remember, this data is from a presentation. It will be interesting to see what the final paper reads about the methods and statistical analysis to determine whether these numbers are accurate.

Nevertheless, a tool such as this that would have numbers of risks to give to smoking patients based on their levels of these compounds would be a powerful weapon in a physician's arsenal. Telling a smoker they are 8 times more likely than a non-smoker to get lung cancer would have a profound impact on them, and hopefully, would be great motivation for quitting. Along with the increased cigarette tax, who would want to continue smoking after hearing something like that?

One of the more fascinating points about this research is that the data and urine samples that the team were analyzing were from studies that had been carried out almost 20 years ago. They had to thaw out 20-year-old frozen urine ... Yuck!

Health News Reviews

Good morning everyone! I have returned from my vacation, and am now ready to return to medical blogging. Over my absence, I was enlightened my a great website that has been fulfilling one of my purposes of this blog for years already. The website is Health News Review. This site offers critiques of health news presented by the major news suppliers in the country (television stations, newspapers, AP, etc.). The reviews are written by a group with health care and reporting credentials, many of whom hold MDs or PhDs. Also, the publisher of the site, Gary Schwitzer, is an Associate Professor at the University of Minnesota School of Journalism & Mass Communication, and runs a health journalism masters program at the school.

I have had the opportunity to read many of their entries, and can quite adequately say they are honest reports that are good for any person who likes to be knowledgable about health. Next time, before you go off and quote some news story you heard on the television to your family and friends, go to this site first, and see if the story is truthful and adequate.

Out of the Ordinary: MLB 2009 Predictions

Since I am on a two-week break from medical school (which shows in lack of recent posts), I thought I could use this time to write a post that is a break from my usual medical posts. Maybe this can be some motivation to also get in a regular post. I'm mostly doing this for my own benefit to keep track of what I think the MLB standings will look like at the end of the year. But why don't you make up your own too, and put them in the comments for fun?

Here are my non-expert, fun, nerdy 2009 MLB predictions:
I'm starting with the National League since everyone usually starts with the American League, and my beloved Cubs are in the NL.

NL East: 1)Mets 2)Phillies 3)Marlins 4)Braves 5)Nationals
NL Central: 1)Cubs 2)Brewers 3)Reds 4)Cardinals 5)Astros 6)Pirates
NL West: 1)Dodgers 2)Diamondbacks 3)Giants 4)Rockies 5)Padres
NL Wild Card: Phillies
NL Champion: Cubs
NL MVP: David Wright, Mets
NL Cy Young: Carlos Zambrano, Cubs

AL East: 1)Red Sox 2)Yankees 3)Rays 4)Blue Jays 5)Orioles
AL Central: 1)Twins 2)Indians 3)Royals 4)White Sox 5)Tigers
AL West: 1)Angels 2)Athletics 3)Mariners 4)Rangers
AL Wild Card: Yankees
AL Champion: Red Sox
AL MVP: Mark Teixeira, Yankees
AL Cy Young: Daisuke Matsuzaka, Red Sox

World Series: Red Sox over Cubs, 4 games to 2

POV: Chiropractic

I am currently in an elective class focusing on Alternative Medicine, a term that encompasses all other therapies people seek for their health besides traditional medicine. As part of that class, I had to shadow an alternative medicine practitioner for 20 hours. I chose to follow a chiropractor, and the following will be my observations about their practice of chiropractic and some of the conclusions I made from those observations.

First, the good. I think traditional medicine practices can learn a lot from alternative practices. The office that I did my shadowing at was not all that aesthetically pleasing, but I could tell the patients felt far more comfortable there than in your typical doctor's office. I ascribe this to several ways the office was run. First, the chiropractor came and got the patients from the waiting room himself. Second, the visits were very quick. If it was a follow-up visit, it was not uncommon for the entire visit to take less than 5 minutes. Lastly, there was minimal support staff and, thus, less intimidation. When you usually go to visit the doctor, there are always people in the office you have no idea what their job is, and then you have to talk to them, and you, the patient on whom the focus of the office should be, don't understand what is happening. This is not so in this chiropractor's office, and I wonder why it could not be more like this in every doctor's office.

Now, time for the criticisms ... and there are many. As a person who has a Master's degree in physiology, I pride myself on understanding the inner-workings of the human body. Therefore, one of the first questions I asked this chiropractor was what exactly he was fixing in his patients, and how that fixing was done. I can fully say that his explanation did not correlate with my understanding of what occurs in the human body. Thus, I can only conclude that his chiropractic practice is based on a faulty education, and loses the majority of its credibility.

A positive aspect for patients to this office was that every patient that came through the door received a diagnosis and treatment. This is what every patient wants when they visit any kind of doctor. However, when taken into context with the previous conclusion, this practice means that these patients were receiving false diagnoses and unneeded treatment. If these patients just read what I wrote, they might ask this: Then why do I feel better afterwards? That, my friends, can be attributable to the power of suggestion, or known to us in the medical field as the placebo effect. Here is a video from the magicians Penn and Teller showcasing just how powerful the placebo effect is. The wikipedia page does a decent job of describing the placebo effect.

The last observation I noticed in this office (and the one that bothered me the most) was this chiropractor "dipped and dabbled" into other alternative medicine methods, and used many variations of treatment on his patients. Now I am not sure if he was trained in these modalities or not, but while I was shadowing, he used acupuncture, applied kinesiology, homeopathy, and nutritional advice. (See the links for further explanations of these modalities.) Now, I have done limited research on all of these modalities, and without getting into too much detail, I believe they all, besides nutritional advice (although his was a little questionable), work via the placebo effect as well. Applied kinesiology really bothered me, and I believe it only serves to reassure the patient of what they, themselves, think is wrong with their body.

Even though I formed these conclusions, I still believe that some patients can gain a benefit of visiting a chiropractor. Patients that I would send to a chiropractor would be hypochondriacs, who need reassurance that something is wrong with them, and chronic pain patients, who have not received any pain relief with traditional treatment. That being said, if a patient of mine told me they were already seeing a chiropractor, I would not have any issue with it. I believe that anything that helps my patient have a better quality of life is good for them.

Is Prostate Cancer Screening Necessary?

This week I was going to summarize the two new studies (found here and here) about Prostate Cancer screening done in Europe and the U.S. However, Tara Parker-Pope, of the New York Times, already published a really nice article about the two. She does, almost exactly, what I like to do with my article reviews: answer the most important patient questions. So, I am going to point my readers in her direction, but I will write something a little later today.

Aspirin a Day Keeps the Doctor Away?

BOTTOM LINE: Help to determine whether you should be on Aspirin if you don't have a heart problem, and what dose.

FOR PATIENTS: If you are a male from ages 45-79 or a female from ages 55-79, then you should consider taking Aspirin with your physician. A high dose of the drug may not be necessary.

Patients might be seeing Aspirin, the time-tested medicine taken for many conditions from a heart attack to a headache, in the recent news. That is because the most recent issue of Annals of Internal Medicine had four articles about the drug. These articles address two major questions about Aspirin that not only doctors ask everyday, but also patients; those who have been prescribed Aspirin, and those who haven't: Should I take Aspirin even if I haven't had a heart problem? And what dose? Let's see what the articles say, one at a time.

The first question was answered by the U.S. Preventive Services Task Force (USPSTF), our now familiar bureaucrats (remember them from this earlier post?) using a review article. That, basically, means they did a literature search for all related articles that have come out since their previous recommendations in 2002, and analyzed them to see if they should change their recs. What they came up with was that for males over 45 to 79 and for females from ages 55 to 79, if the risk of a gastrointestinal bleed is less than that of having a heart attack, then a daily Aspirin could be of benefit. They base this recommendation on "new evidence from 1 good-quality RCT, 1 good-quality meta-analysis, and 2 fair-quality subanalyses of RCTs [that] demonstrate that aspirin use reduces the number of CVD events in patients without known CVD." (In this sentence, RCT means randomized, controlled trial, and CVD means cardiovascular disease.)

The second question is answered (to the best of the researchers abilities, of course) by a group called the CHARISMA investigators, who have published a lot of articles, specifically on the drug Clopidogrel/Plavix (remember this earlier post?). You might ask why were they looking at Aspirin? Well, a lot of patients that take Clopidogrel are also on Aspirin, hence the new paper. The limitation to this new paper is it is a retrospective, post hoc analysis, meaning that Aspirin use by the patients were not controlled by the investigators. This results in less of an ability to form a causal relationship between the drug and effects observed. This limited study found that the dose of Aspirin taken, whether less than 100mg or greater than 100mg, did not alter rates of stroke, heart attack, cardiovascular death, or severe or life-threatening bleeding. However, they did find a possible increase in those events if patients were taking over 100mg of Aspirin along with Clopidogrel/Plavix, but the change was not big enough to make that a firm statement.

These two papers will definitely help physicians better determine who should be on Aspirin and what dose to use. As Dr. Shamir Mehta points out in the editorial that is published in the same issue about this topic, hopefully these papers will actually increase the usage of Aspirin, as more and more of the population of the U.S. is at risk for a cardiovascular event. Also, always remember, the decision to be put on Aspirin should be made on a patient-to-patient basis. If a patient is susceptible to a bleed in the head, then it is probably not a good idea.

When to Have a Colonoscopy

BOTTOM LINE: Patients should be fully involved in the decision-making process of their preventative care and treatment.

FOR PATIENTS: If you are over 50 years old, you need colorectal cancer screening (45 if you are African-American). Make sure you know your options for screening.

The American College of Gastroenterology released their guidelines for colorectal cancer screening recently. This organization, to clarify for everyone, is the professional organization of docs who do colonoscopies (camera up the butt, to further simplify) for a living. This release of guidelines may seem like a good thing to most everyone, patients and docs. However, let's really think about this.

This is the first time that this group has released any kind of guidelines on the topic since 2000. Nine years is a long time in medicine. Also, one must remember what these docs do to make money (and a lot of it for that matter). They do colonoscopies. So what, then, do you think they advise for colorectal cancer screening? Does it come at any surprise that they recommend ... COLONOSCOPIES? I think not.

When Dr. Douglas Rex, the lead author of the guidelines and the director of endoscopy at Indiana University, was asked why only colonoscopy was the preferred strategy, he responded that recommending one test "simplifies the discussion with the patients and, as far as we know, is just as effective." He continued and stated that colonoscopy was chosen because of its effectiveness and when carried-out by well-trained examiners "is the best test."

I think this is a prime example of old-school, Doctor-knows-best, medicine. Let me explain.

The U.S. Preventative Services Task Force (USPSTF) is, in their own words, "the leading independent panel of private-sector experts in prevention and primary care." As far as I have seen, most primary care physicians follow the guidelines on screening and preventative measures they produce. The USPSTF just recently published their own guidelines on colorectal cancer screening. These guidelines present many options for primary screening of colorectal cancer: colonoscopy, sigmoidoscopy, fecal occult blood testing, fecal DNA testing, computerized tomographic colonoscopy, and double-contrast barium enema. The guidelines begin with the statement: "The choice of specific screening strategy should be based on patient preferences, medical contraindications, patient adherence, and available resources for testing and follow-up."

This is how medicine should be practiced: The patient makes the decision, once they are informed about all of the options. Discussions should not be simplified with patients. We are talking about their health, and a lot of money (see previous post for more lengthy discussion), not their car. Dumbing down is not justified.