June 25th, 2007 by Dr. Val Jones in Expert Interviews, News
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This is the weird correlation of the week: women who suffer with symptoms of morning sickness during their pregnancies may be less likely to develop breast cancer later on in life. A group of epidemiologists in Buffalo recently reported this finding at a scientific meeting (Society for Epidemiologic Research). No one is sure what this means, and I dare not speculate… but perhaps there’s some kind of link between a woman’s hormone levels produced during pregnancy, the nausea they cause, and the hormonal milieu that is the background for breast cancer? Or maybe this study has turned up a false association. Only time – and a lot more research – will tell. Of course, if anyone should speculate on this, it’s the breast cancer oncologists like Dr. Gluck. So I dropped him an email to ask him what he thinks.
Dr. Gluck said that first of all, the association between morning sickness and decreased breast cancer risk is relatively weak. So here’s what the numbers mean: For the average 50 year old woman, the standard risk for developing breast cancer is about 2% (one in
50). According to this study, that same woman (if she had severe morning sickness at some point during pregnancy), is about 1.4% (~30%
less).
Dr. Gluck speculates (and this is quite fascinating) that women with morning sickness are subjected to a hormonal milieu that may result in permanent alterations in their breast tissue. The breast tissue (having been exposed to surges of hormones, insulin, and changing blood pressure and blood sugar levels) might be less vulnerable to the genetic mutations that cause cancer.
We’ve known for a long time that women who have children are at lower risk for breast cancer than women who don’t… now it seems that there might be something about women who are really sick when they’re pregnant and decreased risk of breast cancer as well.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 24th, 2007 by Dr. Val Jones in True Stories
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During my residency I kept a diary as a way to relieve some of the sadness related to the death and dying that I witnessed. I recorded various encounters in a series of vignettes. Although these are a bit long for a blog, I thought I’d share a few now and then in the hope that they’d preserve the memory of those who are gone. All personal data have been removed so that the identity of the patients is protected.
***
It’s 3:00am and I was paged to examine yet another patient who had fallen out of bed – to rule out a hip fracture.
Too tired to read the chart prior to examining the patient,
I thought I’d leap right into the physical exam. I assumed that the patient would be the usual
elderly woman who, in her sickened delirium, thought she was at home and tried
to walk by herself to the bathroom and fell en route.
I marched into the room and stopped at bed 23. All my pre-conceived notions evaporated as I
looked at the young man before me.
Emaciated and stiff, with all four limbs contracted, he lay on the bed,
clinging to a thin white sheet. The
whites of his eyes flashed in the darkness.
“Hi there.” I said, trying to seem casual at the sight of
the living corpse before me. “I’m Dr. Jones. I heard that you fell. Are you in any pain?”
His eyes suddenly fixed themselves on me and he spoke, not
with a thin raspy voice, but with the robust youthful voice appropriate to his
age rather than the decrepitude of his body.
“I’m in no pain,” he said.
“I was trying to sit down on the chair.
I thought it was against the wall, but it was actually a couple of feet
away. So when I leaned on it, it slid
and I fell on the floor.”
“Do you think you broke anything?” I asked, trusting in his
judgment as his mental status was clearly in tact.
“No, I just scraped my butt,” he said, pointing a frail
finger towards his sacrum.
“Did you hit the floor hard?” I asked as I used my pen-light
to examine his back side.
“Not really,” he said.
“Would you like me to order an X-ray of your pelvis to see
if you broke anything?”
“I don’t think I need it,” he said.
“Well let me see if it hurts when I rotate your leg in your
hip socket, ok?” I pulled down the sheet
and asked the young man to allow his right leg to fall to the side. As I looked down at his hip I gasped slightly
as his inner thigh came into view. A
gaping ulcer lay before me, deep to the bone, exposing tendons and ligaments
with pus, and red knobs of flesh surrounding a football sized hole in the man’s
groin. His paper-thin scrotum lay stuck
to his left thigh. The smell overcame
me, it was at once wet and fetid, with a hint of chemical odor from the
antibiotic ointment that was clinging ineffectively to the fringes of the wound.
“Oh my God. Does that
hurt?” I stammered.
“No, not at all.”
“And does it hurt when I rotate your leg in your hip
socket?” I asked, trying desperately to remain focused on the task at hand.
“No, it doesn’t.”
“Well, then,” I said, gathering my faculties. “I don’t think you broke your hip. And if you don’t want an X-ray, I don’t think
we need one. Perhaps you’d like to go
back to sleep and get some rest?”
“Yes, that sounds good,” he said, drifting off into a
morphine induced altered state of awareness.
I wandered out towards the nursing station, looking around
vaguely for the patient’s chart to make note of my “fall assessment.”
One of the nurses anticipated my need and handed me the
thick plastic folder.
“What does this patient have?” I asked.
“Oh, he has AIDS and metastatic anal cancer” she said as she collected some sputum in a clear plastic cup. “He’s 38 years old.”
“The same age as my boyfriend,” I thought to myself. “And why exactly did he fall?” I asked the
nurse.
“I was trying to help him to get to the commode,” she said printing something on a label. “He fell because I wasn’t strong enough to
hold him up. My right arm is a little
bit weak.”
“And why is your arm weak?” I asked, assuming that it was
because of a small strain injury.
“I have breast cancer,” she said, finally making eye contact
with me.
“Oh my God, I’m so sorry,” I said, feeling the weight of her
diagnosis amidst a ward of terminal cancer patients.
“Well, you know the funny thing is that my husband is
particularly upset. He doesn’t want me
to have a radical mastectomy. He says
that it would hurt to see my body differently than he’s used to… he likes to
think I’m still the bouncy cheerleader I was when we first met. To see me with only one breast is upsetting
to him. And quite frankly, I’m afraid he
won’t be attracted to me anymore. That’s
what scares me the most,” she said, becoming misty-eyed.
My pager let out a familiar series of beeps.
“I’m so sorry,” I said, squeezing the nurse’s shoulder. I paused and tried to be encouraging: “Well, even if you need a mastectomy – I’ve seen some great reconstructive surgeries
where the breast can be reformed at the same time with an implant. Maybe you’ll be a good candidate for that
surgery? I’m so sorry that I have to
run… can we talk later?”
“Sure,” she said, smiling faintly.
***
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 22nd, 2007 by Dr. Val Jones in Medblogger Shout Outs
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Dr. Richard Reece wrote a wonderful personal reflection on the value of hospital ratings. As you may know, there has been much recent debate about their usefulness. With all the different rating systems, a single hospital can be ranked #1 in the country by one source and middle of the pack by another. It’s true that there are many variables to be considered, and that measuring quality is a tricky business. But one would hope that if we were getting close to observing something real about a hospital, most different scoring systems would lead to the same general conclusion.
The fact that this isn’t the case yet says to me that there is a lot of work to be done in standardizing scoring, developing transparency in the system, and removing hospital marketing efforts from objective data.
I am glad that we’re beginning to shine the light on institutional quality, but there is an elephant in the room. When it comes to good medicine, the most important factor is the individual healthcare provider.
I have personally witnessed outstanding medical care in the midst of hospitals with poor reputations, and I have observed horrific outcomes at top ranked hospitals as well. What made the difference? The provider taking care of the patient.
My insider perspective is that consumers are on the right track with physician ratings – worrying more about getting into the hands of a good doctor, than into the hands of the right hospital. But physician ratings can be dangerous – if left open to the public without any form of moderation or intelligent analysis, one patient with borderline personality disorder and a grievance could hijack the rating system and destroy a physician’s public reputation. Safeguards against that sort of behavior can and should be put in place.
The most helpful physician rating system will offer data from multiple sources (patient ratings, peer ratings, health plan ratings) and include sophisticated anti-sabotage algorithms. It’s also important for the ratings to be protected from self-interests (so that the physician herself doesn’t game the system and use it as a marketing tactic).
Rating quality care is complex, and there will always be a subjective element to it. Hospitals are run by flawed humans, healthcare providers make mistakes, and yet everyone wants the same thing: consistently excellent medical care.
And that will never happen – so long as humans are imperfect.
As Dr. Reece says,
Unfortunately, variable costs, variable quality, and variable outcomes
are a function of humanity, regional cultures and their constituencies.
Independent variables are part of the human condition. Some of these
variations may be beyond managerial control…
It’s going to take a while to establish criteria to judge and sort out
the good, the bad, and the ugly. Public disclosure of outcome data and
performance data on the processes of care may help, but they are only
part of a complicated human equation.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 21st, 2007 by Dr. Val Jones in News, Opinion
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An interesting meta-analysis was recently published in the Annals of Internal Medicine. It showed that acupuncture for knee arthritis can reduce pain, but its effects are likely due to the placebo effect. The placebo effect is nicely described in Wikipedia:
A so-called placebo effect occurs when a patient’s symptoms are altered
in some way (i.e., alleviated or exacerbated) by an otherwise inert
treatment, due to the individual expecting or believing
that it will work. Some people consider this to be a remarkable aspect
of human physiology; others consider it to be an illusion arising from
the way medical experiments are conducted.
Because of the mind-body connection, we humans can actually alter our experience of pain if we will ourselves to do so. We experience more intense pain when we’re depressed or particularly fixated upon it (via boredom for example). And we experience less pain when we’re happy (take women immediately after giving birth – they barely even notice the Ob as she sews up their tears).
When it comes to pain management, there are many non-medical techniques that can improve the experience of pain, even if it doesn’t affect the physiology of it. And so if we can find ways to put ourselves in a frame of mind that minimizes the pain sensations, that can be really valuable.
But as far as the physiology of acupuncture is concerned, we have not yet been able to explain exactly how it works. I’ve often wondered if it may be due to the fact that the sharp pain fibers (stimulated by acupuncture needles in different locations) travel along slightly different nerve pathways than the fibers from the actual painful area for which one is getting the acupuncture. The pain input might subconsciously distract the mind from the duller (or more chronic) pain input from the arthritic joint (or other pain generator). This might explain why sham acupuncture works (meaning, putting the needles anywhere, rather than in certain specified meridians).
I’m sure some of you will disagree with this – and it’s only a theory. But it does seem that inserting tiny sharp needles into the skin improves pain sensations in knee arthritis – no matter where the needles are put. How do we explain this placebo effect? I’m not sure – but if the treatment is quite harmless, and seems to decrease pain, how important is it to have an explanation?
And by the way, I was just about to post this when I found another interesting article about acupuncture in the journal Circulation. In this study, they found that acupuncture (when performed 3-5 times a week for 30 minutes each time) was able to reduce blood pressure by about the same amount as a low dose ACE inhibitor pill. Interestingly, though, in this case the needles placed according to Traditional Chinese Medicine (in certain meridians) rather than sham acupuncture (random placement) decreased blood pressure significantly more. I wonder if the TCM placements are activating the autonomic nervous pathways in this case?
At this point the jury’s still out on how all this works. But acupuncture does have measurable effects – even if they’re due to the placebo effect and/or stimulation of the autonomic nervous system. The real question is: would you rather pop a pill each day or travel to and from an acupuncturist’s office 3-5 times a week for 30 minute treatment sessions?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 20th, 2007 by Dr. Val Jones in Opinion
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Little did I know that there is a raging debate about whether or not it’s a good idea to circumcise male babies. I was reading #1 Dinosaur’s blog and almost fell off my chair at the passionate series of comments. Apparently, 90% of American males were circumcised in the 1960s, but that rate has dropped to about 57% today.
Pro Circumcision: circumcision decreases the rate of transmission of HIV and HPV and is hygienically desirable. It does not appear to adversely affect sexual function, is a fairly minor and non-traumatic procedure, and is a reasonable health intervention.
Against Circumcision: condoms are more effective at reducing HIV and HPV transmission than circumcision. It is ethically wrong to circumcise an infant because he cannot give his consent and the procedure is painful. Some people believe that there is an important sensory nerve in the frenulum that is often severed during circumcision.
The American Academy of Pediatrics takes the position that: Existing scientific evidence demonstrates potential medical benefits of
newborn male circumcision; however, these data are not sufficient to
recommend routine neonatal circumcision.
The American College of Obstetricians & Gynecologists takes no position: Newborn circumcision is an elective procedure to be performed at the
request of the parents on baby boys who are physiologically and
clinical stable.
I had always assumed that circumcision was a personal choice that people didn’t feel that strongly about one way or the other. I guess I was wrong!
Why do you think this topic is so passionately debated?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
