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Don’t Get Sick in July?

One of my colleagues just forwarded me a NY Times article by Jerome Groopman.  The article begins with the issue of inexperienced interns – how newly minted MDs begin clinical care for patients in July of each year, and how these rookies can make harmful mistakes.

He goes on to explain that doctors aren’t trained to think well about the diagnostic process (the thesis of his recent book) and that we’d all benefit from studying cognitive psychology.

Dr. Groopman makes some interesting points in this article, but I was most struck by his flippancy regarding the dangers of getting treatment in July.  He simply says, “Today, most hospitals closely watch over interns.”

I personally think the issue is more sinister than that – there are many ways that an intern can make mistakes, without ordering a single test or procedure, and under the full scrutiny of red tape regulations and documentation practices.

When an intern fails to recognize a life threatening condition and chooses to do nothing, or to let the patient wait for an extended period of time before alerting his or her team to the issue, serious harm can befall that patient.  And that harm is not caused by inexperienced procedural technique, or ordering the wrong medicine – it’s caused by doing nothing.  This “doing nothing” is the most insidious of intern errors – and it is not remedied by any form of hospital quality improvement initiatives.  It is the risk that a hospital takes by having inexperienced physicians in the position of first responders.  Interns gather large amounts of information about patients and then create a summary report for their supervisors.  The supervisors (more senior residents) don’t have time to fact check every single case, and must rely on the intern’s priority hierarchy for delivering care.

But many hours pass between the time an intern examines a patient and when a supervising physician checks back in with that patient.  And within that period of time, many conditions can deteriorate substantially, resulting in the loss of precious intervention time.

Dr. Groopman describes an experience from his own life in which a surgical intern (in July) correctly diagnosed his son with an intussusception (twisted bowel) but then incorrectly determined that the baby could wait to go to the O.R.  Of course, untreated intussusceptions are nearly always fatal, and each minute that passes without intervention can increase the risk of death.

And so, in my opinion, it is in fact more dangerous to be admitted to a teaching hospital in July, but not necessarily for the reasons that people assume (procedures performed by inexperienced physicians or drug errors – though those mistakes can be made as well). Rather, it is because interns don’t have the clinical experience to know how to prioritize their to-do lists or when to notify a superior about a patient’s health issue.  Timing is critically important in quality care delivery – and that variable is not controlled by our current intern oversight system.

Now that I’ve completely terrified you – I will offer you a word of advice: designate a patient advocate for your loved one (or yourself) if you have to be in the hospital as an inpatient (especially in July).  If you can, find someone who is knowledgeable about medicine – and who knows how to navigate the hospital system.  A nurse, social worker, or physician are great choices.  That person will help you ensure that concerns are prioritized appropriately when your intern doesn’t yet fully appreciate the dangers behind certain signs symptoms.  If you have no advocate, then befriend staff members who are particularly caring and experienced.  Be very nice to them – but don’t be afraid to insist on being examined by the intern’s supervisor if you really are concerned.  Unfair as it may seem, sometimes the most vocal patients get the best care.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

High Blood Pressure and Hidden Salt

In a charming news article, the BBC reports that the British Sandwich Association is concerned about high salt levels in national fare.  If you have high blood pressure, there is now new evidence that avoiding soup and potato chips will not be sufficient in curbing your salt intake.  Yes, even the humble sandwich can be a good hiding place for sodium.  But this article is even more whimsical than informative.

First of all, I think it’s terribly funny that the “British Sandwich Association” actually exists – and that its public health warnings are taken very seriously.  Second, I think that the contents of common British sandwiches are somewhat disturbing: a “prawn mayonnaise” sandwich lacks a certain appeal in my mind.  And the fact that this variety of sandwich was selected as a representative example of a typical sandwich is also amusing.

And finally, the website for the British Sandwich Association is hilarious.  Check out part of their mission statement:

“To safeguard the integrity of the sandwich market by setting standards
for sandwich making, by encouraging excellence in sandwich making and
by encouraging the development of the industry in terms of skills,
innovation and overall market development.”

And the BBC includes this very astute quote from the organization’s director:

“Sandwiches involve the assembly of ingredients,” said Jim Winship, director of the organisation.   “The fact is that the salt is already in the ingredients…”

Well, I think the take home message here is that if you have high blood pressure or are on a low salt diet, remember that sandwiches often contain very high sodium levels.  The message between the lines is that the British are inherently funny and have bizarre taste in food.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The Power of Positive Thinking

Norman Vincent Peale wrote a bestselling book in the 1950’s,
“The Power of Positive Thinking.”  I read
it a few years ago and found it to be a tad simplistic but it had an undeniable point: a positive attitude is important in
life.

In my last post I described the dangers of magical thinking
– since it opens the door to pseudoscience-touting snake oil salesmen.  But now we will turn our attention to
positive thinking – a favorable psychological condition.

There is no doubt that there is a mind-body connection that
affects health.  “Type A personalities
are known to engage in behaviors that increase the risk for heart attack;
anxiety and perceived stress can cause higher output of adrenaline and
cortisol, and in turn contribute to inflammation, atherosclerosis, heart
disease, sleep disturbances, and weight gain.
Depressed individuals (for example) are more likely to suffer from pain
syndromes
, and may have impaired immune function.

Because our mind influences the health of our body, it is
physically therapeutic to focus attention on peace of mind as a preventive
health measure.  And in so far as
techniques are developed to reduce stress, decrease mental anguish, and improve
psychological wellbeing – they are helpful in keeping the body in a healthier
state.

Now, the temptation is to
exaggerate the benefits of peace of mind – that one might be able to avoid
cancer (for example) with the right attitude, which is blatantly false.  So this is where positive thinking and
magical thinking can be confused.
Magical thinking ascribes excessive value to a treatment, while positive
thinking understands the limitations of treatments and yet respects the reality
of the mind-body connection.

Let’s consider back pain, for example.  A magical thinker would look for the “secret
cure” for their back pain, and turn over every stone – fully anticipating that he would discover a miracle solution that others don’t know
about.  He would read books promising the
ultimate back treatment “that your doctor doesn’t want you to know about” and
would spend a great deal of money on treatments that have been
rumored to have some benefit in treating back pain (without any supporting evidence).  The magical thinker is vulnerable to snake
oil, and would rather risk thousands of dollars on experimental treatments than
consider traditional modalities first.

A positive thinker, on the other hand, will realize that
back pain is difficult to treat, has variable causes, and responds to different
therapies based on an individual’s unique circumstances.  A positive thinker would have a realistic
view of recovery, would accept the limitations of therapeutic options, but
would focus on his abilities rather than his disabilities and look for ways to
make the best of his current circumstances.
He would actively participate in physical activity, perhaps join a support
group, get good rest and engage in a healthy lifestyle while working towards a
brighter tomorrow one step at a time.

Definitions for clarity:

Snake oil is a treatment whose efficacy is knowingly exaggerated by those who wish to turn a profit on its sale.  E.g. diet pills that will “miraculously correct morbid obesity in a matter of weeks.”

A placebo is a treatment that has no known plausible mechanism for a physical effect – but may affect the individual through the mind-body connection.  E.g. a sugar pill that is substituted for a pain killer may cause a patient to experience his pain differently, though there is no active ingredient in the pill.

An untested treatment is neither snake oil nor a placebo but could be used as either under certain circumstances.  It is simply a proposed intervention of unclear clinical significance.  There are many of these currently undergoing scientific review, and it takes patience to analyze their potential efficacy and safety.

A magical thinker is a person who is willing to accept snake oil as a valid treatment option for his condition despite a vast preponderance of evidence to the contrary.  Magical thinking is belief-based, rather than evidence-based.  Many very good and reasonable people are tempted to adopt magical thinking under duress.

A positive thinker is a person who choses to look for the positives in all circumstances, and approaches health with a can-do attitude.  Realistic and yet optimistic, the positive thinker will focus on abilities rather than disabilities – and reach out for support as needed to optimize his psychological well being.

All of this is simply to say that a positive attitude, peace of mind, stress reduction techniques and a healthy lifestyle are an important foundation for good health.  Placebos are most relevant for influencing psychological well being or pain perception (obviously they’re not appropriate for treating infections, type 1 diabetes, and the like), and magical thinking and snake oil are dangerous hindrances to wellbeing.  Stay positive and protect yourself from snake oil salesmen.  Knowledge is power. There are voices of reason to guide you here at Revolution Health.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The Power of Magical Thinking

The most outrageous lies that can be invented will find believers if
a man only tells them with all his might.

–Mark Twain

I’ve always liked the term “magical thinking.”  I first discovered it in medical school when
we were learning about normal childhood development.  There is a period of time (about ages 3-6) in
which all children believe in magic – things that are not possible or rational
appear plausible to them.  I suppose that
Peter Pan is based on this psychological window – when children grow too old
they can’t go to Never Never Land anymore because they lose their ability to
fly (aka believe in magic).

As adults, we often remember our childhood fantasies with
fondness.  We relive the experience with
our kids, and enjoy the carefree wonder that comes along with fully believing
in implausible things.  In general,
magical thinking is an enjoyable part of childhood.

But there is a more sinister form of magical thinking – and
that develops when adults abandon reason for implausibility.  We see this in medicine quite a bit, as it is
the soil in which the proverbial snake oil salesman can grow his thorny weeds.  Preying on fears in a vulnerable victim, the
snake oil salesman leads the person down a common garden path of partial
truths, twisted facts and sheer lies.
Here are some of his favorite tactics:

  1. Trust
    erosion.
    “Your doctor is keeping
    important (if not life-saving) treatment options from you.”  Snake oil salesmen love to write books with the
    following titles “What your doctor won’t tell you about X.” or “New
    scientific break through X that your doctor doesn’t know about…”  This tactic is meant to break the trust
    between physicians and their patients, causing second guessing and
    unnecessary rifts.  More often than
    not, your doctor doesn’t know about treatment X because it’s so ridiculous
    that they wouldn’t give it a second thought or the medical community has
    already disproven it.
  2. Conspiracy
    theories.
    Snake oil hucksters love
    to tell you that the government (or your hospital, or your pharmacist, or
    your health plan, or your healthcare provider) is conspiring against you
    with the pharmaceutical companies (or your health insurance, or your
    doctor, etc.) to prevent you from getting the care you need or to coerce
    you into getting treatment that you don’t need.  Conspiracy theories are ubiquitous in
    the snake oil world and they are the most obvious red flag identifier in
    their arguments.  So if the next
    treatment option you’re considering is promoted with arguments that it’s
    best for you specifically because the evil government/pharmaceutical
    company/hospital/doctor is trying to prevent you from taking it  – be very wary indeed.
  3. Playing
    the victim.
    When rational
    scientists poke holes in the snake oil salesman’s pitch, his favorite
    argument is “I’m being attacked and suppressed by those who don’t want YOU
    to know the truth. This proves that what I’m saying is true – why else
    would they want to silence me!?”
  4. Making
    you feel inferior.
    The snake oil
    salesman loves to point to the “wild success” of treatment X in Europe, Asia, or any other country than your own.  He wants you to feel that you’re late to
    the party, and that everyone else is ahead of you and has already been
    enlightened.  You feel ashamed of
    your ignorance and want to get in on something that has thousands (perhaps
    millions) of foreign supporters – so it must be safe/true/right.
  5. Pseudoscience
    jargon.
    To give their snake oil an
    air of credibility, the salesman will use medical-sounding words to
    describe its purported mechanism of action. This is where the salesman can
    really work his art into the minds of magical thinkers.  The more convoluted and implausible the
    story, the more magical it is – and the better able to capture imaginations.
  6. A secret cure. Diseases can be crippling and devastating, leading people to despair.  The most serious and life threatening diseases (especially if there is no known cure) are the favorite target of snake oil salesmen.  Desperation breeds magical thinking, and opens the door to all kinds of false promises on the part of hucksters who have no qualms making money on fruitless “cures.”  They often pitch their snake oil as a secret cure that only a select few people know about (or have access to).  If a disease has no known cure, you can be 99.9% sure that a promise of a “secret cure” is an unconscionable ploy to gain financially from the suffering of others.

And so, dear readers, one must never underestimate the power
of magical thinking.  It is the bedrock
of bad medicine, can lead people away from life-saving therapies, and will
continue to exist for as long as people are willing to entertain the arguments
of the snake oil huckster.  Sadly, I
predict that snake oil will be around for as long as human suffering exists –
and it will inflict its venom most effectively on the ignorant, desperate, and
vulnerable.  It can be vanquished,
however, on a case-by-case basis by its only natural foe: the scientific
method.  Hold fast to evidence based
medicine, and you will avoid much of the pain of pseudoscience, thorny lies,
and snake oil.  I will be there with you,
fighting the good fight.

In my next post I will describe the power of positive
thinking – which has value in medicine, as do placebos.  I will explain the difference between the
placebo effect and snake oil, an often confused but important distinction.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

New Diet Pill, New Health Risks

There is a new diet pill undergoing testing in Italy.  The pill expands in your stomach, suppressing
appetite by giving you a false sense of fullness, sort of like those dehydrated
sponges that expand dramatically when you get them wet.

On the surface it sounds as if this pill might be a
reasonable approach – but there are 2 big problems:

  1. This
    method (filling the stomach to give a sense of fullness and reduce eating)
    has been tried before and has failed to produce the desired result.  Back in the 1980’s scientists attempted
    to use an inflated stomach balloon (Garren Bubble) to suppress hunger.  Unfortunately it didn’t work, and put
    people at high risk for gastric ulcers and other dangerous side
    effects.
  1. There
    is a serious risk of bowel obstruction with this pill.  Once the tablet dissolves in stomach
    acid, the cellulose condenses to produce a bezoar (rock like substance)…
    the pill’s contents can then become wadded up like a rubber tennis ball
    and not pass through the gut safely.
    In fact, the pill could cause a fatal obstruction.

So, as we continue on our quest for the magic pill to cure
our obesity epidemic – we must reject yet another valiant effort.  Sorry folks, it’s back to good old diet and
exercise for most of us.

*Many thanks to Dr. Brian Fennerty who discussed this pill’s
safety with me in a recent interview.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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