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Informed consent & the animal guessing game

Growing up in Canada, my family spent a lot of time in the car. While my European friends would tell me how they could drive through 4 countries in a matter of hours, in Canada I couldn’t get part of the way through our smallest province in the same time period. Canadians have to travel long distances to get anywhere, which is part of the reason why they’re such a tolerant and patient lot.

So on these long drives (long before the days of portable entertainment devices) my family would have to think of ways to pass the time. Our favorite game was inspired by “20 questions.” We called it “the animal guessing game.”

It basically worked like this – you thought of the most unusual animal you knew of (perhaps something you’d seen on Animal Kingdom or in an animal encyclopedia) and the rest of the family would ask yes and no questions until they guessed what it was, or all agreed to being stumped.

Now, most of us would systematically narrow the field of possibilities by asking typical questions related to size, territory, habitat, skin type (fur, scale etc.) and so on. But my younger sister would always begin by asking the same question:

“Does it have fangs?”

At the time I thought she was hopelessly silly and incapable of systematic analysis. So few animals, after all, would fall into that category. Surely that wasn’t a good lead question.

But as I reflect on my sister’s perseverance on fangs, I realize that she was using an emotive hierarchy. To her, animals with fangs were so frightening, that she wanted to get it out of the way first thing – to be sure that we weren’t going to be spending time reviewing the life cycle and eating habits of animals with sharp teeth.

You know, it may seem funny, but I think that when it comes to matters of medicine some patients feel the way my sister did about the animal guessing game. They’re in unfamiliar territory, they are afraid of a real or perceived threat of a painful test or procedure, and they are internally focused on that threat to the exclusion of the big picture.

Doctors have the natural tendency to be removed from the emotional priorities of patients. We think that the patient is most interested in the evidence behind certain tests, the statistics, the technical aspects of a procedure – but sometimes as they try to comprehend the details of your informed consent, they really have one burning question:

Does it have fangs?

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

Genetic engineering & mosquito bites

As spring approaches, we can expect a new onslaught of pollen, bugs, and mud puddles. Mosquito eggs will hatch in stagnant water, and a new generation of hungry little disease vectors will be lurking in wooded areas, awaiting their first meal.

Luckily for those of us who live in North America, those annoying mosquito bites are unlikely to infect us with malaria.

A team of scientists committed to eradicating malaria (one of my personal favorite parasites) has taken a new approach to reducing transmission rates: creating a strain of malaria-immune mosquitoes.

I had been under the mistaken impression that mosquitoes lived in perfect harmony with malaria parasites, but apparently the organisms can make them quite ill as well. Not ill enough to die immediately (hence their ability to spread the disease) but ill enough to die prematurely.

So if we could create a malaria immune mosquito, we could give them a survival advantage over their peers, thus slowly influencing the mosquito population in favor of the new strain. This could result in a new population of mosquitoes who could not harbor malaria.

In humans, malaria parasites have learned how to attach themselves to red blood cell proteins and incubate inside the cells. In mosquitoes, the parasites latch on to a protein (called SM1) on the surface of epithelial cells of their gut lining. Through the miracle of genetic engineering, we’ve managed to alter the SM1 proteins in certain mosquitoes, making them immune to invasion by parasites they ingest through infected blood.

Although the immune mosquitoes are not ready for prime time release in malaria endemic countries (the research only showed that the scientists could genetically engineer resistance to one strain of malaria), it sure would be interesting to see if we could use mosquitoes themselves to fight a disease that claims the lives of over one million people per year.

This is a rare case of a problem becoming the solution!

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

Are physician salaries too high?

I am opposed to millionaires, but it would be dangerous to offer me the position.

–Mark Twain

As we consider the wastefulness of the healthcare system, I have heard many people complain that physician salaries are one of the main culprits in escalating costs.

Dr. Reece compares the average income of some of the highest paid physician specialists, with that of hospital executives, medical insurance executives, and fortune 500 CEOs. Check this out:

Highest Paid Physicians

1. Orthopedic, spinal surgery, $554,000
2. Neurosurgery, $476,000
3. Heart surgeons, $470,000
4. Diagnostic radiology, Interventional, $424,000
5. Sports Medicine, surgery, $417,000
6. Orthopedic Surgery, $400,000
7. Radiology, non-interventional, $400,000
8. Cardiology, $363,000
9. Vascular surgery, $354,000
10. Urology, $349,000

Executive Pay for Massachusetts Hospital CEOs

1. James Mongan, MD, Partners Healthcare, $2.1 million
2. Elaine Ullian, Boston Medical Center, $1.4 million
3. John O’Brien, UMass Memorial Medical Center, $1.3 million
4. David Barrett, MD, Lahey Clinic, $1.3 million
5. Mark Tolosky, Baystate Health, $1.2 million
6. James Mandell, MD, Children’s Hospital, Boston, $1.1 million
7. Gary Gottlieb, Brigham and Women’s Hospital, $1 million
8. Peter Slavind, MD, Massachusetts General Hospital, $1 million

2005 Total Annual Compensation for Publicly Traded Managed Care CEOs

1. United Health Care $8.3 million
2. Wellpoint, Inc, $5.2 million
3. CIGNA, $4.7 million
4. Sierra Health, $3.4 million
5. Aetna, Inc, $3.3 million
6. Assurant, Inc, $2.3 million
7. Humana, $1.9 million
8. Health Net, $1.7 million

Top Corporate CEO Compensation

1. Capital One Financial, $249 million
2. Yahoo, $231 million
3. Cedant, $140 million
4. KB Home, $135 million
5. Lehman Brothers Holdings, $123 million
6. Occidental Petroleum,, $81 million
7. Oracle, $75 million
8. Symantec, $72 million
9. Caremark Rx, $70 million
10. Countrywide Financial, $69 million

But the real story here is the salary of our primary care physicians – those unsung heroes of the front lines. KevinMD pointed out a recent news article citing $75,000.00/year as the average salary of the family physician in the state of Connecticut, and that their malpractice insurance consumed $15,000.00 of that. Although this is certainly below the national average for pediatricians (they start at about 110,000 to 120,000), I’ve seen many academic positions in the $90,000 to 100,000 range.

Now I ask you, does it seem fair that the vast majority of physicians (the primary care physicians) are making one tenth of the average hospital executive salary? Should doctors really be in the cross hairs of cost containment?

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

Are socks dangerous?

Clothes make the man. Naked people have little or no influence on society.

–Mark Twain

Today I realized that I have spent the majority of my adult daytime hours enduring a continuous, sock-induced lower extremity discomfort. Socks feature a type of tourniquet system that slowly squeezes calf flesh into red indented rings, crowning edematous ankles. Why must socks be so painful? The manufacturers believe that their ability to “stay up” far outweighs the importance of comfort – and so like the sock zombies we are, consumers continue to purchase them under the assumption that painful elastics are simply part of the sock experience.

I decided to search the Internet for sock commiserators, and lo and behold, I found a comment in a diabetes forum about the dangers of tight socks. This person argues that socks can predispose to blood clots, and promote ulcers in those who have preexisting circulatory problems. She goes on to recommend a special type of diabetic sock that is non-binding, manufactured by a company called “sugar free sox.”

I performed a Medline search for articles about “socks” and “stockings” and there were surprisingly few articles. In fact, the majority of articles only mentioned a specific type of medical sock known as “compression stockings” (or T.E.D.s). I didn’t see any studies confirming the potential dangers of the garden variety sock, but it does make intuitive sense that anything that acts as a tourniquet cannot be a good thing for the circulatorily challenged.

Therefore, my recommendation is that if you are diabetic or have any known problems with your circulation, you should do your best to avoid tight socks. I myself am planning to try out these diabetic soft elastic, stretchy socks – and I will wear them proudly about the office in utter contentment and comfort.

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

Do the right thing

Always do right. This will gratify some people and astonish the rest.

–Mark Twain

My favorite writer of all time is Mark Twain. His keen observations and uncanny ability to combine wisdom and wit makes his writing incredibly entertaining, don’t you think? I thought it would be fun to take a few of his quotes and illustrate them with true stories from my mental archives.

Today’s quote is about doing the right thing. I remember a case where a young internal medicine intern was taking care of a 42 year old mother of 3. The mother had HIV/AIDS and had come to the hospital to have her PEG tube repositioned. Somewhere along the way, she required a central line placement, and as a result ended up with a pretty severe line infection. The woman’s condition was rapidly deteriorating on the medicine inpatient service, and the intern taking care of her called the ICU fellow to evaluate her for admission to the intensive care unit.

The fellow examined the patient and explained to the intern that the woman had “end stage AIDS” and that excessive intensive care management would be a futile endeavor, and that the ICU beds must be reserved for other patients.

“But she was fine when she came to us, the line we put in caused her downward spiral – she’s not necessarily ‘end stage,’” protested the intern.

The fellow wouldn’t budge, and so the intern was left to manage the patient – now with a resting heart rate of 170 and dropping blood pressure. The intern stayed up all night, aggressively hydrating the woman and administering IV antibiotics with the nursing staff.

The next day the intern called the ICU fellow again, explaining that the patient was getting worse. The ICU fellow responded that he’d already seen the patient and that his decision still stands. The intern called her senior resident, who told her that there was nothing he could do if the ICU fellow didn’t want to admit the patient.

The intern went back to the patient’s room and held her cold, cachectic hand. “How are you feeling?” she asked nervously.

The frail woman turned her head to the intern and whispered simply, “I am so scared.”

The intern decided to call the hospital’s ethics committee to explain the case and ask if it really was appropriate to prevent a young mother from being admitted to the ICU if she had been in reasonable health until her recent admission. The president of the ethics committee reviewed the case immediately, and called the ICU fellow’s attending and required him to admit the patient. Soon thereafter, the patient was wheeled into the ICU, where she was treated aggressively for sepsis and heart failure.

The next day during ICU rounds the attending physician asked for the name of the intern who had insisted on the admission. After hearing the name, he simply replied with a wry smile, “remind me never to f [mess] with her.”

The patient survived the infection and spent mother’s day with her children several weeks later.

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

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