Image Credit: Dan Page, Boston Globe
What is the US going to do about our current and future primary care physician shortage? Many believe that the solution is to expand the scope of nursing practice, and license non-physicians (such as naturopaths) to practice medicine. In the face of scarcity, 17 states have licensed naturopaths to provide primary care and nurse-led, in-store pharmacy clinics are gaining popularity.
Studies have shown that nurse practitioners are as capable as physicians at treating common primary care complaints such as strep throat and headache. What studies have NOT shown is that nurse practitioners recognize and diagnose less common diseases with similar symptoms. What if the strep throat were throat cancer? What if the headache were meningitis? Substituting practitioners with half the training and experience of an MD comes at a price. And that price may include missed diagnoses, delay of appropriate treatment, and life threatening consequences.
But the lure of cost savings cannot be ignored. Nurses are paid less to practice primary care, so in theory we could save untold millions each year by having patients see nurses instead of doctors. That sounds good, but now nurse practitioners are lobbying to receive the same salary as MDs for their time. After all, they’re doing the same work, right? Never mind that everyone they treat must be squeezed into a limited set of diagnosis codes – when all you have is a hammer, then everything starts looking like a nail. “Poof” goes the savings, while care quality standards are permanently reduced by forced limitations on differential diagnoses.
A better solution would be to find ways to extend physician reach and expertise with telemedicine platforms, longer patient visit times, and by reducing their non-clinical practice burden. Nurses and ancillary providers are valued members of the clinical team who are dearly loved by patients and doctors alike, but they simply do not have enough training to be ruling out tens of thousands of rare diseases and conditions. This is why we need physicians at the helm of the clinical team – to make sure that patients are on the right treatment pathway.
Some nurses cry “prejudice” when physicians suggest that MDs provide better primary care. But we all know that knowledge and experience are a critical asset when lives are at stake. As the research results begin to roll in regarding better patient outcomes under the care of physicians versus nurse practitioners, common sense tells us that outsourcing primary care to the less qualified will have undesirable consequences for some. And if you choose to get your primary care from a naturopath or nurse, you’ d better hope that headache isn’t anything serious. Because a little savings now could cost you your life.
Cell phones, microwave ovens, wi-fi, smart meters. What do they have in common? They all emit radiation in the radiofrequency range. And they all radiate controversy. Given that these devices are set to become as commonplace as light bulbs, it is understandable that questions arise about their possible health effects. There are all sorts of allegations that exposure can trigger ailments ranging from headaches to cancer. Allegations, however, do not amount to science. And there is a lot of science to be considered.
Let’s start with the fact that an alternating current flowing through a wire generates an electromagnetic field around it. This field can be thought of as being made up of discrete bundles of energy called “photons” that are created as the electrons in the wire flow first in one direction then in the other. Photons spread out from the wire, their energy depending on the frequency with which the current changes direction. The number of photons emitted, referred to as the ‘intensity’ or ‘power” of the radiation, depends on the voltage, the current and the efficiency of the circuit to act as an antenna.
In ordinary household circuits, the direction of the current changes sixty times a second, that is, it has a frequency of 60 Hz, the unit being named after Heinrich Rudolf Hertz, the first scientist to conclusively prove the existence of electromagnetic waves. The photons emitted by such a circuit travel through space and have the capacity to induce a 60Hz current in any conducting material they encounter. Essentially, we have a “transmitter” and a “receiver.” If special circuitry is used to produce current in the range of 10 million (10MHz) to 300 billion Hz (300 GHz), the photons emitted are said to be in the radiofrequency region of the electromagnetic spectrum. That’s because with appropriate modulation at the transmitter (amplitude modulation (AM), or frequency modulation (FM)) these photons can induce a current in an antenna that can be converted into sounds or images.
But what happens when photons in this energy range interact with living tissue, such as our bodies? The greatest concern would be the breaking of bonds between atoms in molecules. Disrupting the molecular framework of proteins, fats and particularly nucleic acids can lead to all sorts of problems, including cancer. However, photons associated with radiofrequencies do not have enough energy to do this, no matter what their intensity. An analogy may be in order.
Consider a weather vane sitting on a roof. It is mounted on a sturdy metal rod, but of course can spin. You decide you want to knock it off the roof, but all you have are tennis balls. You start throwing the balls, but even if you hit the support, nothing happens. You just can’t impart enough energy to the ball to have it break a metal rod. And it doesn’t matter if you gather all your friends, and they all throw balls at the same time. You may have increased the “intensity” of your efforts, but it doesn’t matter, because no ball has enough energy. Of course if you had a cannon, you could knock down the target with one shot. That’s why high energy photons such as generated by very high frequency currents, as in x-rays, are dangerous. They can break chemical bonds! While you are not going to damage the weather vane with the tennis balls, you can surely make it spin, and the friction generated will heat up the base, the extent depending on how many balls are thrown.
Now, back to our photons. In the radiofrequency region, no photon has enough energy to break chemical bonds, but they can make molecules move around, generating heat. The more photons released, the greater the heating effect. This is exactly how microwave ovens work. They operate at radiofrequencies, but at a very high intensity or “power” level, meaning they bombard the food with lots of photons causing the food to heat up. You certainly wouldn’t want to crawl into a working microwave oven and close the door behind you. Similarly, you wouldn’t want to stand right next to a high power radio transmitting antenna, such as used by radio or TV stations, because you could get burned very badly. But the number of photons encountered drops very quickly with distance as they spread out in all directions, so that even standing a few meters from the base of such an antenna would not cause any sensation of heat. Just think of how quickly the heat released by a light bulb drops off with distance.
The “smart meters” that are being installed by electrical utilities monitor the use of electricity and relay the information via a built-in radio transmitter. But the radiation to which people are exposed from these meters quickly drops off with distance, as with the light bulb, and is way below established safety limits. Furthermore, the smart meters only transmit for a few milliseconds at a time for a grand total of a few minutes a day! Cordless phones, cell phones, routers, baby monitors, video game controls and especially operating microwave ovens expose us to similar radiation, usually at far higher levels. Smart meters are responsible for a very small drop in the radiofrequency photon bucket.
It must be pointed out, though, that safety standards are essentially based on the heating of tissues. But what about the possibility of “non-thermal” effects? What if radiofrequency photons cause damage by some other mysterious mechanism? Over the last 30 years more than 25,000 peer-reviewed papers have been published on electromagnetic fields and health, many devoted to non-thermal effects. Health agencies do not find present evidence persuasive of a hazard at ordinary exposure levels, and given the extent of research that has been carried out, it is unlikely that one will be identified in the future.
Although an overwhelming number of studies on cell phones and brain cancer have shown no effect, admittedly some have suggested a barely detectable link. Despite the weak evidence, the International Agency for Research on Cancer has classified electromagnetic fields associated with radiofrequencies as “possibly carcinogenic,” indicating a level of suspicion without any implication that the fields actually cause cancer. This notion pertains to cell phone use and has nothing to do with the far weaker fields associated with wi-fi and smart meters. I would have no issue with a smart meter in my house.
What then about those consumers who claim they have developed symptoms after smart meters were installed? I think it is appropriate to consider John Milton’s poetic view of the power of imagination: “The mind is its own place, and in itself can make a heaven of hell and a hell of heaven.”
Joe Schwarcz, Ph.D., is the Director of McGill University’s Office for Science and Society and teaches a variety of courses in McGill’s Chemistry Department and in the Faculty of Medicine with emphasis on health issues, including aspects of “Alternative Medicine”. He is well known for his informative and entertaining public lectures on topics ranging from the chemistry of love to the science of aging. Using stage magic to make scientific points is one of his specialties.
Dr. Val "After" Photo #1
I just completed 8 weeks of what I’d call “extreme dieting and exercise.” I don’t mean dangerous starvation and constant exercise, I mean the hardest “medically safe” amount of diet and exercise possible. It involved about 3 hours of exercise per day (6 days/wk), along with a calorie-restricted diet of 1500 calories/day (no refined carbs, only healthy fats, relatively high protein). My exercise consisted of heavy weight lifting, kettle bell sets, kickboxing, and sprints on the bike, summit trainer, and on an outdoor track, with long walks each afternoon. Trust me when I say – I pushed myself to the very limits of what my body could handle without becoming sick or injured. I did this with the help of my dear friend and trainer Meredith Deckert.
Why on earth would I do something so extreme? Well, first of all, I wanted the “right to bare arms” on my wedding day. I just woke up and realized I was getting married in 8 weeks and that I’d have photos of the event memorialized for my future kids and grand kids… so the “bat wings” had to go (you know what I’m talking about, ladies), and the time till “lift off” was pretty short – hence the need for maximum effort.
Secondly, I was scientifically curious to know what a “best case scenario,” two month, physique optimization strategy might produce. I knew I wouldn’t cheat on the diet or fall off the exercise wagon, so at least I could be sure that results were based upon strict adherence. Self-reports of diet and exercise regimens are notoriously inaccurate, so this doubting Thomas had to see for herself! (Of course n=1 in this experiment and won’t correlate exactly with others’ experiences due to differences in starting fitness, body fat, age, genetics and gender).
And Thirdly, I wanted to experience (first hand) what is possible so that I could empathize with my patients who were trying to lose weight, and provide personal anecdotes of encouragement. Since America’s biggest health challenge (pun intended) is obesity, I feel obliged to do my part to model lean living. Otherwise, what right do I have to teach others what to do? (Note that heavier physicians are less likely to educate overweight patients about weight loss).
So what did I learn? Each of these probably merits its own blog post, so I’ll summarize briefly and dig into the details with you soon…
1. Calorie math doesn’t necessarily work with the bathroom scale. We’ve all heard that a pound of fat equals 3,500 calories, so that if you decrease your calorie intake (or increase your calorie burn) by that much, you WILL lose a pound on the scale. That has not been my experience (I lost an average of only 30% of what the scale should have shown based on the math). I have some theories as to why that might be (which I’ll share later), but suffice it to say that if you are “doing everything right” and the scale is not rewarding you – take heart!
2. Weight training improves how you look MUCH more effectively than cardio. Before my extreme diet, I was running 1/2 marathons and spending hours on the spin bike. I was in excellent cardiovascular shape, but I had a relatively high percent body fat (about 30%) and I was certainly not getting “skinny” from all the running. I was actually losing muscle and looking softer and more “out of shape.” Dialing down the cardio and increasing the weight training had a rapid, visible impact on how athletic I looked.
3. Your leaner self may not look the way you think it will. When I first began my weight loss journey, I imagined that I would slowly melt away all the excess fat to reveal a lovely ballerina inside. What I found was that after the fat was gone, I wasn’t a ballerina at all. I looked a lot more like a wrestler! People really have different genetically determined body types – and no amount of diet and exercise will make us look like someone else. We’ll just look like our best selves, which is ok! Don’t fall into the trap of thinking that success only looks like a Sports Illustrated swimsuit model. After all, Olympic athletes all have very different bodies, and are at the top of their respective games! (This fun, height and weight database shows how you compare to recent Olympians.)
4. Clothing size is the most helpful measure of success. After 2 months of intense diet and exercise the scale only changed by about 6 lbs. The body impedance analyzer told a little different story (the InBody 520 estimated that I had lost about 10 lbs of fat and gained 5 lbs of muscle with an overall percent body fat loss of about 4%.) But the truth is, that nothing measured my success as well as clothing. I dropped nearly two dress sizes and had to buy a new wedding dress a week before the event! So if your scale isn’t showing you love, what are your jeans saying? Listen to them.
Conclusion: In my experience, the best a slightly overweight, middle aged woman can do (safely) in 8 weeks is lose 10 lbs of pure fat and gain 5 lbs of muscle. It is extremely difficult to achieve that much, and I would highly recommend doing it over a longer period of time. Is the pain worth the effort? Here are my “before” and “after” photos. What do you think?
Before: (151 lbs)
After (145 lbs):
A recent, 358-person survey conducted by researchers at Yale University (and published in the International Journal of Obesity) suggested that patients may be less likely to follow the medical advice of overweight and obese physicians. Survey respondents were 57% female, 70% Caucasian, 51% had BMIs in the normal or underweight category (31% overweight and 17% obese), and were an average age of 37 years old.
Respondents rated overweight and obese physicians as less credible than normal weight doctors, and stated that they would be less likely to follow advice (including guidance about diet, exercise, smoking cessation, preventive health screenings, and medication compliance) from such physicians. Although credibility and trust scores differed between the hypothetical overweight and obese providers and normal weight colleagues, the respondents predicted less of a difference between them in terms of empathy and bedside manner. Respondents said they’d be more likely to switch physicians based on their weight alone. There was no less bias against overweight and obese physicians found in respondents who were themselves overweight or obese.
The study authors note that this survey is the first of its kind – assessing potential weight bias against physicians by patients of different weights. Previous studies (by Puhl, Heuer, and others) have documented weight bias against patients by physicians.
While the study has some significant limitations (such as the respondents being disproportionately Caucasian, thin, and female), I think it raises some interesting questions about weight bias and physicians’ ability to influence patients to adopt healthier lifestyles.
Considering the expansion of pay-for-performance measures (where physicians receive higher compensation from Medicare/Medicaid when their patients achieve certain health goals -such as improved blood sugar levels), being overweight or obese could reduce practice profit margins. If patients are less likely to follow advice from overweight or obese doctors, then it stands to reason that patients’ health outcomes could suffer along with the doctors’ income.
I’m certainly not suggesting that CMS monitor physician waist circumferences in an attempt to improve patient compliance with healthy lifestyle choices (Oh no, did I just give the bureaucrats a new regulatory idea?), but rather that physicians redouble their efforts to practice what they preach as part of a commitment to being good clinicians.
Some will say that the problem here is not expanding provider waistlines, but bias against the overweight and obese. While I agree that weight has little to do with intellectual competence, it does have to do with disease risk. Normalizing and destigmatizing unhealthiness is not the way to solve the weight bias problem. We know instinctively that carrying around a lot of extra pounds is damaging to our health. It’s important to show grace and kindness to one another as we join together on the same health journey – a struggle to make good lifestyle choices in a challenging environment that tempts us to eat poorly and cease exercising.
To doctors I say, let’s fight the good fight and model healthy behaviors to our patients. To patients I say, show grace to your doctors who carry extra pounds – don’t assume that they are less competent or knowledgeable because of a weight problem. And to thin, female, 30-something, Caucasian survey respondents I say – Wait till you hit menopause before you judge people who are overweight!
Finding Nemo is one of my favorite Disney-Pixar cartoons. Not only does it have a cute story line, but it’s full of medical themes – consider the movie’s namesake with a congenitally deformed fin (Nemo), the shark with addiction problems (Bruce), and the blue tang fish with memory impairment (Dory). Even Nemo’s captor turns out to be a dentist! But when I think about the scene where the fish attempt escape from the dentist’s tank by plugging up the filter system to get him to remove them for cleaning, I always think about kidneys. Yep, you heard me right. Kidneys.
Kidneys are fairly under appreciated organs. They filter waste out of 200 liters of blood each day, much the way a fish tank’s filter system purifies its water. Most of us probably don’t even notice a fish tank filter when we gaze at the plastic plants, pebbles, and colorful animals inside the tank – just as we don’t give our kidneys a second thought until they cause us problems.
But the reality is that an astonishing number of people will develop chronic kidney disease (CKD) in their lifetime, largely due to complications from diabetes. An estimated 26 million Americans have CKD, and the majority don’t even know it. Our fish tank filters are failing slowly – and the build up of “algae and grime” just doesn’t cause symptoms until very late in the failure process.
Since March is Kidney Awareness Month, I thought it would be a good time to reflect upon the hard work that our little guys are doing each day. Beyond filtering drugs and chemicals from the blood, kidneys balance body fluids and electrolytes, create Vitamin D, regulate our blood pressure, and produce hormones that stimulate our bodies to produce red blood cells. In fact, anemia can be one of the first signs of kidney failure, and may be experienced as generalized fatigue. People with CKD often suffer from anemia, which can be treated with dietary changes, oral iron, IV iron, or blood transfusions depending on disease severity.
So whether or not you’ve been feeling fatigued, why not ask your primary care physician to check your kidneys next time you’re there for a check up? A simple blood test can identify many kidney diseases early on – so that you can take steps to keep your filter system healthy for life. Just ask Nemo – being in a dirty fish tank is no way to live.
For more information about CKD and anemia, please check out this infographic: