Ed’s corner of the web

Shadowfax wrote a nice little post today about docs who “practice scared” - those poor souls (I think every doc knows at least a couple) who order tests and call consults left and right, worrying constantly about this zebra* or that, admitting everyone who sneezes. It’s an interesting problem, one which I deal with almost every day I’m at work, and one for which I don’t think there’s an easy solution.

What struck me the most about Shadowfax’s post was his idea that fear of litigation, which is unfortunately bandied about a lot in the practice of medicine, is often used as a scapegoat or excuse to cover up the real reasons for practicing scared - usually the fear of missing a diagnosis, ordering the wrong treatment, or doing unnecessary harm to a patient. This idea really rung true to me. As real as the threat of litigation may be (and one could argue a long time about the relative size of this threat), I feel it’s used too often by doctors to justify actions they don’t feel they would do otherwise. Fear of failure is always going to be there, and rightly so. But coating that fear with a veneer of victimization by the malpractice industry is intellectually dishonest and accomplishes nothing.

You’re going to make mistakes. You don’t know everything. You’re human. I think once young, apprehensive doctors can get their head around those ideas (and some, it seems, never really do), they take a giant step towards the best practice of medicine. Not that errors are good, but once you allow yourself the intellectual freedom to make mistakes and miss things, you not only gain the ability to sleep at night, you also think much more clearly. Your brain is suddenly free of the noise of unnecessary worry and better able to perform its higher functions of reasoning and judgment. Instead of the equivalent of thinking, “Don’t mess up. Don’t mess up. Don’t mess up,” all the time, you become free to make rational decisions based on logic and the best evidence.

And notice how I said that the goal of all this is providing the best practice of medicine. This is should not be confused with being as thorough or as cautious as humanly possible, as these are very different things. Sure, you could do a million dollar workup and shotgun therapy on every person who walks through your door. Sure, if you did this a thousand times, you might pick up a couple diagnoses here or there that you wouldn’t have otherwise. But along with those couple extra diagnoses, you would also be saddled with a couple extra cases of cancer from all the radiation you ordered, more than a couple cases of significant side effects from medications you gave unnecessarily, and billions of microbes that are now resistant to the antibiotics you prescribed so liberally. Here, small short term benefits come at the cost of greater long term detriment.

Fear being a part of the human condition, it’s only natural for us medical professionals to have the fears that we do. It’s necessary to understand one’s fears in order to better manage them, but passing the responsibility for that fear on to the bogeyman of malpractice litigation prevents doctors from performing that crucial, honest self-examination. I don’t expect doctors to become cold, emotionless, computational machines (although that could be kinda cool), but I do expect them to try to rise above their fears for the sake of their patients. Far from being a service to their patients, doctors who test and treat too liberally cause more suffering than they relieve.

*Zebra is doctor speak for a wildly unlikely diagnosis, eg. African sleeping sickness in a healthy American kid with a fever.

Carisa and I had the pleasure this last Saturday of attending the wedding celebration of Mary Ly and Chin Song. We knew Mary from the Korean language classes we took through the Brookline Center for Adult Education, and we were happy for her, if a little sad to see her off to the West Coast.

I had brought my camera along in hopes of adding some interesting angles or framings of the wedding, but I soon found my efforts to be completely unnecessary. There were two photographers, two videographers, and even a lady running around carrying a slave flash on a pole. Far from adding anything to the photos, I had to throw elbows to even get the few snapshots I did. And even when I wasn’t fighting for physical space, I had to deal with errant flashes and video camera lights messing up my metering and white balance (you can see the cool bluish light from a video camera in the picture above).

Failed attempts at photography aside, we had a great time. The reception was at Jin Asian Restaurant, a monolith of a restaurant rising above Route 1 in Saugas like some mythical Chinese palace. The meal was ten courses and almost solid protein - cold cuts, mixed seafood, lobster, chicken, fish. My personal trainer would’ve been happy for me. We didn’t even see carbohydrate until the ninth course. The first plate appeared a little after seven, and we finally finished with cake at around 10:30. It was a very filling meal.

Intermixed with the steady stream - river, really - of food were games, toasts, dances, cake cutting, speeches in three languages, and a slideshow. Mary had two costume changes. Chin (who is Korean) made a game attempt at a speech in Vietnamese. Mary (who is Vietnamese) whipped out some perfectly-inflected Korean that made my jaw drop to the floor. When Carisa and I finally rolled out of the parking lot of the restaurant, we knew that we had never seen a wedding like this, and we felt very lucky to have had the opportunity. So thanks to Mary and Chin for throwing a great party, and best of luck to the two of you as you depart on your grand adventure.

Other photos from the wedding.

I got a message in my inbox a couple days ago highlighting a recent controversy in infant formula. Now infant formula is controversial enough to begin with, so some sort of brouhaha is certainly nothing new. But this one struck me as, if not sinister, certainly a little troubling. Evidently a particular market-leading brand of organic infant formula is being sweetened with sucrose as opposed to the lactose used in other brands of infant formula. Since sucrose tastes more sweet than lactose, this gives the sucrose-sweetened formula a sweetness equivalent to “grape juice or Country Time lemonade” as opposed to the “unsweetened apple juice” of other brands. Maybe this substitution is a simple cost-cutting measure instead of a concerted attempt to sway a baby’s formula taste preference - maybe. In either case, sucrose is also less preferable to lactose because it might cause more rapid tooth decay. We cannot be sure at this point if, by feeding our babies sucrose-sweetened formula instead of lactose-sweetened, we are giving them an early sweet tooth that has the potential to lead to nutritional ramifications down the road (obesity, diabetes, etc.), but at the least it sounds like a bad idea. Consumers and physicians, take heed.

Photo by Wendy Harman

Carisa and I went to see the new Indiana Jones movie last Friday.  Meh.  While it was not quite the childhood-ruining, franchise-destroying crap that Episode I was, there were no terribly redeeming traits about it, either.  (Spoiler alert!)  Returning a crystal skull to a hidden temple in the jungles of South America at least sounds like a cool plot on the surface - but when you mix in nuclear testing, commentary on McCarthyism,  alien coverup conspiracies, and cute CG animals, the idea sort of gets lost in all the noise.

The Indy franchise has always had a gritty flavor, so the hyper-real CGI liberally sprinkled throughout the movie feels contrived and out of place.  What was supposed to be a breathless action sequence gets ruined by Shia Lebouf going Tarzan through a CG forest with an army of CG monkeys.  Yes, an army of CG monkeys.  Might as well be Ewoks.  I didn’t even mention the CG prairie dogs.

Cate Blanchett is underused but is still ten times more memorable than Indy’s sidekick, for whom you hardly care when he gets sucked into another dimension.  (Seriously, another dimension.  Is this still Indiana Jones?)  The batty, nearly aphasic kidnapped archaeologist adds nothing to the story.  At least it was good to see Karen Allen as Marion Ravenwood again.

Oh yeah - the movie ends in a wedding.  Honestly, as I continue to type this stuff, I have to remind myself over and over that this really was an Indiana Jones movie.

I could go on and on, but I guess it really doesn’t matter.  The movie is going to make (and already has made) a jillion dollars.  People are going to go see it regardless of what the reviews are (just like I did) because of the history of the franchise.  I know that sequels don’t automatically have to suck, because there have been examples of ones done well (immediate example: Temple of Doom).  So I free up 2+ hours of my time and pay 12 bucks to go into a movie like this hoping, perhaps naively, for something that enriches an entire franchise’s mythology, adds to the magic of a fictional world.  And it hurts when, more times than not, the expectations come crashing down and the movie ends up sucking.  You wonder if the people in charge are just asleep at the wheel, if they made the mistake of taking themselves too seriously, or if they’re just turning the crank to print some money.  In any case it’s a damn shame.

Ok - lament over.  I hear Iron Man is pretty good.

Let me set the record straight first: I’m a huge NPR fan.  I think I first got hooked around 9/11, and I’ve been an avid listener ever since.  Of the six preset stations on the car radio, the other five combined don’t get half as much playtime as NPR, which in my neck of the woods is 90.9 WBUR.  I enjoy the high-quality reporting, the engaging interviews, and even the fun weekend shows like Wait Wait Don’t Tell Me.  I enjoy the whole affair so much that a couple years ago, I felt bad being a freeloader and started making yearly contributions.  And beyond simple enjoyment, I also find myself learning a lot from listening.  It’s become a significant and trusted source of information for me.

You can imagine my consternation, then, when a couple weeks ago my morning commute with WBUR was interrupted by an ad for a company providing ”detoxifying” services with “ionic energy fields”, oxygen supplementation, and nutrient supplementation.  I won’t give the name here for fear of upping the company’s notoriety somehow.  It was a rude, jarring, pseudoscientific intrusion into what was typically a very informative drive.  How could WBUR advertise this crap?  I knew they needed sponsors, as any public radio station does, but surely this was bending too low.

I almost blogged about my dismay that day, but work soon had me running around enough to forget that morning’s insult.  My wedding and honeymoon came and went shortly thereafter, and I returned to my happy NPR listening habits, past injuries forgotten.

Until today.

I’m driving up Route 2 towards Concord, enjoying ”Only a Game”.  The usual WBUR sponsor bit comes on, but this time instead of Landry and Arcari or the MFA, the nice female radio voice spits out the name of a school of homeopathy!  Let me say that again - homeopathy.  You have got to be kidding me.  What’s next - sponsorship from a Boston psychics organization?  Noni juice manufacturers?  WBUR already broadcasts Science Friday.  Maybe they should add Woo Wednesday to attract more sponsors.

So I’m calling out WBUR on this one, and I hope others do, as well.  And remember, WBUR, it’s only because I love you.  I know public radio money is not exactly overflowing, but there have to be some standards on who it’s ok to take money from.  Those who make their living duping their customers with potentially harmful pseudoscience should not be given the opportunity to spread their message on stations such as WBUR, stations that exist to educate and provide information.

In preparation for our honeymoon trip to Australia, Carisa wanted to get me scuba-certified. I admit to having been a little apprehensive about the whole thing, as I am - at best - a poor swimmer. Still, I’m a confident and strong snorkeler, and scuba seemed the next step if I was going to scratch my underwater photography itch. So, we did our course work and pool work through Mass Diving (highly recommended), and we booked a trip to Turks and Caicos to do our checkout dives.

Our destination in Turks and Caicos was Salt Cay (pronounced “key”), a remote little blip of an island measuring about 2 miles long and having a little over 60 year-round inhabitants. To get there, we flew from Boston to Miami, then Miami to Providenciales, then Providenciales to Grand Turk, and then finally Grand Turk to Salt Cay. If you can imagine in your mind a quiet, tropical backwater where time and worries blow away on gentle ocean breezes, then you pretty much have a good idea of what this place is all about. Well that and really great diving.

Can you believe it? Me!

Of course, having only dove in a YMCA pool prior to this, I didn’t have much to compare it to. But still, I thought it was really great regardless, and Carisa - who has a little experience diving elsewhere - also gave it high marks.

The birding was fun, too, as you can see from the rest of the photo library. But I think coolest of all (along with the diving) were the people on the island. Comprising a mixture of native Belongers, immigrants from other Caribbean countries, and ex-pats from the States and the UK, the unifying traits among the island’s inhabitants were openness and friendliness. Everyone waves at everyone as they pass. People stop and chat with complete strangers. Even the dogs are super friendly.

We also ate surprisingly well for being so far off the beaten path. Special thanks here go to Porter Williams and Miss Nettie.

So bottom line is we had a truly wonderful and restful time while we were there. We felt like we had slipped a little off the map and out of the normal flow of time. It was a very nice feeling.

After an almost two-month hiatus, I’m taking another plunge with the blog.  I’ll admit, I was this close to giving up on it entirely.  It wasn’t the writing requirements, it was the incessant blog spam.  Tramadol.  Soma.  Phentermine.  It got to be too much to keep up with in late March/early April, so I stopped blogging entirely to see if anything changed.  The spam still kept flowing into my moderation list for a couple weeks, but then it seemed to taper off a bit.  A couple days ago, I returned from being out of the country for two weeks (more on that later), and what am I greeted by but - amazingly - no additional spam!  So I have a little hope now that maybe this little blog has fallen off the radar of the zombie comment spam engines.  Anyone know how to avoid this crap?  I enjoy blogging and would like to continue doing it, but if it means sifting daily through the mountain of spam I was getting before, then I honestly won’t be able to justify the time.  So anyway, here goes again…

For all of the ridiculousness that seems to happen in Massachusetts (stupid bomb scares, gorillas on the loose, the Big Dig, Mitt Romney, I do like to think that we’re ahead of the curve overall. So I was pleased to read that our state legislature was seeking to ban gifts to doctors.

Coming up through the ranks, it was easy to see the pervasiveness of drug company marketing in the form of gifts and freebies. Pens, notepads, microfiber lens cloths, and the occasional pocket guide were just the tip of the iceberg. The “Cipro breakfast” was well known among the medical students as a good place for a nice free meal. Drug-sponsored lunch conferences were always popular, and the exalted drug dinner, which we were rarely privy to as mere medical students, was sought after highly. Luckily, the idea that accepting these sort of inducements was, at best, ethically iffy and, at worst, altering our medical decision-making was filtering up through the medical school and medical staff. The behavior, if not frowned upon sternly, was at least questioned.

Unfortunately, here I am almost ten years later watching the same conflict play out. We already have a strong inkling that pharmaceutical company contact with physicians changes prescribing practices. Indeed, one would hardly expect the pharmaceutical companies to continue pursuing this expensive tactic if it didn’t work. Yet still we allow them easy access to medical students (this thread is disturbing to me), residents, and physicians through free meals, freebie items, drug samples, sponsored CME, and other such means. And even if you don’t believe a simple logo pen could affect someone’s medical practice, you have to admit it looks really fishy to a patient when you sign a prescription for them using a pen with the same drug’s logo on it. It’s just a bad idea medically and ethically.

So I, for one, will cheer on Therese Murray’s efforts in this regard, and I support other states’ efforts with similar measures. If you, as a physician, would rather not see the government stepping in in this way, then alter your actions so they don’t see the need to step in. As a practicing physician, I’ve tried hard to refuse any and all gifts or inducements from drug companies, even pens. I’m such a bastard that when I cover for another doc’s primary care practice, I won’t even sign for the practice’s drug samples. (And it even turns out that free drug samples aren’t the safety net we like to believe they are.) I think if everyone moves in a similar fashion to stem the tide of these inducements, the end result may very well be the better practice of medicine - based on the best scientific evidence, not on what ad we last saw - and possibly more cost-efficient medicine as we forego the latest shiny name brand drug for the generic that works just as well.

I blogged about this story when it first came up back in August.  I knew it was going to be bad news, and sure enough, it is.  Now the surgeon is facing criminal charges - three felony counts, at that.  Dependent adult abuse, administering a harmful substance, and unlawful controlled substance prescription are the criminal counts, and on top of that there’s the wrongful death suit from the mother.  While it seems pretty apparent that this surgeon crossed over some ethical boundaries, the weight of the criminal charges seems a little hefty to me.  I wish I knew more of the facts of the case.  Don’t get me wrong - the surgeon committed some rather egregious errors and should be firmly sanctioned for them, but I don’t think his overzealousness to help someone else should land him in prison.  Of course, the damage to the transplant community has been done and will likely only spread over the next couple years as this case plays out.  That is probably the biggest loss of all.

With all of today’s talk about ricin found in Las Vegas, I have to tell a little story. I remember first learning about ricin way back in Prof. Krieger’s 7.20 class (Human Physiology) in college. The class distinguished itself from most other biology-major fare by being immediately and directly applicable to real life. The mention of ricin, however, was especially memorable to me because it was mentioned in the setting of the Bulgarian umbrella murder. It wasn’t a particularly positive use of biology, but I was pretty impressed. Espionage! Assassination! Secret spy gadgets! All made possible with science. If I remember correctly, one single molecule of ricin was capable of killing a human cell. That’ll make you pay attention.