Ignorance or Apathy?

The 61 year old female was being seen two months after surgery for tubular carcinoma of the breast. She complained of an abdominal wall mass which was mildly tender, subcutaneous and nodular, measuring 4x2x2 cm. Her doctors were immediately concerned about either metastatic breast carcinoma or a recurrence of her follicular lymphoma diagnosed in 2001.

She underwent total excision of the mass, and the tissue was analyzed in using various immunohistochemical studies. There was no evidence of malignancy, only lobular panniculitis with paraseptal lymphoid follicles and vasculitis. Her doctors then continued the workup, including consideration of SLE. It was only after talking with her surgeon that it was revealed that she had been giving herself subcutaneous injections of mistletoe extract in her abdomen. She had heard about this treatment from a friend and was referred to a "complementary therapist" through her primary care practitioner.

The details in this real-life case published in the British Medical Journal in December, 2006 illustrate well the findings in a recent survey released in January. In this nationwide study, investigators at the NCCAM measured complementary and alternative medicine (CAM) use among patients. They found that two out of three adults age 50 and older have used some form of CAM, but 77% of them never discussed it with their physician. The two most common reasons why CAM was not discussed were that patients didn’t know they should (30%) and the doctor never asked (42%). According to the respondents, family and friends were their primary source of CAM information, followed by publications, physicians, Internet, and radio (interestingly, though, the second most common response regarding CAM sources was "I don’t know"). The survey also found that nearly three-fourths of respondents were currently taking multiple prescription medications, and 60% were taking one or more over-the-counter medications.

This study is available at the National Institutes of Health website and provides valuable insights into CAM use among patients.

Just following orders, sir!

NEJM 356;6, Feb 8, 2007 pp. 593-600.

The latest issue of the New England Journal (356;6. Feb. 8, 2007) has an interesting article: "Religion, Conscience, and Controversial Clinical Practices" in which the investigators sought to determine the degree to which a physician’s personal beliefs impact the patient’s autonomy. They asked the following three questions:

If a patient requests a legal medical procedure, but the patient’s physician objects to the procedure for religious or moral reasons, would it be ethical for the physician to plainly describe to the patient why he or she objects to the requested procedure? Answer: 63% said yes.

Does the physician have an obligation to present all possible options to the patient, including information about obtaining the requested procedure? Answer: 86% yes

Does the physician have an obligation to refer the patient to someone who does not object to the requested procedure? Answer: 71% yes

They found that white males who were religious were the most likely to object and disagree with the obligation to inform patients where to obtain such a desired procedure. This is a fascinating topic for me, a practicing Catholic white male physician, and I’ve come to realize that I’m even further removed from my colleagues. For example, while the investigators’ specific question about birth control had to do with prescribing to minors without parental consent, I do not prescribe birth control for any reason. My office staff is trained to tell all new female patients of reproductive age that I don’t do this.

I honestly don’t know exactly where my boundaries lie, but they have to do with the question of whether life is being destroyed. For example, I absolutely will not be complicit in any way with one of my patients who wants an abortion. If asked, I will certainly outline all the available options, but I will not actively assist her with finding someone who will perform an abortion. I recognize the sanctity of life from moment of conception to the point of natural death, which means euthanasia is out, as well.

On the other hand, I have given Viagra to people who are engaging in fornication. I have referred patients to be mutilated by means of vasectomy or tubal ligation for the sole purpose of infertility. Does it keep me awake at night sometimes wondering if my prescription for Viagra allowed a man to have an extramarital affair? Yes, but I justify it somehow by concluding that I’m not destroying a human life and that my personal responsibility for others’ lives has to stop somewhere. For that matter, I treat patients who are actively homosexual, actively promiscuous, or have other worldviews with which I disagree. I don’t claim to have all the answers, but just as I have the right to discharge a patient from my practice for noncompliance with my recommendations, I have the right to practice medicine the best way I know how.

If I’m asked, I will tell women why I don’t believe in prescribing birth control. To my knowledge I can only think of one woman who found my personal stance unacceptable and went somewhere else.

I noticed that the lowest percentage of responders in this study were OB/GYNs (7%) – the same specialty that deals most often with issues like abortion, birth control, fertility, etc. Is that a coincidence? My position is that my job is to inform patients fully on the options and consequences of their decision making, but I do not have to take an active part in their doing something to which I am morally opposed. My patient’s right to self-determination is not removed by my refusing to participate in these actions. This opinion places me at odds with Savulescu who wrote, "a doctor’s conscience has little place in the delivery of modern medical care" and that "if people are not prepared to offer legally permitted, efficient and beneficial care to a patient because it conflicts with their values, they should not be doctors." ( Conscientious objection in medicine. BMJ 2006;332:294-7). Come to think of it, Mengele was very efficient...

After all, if something’s legal it must be moral.

Hall of Shame

Two of my favorite all-time baseball players, Cal Ripken, Jr. and 98.5%
Tony Gwynn, have been voted into the Major League Baseball Hall of Fame. Ripken received 98.5% of the votes and Gwynn received 97.6%

This begs the question - who the hell were the 1.5% and 2.4% of people who voted against them? Are you kidding me?

Did you know that the word "gullible" isn’t in the dictionary?

The Federal Trade Commission has levied 25 million dollars in fines and penalties against companies marketing 4 weight loss products: One-A-Day Weight Smart, Xenadrine EFX, Cortislim, and TrimSpa.

When ephedra became the first dietary supplement to be banned by the FDA after being linked to 155 deaths, manufacturers scrambled to offer "ephedra-free" alternatives. For example, Xenadrine EFX contains bitter orange (Citrus aurantium); but bitter orange is metabolized into synephrine which is still very similar to ephedra in its pharmacodynamics. Ironically, the FTC also discovered that in one of the Xenadrine studies the placebo group actually lost more weight than the study group!

The makers of Cortislim (and Cortistress) were accused of using infomercials that were deceptively formatted to look like legitimate talk shows as well as making unsupported claims of weight loss and prevention of osteoporosis, obesity, diabetes, Alzheimer’s disease, cancer, and cardiovascular disease.

Trimspa contains Hoodia gordonii and is known for its famous spokeswoman, Anna Nicole Smith, who claimed to have lost 69 pounds in 8 months. Apparently Trimspa thought that a woman whose main claim to fame was being an topless dancer who married a billionaire thrice her age was a compelling enough reason to have her represent their product.

One-A-Day Weight Smart is brought to you by Bayer which also makes Cipro, Avelox, and Levitra (and the ill-fated cholesterol drug Baycol). The FTC concluded that Bayer's claims that it increased body metabolism were unscientific and objected to their ad that recommended only one exercise: "lift the bottle, twist the cap, and bend your wrist to take the pill."

No, seriously. For their transgressions Bayer will pay a 3.2 million settlement, the largest civil penalty ever issued by the FTC. At the press conference January 4th, FTC chairman Deborah Majoras discounted the use of testimonials in advertising by pointing out that the person is paid to do so, and that they often had additional diet and personal trainers to help them. She also listed some "red flag" claims that consumers should be wary of:

Causes substantial weight loss regardless of calories consumed.

Causes permanent weight loss even if one stops using it.

Blocks absorption of fat or calories.

Enables users to lose more than three pounds a week for more than four weeks.

Causes substantial weight loss for all users.

Causes substantial weight loss by wearing it or by rubbing it into the skin.

Blessed be Google

Forget just googling your name, doctors are using this powerful search engine to help diagnose diseases. A new study in the British Medical Journal demonstrated that googling worked to identify the disease 58% of the time from the Case Records of the New England Journal of Medicine.

We're just that much closer now to the Star Trek Tricorder that Bones used to diagnose patients.

Egocentric Parenting

There is an interesting topic at Medpundit linking to an article describing situations where parents will, using Pre-implantation Genetic Diagnosis (PGD), intentionally select embryos "for the presence of a disability." Since I don't want to start an war Medpundit's comments section, I will elaborate here.

Medpundit correctly (I think) characterizes this is "still an egocentric mindset. Parenting as self-gratification." However, I disagree with this statement: "It's really no different than parents who use the procedure to avoid having a child with a disability."

With PGD, embryos are created in vitro and their DNA analyzed. If there are unwanted characteristics or genetic predispositions found (such as Huntington's Chorea, Tay Sach's disease, etc), that embryo is not implanted. I have two objections. First, who decided that a woman is pregnant only after implantation? The only difference between a newly-fertilized egg floating through the fallopian tube and one that is newly-implanted is merely a matter of real estate - location, location, location. The embyro's inherent properties remain exactly the same.

Therefore, using PGD to avoid having a child with a disability means that the offending embryo in question is not implanted. Since this will result in the death of that embryo, there is a gigantic difference between this and parents who use PGD to select a child with disabilities. While the latter calls into question those parents' suitability for raising children, the former is nothing less than infanticide.

As a former embryo myself, I think that just as children don't pick their parents, parents should not be allowed to pick their children.

Noni No-No

Proprietors of the Polynesian and South Pacific noni plant (Morinda citrifolia) believe it to be the next great panacea. Of particular interest is the substance named "xeronine" by Ralph Heinicke, former pineapple enzyme researcher for Dole. Noni's various phytochemicals are thought to have beneficial effects based on isolated findings in animal and laboratory tests. For example, a Hawaiian study suggested that high-dose intraperitoneal injections of noni extended the life of mice with lung carcinoma (Proc West Pharmacol Soc. 1994;37:145-6). A separate unpublished study reported in vitro activity against mycobacteria. Another study suggested sedative and analgesic effects on animals.

Although no human studies have been completed, there have been case reports of potential harm such as hyperkalemia (Am J Kidney Dis. 2000 Feb; 35 (2):330-2), hepatoxicity (Europ J Gastroenterol., 2005; 17:445-7) and possible Coumadin resistance (Am J Hematol. 2004 Sep;77(1)103). Furthermore, one study of noni leaf extract screening for antibacterial activity using disc diffusion demonstrated no effect on K. pneumoniae, P. aeruginosa, E. coli, S. aureus, and MRSA (Trop Biomed. 2005 Dec;22(2):165-70). Interestingly, even Heinicke admits that xeronine is almost impossible to detect, and that noni's activity is dependent upon fresh fermentation and gastric motility. After a comprehensive review, Dixon concluded that "the celebrity of noni is out of proportion to the facts" (Economic Botany. 1999. 53(1) pp 5 1-68).

Despite the paucity of evidence, noni has attracted many ardent followers including spokesman actor Danny Glover (star of "Lethal Weapon" and admirer of Hugo Chavez). The National Center for Complementary and Alternative Medicine is currently enrolling patients in a Phase I clinical trial, but at this point it appears that one can get the same antioxidant properties from a can of V-8 juice, and that the "energy boost" achieved is merely from all the sugar sweeteners used to conceal its putrid taste and smell. Perhaps it is no coincidence that the only existing patent for noni is actually for "eliminating grease, sewage odor and hydrogen sulfide from restaurant grease traps and municipal sewage systems" (patent #4666604).