Designated Listener, Part II

Seems like there's a run of bad health luck in the lives of those around me here recently. I found myself, once again, sitting in as designated listener for a loved one (LO) during an important consultation. This time, I noticed a few eye-openers about the way my colleague conducted the visit, so here's three rules for MDs in the consultation room:

1. Doctors who don't get appropriate touching should skip touching altogether.
   This guy often stood with hand on LO's shoulder or occasionally sat with hand on LO's knee. I prayed that LO would not haul off and smack him. Honestly, it was not the time or place for such touching, and, in any case, LO exudes 'don't touch me' from every pore of his body.
2. Explain your thoughts, but don't dither.
   The doc was clearly puzzled by the situation and was thinking on his feet. As he mused about the possibilities in a roundabout, back-and-forth, sort of way, he finally came up with what I thought were three appropriate theories. LO concluded, not inappropriately, that this physician was fairly clueless about LO's condition.
3. Explain, but don't over explain.
   The physician gave so many simplistic 'for examples' that he came off as patronizing. Patients may need simplification, but, here I completely agree with LO, this was WAY too much dumbing down.

As an aside, our consultant stood through most of the visit in a stance appropriate to a college defensive back. I assume that at some point in his career he was just that, but it was a little strange there in the examining room.

Blood vessels love grape juice

They're not just passive pipes anymore. Blood vessels, or rather the single layer of cells known as the endothelium that line these passages, actively regulate blood pressure, blood flow, clotting, inflammation, and the immune response. And endothelial cells love purple grape juice whether it's fermented or not.

Persons with arterial disease such as hypertension or atherosclerosis are known to have endothelial dysfunction. In other words, their blood vessels are unable to expand normally in response to such things as exercise and cannot, therefore, efficiently increase blood flow and oxygen delivery when needed. Researchers are able to measure the health of the endothelium and its ability to increase blood flow by a simple test called flow-mediated dilation (FMD).

This test uses ultrasound technology to measure the diameter of the brachial artery at the elbow. A blood pressure cuff is then inflated on the forearm to the point where blood flow through the area is stopped. When the cuff is released, blood surges back into the forearm. Ultrasound is again used to the brachial artery, and the state of blood vessel health can be judged by the post-test expansion of this artery.

Fifteen patients with proven coronary artery disease were hooked up with daily grape juice over the course of 2 weeks(1). Prior to being juiced, these patients, as expected, demonstrated impaired FMD. After 14 days of Welches (and this must be concord grape juice), their FMD tripled. No such changes were observed in other studies conducted with OJ or grapefruit juice.

Grape juice kind of makes my skin crawl, but I drink it anyway. Pair it up with dark chocolate and oatmeal, and your endothelium will be relaxed, your arteries surging with blood.
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(1)Stein, JH et al. Purple grape juice improves endothelial function and reduces the susceptibility of LDL cholesterol to oxidation in patients with coronary artery disease. Circulation. 1999 Sep 7;100(10):1050-5.

Designated listener

Unfortunately, I was the designated listener for a good friend yesterday. I sat through the doctor's appointment with her and took notes while she more or less heard the words that would change the course of the rest of her life.

The doctor did a wonderful job with a most difficult task. She started the conversation with "I am so sorry that you have to come see me today." She spent nearly an hour and a half with us, explaining and also doing a fair amount of listening herself.

Afterwards, we went out to lunch. Shortly after ordering, the waiter returned to the table. "I'm afraid I have some bad news," he said. "We're out of the foie gras."

She and I didn't know whether to laugh or cry. Bad news indeed!

The benefits of Deplin

I wrote about Deplin recently. Billed as a 'medical food,' it is an fancy new methylated version of folate that easily enters the brain. Being a good sport and an inquiring mind as well as a doctor, I thought I'd give it a try.

The downside of Deplin is that it does indeed interfere with sleep. On the plus side, however, I have noticed an increased ability to focus on loathsome tasks involving numbers. My theory is that I have been borderline low on norepinephrine, the lack of which makes me inattentive and anxious. This new source of methylated folate is, perhaps, hard at work promoting norepinephrine production in my aging brain.

I have not yet heard back from several patients whom I have started on Deplin. I hope that it will improve their response to antidepressants and decrease that lethargy that sometimes accompanies the use of SSRIs. This side effect may be due to a down-regulation of norepinephrine receptors in the brain.

I said...MOVE YOUR REINDEER!

You may be surprised to discover that reindeer herding is a hazardous, noisy profession, what with all those braying reindeer and roaring snow mobiles. However, Finnish researchers have found that hearing loss among the herders is not just about nerve damage from noise exposure. Those tundra hands who escaped job stress through smoking, particularly those indulging in more than 144,000 cigarettes (a pack a day for 20 years), had significantly more hearing loss than their non-smoking herd-buddies.

Lest you think this danger does not relate to your daily life, this finding was repeated in a study of 1,500 Japanese office workers exposed to nothing more than the ringing of phones and computer games, There, the risk of high-tone hearing loss among heavy smokers was more than two times greater than those who abstained.

No wonder our pleas to our smoking friends to quit sometimes fall on deaf ears.

"Etiquette-based medicine"

Patients ideally deserve to have a compassionate
doctor, but might they be satisfied with one who is
simply well-behaved? ...A doctor who has trouble feeling
compassion for or even recognizing a patient's suffering
can nevertheless behave in certain specified ways that
will result in the patient's feeling well treated..
---Michael Kahn, MD

Dr. Kahn calls for a good manners curriculum in medical education in the latest edition of the New England Journal of Medicine.(1) He provides an example of a behavioral checklist that clinicians should follow to promote civility and respect in our patient encounters, including:

1. Introduce yourself.
2. Shake hands.
3. Sit down.
4. Smile if appropriate.

I'm sure you've all had encounters with physicians who were less than polite. My Mom's first doctor at the nursing home, shortly before I fired him, spent five minutes in her room during which he never looked at her once nor addressed a single remark to her. I saw a dermatologist a few years back who walked in one door of the exam room, moved slowly past me looking closely if briefly at the area of concern on my forearm, then scurried out the door at the other end of the room. Period. End of encounter.

I agree with Dr. Kahn. If you can't teach all medical students compassion, pass along a few basic rules of etiquette, and train them to shake hands and sit a spell.
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(1)Kahn, MK. Etiquette-Based Medicine. NEJM. Volume 358:1988-1989.

Post-vaccination syncope

Early in my medical school career, some brave pediatrician rounded up a group of us to observe a circumcision. The mom among us (brave soul had a young son at home) turned white as a sheet mid-procedure and sank to the floor in a faint.

This loss of consciousness as a result of undergoing an unpleasant experience is called vasovagal syncope. Completely involuntary, changes in automatic body functions after an intense experience result in overactivation of the parasympathetic nervous system (drop in heart rate) and withdrawal of sympathetic tone (dilation of blood vessels with a subsequent drop in blood pressure). Blood flow to the head diminishes (thus white face), and down she goes.

Actually, she is not completely accurate. The most common vasovagal reactions we see at the office are young men swooning after blood draws. Per the May 2nd Morbidity and Mortality Weekly Report, however, there's a new trend in fainting--teenage girls going to ground after vaccinations.

Experts theorize that the upswing in adolescent girls getting shots due to the rise in recommended vaccines such as the Gardasil series against HPV has caused this surge in syncope. While sinking to a prone position restores blood flow to brain, the worry here is that the young lady will injure herself while sinking, or will take out others if she sinks and drives.

Last year, one of my neighbors, a girl of 15, came to my office from her nearby school to get her tetanus shot. No one likes to be needled, but K was particularly dramatic about her distaste for the task. Nevertheless, she finally received her shot, and fifteen minutes later, we headed for my car as I was done with work and had offered to take her home. Halfway there, K complained of dizziness, and when I looked over she was out like a lightbulb, twenty-some minutes post-vaccine.

Our experience underlines the importance of the Advisory Committee on Immunization Practices' (ACIP) recommendation: Keep the drama mamas and the papas under observation for 15 or more minutes after they twitch their way through their ordeal.

Aspirin and breast cancer

I am often asked whether or not I'd recommend the daily use of aspirin. Specifically, with respect to heart disease prevention, 2003 guidelines suggest that those at 10% risk of a heart attack in the next 10 years do just that. Wondering if that's you? Check out Risk assessment tool. Some suggest that the 10% threshold be raised to 15-20% 10 year risk to avoid putting every man over 70 on aspirin due to the risk of bleeding in the GI tract.

Doctors at the National Cancer Institute checked out questionnaires from over 127,000 female AARP member with respect to NSAID usage (aspirin, ibuprofen, and other anti-inflammatory analgesics) and breast cancer incidence over six years(1). While the use of non-aspirin NSAIDs did not affect the risk of breast tumors, the daily use of aspirin dropped the risk of estrogen-receptor positive cancers (the most common type) by 16%.

Just yesterday, a patient asked me if she would experience pain if daily aspirin use was irritating her stomach to the point of bleeding. I have had three patients over 25 years of practice with catastrophic hemorrhages from aspirin use. Two of them started vomiting bright red blood as their first sign of trouble. The third walked into the office on shaky legs, weak and white as a sheet from blood loss over the previous months. He did not realize that black stools were a sign of blood loss through the GI tract. Pepto-Bismol users, don't freak out. PB makes stools black too!

Do I take a daily aspirin? Yes, I do. I've done so every since the Nurses' Health Study results showed that 20+ years of consistent aspirin use, at least 4-6 times per week, cut the risk of colorectal cancer by 46%(2). This study was published in 1995, so I've got 7 years to go to reap my rewards.

Please note, this post is for informational purposes only. Decisions such as daily aspirin use should be made in consultation with your personal physician who is familiar with your health history.
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(1)Gierach, G et al. Nonsteroidal anti-inflammatory drugs and breast cancer risk in the National Institutes of Health-AARP Diet and Health Study. Breast Cancer Res. 2008 Apr 30;10(2):R38 [Epub ahead of print].
(2)Giovannucci, E et al. Aspirin and the risk of colorectal cancer in women. N Engl J Med. 1995 Sep 7;333(10):609-14.

Deplin

see also Deplin Testimonial for a report on Deplin from a patient with multiple sclerosis

The PamLab drug rep is moderately annoying. I hate to think that the messenger would affect my interest in the message, but, alas, it did for months. He finally staged a lunch 'n learn,* but also, much more importantly, he brought in an article by Dr. Stephen Stahl that caught my attention big-time.

Dr. Stahl is Dr. Psychopharmocology. He literally wrote "The Book" also known as Essential Psychopharmocology. If ever you suspected that the use of psychoactive drugs is a lot of baseless hooey, check out this tome.

Unfortunately, this world is a fast-paced one that demands more attention, energy, and multi-tasking than many can manage. As a result, there's a lot of overwhelm and depression going around. One could only wish that antidepressants were unnecessary, but a lot of people struggle to get a grip on their mood while being bombarded with the pressures of modern life. As a result, these drugs can be lifesavers, or at least change surviving into thriving.

That said, antidepressant medications aren't perfect. In many cases, some relief is obtained, but it's either not enough or marred by the side effects of the drugs. So patients find themselves limping along with ongoing fatigue, inertia, decreased concentration, or other symptoms that impair their quality of life.

The search continues, therefore, for 'augmenting agents' that improve response to antidepressants. Enter Deplin, billed as a 'medical food' which falls somewhere between food and drugs per the Food and Drug Administration who will soon need to change their name to the Food, Medical Food, and Drug Administration. Per them, Deplin aka L-methylfolate--an active form of folate--is so classified because it is:

...intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.(1)

Now how good is this?!? A new drug, er medical food, that's a glorified vitamin, that has great science behind it for the treatment of depression which is at least half my practice. And being a child of the '60s, always willing to pop a pill to alter mood, I've tried this product myself, and I'm impressed with the results after just a few days of use. But this post is long enough, check out methylfolate and depression for more information on how Deplin works.
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*And lunch was a Subway sandwich on a stale roll and a liter of Diet Pepsi. After the luncheon, he left but hurried back in to grab the leftover pop. So don't think he bought my interest with a fancy meal!
(1)Food and Drug Administration/Center for Food Safety and Applied Nutrition. Food Safety and Applied Nutrition, Medical Foods. Available at: http://www.cfsan.fda.gov/~dms/medfguid.html.