Questions you should ask your doctor

  1. What is my blood pressure? Is it OK?
  2. Have I been checked for diabetes?
  3. How is my cholesterol? Is that OK?
  4. Am I due for any vaccinations?
  5. Do I need any cancer screening, such as PSA, colonoscopy, mammogram, pap smear?
  6. How is my weight? What is my body mass index (BMI)?
  7. Here is my medication list–does it match yours?
  8. What is my overall cardiac risk? (e.g. see this link).
  9. How do I quit smoking?

Gary Null can kiss mein tuchas

But apparently he’d rather have me fill it with coffee. Really…I mean it. I love coffee, but c’mon now! I can’t stand that this idiot is given time on public television during pledge drives to peddle his woo

Blogging on Peer-Reviewed ResearchI stumbled across a website that goes on and on about the supposed vast conspiracy of the medical community to…well, I’m not sure. Anyway, given that you have to buy Gary Null’s quack tomes to get his advice, it’s hard to know exactly what he is selling. The conspiracy theorist from the above-linked site was kind enough to share some of Null’s secrets (at least they are cited that way:
Cervical Dysplasia, Fibroids, and Reproductive System Cancers. Excerpt from The Woman’s Encyclopedia of Natural Healing by Dr. Gary Null.Seven Stories Press, 1997), so that we all may benefit. Here is an excerpt on cancer treatment, and I warn you, poo-woo abounds:

Coffee enemas. “These enemas have been used by thousands of cancer patients, outside the realm of traditional medical care, because they work.

Ok, where is the proof of that? Here is the proof that they don’t work:

  1. Ernst, E. M.D., Ph.d., F.R.C.P. (Edin). Colonic Irrigation and the Theory of Autointoxication: A Triumph of Ignorance over Science. Journal of Clinical Gastroenterology. 24(4):196-198, June 1997. (Make sure to follow the references to the primary sources).
  2. Green, S. A critique of the rationale for cancer treatment with coffee enemas and diet. JAMA. 1992,Dec 9; 269(13),1635-6.
  3. Alison Reed, Nicholas James and Karol Sikora.Mexico: Juices, coffee enemas, and cancer. The Lancet. Volume 336, Issue 8716, 15 September 1990, Pages 677-678.

Boiled coffee in retention enemas stimulates the liver’s enzyme system, which in turn causes great relief from pain in cancer patients.

There are no studies to support this statement.

The liver has more than a thousand documented medical functions. When we help it to work better and faster, the cancer patient’s overall physiological condition changes, sometimes within hours, and certainly within the first several weeks of treatment. You have a whole different person. People come off gurneys and out of beds, excruciating chronic pain is eased, and addiction to morphine is broken.

Typical woo. Miracles from simple substances. The entire auto-intoxication idea is false (see first article above), as is the idea of the liver needing some sort of help.

Every three minutes, all the blood in our bodies goes through our liver. Our livers and small intestine walls have an enzyme system with a fancy name that we will call GST for short.

Why abbreviate? Does he think you are stupid or is he trying to hide something?

This enzyme system naturally responds to cancer in the body by going up, and the coffee enema has been shown in laboratory experiments with rats, and in later experiments with humans, to produce increased liver bile flow, and to stimulate the GST enzyme system. In fact, it’s raised to 700 percent of normal levels of activity. When the GST system is running that fast, it can effectively remove tumor toxins from the bloodstream. And it doesn’t take very long. The effects of these coffee enemas will last for sometimes four, six, or eight hours before a feeling of discomfort and pain around the tumor returns. They’re that effective.

Actually, the few human articles on cancer and GST showed that it may contribute to cancer’s resistance to chemotherapy. (Theo P.J. Mulder, Johannes J. Manni, Hennie M.J. Roelofs, Wilbert H.M. Petersand Anne Wiersm. Carcinogenesis. Volume 16, No. 3, 1995.) Or, perhaps one form of it helps prevent cell damage in Parkinson’s disease. Or maybe it can be used as a tumor marker. Either way, GST has never been tested as a therapy for anything in humans. (Yes, I actually took the time to do a MedLine search on this.)

Additionally, putting coffee up your ass is not proven to stimulate GST or anything else in the liver…what else might me stimulating about it? Hmm…

You have to know how much coffee to use: a quart of water with three tablespoons of coffee boiled in it. That’s cooled and strained, not filtered, because a filter would remove some of the molecules that stimulate the GST enzyme system. The coffee is safely taken into the colon, while the person is lying on his or her right side, retained for 10 to 15 minutes, and then released. Patients doing this without the supervision of a physician should know that anything cooler than 100 degrees is going to cause cramping in the intestines.

So, basically, if you are watching your local PBS pledge drive, and the charismatic Null recommends his books to you, remember how much good advice they contain. If you have ovarian cancer and pour coffee up your tushie, some guy thinks it will help you. Or at least, it will help him— to buy a boat.

Newsflash! Mercola bemoans ignorance of Americans! Offers to help for only $25/month!

I’m off to the west coast (of Michigan) for a few days, and if I don’t blog, I shall die…or something. So I have a few posts from my old blog to share with you.

This is rich. This is really rich. Mercola is speaking out against the one thing that keeps him in business: the scientific illiteracy and credulity of Americans. He bemoans ignorance that leads to beliefs such as “the Sun revolves around the Earth”, or the bird flu panic. Then, presumably with a straight face, he invites you to join his “inner circle”, further perpetuating ignorance, and relieving you of the inconvenience carrying around twenty-five bucks that was burning a hole in your pocket (that’s per month).

His “inner circle” includes access to such venerable titles as, “The Psychology of Vaccine Injury Awareness, Plus Excerpts from the Book The Sanctity of Human Blood Vaccination Is NOT Immunization”, and, “Ancient Dietary Wisdom for Tomorrow’s Children”.

Want to avoid ignorance? How about reading the newspaper? Joining a book club? Reading reliable online health resources? Avoiding quacks and cranks?

Cancer 201—treatment basics

Once a cancer has been diagnosed, we must use our knowledge of biology, medicine, and clinical trials to plan treatment. Treatment can be curative or palliative (that is, with a goal of reducing symptoms or extending life, rather than effecting a cure).

Understanding cancer treatment requires a little bit of basic biology, and as with all of my more “science-y” posts, please forgive any oversimplification (but please also note that this complexity stands in stark contrast to the simplistic altmed cancer “cures”), or for overtopping the head of the hapless non-scientist.

As you recall from Cancer 101, cancer is a proliferation of abnormal cells. This fact alone, that the cells are actively dividing, gives us a target for therapy.

Cells go through particular phases in their lifetimes, but these phases aren’t as simple as “birth, growth, death”. The life of a cell is roughly divided into the cell cycle, during which the cell is preparing for and conducting cell division, and the G0 (G sub zero, or G-naught) phase, where the cell simply goes about all of it’s non-reproductive business, such as structural support and protein production. Normal tissue has a fairly balanced growth fraction, that is the number of cells dividing is roughly equal to the number of cells being lost (to normal programmed cell death and other normal attrition). Cancerous tumors have a higher growth fraction than normal tissue, that is the number of cells in cycle is higher than the number of cells being lost (to programmed cell death, etc.).

Continue reading “Cancer 201—treatment basics”

Why be in such a hurry (to kill someone)?

Once again, I find myself straying into a political issue (although I’d argue that it’s more a human rights issue). I understand that I’m probably in the minority in this country in my opposition to the death penalty. My fellow Americans generally vote to allow it, and my vote only counts once. One area where my opinion my carry a bit more weight (or maybe not) is in the area of medical ethics. Given that the death penalty is legal in the U.S., what role should doctors play?

Troy Anthony Davis is a guy that Georgia wants dead so badly that they can’t be bothered to wait for the U.S. Supreme Court to weigh in (SCOTUS is scheduled to discuss the case on the 29th, six days after the state kills Davis).

But here’s the part that really gets me as a physician (from the Atlanta Journal Constitution):
Continue reading “Why be in such a hurry (to kill someone)?”

I’ve been (not) workin’ on the railroad

This story is disturbing for a host of reasons, but there’s a medical ethics issue hiding in here.

Apparently, if you work for the Long Island Railroad, you can retire at 50, then claim disability for a job you no longer have, and collect both a disability check and a pension. I shit you not. But it gets better. According to the Times, “Virtually every career employee — as many as 97 percent in one recent year — applies for and gets disability payments soon after retirement….”

I strongly encourage you to read the whole article, but let’s focus on a particular point.

Dr. Melhorn, who has studied disabilities, said the numbers alone were a cause for concern, “in particular if there seems to be a limited number of physicians who are providing this disability impairment.
L.I.R.R. employees favor certain doctors, and their disability applications are sometimes so similar as to be almost interchangeable, said one Long Island resident who has seen dozens of those applications. That person said that M.R.I.’s merely document physiological changes that commonly affect people over the age of 50.
(empasis mine)

In my practice, I often have to fill out temporary disability forms. It’s pretty standard—when a patient has a knee replacement or a heart attack their work requires them to file certain papers.

There is a separate subset of patients who believe themselves to be completely disabled, and want me to fill out forms from the state to help them get disability payments. Very few of my patients are so disabled as to be unable to work at all, ever. But many of them think they are. Who wouldn’t want to collect a check for doing nothing? I usually tell them that if I answer the questions on the form truthfully, they are unlikely to ever get disability. I let them decide at that point whether they really want me filling them out (which may, of course, be passing the buck, and ducking a responsibility, but since the state can assign doctors for disability exams, I don’t feel I’m shirking).
Continue reading “I’ve been (not) workin’ on the railroad”

End Elitism Now!

This isn’t just about politics—really. This has something to do with science.

You see, one of the memes of this campaign is “elitism” (whatever that means). The appeal of Sarah Palin, we are told, is her “everyday-ness”—she’s just a regular gal, not like those elitist politicians in Washington (which presumably includes her running-mate).

Sarah Palin is not a “regular gal”. She come from an earthy rural background, but she is clearly intelligent, politically astute, and competent, having ascended to the governorship of one of our states while at the same time raising a large family. This woman isn’t ordinary—she is extraordinary.

Barak Obama also rose from small circumstances, a peripatetic mixed-race child who used his intelligence to become a scholar, and evenually senator.

John McCain was just a pilot—not a political “insider”.

You get the idea.

But back up for a second. John McCain was a pilot…a fighter pilot…member of an elite force of strong, brave, intelligent (at the time) men. The best of the best. And that’s a good thing. When I think about the folks we have flying missions all over the world, I’m hoping they are the elite, the best of the best. Not just anyone can fly an F-18. And not just anyone can be president.

If you’re planning on being one of the two or three most powerful people in the world, it’s not good enough that you’re “a regular gal”, even an extraordinary regular gal. You better be the best of the best, intelligent, competent, tireless.

Professions require an elitism of sorts. You may want a doctor who understands you, but you don’t want one who is ordinary. You don’t want a jet pilot who is merely competent. And you don’t want a president who is just like everyone else. I want a president who was an elite pilot, an elite constitutional scholar, a long-standing senator. I don’t want an everyman or everywoman.

Our president should be elite—not removed, not distant, but the best of the best. Three of the four candidates for president/vice president are elite enough. One is merely extraordinary.

Mormons Supporting CA Gay Marriage Ban Big Time

Here’s a bit of a surprise. In California, our Supreme Court legalized gay marriage. Opponents quickly arranged a ballot proposition to reverse the ban. Support for the ban has been slipping, from almost 50% earlier in the year, to 42% in July, and now to 38% in the latest Field Poll.

Mark Schoofs reports in today’s Journal that the Mormons are large backers of the marriage ban proposition:

Members of the Church of Jesus Christ of Latter-day Saints have contributed more than a third of the approximately $15.4 million raised since June 1 to support Proposition 8. The ballot initiative, if passed, would reverse the current right of same-sex couples to marry.

It’s clear from the article that church officials are directing the flock to donate. I hope that the IRS investigates them.

So, why do the Mormons care about gay marriage? It’s a funny question, in that one of the principal conservative arguments against gay marriage is that it will open the door to polygamy or marriage with young children. But Mormons care more about purity of essence, it appears:

Same-sex marriage hits at the heart of Mormon theology, said Terryl Givens, a professor of literature and religion at the University of Richmond. According to scholars and documents on the Mormon Church’s official Web site, couples married in a Mormon temple remain wedded for eternity and can give birth to spirit children in the afterlife. Most importantly, Mormons must be married to achieve “exaltation,” the ultimate state in the afterlife. Mormons also believe they retain their gender in the afterlife.

“This all explains the Mormon difficulty with homosexuality,” said Mr. Givens. In a theology based on eternal gender, marriage and exaltation, “same-sex attraction doesn’t find a place.”

Who’s your hospitalist?

Me: Hi, I’m Dr. Pal and I’ll be taking care of you here in the hospital.
Patient: Where the hell is my real doctor?
Me: He’s at the office seeing patients. He doesn’t come to the hospital anymore.
Patient: Why the hell not?
Me: Well, it’s complicated, but it’s getting harder and harder for doctors to pay their overhead. They have to see more and more patients, and in the time it takes to come to the hospital and see one patient, he can see 5 or 6 in the office.
Patient: What’s wrong with him just getting up earlier?

OK, time for a brief lesson on modern medical practice. First of all, I’m an internist. In the old model, an internist sees patients both in the office and in the hospital. Over the last decade or so, there has been a shift in practice. Fewer and fewer outpatient primary care doctors see their own patients in the hospital. Most now use “hospitalists”, internists who specialize in taking care of hospitalized patients.

There are several reasons for this.

First, hospitalized patients are much sicker than they used to be. To meet the “severity of illness”, and “intensity of service” requirements, you have to be pretty darn sick. This means that hospital care is more complex and specialized. Still, it’s not impossible to keep up with both outpatient and inpatient medicine.

Second, there are the financial pressures. Margins are very thin in small practices. Medicare pays me perhaps seventy bucks to see a patient. In the time it would take me to go to the hospital, I could have seen a whole lot of patients, and seeing a hospital patient doesn’t pay all that much more. Not only that, but to pay the bills, you have to see lots and lots and lots of patients, which leaves even less time for other things, such as family, eating, urinating.

I’m in a unique situation, in that I need to be at the hospital every day to teach, so seeing my own patients is no big deal. But for most internists, it’s becoming impossible. Taking care of hospital patients is not just the 10 or 15 minutes at the bedside; it’s the paperwork, phone calls, and pages; the discharge planning, the specialists. Each hospital patient is more work than any 5 office patients, for the same pay.

Where does that leave patients?
Continue reading “Who’s your hospitalist?”

Cancer 102

In Cancer 101, I gave some basics to understanding cancer. A commenter asked a good question, and our next lesson will attempt a simple answer.

The question regarded how a pathologist can tell if a cancer is “invasive” by looking at a specimen. Well, depending on the specimen, the answer changes, but let’s use the colon as an example. Most colon cancers start out as benign polyps. Eventually the cells in the polyp can become malignant, and after that, they can they can begin to grow through layers of normal cells.

Here is a diagram of a cancer of the colon at various stages. As you can see, at a certain point, the cancer begins to grow through each layer. The ability to grow through, or invade, other layers is one of the things that makes cancers behave in a nasty manner.

i-879e97c9f33a541f1465fb682da71e1e-cancermicro.jpgHere is a piece of colon cancer under the microscope. This could have been from a biopsy of a polyp, or from a tumor completely removed by a surgeon. The stripe of light purple cells labeled “normal muscle layer” should extend across uninterrupted. Instead, a glob of darker purple cells is growing through the muscle layer, destroying it. Once the cancer cells get to a blood vessel, they can go anywhere in the body (metastasize). That’s bad.

I hope that’s helpful.