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The Right Rx for Sleepy Residents?
In 1984 an 18 yo patient, Libby Zion, was admitted to a New York Hospital and died the next day. Though never proven, the suspicion was that her death had been due to the interaction of two medicines given to her by the physicians in training (residents) who had attended to her. Her father, a prominent lawyer and columnist, ultimately came to blame her death on the work conditions of those physicians who had been in charge of 40 patients that night during their 36- hour work shift.
At the time the case became highly publicized. Though the vast majority of physicians were not aware of the drug interaction implicated in Libby’s tragic death and the hospital had no system to flag such an interaction as potentially life-threatening, the focus became the number of hours that physicians - in - training worked. To “solve” the problem of sleepy overworked residents potentially making dangerous errors in judgment, New York State enacted a law in 1989, now commonly known as “Libby’s Law,” that mandated that residents could not work more than 80 hours a week and no more than 24 consecutive hours. The accrediting agencies that regulate physician training programs eventually followed suit.
Though the public may have been satisfied, in medical circles a new debate began to be heard. “Handoffs’ from one shift to the next were increasingly being recognized as times where mistakes tended to occur. Residents leaving early created more handoffs and the potential for more mistakes. As an unanticipated consequence the next day’s shift might not fully understand complicated events that had taken place the night before.
In particular residents in surgical training programs, recognized by those in the profession as the most demanding and grueling of all training programs, were upset. Did it really make sense for a resident in the middle of surgery to be tapped on the shoulder and told to leave if his or her time limit was up? Was it fair to the patient? Was it not important to see the next day what had been causing that terrible belly pain the night before?
Residents trying to get caught up on their patients at 5:30 am before the day’s surgeries began were told by program directors (fearful of losing their accreditation) that if they were ever again caught coming in that early, they would be drummed out of the program. Torn by a duty to do what was best for the patient while following the rules, residents were often tempted to fudge their reported hours.
Now, decades later, the most definitive study to date on the effects of limiting resident hours on patient outcomes has been published. In the study reported in “The New England Journal of Medicine,” over the course of one year half the surgery programs in the country stuck with the present stringent rules while the other half were given an exemption that allowed residents to work more than 24 hours straight (by law New York programs were excluded). There were no statistical differences in the outcomes of the patients as measured by either death or surgical or other complications. Also measured was the resident’s perceptions. From the perspective of the surgical residents, patients got better care and the doctors themselves received better training with the more flexible rules that allowed them to work more than 24 hours straight.
Those residents forced to go home earlier did perceive that their life outside of the hospital was more pleasant with more time with family and friends, time for extracurricular activities, rest, and health. That, of course, should be no surprise; but it speaks to another unintended consequence of Libby’s Law: It may be contributing to a changing mindset of physicians in training who are being viewed increasingly as shift workers both by themselves and by the corporate entities who increasingly come to employ them…… And that is the unintended consequence that I and physicians of my generation worry about the most.
Dr. Edward Taubman has been practicing primary care medicine in Olney since 1979. His daughter recently finished her surgical training.
This article first appeared in the Greater Olney News
In the age of the internet how do you as a patient get your information when making decisions about your health? A poll a few years ago found that about 2/3 of patients thought that the internet made them better informed about their medical concerns. So how reliable is the internet? There is surprisingly little information on the topic. An article published in 2012 in the journal of pediatrics analyzed the results of 100 google searches encompassing 1300 websites in regards to the safest position for infant sleep and found that 28% gave inaccurate information. As a group those websites trying to sell something were reported to be accurate only 8.5% of the time. Yet even information on government, national association, or university websites was often inaccurate or outdated.
But what about those news flashes about new findings published in the New England Journal of Medicine or other major medical journals? One of my favorite recent articles was a review by Dr Christopher Labos in Medscape describing why what we read in the medical literature is not always correct. All studies are subject to errors ranging from flawed assumptions to just plain chance. Ultimately, for a study to be accurate, it should withstand the test of time and be replicated - which is really the scientific method. However, not all studies are replicated and negative studies often never see the light of day. Lobos cited a review of 45 studies in major medical journals; 24% were never replicated, 16% were contradicted by further studies, and in another 16% the effect reported turned out to be smaller than originally published.
Some of the associations reported in the past which made headlines and which have turned out to be false include: Coffee consumption increases pancreatic cancer risk, cell phones cause brain tumors, and estrogen replacement prevents heart disease. In the case of cell phones and brain tumors, the initial association relied on patients’ recollections of how often they used their cell phones. When they went back and looked at actual cell phone records, the reported association was not true.
Then there is the issue of relative risk vs absolute risk: Headlines may trumpet a 50% decrease in your risk of getting some ailment. However, if your risk of getting that something was only one in a hundred to begin with, then cutting your risk in half only cuts your risk by half of one percent. As another example of relative risk, Labos cited one article reporting that the risk of having a heart attack increased by 50% in the hour after drinking a cup of coffee. However, every day millions of people are having coffee and going off to work rather than the hospital. When looked at from the perspective of absolute risk, that translates to one additional heart attack for every 2 million cups of coffee served – a much more reassuring statistic. Some things to think about when you hear about the next “breakthrough”.
Dr. Edward Taubman has been practicing primary care medicine in Olney since 1979. He can be reached at 301-774-5400
How To Become A Mindful Eater
Andrea Lopes, LCSW-C
The term Mindfulness is rapidly increasing in popularity as a way to reduce stress, decrease anxiety, increase productivity, and enjoy a more fulfilling life. Mindfulness has also been found to be very effective at helping people identify their physical cues of hunger and satiety and to reduce emotional/stress and mindless eating.
The definition of mindfulness is nonjudgmental awareness of the present moment using all of your senses. Instead of focusing on restricting yourself, mindfulness helps you tune in, using all of your senses. You learn to notice how you feel when you eat different foods, when you are full, tune into experiencing the appearance, aromas, flavors and textures of your foods, and to slow down the process of eating.
A Few Tips to Become a Mindful Eater:
Eat mindfully by turning off the television, computer, and phone. Sit at the table. Notice the aromas, textures, flavors and pay attention to your hunger and fullness signals. This way you will enjoy your meal and feel great when you finish.
May you get that colonoscopy you have been putting off: With the advent of routine colonoscopies, the incidence of colon cancer has been declining. Nonetheless, colon cancer continues to strike otherwise healthy people - most of whom do not have family histories of colon cancer. Colonoscopy remains the best preventative screening test as it both finds and removes precancerous polyps. If you still refuse to get a colonoscopy, the new Cologuard stool test is an alternative. Cologuard uses DNA technology to screen for cancerous DNA elements being shed in the stool. Though not as accurate as a colonoscopy, it is better than wishful thinking.
If you are of Jewish descent, may you consider a BRCA genetic test: One in forty American Jews, both men and women, carry a genetic misspelling that can greatly increase their personal and their family’s risk of breast and/or ovarian cancer. In a study in Israel, just testing men led to identifying families at risk and saving lives. In this case knowledge truly is power as it opens up doors to prevention for you and your loved ones.
If you are predisposed to heart disease, may your systolic blood pressure (the upper number) be 120 or less: After years of debate, the latest big study known as SPRINT showed that lower is really better. People in the study treated to a systolic goal of 120 had 25% less cardiac events that those treated to a higher goal of 140.
May you get that sleep study that you have been putting off. Are your ribs sore from being poked by your spouse, and your snoring shaking the house? Sleep apnea can have serious consequences and has been linked to a number of cardiac ailments, including high blood pressure and an irregular heart rhythm known as atrial fibrillation. So stop being in denial and get checked out. You may be pleasantly surprised that, after treatment, you have more energy; and the grandchildren may be willing to come for sleep-overs!
May you go for that hearing evaluation that you have been delaying. If your spouse keeps asking you to lower the TV, you need to be evaluated. Hearing is a “use it or lose it” situation; in order to prevent further hearing loss, your brain needs hearing stimulation that hearing aides can provide.
May you stop being your own primary care physician: Are you going to multiple specialists but no one is in charge? Getting your medical advice from the Internet, friends and neighbors? Getting your shots at the supermarket and then complaining that primary care medicine is going the way of the local hardware store? There are good primary care practices out there! Why don’t you interview a few and see if you can form a partnership with one of them? You entrust your car to the mechanic and your dog to the vet, so this coming year do the same for your health.
This posting first appeared in the Greater Olney News
Previously we spoke about the confusion out there in regards to target goals for your blood pressure. So what about your cholesterol? We have known for decades that the higher one’s cholesterol the higher one’s risk for heart disease. Yet news reports say that eggs are no longer bad for you and drugs used to treat cholesterol cause diabetes; even as national guidelines say more people should be taking them. No wonder people are confused.
In 2013 new guidelines for the prevention of heart attack, stroke, and sudden death were issued by the American Heart Association, the American College of Cardiology, and the National Heart, Lung, and Blood Institute. Their panels of experts tried to review and critique the world's vast literature on these issues and come up with recommendations.
They recommended that everyone with a history of blocked arteries, and everyone with diabetes, be on a statin drug (atorvastatin, simvastatin, pravastatin and others), regardless of their cholesterol numbers. Furthermore, everyone with an LDL "lousy" cholesterol of 190 or more should be on a statin, and everyone at increased risk for heart disease (as defined by their calculator) consider being on a statin.
The mainstay of cholesterol drug treatment, the statin class of drugs, has been with us for over 30 years and almost all doctors I know take them. While safe and effective for most, statins can be difficult for some people to tolerate because of muscle pains or even weakness. So what might the risk be of developing diabetes due to taking statins? By one estimate 1 to 3 new cases of diabetes per year for every 1000 people taking the medication. By my calculation, if twenty years ago a 50-year-old was started on statins, then today at age 70 he or she might have incurred a 4% additional risk of having diabetes. To keep that in perspective, the CDC in its National Diabetes Fact Sheet stated that almost 27% of Americans over the age of 65 have diabetes, fueled by the growing epidemic of being overweight and obese.
*Other drugs can be used to treat high cholesterol. Niacin, which has been around for a long time and can increase the “good” or HDL form of cholesterol, has yet to show that it is safe and effective. Similarly, drugs known as fibrates (tricor, lopid and others) have struggled to show their benefit. Zetia which modestly blocks cholesterol absorption was under a cloud for over a decade with a recent study finally showing it to be safe and modestly effective. Newer drugs that raise the “good” HDL cholesterol have not come to market because of safety concerns including some deaths.*
Just as the statin drugs have become generic and inexpensive, a brand new and extremely expensive class of drugs, the PCSK9 inhibitors, has reached the market. These drugs work on something called LDL Receptor Metabolism and can lower "lousy" cholesterol levels dramatically. The PCSK9 inhibitor drugs are modeled on the fact that a handful of people have been discovered with genetic variations in their PCSK9 genes that naturally lower their LDL levels from a typical 130 or so to only 15 ! Is lowering one's cholesterol so low safe? As far as we can tell, people born with these rare genetic variations are otherwise healthy and importantly without signs of arteriosclerosis.
PCSK9 inhibitors have the potential to be game changers in the treatment of high cholesterol, either alone or in combination with statins, and as an effective alternative for those truly intolerant of statins. One drawback other than cost: they need to be given by self-injection.
With cholesterol levels pushed down that low, it is conceivable that this class of drugs might not only slow down arteriosclerosis but actually reverse it. Though preliminary safety data look good, it may well take decades of experience to know for sure that these drugs don't have unintended consequences. Almost three decades after approval, we are still learning about the pros and some of the cons of statins.
In the meantime lifestyle changes such as weight loss and increased exercise, best addressed by a multidisciplinary approach, can make a big difference for many people in both their cholesterol numbers and their risks for diabetes and cardiovascular disease. Statins, meanwhile, will likely remain an important treatment for some time to come.
A few weeks ago, the Progressing/Post-Core group and I visited ROOTS MARKET in Olney. Here are some of the more interesting items we found:
Near the beginning of National Eating Season (early November) we came up with nearly two dozen great suggestions for how to make it through the holidays without gaining weight. Thanks to all our weight loss group participants and especially Woody, Jane, Kitu, Maria, Erin, Barry, for helping to come up with these ideas!
1) Make less food. Less leftovers = less eating.
2) Increase your fiber intake. Even if you do overeat, the food will pass through you more quickly and less calories will be absorbed if you keep your vegetable, fruit, legume, and whole grain intake high.
3) Use smaller plates when going to people's homes for parties or dinners. An analysis of studies performed on this behavior found no significant differences in food intake based on the size of dish ware used. However, larger plates were associated with larger portion sizes ( Obes Rev. 2014 Oct;15(10):812-21.)
4) Bring your own foods with you. As an example of the concepts of cue control/stimulus control/environmental control, you will tend to eat what's around you. Taking your food environment with you helps to reduce the chances you'll overeat outside your home.
5) Eat only small amounts of richer foods. Let's face it - eating per se isn't the problem; overeating is. The fact is, you can enjoy a variety of foods, even some richer ones, as long as you're willing to keep the portion size down.
6) Weigh yourself every day as a reminder of your progress and what your limits should be for that day.
7) Eat before you leave home so that you're less likely to walk into someone's home hungry and then overeat.
8) Continue with a food & exercise diary as a way of controlling your input and output.
9) Increase your physical activity as a means of offsetting your higher food intake.
10) Keep your head and hands busy to avoid the temptation of going into the kitchen to eat leftovers.
11) Slow your meals down by participating in conversation between bites. An analysis of 23 studies done on this topic (Int J Obes (Lond). 2015 Nov;39(11):1589-96.) indicated that people who eat fast weigh roughly four pounds more on average than those who eat slow. Those who eat more quickly have twice the risk for becoming obese as those who eat more slowly.
12) Don't eat at your desk. People who don't take their breaks tend to hurry through meals and not enjoy their food.
13) Order out for the holidays. This way, you will have less leftovers to deal with.
14) Go out for the holiday meal. No cooking! No clean-ups! NO LEFTOVERS to gain weight on!
15) Know yourself. If you tend to overeat on leftovers, send them home with friends or donate them. If alcohol tends to cause you to over-indulge, don't drink at parties and get-togethers.
16) Write a list of what you will eat in advance. You're more likely to stick to a lower calorie meal if you decide on it before you eat it.
17) Bring in healthy foods to work to share with others. Your co-workers will be glad that juicy apples and healthy treats are available to help them avoid the temptation of fattening holiday cookies and candies.
18) Indulge in low calorie and high fiber desserts such as a sugar free Jell-O mold with fruit or banana or apple bran muffins.
19) Plan your indulgences. Everyone gets to have foods they don't usually eat during holidays. If you choose these rather than being caught by surprise by temptation, you'll avoid the guilty feelings that often come with eating higher calorie foods.
20) INDULGE ON THE HOLIDAYS. Overeating at one meal and on one day doesn't interrupt your progress with weight loss. Rather, it's the leftovers that cause overeating on the days after the holidays that are a cause of weight gain.
If you are confused as to what your target blood pressure should be, you are in good company. Every decade or so the NIH/National Heart, Lung, and Blood Institute (NHLBI) convenes a group of experts to reach a consensus on the desired numbers. The most current national guidelines, known as JNC 8 (Eighth Joint National Committee), were released just last year and recommended a number of changes in target blood pressure recommendations for the systolic (the upper number) and the diastolic (the lower number).
§ For most people the goal remained to get the blood pressure below 140/90
§ However, for those over the age of 60 the goal shifted upwards to 150/90
§ For those with diabetes and kidney disease, the goal blood pressure was no longer a lower 130/90 but shifted upwards to that of the general population, (ie. 140/90 and 150/90 for those over 60).
Why the upward change? Part of the answer lies in the changing role of the expert committee. In prior years the experts would pool their personal and research expertise, debate the meaning of the vast literature, iron out their differences, and come up with an updated set of recommended standards.
However, reflecting a pervasive trend in medicine nowadays called "Evidence Based Medicine," the experience of experts (as well as your doctor) is increasingly minimized. In the Evidence Based Medicine era published studies are king. If they don't support a point of view beyond a shadow of a doubt, then that point of view is not considered.
In this instance, since the literature to date has not conclusively shown that lower blood pressure is necessarily better and the opinions of the experts were throttled, the committee has had no choice but to set the target goals higher.
So, with that in mind, even though many physicians were uncomfortable with the recommendations, it seemed as if these were to be the new standard for probably another decade until JNCH9 would come along.
A New Standard? - Treat by press release
Last month the NHLBI issued a press release. It said that an ongoing trial that they were conducting known as SPRINT that began in 2013 and which was scheduled for completion in 2018 was stopped early because it showed that treating the upper level of blood pressure (systolic) to a target of 120 seemed better than treating to a less stringent goal of 140. This self-proclaimed breakthrough was quickly picked up by the news media; suddenly it seemed we needed to change our approach to hypertension and once again lower our target goals.
What wasn't mentioned in the 30-second news flashes was that to get to a systolic blood pressure of 120 would often take up to four medicines, that only 9000 people were in the study, that diabetics were not part of the study, and that the study was yet to be published - let alone reviewed by outsiders; which is an important tenant of evidence based medicine.
Personally I think it was unfortunate that the NHLBI issued a press release on this. The media and the public do not understand that press releases are not the final word. It would have been better for the study to have been published first and critically reviewed by outside experts. For all we know outside experts might ultimately conclude that the study was flawed or stopped too early. So now what should patients and doctors do?
I do suspect that ultimately this newer study, once validated, will again tilt us towards tighter blood pressure goals. However, we have to recognize that medicine is not black and white; there are lots of grays. Arteriosclerosis and its complications are a lifetime in the making, perhaps even starting in the womb; and we may never have definitive answers from short term studies. Treatment decisions about blood pressure need to be individualized as much as possible. For the elderly, in particular, side effects, including falls, caused by multiple medications may be their biggest threat.
At the end of the day, guidelines should be recognized for what they are - guidelines. If your health care provider is deciding how to treat you strictly based on the guidelines on their iphone, it might be time to change. A nuanced and individualized discussion with an experienced physician who understands your needs should be your expectation.
This Article First Appeared in the Greater Olney News
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