The Art of Medicine.

The Conversation.  Pt 2.
             
The  conversation between physician and patient is the most important aspect of the art of medicine as distinct from the science of medicine.    Art means skill, craft, craftsmanship, and traditionally has only been a part of medical education is so far as the student could observe it being practiced (or not practiced)  by his teachers.  Thus it was a hit and miss affair as to whether your mentor was a William Osler or a Josef Mengele.  One of the most promising signs of change was the recognition that the art needed to be recognized and to be taught and in the fifties and sixties the foundation of organizations such as the College of  General Practitioners of Great Britain, the College of Family Physicians of Canada and the American Academy  of Family Physicians seemed committed to focus on these areas.  Simple and obvious aspects of conversation were recognized, including the fact that the patients should understand the nature of their illness and its treatment and feel sufficiently comfortable to ask questions.   The physician's understanding of the myriad factors that influences the patient's welfare and ability to cope with their disease has an impact on the effectiveness of any treatment regimen.  This is what patient centred care was supposed to be all about.  Although the above mentioned organizations made some impact on teaching students to interact with patients and introduced hitherto uncommon methods for observing the quality of communication and interaction  between patient and doctor, there are other influences that that are diminishing the initially favorable impact of such methods.   It is still true that some students go through their program without having their skills  adequately observed in  the practice of the science or art of medicine.   The various Colleges have taken  their eye off the ball and often seem to be focusing on the wrong thing.   I sometimes wonder whether any medical student ever fails out of medical school today, because just as the practice of medicine has become distorted by fear of litigation, so have the actions of Colleges and Universities.
                 Back to the conversation for a minute before winding up, as a young doctor I found it very difficult to give patients bad news. (Docs are actually human too!)   Most of my patients were young and healthy and had young healthy families, so I didn't often  have to deal with the situation.But every now and then, catastrophe struck.   Initially, I found it really hard to broach the topic.  Thinking about it, I knew there was no way to make bad news sound like good news, no matter how hard I tried.    Instantly I got it, I knew that in  all sincerity I had struck the right honest note, that I used ever since.  This is how I said it, sincerely and regretfully:  "There is no way to make bad news sound like good news, this is what's wrong........."

Any ideas about the Art of Medicine? If you have please share them.
                      
                 

The Gut/Brain Axis Pt 2.

Human Gut Microbiome Details

The total number of genes in the various species represented in our internal microbial communities (microbiome) likely exceeds the number of our human genes by at least two orders of magnitude. Therefore, it seems appropriate to consider ourselves as a composite of many species - human, bacterial, and archaeal - and our genome as an amalgam of human genes and the genes of our microbial ‘selves’.
Without understanding the interactions between our human and microbial genomes, it is impossible to obtain a complete picture of our biology. Our microbiome is largely unexplored.

Pre-Human Microbiome Project

The Human Gut Microbiome Initiative (HGMI) (a precursor to the Human Microbiome Project) represents a logical, timely, and cost-effective extension of the Human Genome Project. It promises to improve our understanding of the foundations of human health, and of many common diseases that are the subject of basic and clinical research sponsored by the NIH. The human gut microbiome endows us with physiologic capabilities that we have not had to evolve on our own. It is essentially a bacterial ecosystem residing in the human GI tract; an efficient bioreactor, programmed to break down food and supply us with the extracted energy and nutrients. The HGMI seeks to deliver a more comprehensive view of our biology by providing deep draft whole genome sequences for 100 species representing the bacterial divisions known to reside in the distal gut. Fifteen of these genomes will be selected for finishing. The deposited, curated genome sequences will provide another phase of understanding the “human” genome sequencing project and will serve as a model for sequencing other human microbial communities.
The human GI tract is predominantly a bacterial ecosystem. Cell densities in the colon (1011-1012/ml contents) are the highest recorded for any known ecosystem. The vast majority belong to two divisions (superkingdoms) of Bacteria - the Bacteroidetes (48%) and the Firmicutes (51%). The remaining phylotypes are distributed among 6 other common groups and several rare groups. The sequenced organisms were chosen from the 11,831-member 16S rRNA sequence dataset generated from the human colonic microbiota of three healthy adults.
-- Adapted from the Human Gut Microbiome white paper (pdf).

How Stupid can you Get?

Unbelievable!
          The British Columbia Human Rights Commission has agreed to review complaints filed by the Trans Alliance Society and a group of transgender and intersex individuals ((whatever that is).
          This is their incredible argument: Doctors should stop assigning the sex of a baby after "a quick inspection of the baby's genitals at birth, when it is possible they may identify under a different gender or NO GENDER years later"  Talk about the inmates running the asylum!  I've delivered hundreds of babies and never had a problem.  Ninety nine point nine percent had normal external genitalia.  Normal means ordinary or usual, not strange or unusual, not too difficult to understand.   Normal babies have a penis or a vagina and a male or female gender.  The continued existence of the human race depends on this simple and obvious fact.  How can these people be so stupid that they cannot recognize this.  They are so pre-occupied with being 'politically correct' that they don't recognize the fundamental necessity of normalcy for the race to continue.  Nature does not recognize 'political correctness'.  These idiots actually want gender left off the birth certificate just in case it makes it difficult for those who decide the organs they were born with are incorrect.  If we go along with this we are bigger idiots than they are.
          The Vancouver human rights lawyer stated that it is incorrect to assume there are only two genders and that you can't tell a child's gender at birth, which is a "crazy making experience".   Maybe she can't,  I hope this woman knows more about the law than she does about medicine. 
           Let's hope sanity prevails and that we recognize that the minute number of individuals that fall outside the normal receive appropriate management and /or treatment.  Let us not try to "normalize" the abnormal.  If we try it will result in much wider suffering and alienation than we are dealing with now.

The Gut/Brain Axis.

The  Gut - Brain Axis.

          Your gut is populated by an astronomical  number of microbes that play a large role in maintaining your health.  Just how great a role we are only starting to learn.   The gut  microbes and their activities communicate with  the brain in a relationship known as the gut–brain axis, a phenomenon we have only recently begun to research.    There is a mutual relationship in that the intestine serves as the host to the bacteria and the bacteria give something in return.  So the lack of the normal  healthy microbes  may ultimately lead to disease.  This can lead to neurological, psychological, metabolic and gastrointestinal disorders.  This includes disorders such as depression, autism, obesity, irritable bowel  syndrome and various bowel including irritable bowel syndrome.  The good news is that gut microbes may be altered with the use of probiotics, antibiotics, and fecal transplants.  There is considerable research going on in this area at present.

          The communication between the brain and the bowel has been known for many years.  In 1822 when Alexis St. Martin accidentally shot himself in the stomach, he was left with a wound that communicated from his stomach to the outside.  The fistula never healed completely leaving a portal for his surgeon to observe the digestion that was going on and how it was altered by various stresses that the good doctor subjected him to, in a series of experiments that would never be tolerated today.  They did however result in much new knowledge about digestion and observable mucosal changes in response to stresses of various kinds.

         The normal  bowel bacteria (commensals) colonize the bowel soon after birth and live on throughout    A growing body of research indicates that the communication between the bowel and the brain  flows in  both  directions. The host intestine provides the bacteria with rich energy resources and the microbes aids in governing homeostasis within the host, commonly linked with the well-being of mood, metabolism, and the GI tract itself.  Therefore, it is reasonable that the lack of healthy gut bacteria may also lead to a deterioration of these relationships and ultimately disease. Psychological, metabolic and bowel malfunction may occur.
          The good news, restoration of the normal flora is possible.

          Let me know if you are interested in hearing more about this.

"The Conversation."

            As the exchange between patient and family physician becomes increasingly filtered through the computer, I fear the conversation becomes less personal and less spontaneous.  Before the conversation becomes medical, I have frequently found it has to  become personal.  In  many situations a rapport has to be developed before an adequate and accurate history can be obtained.   The introductory exchange before talking 'business' is often as important a source of relevant information as the actual clinical history.  For many patients, the visit is a source of anxiety and it is difficult to get an accurate history from an anxious patient.   It is especially difficult when the physician's gaze is focused on a computer screen and his attention is on his typing, and filling in the algorithmic boxes, many of which have no bearing on the patient's health. Eye contact is at a minimum  The  fee schedule, which rewards the brief and superficial interview and penalizes those who spend more time taking a thorough history and performing a physical examination contributes to this in no small measure.  It's easier to send the patient to the  lab and x-ray after a short history than to waste time delving into the history details and discussing whether the tests are really necessary, as the 'Choosing Wisely' program urges, without giving any consideration to the time it  may take to convince a patient that the test they 'know' they need, isn't necessary at all.. 
           The completion of  the templates, whether relevant or not, are used as a measure of the physician's thoroughness and competence, which they certainly are not, and a bonus system is frequently based on what the administridiots have designated as model practice. The College of Physicians and Surgeons are no more discriminating and make inappropriate judgements based on them.
             Some people,  have a natural  talent for communicating with others, while many do not.  So, what should the conversation be - some warm fuzzy bit of nonsense?  Certainly not.  It should be the establishment of comfortable lines of communication between two adults that sets the tone at the outset of  the relationship. The rapport that it builds will be the prelude to a detailed initial history and physical examination and in fact set the tone to all  further visits.  I received my medical education at a time when the history and physical examination were considered to be the foundation for everything that follows.   It is often very difficult for a patient to share some of their innermost concerns with a physician  they barely know.  A significant amount of time was spent in educating us how to communicate with and examine patients under direct observation.  Many students and residents today are rarely directly observed doing these deeds and having their skills documented.  The art of medicine is largely the art of communication, insight and  understanding and complements the essential scientific skills and knowledge that every physician must have.  High  tech as wonderful as it is, does not replace the art of medicine.   Frequently, a thoughtful history alone allows an accurate diagnosis to be made, or at least points in  the right direction.  Unfortunately, those essential hands-on skills are being allowed to atrophy because they take  time and effort.   The commitment that was evident in previous generations of physicians  is nowadays often considered to be a bit of  arrogance, a bit of a joke (who did they think they were, the paternalistic old fools, God?).  No bright young person going into medicine these days is stupid enough not to put their own and their family's needs and requirements first.  Maybe they are right.   Medicine was a vocation, almost a religion and now it's a job.  Why expect more from physicians than from  anyone one else in any other job?  I guess docs will  just have to get used to doing what their bosses tell them.  Not everyone would agree but that's sort of sad for professionals once recognized as independent thinkers and individualists.   
               I've wandered away from the point a little, but lets hope 'the conversation' will  survive, even if there isn't room for it in the fee schedule.
            

No Quick Fix.

          The Minister of Health intends to reverse the decision previously taken by the government to allow generic drug-makers to produce their own version of Oxycontin.  A powerful narcotic, Oxycontin is a major agent of prescription  drug addiction.    During most of my years of clinical practice, physicians who prescribed narcotics in the abundance that many do today would have been  under investigation by the RCMP.  Some would have been restricted in their prescribing   Recurrent offenders may have been prohibited from prescribing narcotics altogether.  The most serious offenders sometimes had their license suspended or even revoked.  According the Minister, Canada had 401,000 people abusing prescription drugs in 2012 and is probably the worlds largest user of opioids on  a per capita basis.  "Research shows that of the kids who abused opioids, seventy per cent said they got it at home."
            There were always doctors who over-prescribed and I have previously described how a nurse informed me that her niece with an infected hang-nail was prescribed Oxycontin tablets 30 as well as the antibiotic.  She didn't need the  prescription  and  she didn't fill  it.  She took a couple of Tylenol, and gained satisfactory relief.  
             When did this over prescribing pattern become so pervasive?  And why?
             My guess is that the problem which was always there gained much momentum over the past ten years or so and coincided with  a philosophy of demanding  instant gratification on the part of some patients and the reluctance of many physicians  to defy the patients demands even when it is not the best solution to the problem.   Drug seeking patients can get very abusive when denied what they feel they need.  It is easier to write a prescription than get into a harangue with a patient in a busy office practice.  It can take time to convince a patient that your treatment plan is better than theirs.  Political correctness ordains that everyone's opinion is equal.  Of course no patient should be left in pain if it can be relieved, but that doesn't mean that narcotics are called for    When  I  was concerned about addiction patterns developing in some patients and consulted with specialists from  Pain  Clinics, the patient often came back on  heavier doses of narcotics than they had been on before.   General attitudes about drug abuse have changed, including the attitudes of the College of Physicians and Surgeons making  it difficult for those physicians who prescribe more selectively.
              Prescribing patterns have to  be reviewed and use of narcotics has to be better controlled.  Rules for narcotic use have to be clearly defined.  Rules, not guidelines.   Unfortunately, as always, the hard-working appropriately prescribing physicians will be caught up in this, as they always are.  But, then no good deed ever goes unpunished!  

Patron Saint of Socialized Medicine.

                Tommy Douglas is the patron saint of socialized medicine in Canada, maybe even in North America.
               Saskatchewan was the Province that gave birth to what in  Canada we call Medicare. (Quite different to the way the Americans use the word.)   Tommy was a Scottish-born Canadian social democratic politician and Baptist minister. He was elected to the Canadian House of Commons in 1935 ( the year I was born, incidentally).  In the years of the great depression in one of the poorest provinces in Canada he envisioned and then created a provincial health care service that ushered in the first comprehensive health care system in 1960  that was available to anyone in the province of Saskatchewan.  It is the model that gave birth to  the Canada Health Act.
               Saskatchewan is now far from being a have-not province.  It's Heath Minister is reviewing proposed legislation that would allow patients to pay out-of -pocket for MRI scans.  This is aimed at reducing wait times and may result in making MRI scans available at private clinics as soon  as the spring.  For every scan paid for privately , the private clinics would be required to provide a scan at no charge to a patient on the public waiting list.   There is already precedent for this sort of model.  The Workers’ Compensation Board and the CFL Saskatchewan Roughriders currently pay for MRI scans privately and work under the “two-for-one” model.
                Between 4,000 and 5,000 people are waiting for MRIs in Saskatchewan.
“Our wait times still are longer than our recommended waits.” said the Minister. "The number of patients needing scans has grown to 33,000 a year from about 16,000,"he added.
                In Regina, the wait for an urgent MRI scan averages 24 days. A non-urgent scan can take more than seven months. Saskatoon’s wait times are longer.  The recommended wait time for an urgent case is up to a week compared to three months for a non-urgent scan.  Emergency MRIs happen immediately across the province.
               The socialist opposition thinks the proposed legislation is problematic because it could result in delayed treatment for those on the public wait list.  They claim there are people who can't afford a private MRI, and that is correct.  But does their political correctness prevent them from the commonsense realization that the extra funding put into the system by those who can afford it, will reduce the waiting  list by taking the payer off the list and also by virtue of the arrangement for a 'free' public MRI for each private one.  There is no doubt that the arrangement will attract more radiologists and more private clinics, paid for by the voluntary self tax the private purchasers are adding to  the system.
                It is sad that these administridiot ideologues really don't care about the public if their welfare conflicts with their own  irrational concepts.  Health care costs are going to escalate dramatically in the future.  We better start thinking outside of the narrow boundaries that we have imposed on ourselves before our health care system deteriorates any further.
If you have any views feel free to comment.

Brave New World.

Brave New World.
            If you haven't re-read Brave New World by Aldous Huxley recently, it's time you did.  Recently I read about a Toronto Clinic that's bragging that it achieved a first in the fertility world.  It can 're-charge' poor quality ova using young energy producing stem cells from the woman's own ovary.  It is called the 'Augment' program.
            "We are totally satisfied that this is a safe procedure," vaunted the director of the clinic.     This, despite the fact that none of the usual controlled studies have been carried out and the fact that the procedure has not been approved in  the U.S.  There are another eight pregnancies from similarly treated ova.  How they are going  to turn out, no-one can say with any degree of certainty.  An  equally puzzling question is why anyone  would try to engineer already blighted ova into viable pregnancies, when nature had already labelled the ova deficient.  In a society that condones abortions of convenience in the millions, often in the second or  third trimesters, what reasons other than  narcissism can there be to devote resources and expertise to this line of research.    It takes only a slight stretch to consider Huxley's novel as a version of the results of genetic and social engineering  that seems to be much closer to reality now than could have been imagined when  it was written.
              The novel opens in the Central London Hatchery and Conditioning Centre. The year is a.f. 632 (632 years “after Ford”). The Director of Hatcheries and Conditioning is giving a group of students a tour of a factory that produces human beings and conditions them for their predestined roles in the World State. He explains to the students that human beings no longer produce living offspring. Instead, surgically removed ovaries produce ova that are fertilized in artificial receptacles and incubated in specially designed bottles.The Hatchery destines each fetus for a particular caste in the World State. The five castes are Alpha, Beta, Gamma, Delta, and Epsilon. The Director explains that the Bokanovsky Process facilitates social stability because the clones it produces are predestined to perform identical tasks unquestioningly. The cloning process is one of the tools the World State uses to implement its guiding motto: “Community, Identity, Stability.”  Even the Epsilon-minus -morons who are virtual slaves are contented with their lot.
               Much of the contentment was the results of frequent use and  availability of 'soma' (A physically harmless version of marijuana) and all stress and strain were dispensed with immediately, as many try to do today with the less effective pot.  Brainwashing does the rest.  
                The similarity of the way society is unfolding to Huxleys book is frightening.
                Read it again!



         
And if ever, by some unlucky chance, anything unpleasant should somehow happen, why, there's always soma to give you a holiday from the facts. And there's always soma to calm your anger, to reconcile you to your enemies, to make you patient and long-suffering. In the past you could only accomplish these things by making a great effort and after years of hard moral training. now, you swallow two or three half-gramme tablets, and there you are. Anybody can be virtuous now. You can carry at least half your mortality about in a bottle. Christianity without tears - that's what soma is.”
― Aldous Huxley, Brave New World
 Comment, if you have anything to say!
 

Pavlov's Docs.

          Pavlov's dogs have taught a lesson to the world.  Ring the bell and feed the dogs each time you do and eventually all you have to do is ring the bell  and the dogs will salivate.  There is no longer any requirement for effort by the dog, just ring the bell. 
          The politicians and their administridiots have learned well from the model.  Unfortunately, physicians don't.  So, every time it is thought desirable to manipulate physician behavior, they ring the money bell and the docs start to salivate.  Fee for service had enabled physicians  to be, if not the last, at least amongst the last of independent small-time entrepreneurs and to control their own destiny.   Most of them worked hard and provided better service and value than most physicians do today. For years, a dwindling number of them clung desperately to the system.  A few still do.  They remind me of my  father, a very small business man and a perfectionist when  it came to his artisanship, who when offered a more lucrative job working for a mass production firm, turned it down  flat.   When  I  asked him why he wanted to continue struggling and what was the advantage of hanging on, for that's all he was doing, he answered, " I can work twice as hard for  less money, but nobody can tell me how to do my job".  Few would do that today.
           So when politicians started conditioning the docs, they proved to be just as effective as Pavlov.  They did such an excellent job of engineering attitudes that young  physicians feel victimized if they can't join one of the many networks that continue to remodel health care in the model of industry.  They feel left out, excluded.  The stimuli, in the form of cash bonuses have become most effective but are now starting to be reduced.    They will persist for a time yet while the docs are trained to follow whatever guidelines their masters see fit to impose on them but they will be relentless and the screw will continue to tighten.  None of  the administrative organizations which were created to protect our interests and the interests of  the public seem to care.  Physicians will have less and less influence in planning the future of medical  care and all of  the responsibility for it.   Guidelines will  continue to be generated and physician pay will increasingly be determined by how closely they are adhered to, regardless of  individual knowledge and experience.  Eventually, the very people who would benefit the profession and  the public most, will be driven out of it.  The state model will continue to slowly deteriorate.  Somehow, somewhere in Canada some creative group of physicians and other health care professionals will devise a  solution, but things will have to get much worse first.  It certainly won't come from the present usually overpaid health care administration. 

Obesity and the new drugs.

          The U.S. Food and Drug Administration recently approved Saxenda (liraglutide [rDNA origin] injection) as a treatment option for chronic weight management in addition to a reduced-calorie diet and physical activity.  The drug is approved for use in adults with a body mass index (BMI) of 30 or greater (obesity) or adults with a BMI of 27 or greater (overweight) who have at least one weight-related condition such as hypertension, type 2 diabetes, or high cholesterol (dyslipidemia).  Other drugs have also been recognized as being appropriate for the treatment of obesity and we will deal with them later..
          The problem is that older physicians like myself can still remember the last round of miracle drugs that were in vogue twenty or thirty years ago and the damage they caused.  From amphetamines to "fen-phen", which caused valvular heart disease, none of them did anything in the long run to ameliorate obesity and its ill effects.  Certainly amphetamines resulted in decrease of appetite and hyperactivity, and they certainly made patients feel better, for a while at least.  Unless we want to make our already drug addicted society even more drug addicted we should avoid that kind of drug.
          Saxenda is a glucagon-like peptide-1 (GLP-1) receptor agonist and should not be used in combination with any other drug belonging to this class, including Victoza, a treatment for type 2 diabetes. Saxenda and Victoza contain the same active ingredient (liraglutbide) at different doses (3 mg and 1.8 mg, respectively). However, Saxenda is not indicated for the treatment of type 2 diabetes, as the safety and efficacy of Saxenda for the treatment of diabetes has not been established.
          The safety and effectiveness of Saxenda were evaluated in three clinical trials that included approximately 4,800 obese and overweight patients with and without significant weight-related conditions. All patients received counseling regarding lifestyle modifications that consisted of a reduced-calorie diet and regular physical activity.  Results from a clinical trial that enrolled patients without diabetes showed that patients had an average weight loss of 4.5 percent from baseline compared to treatment with a placebo (inactive pill) at one year. In this trial, 62 percent of patients treated with Saxenda lost at least 5 percent of their body weight compared with 34 percent of patients treated with placebo. Results from another clinical trial that enrolled patients with type 2 diabetes showed that patients had an average weight loss of 3.7 percent from baseline compared to treatment with placebo at one year. In this trial, 49 percent of patients treated with Saxenda lost at least 5 percent of their body weight compared with 16 percent of patients treated with placebo.
          Saxenda has a boxed warning stating that tumors of the thyroid gland  have been observed in rodent studies with Saxenda but rats are not human. usually)  Serious side effects reported in patients treated with Saxenda include pancreatitis, gallbladder disease, renal impairment, and suicidal thoughts. Saxenda can also raise heart rate and should be discontinued in patients who experience a sustained increase in resting heart rate. The most common side effects observed in patients treated with Saxenda were nausea, diarrhea, constipation, vomiting, low blood sugar (hypoglycemia), and decreased appetite.
The FDA is requiring the following post-marketing studies for Saxenda:

• clinical trials to evaluate dosing, safety, and efficacy in pediatric patients;
• a study to assess potential effects on growth, sexual maturation, and central nervous system development and function in immature rats;
• an MTC case registry of at least 15 years duration to identify any increase in MTC incidence related to Saxenda; and
• an evaluation of the potential risk of breast cancer with Saxenda in ongoing clinical trials.

       The cardiovascular safety of liraglutide is being investigated in an ongoing cardiovascular outcomes trial..
Here are the actual FDA indications for Saxenda:

Indications and Usage for Saxenda

Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of

•

30 kg/m2 or greater (obese), or

•

27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or dyslipidemia).

After thirty years of treating obese patients  it is difficult to understand how the FDA could approve a potentially dangerous drug for these indications. 

             I would never have prescribed this medication for these indications.

---

---