Can We Have Your Kidney?

For the hundreds of thousands of Americans whose kidneys have stopped functioning, there are two options: lifelong dialysis or kidney transplantation.  Dialysis is time consuming, carries serious risks, and only partially replaces the functions of a healthy kidney.  Patients live longer and have a much better quality of life after receiving a kidney transplant.  The difficulty with transplantation is that donated organs are scarce and transplants are more likely to be successful with living donors than with recently deceased donors.

Physicians and potential donors have been concerned about the health risks involved in kidney donation.  Besides the short-term risk of the surgery, there was a concern that kidney donation over subsequent decades would lead to all the bad consequences of other kinds of kidney injury: high blood pressure, worsening kidney function, eventual kidney failure, and shorter life span.

Because of that, potential kidney donors have to go through a meticulous screening process.  Anyone with any risk factors for developing kidney disease later in life is excluded.  So no one donates if he has diabetes, high blood pressure, protein in the urine (an early sign of kidney disease) or decreased kidney function.

Because of these precautions, it’s been assumed that kidney donors do well after donation and live a normal life, but this has never been actually studied in a large number of donors.  There were also worrisome reports of a few kidney donors who eventually lost all kidney function and needed dialysis themselves.  Was this a consequence of their donation or a random event that would have happened anyway?

A large study in this week’s New England Journal of Medicine attempted to answer the question.  It followed the health, kidney function, and quality of life of thousands of kidney donors and compared them to people in the general population who had the same age, sex and race as each donor.  The results were that the donors had the same longevity, general health, and better kidney function than the general population.  And they have excellent quality of life, on average.  This was trumpeted in the general press as great news for kidney donors.

Not so fast.  I think that this is a perfect example of why it’s important, when possible, to read the original article rather than rely on a newspaper science reporter to filter information for you.  The results are not nearly as heartening as reported.  Remember, all the kidney donors were very carefully screened before being allowed to donate.  So as a group they were much healthier then the general population.  They were then compared with the general population and found that their health and lifespan is no worse.  That’s not good; they should have done much better.  Headlines declared that kidney donors have normal life spans, but before their donation they should have had better than normal life spans.  That’s not a reassuring bit of news about kidney donation.

The authors of the study are very forthright about this important limitation to their findings, but you only find that out if you read their discussion in the original article.

Studies that more accurately determine the long term risk of kidney donation are currently ongoing.  In the meantime, potential donors should not take false comfort from this study.

Learn more:

New England Journal of Medicine article: Long-Term Consequences of Kidney Donation

Los Angeles Times article:  Kidney donors have a normal life span, study finds

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Got Safety?

My bachelor’s degree is in engineering.  (I hear all of you thinking “Ah!  No wonder he’s such a geek.”  But I was a geek long before that.)  In engineering, safety is an entire field of study with formal ways to account for and measure errors, plan for system failures, and quantify the likelihood of adverse outcomes.

Until the last several years, medicine had a very different culture.  Traditionally giving a lot of latitude to physician judgment and autonomy, hospitals had few systems in place to protect patients from unintentional harm.

Yesterday’s astounding emergency landing of an airliner in the Hudson River perfectly crystallizes the engineering safety culture which is practiced daily in aviation.  Pilots have checklists and algorithms for everything, from the routine pre-flight list that is checked before every single flight, to what to do in the rare event that both engines lose power.  Pilots don’t become excellent by exercising autonomy; they become excellent by doing things by the book.

This week, medicine took a page from the engineering culture and made patients much safer.  An important paper in this issue of the New England Journal of Medicine studied the use of a 19-point checklist on all patients undergoing non-cardiac surgery.  The study was done in 8 hospitals in 8 cities all over the world including one in Seattle, Washington.  The checklist is incredibly simple, and was inexpensive to implement.  (I encourage you to look at it by following the link at the bottom of this article.)  The list defines 19 steps that should occur before and after every single surgery, like reviewing if the patient has known allergies, checking that the right antibiotic has been given prior to surgery, and having each member of the team introduce herself.  Each step is simple to understand and to execute and costs very little.

You would think that most of these common-sense practices would be happening anyway prior to the study, but you’d be wrong.  In any case, even with the best of intentions, without an actual list who is going to remember all 19 items at every single surgery?

The results of the study were dramatic.  The rate of death due to surgical complications prior to the implementation of the checklist was 1.5% and after the implementation was 0.8%.  That means that for every 140 patients for whom the list was used one life was saved.  For surgical complications the numbers were even more encouraging.  One complication was prevented for every 25 surgeries.

Hospitals are still a very dangerous place, but we’re finally learning from the engineers and getting serious about safety.

(There will not be a medical news post next week.  Don’t despair.  Posting will resume the following week.)

Learn more:

NY Times article: Simple Checklist Makes Surgery Safer

Wall Street Journal Health Blog post: A Simple Surgical Checklist Saves Lives

New England Journal of Medicine study: A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population

World Health Organization Surgical Safety Checklist

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So Long and Thanks for all the Swag

On January 1 the pharmaceutical industry started imposing on itself a ban against the branded gifts to doctors that have been a constant companion of pharmaceutical sales representatives.  The Post-It notes, pens and coffee mugs bearing the brand names of various medications are gone.  The paperweights and staplers and occasional plush toys with names of prescription antacids and antidepressants and blood pressure medicines will fade into extinction or become collectors’ items.

Last week’s NY Times business section featured an article about this gift ban, with physicians offering diverse opinions on the issue.  On the one hand, it’s difficult to dispute that these trinkets have some subtle effect on physician opinion, otherwise pharmaceutical companies wouldn’t have been handing them out by the thousands.  On the other hand, with Medicare and Medicaid less than a decade away from insolvency, and with the baby boom facing a critical shortage of primary care physicians as they reach retirement, I’m not sure that the Valtrex pad of sticky notes on my desk is the major national problem that needs our attention right now.

So the pharmaceutical sales representatives will still come by our office and tell us how their latest medication is newer and better and safer than their competition, but now the interaction won’t be sullied by the corrupting influence of a free coffee mug.  That’s very reassuring.  I know I’ll sleep better tonight, even without my Lunesta penlight.

(Thanks to my pal and colleague, Dr. Mark Urman, for pointing me to the NY Times article, which also features his partner’s collection of hundreds of pharmaceutical pens.  You can check it out by following the link below.)

Learn more:

NY Times article: No Mug? Drug Makers Cut Out Goodies for Doctors

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Resolutions for a Healthy 2009

Many people use the occasion of the New Year to reflect on the last year and make specific goals for the next.  Resolutions can be very helpful motivators if they are specific, realistic and written down.  Just as people make goals for their careers and their relationships, resolutions for your health are a smart way to work for achievable targets in the health-related struggles you face.

So I encourage you this week to write down your health resolutions for 2009.  Obviously, what progress is achievable is as varied as the people making resolutions.  An elderly lady with balance problems may resolve to attend physical therapy and use her walker consistently and have an entire year without falling.  A younger more active woman may resolve to train for and compete in a triathlon.  There is no objective marker for your goals.  You just have to balance ambition with realism.

My suggestion is to make the resolutions as specific as possible.  Detailed planning will help overcome procrastination and a specific goal will keep you accountable.  So don’t write

  • I’m going to exercise more
  • I’m going to eat less
  • I’m going to lose weight

but instead write something like

  • I’m going to walk for 45 minutes Monday through Friday before work
  • I’m going to join Weight Watchers and attend meetings weekly
  • I’m going to weigh 205 lb on January 1, 2010

If you have diabetes, you should be following your glycated hemoglobin (or hemoglobin A1C).  Write down a goal for it.  If you’re struggling with your cholesterol, pick a goal for your LDL.  If your blood pressure is too high, write down something like

  • My blood pressure will be lower than 140/90 on every doctor visit

If you’re smoking, 2009 is the perfect year to quit (on a specific date that you should pick now).  Obviously, some of these goals may require your physician’s help in terms of adjusting your medications, but your doctor can’t do it alone.

Making yourself accountable to others can also help keep you on track.  Give a copy of your resolutions to your spouse, to your doctor to attach to your chart, to anyone who knows you too well and cares for you too much to let you cheat yourself.

I wish us all a year of peace, health, prosperity and happiness.

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Holiday Medical Myths

Every year the British Medical Journal has a Christmas issue devoted to more offbeat and lighthearted scientific studies.  This year’s issue had an article reviewing holiday themed medical myths.

The article debunks the following myths:

  • that sugar increases children’s hyperactivity
  • that suicides increase around the holidays
  • that poinsettias are poisonous for you or your pets
  • that you lose more heat from your head than any other part of your body
  • that eating at night causes more weight gain than eating any other time of day, and
  • that there is any effective treatment for a hangover

Peruse the article if you want to learn the details.

Thanks to Carina M. for pointing me to the LA Times article.  Merry Christmas and Happy Hanukah to everyone!

Learn more:

Los Angeles Times article:  The year in weird science and myth-busting

British Medical Journal article:  Christmas 2008: Seasonal Fayre

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The Mendacity of Hope

Or: Just Give it to Me Straight, Doc

Any primary care physician from time to time has to give a patient bad news, sometimes terrible news.  These conversations can be extremely difficult for the patient and his loved ones, but also for the doctor.  When the patient is too sick to understand or participate in conversations about his prognosis and his treatment options, the terrible burden falls on his loved ones to have these conversations and make decisions on the patient’s behalf.  When the news is particularly bad, as when the patient is unlikely to survive the hospitalization, many physicians are reluctant to fully disclose the gravity of the prognosis.  Some doctors believe that to be fully honest would take away the family’s hope, or that the family is emotionally incapable of processing the bad news.

An important study in this issue of the Annals of Internal Medicine tested that belief.  The study found 179 critically ill patients in the intensive care units of the UCSF Medical Center who required a ventilator (breathing machine), could not participate in a discussion about their condition and had a high likelihood of dying during this hospitalization.  Structured interviews were conducted with the relatives or loved ones who identified themselves as the decision makers for the patient.

The interview sought to discover the families’ attitudes towards maintaining hope and receiving truthful prognostic information.  The interview started with the question “Some physicians are reluctant to discuss news of a poor prognosis with family members of a critically ill patient because they do not want to take away the families’ hope. Do you think physicians should avoid discussing prognosis in order to maintain hope?”

The results solidly refute the idea that families want to be protected from the truth.  93% said that avoiding discussions about prognosis was not an acceptable way of maintaining families’ hope.

The themes discovered in the study and the individual quotes are quite poignant.  Many relatives said that discussing the prognosis is part of what they expect doctors to do.  One said “Also, I think it’s a matter of respect and I wouldn’t want a doctor assuming that I couldn’t handle something or that I wouldn’t understand something.  That’s demeaning to me.”  And many relatives spoke of sources of hope outside of what is offered by physicians.  “My hope is not based on what doctors tell me; it’s based on how I feel as a person, my spiritual beliefs, how my family and I interact and hold each other up.”

We physicians should learn from this study that families want the truth; we owe it to them.  And we should admit to ourselves that the reason we are so desperate to sugar-coat the prognosis isn’t to maintain the family’s hope; it’s because giving bad news is so difficult.

Learn more:

Annals of Internal Medicine article: Hope, Truth, and Preparing for Death: Perspectives of Surrogate Decision Makers

Annals of Internal Medicine Summaries for Patients: Family Members’ Opinions about Sharing Bad News

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Lugubrious About LABAs

This week an FDA advisory panel reviewed the evidence on asthma medication and released recommendations about a class of inhaled medications that may be unsafe.  Their conclusions drew much media attention.

The panel’s concern is the increasingly worrisome evidence about long-acting beta agonists (LABAs).  LABAs are a family of inhaled medications including Serevent and Foradil which are frequently used to treat asthma.  Studies have shown increased numbers of asthma exacerbations in patients taking LABAs, and one study showed an increased risk of death.  Since most patients take most medicines to avoid death, this is an inconvenient side effect.

Fortunately inhaled steroids, which are another class of medications for asthma, appear to eliminate the adverse side effects of LABAs.  Advair and Symbicort are inhalers which combine a LABA with an inhaled steroid.  The FDA advisory panel judged these combination medications safe, but said that the risks of Serevent and Foradil may outweigh the benefits.

Obviously, don’t stop your asthma inhalers without talking to your doctor, but if you’re using Serevent or Foradil without also using a daily inhaled steroid, a visit with your doctor is in order.

Learn more:

Reuters article: US FDA panel: Two asthma drugs risky but Advair OK

WebMD article: FDA Panel Asks: Are Asthma Drugs Safe?

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Cyberchondria: How Dr. Google Can Make You Anxious

Almost everyone at some time becomes anxious about his health.  Even people who can stay calm through a stock market crash can get worried about new or nagging symptoms.  And while some anxiety about our health is perfectly normal, in some it can reach a level that interferes with day-to-day functioning and becomes incapacitating.  Even when it’s not that bad, anxiety about health is frequently misguided.  Your headache is thousands of times more likely to be due to muscle tension than a brain tumor, and all those brain tumor patient support websites you’re reading won’t make your tension headache any better.

The internet is a very powerful resource to help non-experts educate themselves about their health, but it also frequently escalates anxiety.  Two scientists at Microsoft published an article last month that studied how web search behavior can increase health-related anxiety.  The researchers call this cyberchondria – “the unfounded escalation of concerns about common symptomatology based on the review of search results and literature on the web.”

The researchers studied how people searched the web, and what patterns tended to increase or decrease their anxiety about their symptoms.  They found that many people, when searching the web for a symptom, mistake the rank order of search results as the order of likelihood of the diagnoses found.  For example, a search for “headache” will return lots of results about caffeine withdrawal, muscle tension and brain tumors (and lots of other causes).  But the order in which those results appear has nothing to do with the likelihood of these conditions.  Brain tumors may appear first simply because there is more written about brain tumors and more research being done on brain tumors, but they are exceedingly rare especially compared to common causes of headaches.

Many physicians went through a similar experience as medical students.  We would become convinced that we had whatever obscure disease we were studying.  The ongoing joke was “I think I have lupus, and I think you do too.”  The common theme between medical student anxiety and cyberchondria is access to information in great excess to judgment or experience.  Now, with the internet, we can all be first year medical students.

(Thanks to Timo K. for pointing me to the Microsoft article and to my cyberchondriac patients for realizing they probably don’t have lupus.)

Learn more:

Microsoft Research article:  Cyberchondria: Studies of the Escalation of Medical Concerns in Web Search

NY Times article: Microsoft Examines Causes of ‘Cyberchondria’

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Thank You

Before we gather with loved ones to give thanks for our abundant blessings and eat until we lose consciousness, I wanted to take this opportunity to express my gratitude to you.

To all my readers, thanks for all the medical news articles, the feedback and the encouragement.  The weekly writing would get very dull if I thought I was talking to myself.

To all my patients, thanks for granting me the greatest thing anyone can expect from a career – getting paid to do what you love.  I appreciate your loyalty.

I wish you and yours a happy Thanksgiving.  I hereby grant all of my patients a one day reprieve from the dietary restrictions I harangue you about during the rest of the year.  You may eat what you like provided that instead of counting calories, you’re counting blessings.

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On Being Doc and Being Happy

Early in life we all have to choose which of the seven dwarfs we want to be.  Most of us physicians, for mostly altruistic reasons, chose to be Doc.  But it turns out that many of us instead ended up being Grumpy.

A survey of twelve thousand U.S. physicians released this week by the Physician’s Foundation paints a grim picture of our morale, and it received a lot of press.  78% of physicians believe that there is a shortage of primary care doctors today.  49% of doctors said that they were planning to shrink their practice or retire entirely in the next few years.  60% of doctors would not recommend medicine as a career to students.  94% said they were spending more time with non-clinical paperwork than a few years ago and 63% said this caused them to spend less time with patients.  (You can read more of the results by following the link below.)

Now, we should keep in mind that the Physician’s Foundation is basically a doctors’ grievance group which exists to get more money out of insurers, so they’re as likely to publish a study saying doctors are happy as an oil industry lobby is to declare that we have enough energy.  So we should take these results with a big grain of salt.  But, still, the overall picture isn’t encouraging.

My advice to patients is to make sure you have a primary care doctor now.  If you wait until you’re sick, the doctor you were hoping to see may be out of practice or may be full.

My advice to physicians is to reclaim your autonomy.  If you’re working too hard, work less.  If you’re making too little, drop your contract with the insurer paying you least.  If you’ve reached the point that you hate what you do or are losing money doing it, do yourself and your patients a favor and retire or change careers.  Physician unity isn’t going to help us.  (Note well the fate of the UAW.)  Our only hope lies in physician independence, excellence, and love of our work.

We have to demonstrate to today’s students that we can be Doc and also be Happy.

Learn more:

USA Today article: Primary care doctors in short supply

LA Times Booster Shots: Docs aren’t happy, and if docs aren’t happy …

Survey results from The Physician’s Foundation

My post about the coming primary care shortage: Will Primary Care Survive?

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