Sunday, March 25, 2012

Last July, McDonalds’ Happy Meals became a little less happy. Kids in pursuit of culinary happiness will have to be satisfied with fewer French fries and some added fruit. Surprisingly, the calorie count only decreased by 20%. McDonalds held firm on the request to discontinue toys in the Happy Meals, despite opponents’ arguments that these trinkets emit an encrypted electronic signal that lure kids to the golden arches.

The Enemy of Mankind

An Indiana billboard offers this announcement along with a graphic photograph that depicts innocent hot dogs masquerading as cigarettes in a cigarette package.


This publicity effort was spearheaded by the carniphobic group Physicians Committee for Responsible Medicine (PCRM). This organization advocates that all of us restrict ourselves to the pleasure of an all plant diet. The billboard was a shrewd move. Beforehand, none of us had ever heard of these guys. Now, for a few hundred bucks, they achieved national exposure.

I’m for folks making informed choices. I don’t like it when the government or other organizations try to impose their views and practices on the rest of us. If I want to start and end my days with a Big Mac or two, then I should be free to do so without interference from others. Just as I would not lean on my vegan friends to savor some barbecued chicken wings, I don’t want to cajoled or shamed into giving up burgers for some kind of seaweed surprise.

Veggie enthusiasts point to research that concludes that carnivorous humans have higher cancer rates. If you can’t easily separate a man from his steak, then bring cancer into the conversation. This research is murky and there are enough conflicting results to satisfy all points of view on this issue. Indeed, if we eliminated all foods that have been linked to cancer, we might all be nourished by total parenteral nutrition (TPN) infused intravenously, as we do for hospitalized patients who cannot tolerate an oral diet. Of course, TPN would have to be chemically analyzed by an independent group, commissioned by the PCRM, to verify that no nano-traces of animal products were present.

I’m not in favor of obesity. As a physician and a citizen, I counsel folks to make wise food and beverage choices. But, it is their choice to make, not my mandate to impose. If more calories and girth make folks happier, and they are informed of the potential consequences, then they should be permitted to live without interference. Is it society’s responsibility to inform the citizenry of dietary risks, or does the individual have a responsibility to exercise due diligence? In 1890, an article in the Harvard Law Review (Do they still eat meat at Harvard?) penned by Louis Brandeis and Samuel Warren opined that we have a right to be left alone, although this language does not appear in the Constitution. Indeed, doesn’t this ‘right’ define the relationship that we have with our government?  It would have been more fun on this post if the 'right to be left alone' was written by Felix 'Frankfurter', who was as Associate Justice of the U.S. Supreme Court.

What’s your definition of a ‘Happy Meal’? A greasy burger smothered with onions and coated with melted cheese? Kentucky Fried Chicken? Sugarless granola with 6.5 oz of skim milk? A carrot smoothie with probiotics? TPN?

The PCRM argues that hot dogs and similar products should carry warning labels, such as appear on cigarette packages. My response? Where would the warning labels stop? Ice cream? Chocolate? White bread?

The American Meat Institute has challenged the PCRM’s assertions, as we would expect. Both sides likely spin stuff to serve their agendas. One side eats Big Macs with relish. But, one side is telling Whoppers.

Sunday, March 18, 2012

End of Life Care: The Feeding Tube Frenzy

Okay, readers, how many of you desire to have a feeding tube inserted into your belly one day? Some of you? A few of you? All of you? Not me, that’s for sure. So, if there comes a time when I cannot speak for myself, let this blog post serve as a statement of my philosophy that I do not wish to be subjected to everything that medicine may have to offer. If I am enjoying no meaningful life, and if I am not giving pleasure to others…
I placed yet another feeding tube (PEG) in a patient this week. This is often an unsatisfying experience for me as I am not always serving the patient’s interest. Usually, the patient is not capable to express his own views and the decision is properly delegated to the family or to a designated medical power of attorney (POA). In this instance the tube was medically indicated and I reviewed the procedure and the alternatives with the 3 daughters in a conference room.

The daughters were uncertain how to proceed. The ladies were clearly vexed. One of them was the POA. I counseled them to take more time to weigh the options. While the decision was difficult, the situation was not emergent and they had the luxury of time to deliberate. I reminded the POA that her charge was not to make a decision based on what she felt was in her mother’s best interest, but to make the decision that her mom would make if she were able to do so. This distinction is critical if the patient’s autonomy and medical ethics are to be respected.

Hours later, the daughters all agree to proceed with the PEG, and I did so.

Luckily, there was a consensus, as it would be very problematic to proceed if there was a split decision, even if the POA has the legal right to decide. Indeed, if this occurred, I would make every effort to facilitate a unanimous decision, and might recruit other professionals to assist in this effort. It is easy to forecast the family tensions that might ensue when there is discord on how to proceed. There are times, however, when a consensus is impossible, and the POAs directive must be followed. In such cases, at least there is a POA to make the difficult decision. When there is no POA, and the family members are torn, then the situation is delicate and difficult.

Most of the PEG tubes I place are in demented elderly individuals who reside in nursing homes. For many of them, these tubes are a rite of passage and provide a convenient portal to administer nutrition and medication. Are they truly necessary? Certainly not. Indeed, there have been numerous medical studies in recent years that conclude that individuals with advanced dementia do not benefit from feeding tubes. Moreover, the notion that feeding through PEG tubes provides comfort to patients has been challenged.

Resources are limited. If every nursing home patient had a dedicated aide who could devote the time necessary to help patients eat, then they wouldn’t need a gastroenterologist like me to violate them. In addition, eating food in the conventional manner provides gustatory and social pleasures. Do we want to deprive a patient of any of life’s remaining pleasures, when so few of them are remaining?

There is an aspect of the PEG procedure that does give me pleasure, and I experienced it this past week. I had placed a PEG in a rugged and vigorous man 2 months ago who had a temporary impairment in his swallowing function. This week, he came to my office for me to remove the tube. This is a rare event as most PEGs are placed for indefinite use.

Many hospitalized patients are advised to undergo PEGs when a swallowing study demonstrates dysfunction. My suspicion is that many of these folks have had this ‘dysfunction’ for years, and yet have managed to get through thousands of meals over the years without loss of life. In these cases, the PEG tube can be justified, but may not be truly needed.

Obviously, many PEG tubes are absolutely necessary and should be placed. It’s the rest of the PEGs that I’m lamenting over. Ask your gastroenterologist if he has ever placed an unnecessary PEG tube. If he says no, then whip out the polygraph equipment.

My advice? Make sure you have a living will with a designated medical power of attorney who will reliably act on your behalf, should the need arise. Otherwise, you might end up going down the tubes.

Sunday, March 11, 2012

Is Treatment for Hepatitis C Hype or Hope? Big Win for Big Pharm

I see many patients with hepatitis C (HCV).  None of them are under treatment and they all feel quite well. Why don't I treat them?  After all, potential consequences of HCV include:

  • Cirrhosis
  • Hepatocellular carcinoma. or liver cancer
  • End stage liver disease with all the trimmings
  • Liver transplantation
  • Death
One would think that a portentous list like this would justify any treatment, even hazardous therapies.  But, I've never seen it this way, and my hepatitis C patients are all doing well under periodic observation.

Yes, I know that the disease can be serious.  I recall one patient
with advanced disease whom I referred for consideration of a liver transplant many
years ago.  There may have been a few others along the way who received treatment for the disease also.

The vast majority of hepatitis C patients I see in my community practice feel entirely well and the diagnosis is discovered by accident.  In other words, these patients did not exhibit symptoms or abnormal findings on the physical examination that led a physician to suspect a liver condition, which then led to testing for hepatitis C. Some of them were picked up by the blood bank when their gift of life was declined after hepatitis C infection was discovered. Sometimes, a life insurance company makes the diagnosis during their health assessment as they try to cull out from their enrollees those destined to ascend skyward prematurely.  In most cases, patients are diagnosed with hepatitis C when physicians like me order diagnostic HCV blood test to evaluate abnormal liver blood tests.  Nearly all of these patients have no symptoms of liver disease and the abnormal liver blood tests may not even  be a HCV manifestation.

What should we advise patients with HCV who feel perfectly well?  Of course, patients should make the call after they have been informed of the risks and benefits of treatment.  In my experience, after this discussion, none of these patients wants to proceed.  Hopefully, I try to meet my obligation to present the issues to them fairly.  I am certainly aware of my bias, and do my best to compartmentalize it.

I think that there has been a rush to treatment with these patients.  Academic centers tend to be more enthusiastic about racing for the HCV cure with toxic medicines, although in fairness, their HCV population is very different from mine.  Their patients are much more ill, so the risk/benefit analysis of treatment may calculate out differently.  Nevertheless, academicians in writing and on the speaking circuit tend to extol the virtue of treatment, which they regard as the default response.  Watchful waiting just doesn't have the red meat appeal for liver gurus.  They argue that eradicating the virus will prevent the dire consequences I listed at the top of this post.  However, when there was only treatment available 20 years ago - injectable interferon -  academics were gaga over this it, which had a full page of side effects and was effective in less than 20% of patients treated.  I'm amazed that interferon slid by the FDA.  Now, HCV can be cured in a majority of patients, according to data from two drugs approved in 2011 to treat the disease, although there remains substantial toxicity from the medications. .

Even experts acknowledge that only a minority  of HCV patients will develop serious complications.  I'm not persuaded that we have a reliable method to determine who will progress and who won't. And if we did, how firm is the evidence that treating a patient who is destined for cirrhosis will avert this outcome?  Those who believe in HCV treatment will find data to support their view and practice.  And those of who are skeptics will do the same.  That's the beauty of medicine.  There's always conflicting studies to choose from to support any view.

What would Newton say?

Many of my HCV patients can date with some precision when they contracted the virus.  The event may have been a blood transfusion decades ago or from intravenous drug use during a youthful period of hard times and bad judgement. Many of these patients, therefore, have had the virus for decades and are not suffering any ill effects.  While I cannot guarantee a sanguine outcome, I view this in Newtonian terms.

An HCV virus that is asleep tends to remain asleep.

Other physicians don't share my approach and may be dismissive of my nihilism. I wonder how many of them would accept a treatment with enormous toxicity and cost for themselves as readily as they prescribe it to others?  This question applies to all physicians, including me, who prescibe medicine and advise patients.  Remember, we physicians discuss the risks of all treatments with patients in advance. But, we don't suffer the complications.

HCV patients, get informed.  Make sure the treatment won't be worse than the disease.

Sunday, March 4, 2012

Chardon, Ohio: Searching for Answers

Volcano - A Metaphor of Evil

This past week, I awoke to read a chilling headline in tall black letters that announced that some innocents were shot by an assailant who himself was still a boy. We read these headlines and watch related images every day as the volcanoes of evil around the world never stop spewing out their merciless lava. Why this happens is a question that tests the most erudite theologians, who must try to comfort us and help us to understand what can never be explained.

This wanton murder was not a suicide bombing in Baghdad or a Taliban ambush on NATO troops in Afghanistan. This shooting occurred in Chardon, Ohio, a small town less than half an hour from my home. I remember being there a few years ago for their maple syrup festival.  A 17-year-old kid allegedly came to Chardon High School and in a few moments changed the lives of many thousands of innocent people. As I write this, I am still plagued with deep sadness and sharp anger. I cannot fathom how a mind and a heart can become so poisoned that an act of pure evil can be planned and implemented.

There were teachers in the school who put their lives in jeopardy to protect their kids.  The very best of humanity and the very worst both appearing in the same tableau.

Since Columbine, we learned that even our schools are not the sacred sanctuaries for our kids as they should be, and they used to be. When I was in high school, my fear was being shaken down for a quarter or getting pushed around on the stairwell. And, we had some fights in the schoolyard. What a difference a few decades make.

I write this before looking at the newspaper this morning. What sanguine greeting awaits me today?

I believe so strongly in forgiveness and redemption, but at times I struggle with both of these virtues. I believe that there is no act that cannot be forgiven, but I admit that for some acts it may be beyond my capacity to do so. Yet, I have seen people forgive the seemingly unforgivable, and I admire them.

Chardon, Ohio is your town too.

Pulpits across the country will admonish us to look skyward for answers. I think this is good advice, because all the rabbis, priests, ministers, imams and ministers here on earth won’t be able to silence the volcanos or explain them.