Outhouses and Obesity?

Steven Dubner at the Freakonomics blog makes an, um, interesting argument for one possible factor in the rise of obesity, outhouses:

Is it possible that the availability of good plumbing has contributed to our national weight gain? This may sound ludicrous, but think about it for just a moment. Very few people have to trek through the night to use an outhouse anymore; furthermore, restroom facilities are readily available just about everywhere — which means you don’t have to worry about getting rid of your waste, which frees you up to consume as much as you’d like.

As a kid, I remember taking a long bus ride to New York City for a ballgame. There was no bathroom on the bus. No one on the bus was drinking anything either. (Yes, this was before you could readily buy bottled water; but there were such things as cans of soda.)

A few times in the recent past, I’ve rented a summer house with no garbage pickup. This meant not only paying for how much waste you produce, but also storing your trash until the one day that the dump is open. During these times, our behavior changed radically: not only did we compost all our food waste to cut down on stink, but we thought about everything we bought before we bought it to make sure we wanted to deal with the waste. As a result, we bought a lot less.

I know of no legitimate research connecting plumbing and obesity, though I would be interested in hearing from anyone who does.

I'm not really sure where to begin on this one. Even if this were a factor, I think the low cost of high density calories through agricultural subsidies would dwarf any effect. Furthermore, this argument could be made about any technological advancement made in the past century. For example, cars have caused people to walk less, therefore consuming less energy daily, thus, cars cause obesity. Clearly, the argument is too simplistic. While an interesting thought, I can't imagine any serious scholarly work has been done on this topic.

On Becoming a General Surgeon

While I'm not going into general surgery, I think I still hold a romanticized notion of the general surgeon as some kind of master-of-the-universe figure who works smoothly and calmly with a high degree of precision. This, despite much evidence to the contrary. Even taking my experiences into account, I never thought the general surgery residency could be that bad. However, this interview on EMPhysician with a general surgeon (who eventually did a vascular fellowship) has me thinking otherwise:

How did you stay sane during training?
I didn't, actually. I just worked all the time. I gained 25 pounds, and developed varicose veins and plantar faciitis so painful, I took analgesics constantly. My blood pressure went up, and despite my best efforts, I could not eat healthy as a resident. I developed prediabetes, and basically ignored my physical needs altogether. It is a show of weakness to express the need for the requirement of basic human needs as a surgical resident. Going to the bathroom was a big deal, actually. My only saving grace was the fact that I was only in my mid/late 20s, and my body tolerated the abuse...abuse that would be difficult (perhaps impossible) to physically recover from for someone a bit older.

I had no hobbies, nor could I engage in any meaningful discussion with other people (outside of medicine), since I had no time to engage in the world activities and issues. I became very one dimensional, and my entire identity became "me, the surgeon."

Keep reading the post for a wide-ranging interview on the ups and downs of training to be a surgeon. Interesting stuff, wish I'd read it a long time ago.

Updated 2015-12-14

Disimpaction

Comics on Indifferential Diagnosis via Scalpel or Sword:


LOL, so true. Check out Indifferential Diagnosis for more "Ideal Vs. Reality"

Long on Radiology

Kevin, M.D. has had a few posts recently about CT Colonoscopy, including this one entitled "Colonscopy turf wars":

What if Medicare decides to cover "virtual", or CT, colonoscopies? Well, it's going to be ugly.

Colonoscopies are the primary reason why GI physician salaries are so high. They're going to do all they can to justify continuing to perform endoscopic colonoscopies.

It's a similar situation with CT-angiograms and the cardiologists.

If physician specialties were stocks, I'd go long in radiology.

Sweet! I'm going long on radiology too! About 40 years long... hmm. Heh, well, the radiologist salaries are enough to keep me motivated, I guess.

In reality, I think radiologists aren't necessarily in the clear on this. Like cardiology, one can see gastroenterologists eventually co-opting the reading of such studies with the justification that if something is found, they would be the ones who would have to go in and scope the patient anyway to find a tissue. The turf wars shall continue...

America's Most Stressful Cities

Chicago, Illinois
(Source: Inhabit)

This post isn't directly related to medicine, but it is related to medical students applying for residency programs across the country next year (namely, me). Forbes recently put out a list of America's Most Stressful Cities. You can flip through Forbes' slideshow, or simply check out the list below, courtesy the Consumerist:

America's Most Stressful Cities:

10. Philadelphia, PA

9. Providence, R.I.

8. Salt Lake City, Utah

7. Cleveland, Ohio

6. San Diego, Calif.

5. San Francisco, Calif.

4. Los Angeles, Calif.

3. Detroit, Mich.

2. New York, N.Y.

1. Chicago, Ill.

Why Chicago?

Chicago has a 7.3% unemployment rate, the eighth most polluted air in our ranking and in city where everybody drives to get around, a gallon of gas costs a nickel under $4 dollars.

Hmm... something to consider as we traipse across the country in search of employment.

Are Women Treated as Pre-Pregnant?

(Source: Candid Chatter)

Pre-Pregnancy was not a concept I had ever encountered in medical school. However, according to a post on the Well blog, it is a pervasive problem for many women under 40:

A recent report raised concerns about women of childbearing age sharing prescription drugs. While the focus of the study was on drug sharing, readers of the Well blog took the discussion in an entirely different direction.

“I agree that this is a serious issue, but I take great offense at the notion that this is particularly worrisome because these women are of childbearing age,” wrote reader Sharon. “Not all women are “pre-pregnant.” We are more than our uteruses!”

Reader Jennifer agreed.

“Framing this as a women’s issue because we have the ability to become pregnant is just insulting. I am tired of being thought of only as a breeding machine who should be regarded as “pre-pregnant” at all times.”

I was shocked by the reaction, although many other readers chimed in, agreeing that too often women in the health system are treated as “pre-pregnant.”

To talk more about the issue, I called Cindy Pearson, a long-time women’s health activist and executive director of the National Women’s Health Network.

“You accidentally stumbled into an area that women have had very intense feelings about for at least 40 years,” Ms. Pearson said. “American history is very heavily affected by the first time we as an entire country realized that drugs could cause harm to the fetus, and that was thalidomide in the early 1960s. It changed the course of medical care.”

While more awareness about the risks of drugs to a developing fetus is a good thing, it hasn’t always led to better health care for women, Ms. Pearson said.

“Ever since, women … feel that if they’re ovulating, they’re treated with bikini medicine,” Ms. Pearson said. “The attention all goes to their reproductive organs, and that is not right either.”

Strange. I've never encountered such an attitude in the past three years. And frankly, while I understand their concern, I think the risk of having a child without proper prenatal care is much worse potentially. The article states that health care for women was somehow worse because of this situation, but does not provide any evidence. Of course, that is not right either, but I still think it is better to err on the side of having too much prenatal care and overly focusing on the act of reproduction versus the alternative. Is it fair? Not entirely, but I think it's the most practical solution given how pregnancies often occur.

What do you think, ladies? Ever feel like you're treated as pre-pregnant? Please leave a comment and let me know what happened if you were treated this way.


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Lowered Expectations

"The Doctor" Sir Samuel Luke Fildes
(Source: Wikipedia)

As a medical student, one often has shortened horizons, worried only about the next patient or next pimp question, living from hour to hour, wondering what new challenge will arise next. However, this situation becomes even more frustrating when one is working in an inefficient system, with hundreds of little pauses during the day, time that is wasted and benefits no one. What I have found that helps me get through the day is to have lowered expectations. Whenever I find myself feeling unusually surly in the hospital, I often notice it is because I am the victim of my own expectations.

What does he mean, you wonder? Take one day a few weeks ago, for example, when I once again fell victim to my own expectations. I recently started my Ob/Gyn rotation. By some stroke of luck, I was assigned to the VA gynecology clinic, which as you can imagine, has a relatively low volume of patients. We only have one OR day a week, and on that week, only one case scheduled. The case turned out to be a hysteroscopy with planned polypectomy. I asked my resident when I should arrive; she said 8. I asked her how long the case would be (as I had lectures to attend in the afternoon); she said not very long, 15 minutes tops. So, I dutifully arrived at the PACU at 8am. No resident, no patient. I waited... and waited... and waited. In fact, I saw the attending first, around 9am. He also had seen neither the resident, nor the patient. Finally, around 10:30am, both had been located. Apparently, the patient had not her pre-op chest x-ray. Okay, so waiting was boring, but no big deal. I checked email, surfed the web. The case should be quick. Everything worked out okay, right?

Wrong.

The case dragged on for nearly 2 hours before I finally excused myself to attend lectures. The presumed polyp turned out to be a fibroid, but no one had surmised this after the first hour... or the second. Not only that, but the OR lacked the proper tools to tackle a fibroid. Imagine taking those blunt scissors kids use in kindergarten and try to cut through a piece of rope. The whole exercise was pretty ridiculous. Luckily, in the end, they somehow managed to get it out, but what a struggle.

Why am I complaining about this? Well, I try to temper my own expectations as best I can, but it is shocking to me how wrong residents often are about OR start times and length. For people who work on procedures day in and day out, this should be routine. Sure, complications during the case can affect times, but I would expect that to be true of complex patients undergoing complex procedures. Yet, it is often the "simple" case that ends up taking ridiculously long because no one has the proper expectation for its difficulty level and then end up being unprepared for when the unexpected does occur.

Long story short: never trust a resident's estimate of how long something will take. Never.


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Fructose and Lipogenesis

An interesting study from UT Southwestern notes that the rate of lipogenesis is increased when glucose is replaced with fructose:

In the research, six healthy individuals went through three tests where they had to drink a fruit drink mix. In one test, the breakfast drink was 100 percent glucose, similar to the liquid doctors give patients to test for diabetes — the oral glucose tolerance test.

In the second test, they drank half glucose and half fructose, and in the third, they drank 25 percent glucose and 75 percent fructose. The tests were random and blinded, and the subjects ate a regular lunch about four hours later.

The researchers found that lipogenesis, the process by which sugars are turned into body fat, increased significantly when as little as half the glucose was replaced with fructose. Fructose given at breakfast also changed the way the body handled the food eaten at lunch. After fructose consumption, the liver increased the storage of lunch fats that might have been used for other purposes.

Hmm... guess I should lay off the colas, huh?

Social Networking and Proprioception?

Social Networking (Source: Simon Whatley)

A friend recently sent me an interesting article on social networking, specifically twittering, that compared the phenomenon to proprioception. As you all know, proprioception is our sense of relative position within space. It's what lets us know that our foot is pointing upwards or that our thumb is pointing down. How does proprioception apply to social networking though?

When I see that my friend Misha is "waiting at Genius Bar to send my MacBook to the shop," that's not much information. But when I get such granular updates every day for a month, I know a lot more about her. And when my four closest friends and worldmates send me dozens of updates a week for five months, I begin to develop an almost telepathic awareness of the people most important to me.

It's like proprioception, your body's ability to know where your limbs are. That subliminal sense of orientation is crucial for coordination: It keeps you from accidentally bumping into objects, and it makes possible amazing feats of balance and dexterity.

Twitter and other constant-contact media create social proprioception. They give a group of people a sense of itself, making possible weird, fascinating feats of coordination.

For example, when I meet Misha for lunch after not having seen her for a month, I already know the wireframe outline of her life: She was nervous about last week's big presentation, got stuck in a rare spring snowstorm, and became addicted to salt bagels. With Dodgeball, I never actually race out to meet a friend when they report their nearby location; I just note it as something to talk about the next time we meet.

The author Clive Thompson does pose an interesting idea, and I can see why he used the term proprioception. However, I think the term is misleading. When used in terms of physiology, the term implies one's own relative sense of position. But, in the social world, the term is being applied to your friends' mental and physical states relative to your own (or, one could argue, relative to your prior knowledge about them). Although I'm not particularly a fan of the awkward physiological analogy, if one must be made, I think the social networking phenomenon is more akin to the way in which our brains integrate various sensory inputs to form a coherent image of the outside world. Online social networks help us with social integration as we process what our numerous contacts are doing in the real world in real time.

Somehow though, I don't think social integration will catch on quite like proprioception...

Sarah Palin: Charging Victims for Rape Kits

Gov. Sarah Palin has come under increasing media scrutiny for her political positions. However, one that is medically relevant and seems pretty indefensible is her stance as mayor on rape kits. These are the exams performed on patients who claim they are victims of rape or sexual assault. During her tenure as mayor, her town Wasilla began charging victims for these exams. Eventually, the Alaskan legislature realized how presposterous this was and banned the practice. Initially, Palin denied any involvement through a spokesperson:

Palin spokeswoman Maria Comella said in an e-mail that the governor "does not believe, nor has she ever believed, that rape victims should have to pay for an evidence-gathering test."

"Gov. Palin's position could not be more clear," she said. "To suggest otherwise is a deliberate misrepresentation of her commitment to supporting victims and bringing violent criminals to justice."

Comella would not answer other questions, including when Palin learned of Wasilla's policy or whether she tried to change it. The campaign cited the governor's record on domestic violence, including increasing funding for shelters.

However, further investigation found that Palin indeed did sign into law the budget cuts that forced victims to be charged for the rape kits:

Under Sarah Palin's administration, Wasilla cut funds that had previously paid for the medical exams and began charging victims or their health insurers the $500 to $1200 fees. Although Palin spokeswoman Maria Comella wrote USA Today earlier this week that the GOP vice presidential nominee "does not believe, nor has she ever believed, that rape victims should have to pay for an evidence-gathering test...To suggest otherwise is a deliberate misrepresentation of her commitment to supporting victims and bringing violent criminals to justice," Palin, as mayor, fired police chief Irl Stambaugh and replaced him with Charlie Fannon, who with Palin's knowledge, slashed the budget for the exams and began charging the city's victims of sexual assault. The city budget documents demonstrate Palin read and signed off on the new budget. A year later, alarmed Alaska lawmakers passed legislation outlawing the practice.

For someone who is clearly running on the premise that as a mother of 5, she will champion women's rights if elected to higher office, this is a sad and shocking situation. Putting aside her views on abortion, this in itself should be a signal to people whose primary issue is women's rights whether Palin truly represents their interests. And, as health professionals, I would hope that this situation is not repeated in other locales, although it undoubtedly has been in the past.

The Web 2.0 EMR?

Kevin M.D. has an interesting post about the poor implementation of current EMR efforts. As his post notes, none of the innovation people see in online apps like Facebook or Google Docs are being used in EMR services. The post primarily refers to a piece by hospitalist Bob Wachter. So yea.. Why hasn't social networking affected EMRs yet?

One problem is that much of health information technology is staffed and programmed by has-beens. There is very little innovation, with most of forward-thinking ideas confined to sites like Google, Facebook, and MySpace.

It would be nice if an electronic record was designed with the singular focus being the end-user experience. They should make physician's lives immeasurably easier, and significantly decrease the time spent charting and tracking patients.

There are very few record systems that meet even this minimal standard.

An EMR like Facebook? We can only wish.

Indeed, a EMR with a Facebook-style interface would be a godsend. I think the real problem currently though is not necessarily a lack of technological know-how, but rather the high cost of implementing such systems and the relatively poor demand. Furthermore, the medico-legal environment also contributes to physicians being unwilling to abandon the old forms that worked on paper. Hopefully one day physicians will take that step en masse into the brave new world of social networking-based EMRs.

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Doctors Laughing at Patients?

Sure, it happens. And it's not a positive. It speaks to a lack of professionalism in medicine. However, I find it sad that CNN once again resorts to alarmist headlines to draw in readers rather than putting a less sensationalist title and seriously exploring the issue and its causes. The author of "Ever wonder if your doctor is laughing at you?" states:

You're sick, in the hospital, or maybe even undergoing surgery. The last thing you want to contemplate is the thought that your doctor might be making fun of your toe rings while you're anesthetized.

But does it happen? Yes. According to a survey of doctors starting a residency in internal medicine, 17 percent had -- along with their colleagues--made fun of a patient, sometimes when the patient was under.

Egad. Is nothing sacred? The good news, though, is that 94% of the 110 medical interns who took the anonymous survey realized that such behavior was inappropriate, according to a research letter published in the Journal of the American Medical Association.

That means that only seven doctors in the survey thought that type of behavior was A-OK.

I guess it's not that surprising, given the behavior of our on-air favorites. From "Grey's Anatomy" to "House," the overwhelming warts-and-all portrait seems to be this: Doctors are human. They fall in love, they get angry, and they like a good chuckle -- sometimes at the patient's expense.

As I've noted previously, such pieces tend to drive a wedge between doctors and patients. CNN is especially guilty of this practice. Given the coverage of the election this season, I seriously wonder if reporters should be required to get licenses before publishing pieces. I don't mean to restrict anyone's freedom of speech, but I think the media often does a poor job on reporting on issues of great importance to the public. If doctors and lawyers have to have licenses to practice because of the harm that can occur if they do not, why not the media as well? With a licensed media, people would have some way to judge if a reporter was qualified or not. You could still have blogs and alternate sources, but such a system would hopefully increase one's trust in the pieces we read everyday.

David Newman in Hippocrate's Shadow: Paranoia in Medicine

I always find it frustrating when I come across an article that seems to drive a wedge between doctors and patients. The relationship is under siege enough as it is. Why introduce more suspicion? Well, I suppose some people do it to make a buck, such as this book promo piece in the Sun-Times:

Your doctor keeps secrets from you -- and a new book reveals them.

Dr. David Newman, a New York City emergency physician, tells what doctors don't want you to know in his book, Hippocrates' Shadow: Secrets From the House of Medicine (Scribner, $26).

• Doctors don't know as much as you think they do. For example, they don't know what causes most back pain -- or what makes it better.

• Doctors do know that many tests, drugs and procedures they order and prescribe either don't work or haven't been proved. Case in point: They keep prescribing antibiotics for colds and bronchitis.

• Doctors like ordering tests better than they like listening to you.

"These doctors are not bad human beings,'' said Newman, who trains medical students and residents at Columbia University.

Time limits, lawsuit fears and the demands of insurers deserve some blame for the truth gap, but medical training and traditions play big roles, he said.

Take the antibiotic problem. Studies show that half of all patients who go to a doctor with a cold are prescribed an antibiotic. Colds are caused by viruses; antibiotics kill only bacteria. "Doctors think patients want a prescription," Newman says. They also know that patients feel better once they get that "magic pill," he said.

But doctors should know that patients are just as satisfied when physicians take a few minutes to explain why antibiotics won't help and suggest symptomatic relief -- relief that won't come, as some antibiotics do, with side effects such as diarrhea, yeast infections and allergic reactions.

Doctors also don't like to admit that many test results are not as black and white as they appear.

"It's not uncommon for the decisions we make to be entirely based on opinion," he said.

Letting patients in on these secrets allows them to make better, more healthful choices, he said.

Now, I am certainly all for patients being informed consumers. I think it makes the experience better for all parties involved, and in the long run, leads to better health outcomes. However, pieces like this only sow the seeds of doubt in the minds of patients. I hope the book takes a more balanced view, but it would indeed be sad if a physician was spreading this view about his colleagues to the general public. We need to have our patients' trust, not evoke their suspicions.

Sarah Palin's Birthing Guide

As I am on Ob/Gyn right now, a friend sent this to me regarding the controversy surrounding Sarah Palin:

Pregnant? Out of state? Practice the Palin Method!

Just as the pundits predicted, America is falling in love with Sarah Palin, America's supermom -- and soon to be grandmom (and maybe even great-grandmom, depending on whether Bristol has a girl and how soon that girl becomes fertile). Palin, as we're finding out, is a "maverick," who "does things her own way." Including not only the way she runs a family, but the way she creates a family. Lost in the rumor about whether Palin had faked her last pregnancy was the true story of how Palin actually had her last child Tram Trim Trig.

While some choose natural childbirth, some choose Lamaze, and others choose traditional hospital arrangements, Palin chose to get on a plane after her water broke and fly from Texas to Alaska, with a stop in Seattle. Was it because she wanted to be closer to God? Or did she hear about Alaska Airlines Northern Bites® Hearty Picnic Pack ($5)? Nobody knows, but, hey, the baby's alive, so the gamble paid off. Plus, you don't get frequent flyer miles in Lamaze class, ladies.

Palin, as the country is about to learn, has lots of ideas about how you should run your life. Including the part that involves your vagina (lots of ideas about that area).

So if you're pregnant, and bored with the tired old risk-free method, try the Palin method...

Keep reading to see the Sarah Palin 9 Step Method to giving birth.

The Future of America's Healthcare: Obama vs. McCain

Recently at dinner, a few friends and I were discussing politics and healthcare. While we all had our own opinions, we came to the sad realization that none of us really knew the candidates plans in depth. I had previously written about Obama's and Clinton's healthcare plans, but that was months ago, and did not include anything about McCain's proposals. Curious, I tried reading a little bit online about the two proposals. I came across an article in the New England Journal of Medicine regarding their positions:

McCain's plan embraces market forces and promotes individually purchased insurance (see red box). Its centerpiece is a change in the tax treatment of health insurance. Currently, workers do not pay taxes on health insurance premiums paid by their employers. The McCain plan would eliminate this tax exclusion and use the revenue generated — projected to be $3.6 trillion over 10 years — to pay for refundable tax credits for Americans obtaining private insurance ($2,500 for individuals, $5,000 for families). Uninsured Americans could use their credits to help buy insurance coverage on the individual market, and workers with employer-sponsored insurance could use theirs to offset the cost of paying taxes on their employers' premium contributions or to purchase coverage on their own.

^{The article discusses Obama's healthcare plan well:}

In contrast to John McCain's emphasis on markets and deregulation, Barack Obama's reform plan relies on an employer mandate, new public and private insurance programs, and insurance-market regulation (see blue box). The core of the Obama plan is a requirement that employers either offer their workers insurance or pay a tax to help finance coverage for the uninsured (some small businesses would be exempt, and others would be subsidized). The Obama plan would also create two new options for obtaining health insurance: a new government health plan (similar to Medicare) and a national health insurance exchange (a purchasing pool analogous to the Massachusetts Connector) that would offer a choice of private insurance options. Both would be open to persons without access to group health insurance or other public insurance, as well as to small businesses that wanted to purchase coverage for their workers. Income-related subsidies would be provided to help lower-income persons afford coverage. And private insurers could not deny coverage because of preexisting conditions or charge substantially higher premiums to sick enrollees: the Obama plan would end medical underwriting according to health status.

^{Admittedly, I am a bit biased towards Obama, but I think I'll discuss my thoughts in a future post after I have had more time to digest their proposals. Anyone out there already come to a conclusion? How does McCain's free market solution compare to Obama's hybrid government / competition plan?}

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Medicine, Teen Pregnancy, and Bristol Palin

The big story this week, after news broke that John McCain had selected Alaska governor Sarah Palin as his running mate (and soulmate, apparently), was that her daughter 17 year old Bristol Palin is 5 months pregnant. As I am currently on my Ob/Gyn rotation, I wondered what additional risks being pregnant as a teenager carries. 

Per the American Academy of Child and Adolescent Psychiatry, teenage pregnancies carry many risks for the teen mother and her child:

Adolescents who become pregnant may not seek proper medical care during their pregnancy, leading to an increased risk for medical complications. Pregnant teenagers require special understanding, medical care, and education--particularly about nutrition, infections, substance abuse, and complications of pregnancy. They also need to learn that using tobacco, alcohol, and other drugs, can damage the developing fetus. All pregnant teenagers should have medical care beginning early in their pregnancy.

Teen pregnancies themselves have been declining in recent years, but have started to rise again:

Teen pregnancy rates in the United States declined steadily from 1991 to 2005—from 60 out of 1000 teenagers in 1991 to 40.5 out of 1000 in 2005. In 2006, however, the teen pregnancy rate increased to about 42 out of 1000. Approximately one-third of young women in the United States become pregnant during their teens. More than 80% of teen pregnancies are unintended and unintentional. The highest teen birth rate occurs in Hispanic women (83 out of 1000 in 2006).

Apparently, the Aleutian women are holding their own. Heh, anyway interestingly, this decline is attributed to sex education, which McCain and Palin oppose: 

Declining teen pregnancy rates are thought to be attributed to more effective birth control practice and decreased sexual activity among teens. The most dramatic reduction in teen pregnancy—23%—has occurred among African American teenagers.

Going back to the baby, it faces risks beyond merely those to its health:

In addition to increased health risks, children born to teenage mothers are more likely to experience social, emotional, and other problems. These problems include the following:

• Children born to teenage mothers are less likely to receive proper nutrition, health care, and cognitive and social stimulation. As a result, they are at risk for lower academic achievement.
• Children born to teenage mothers are at increased risk for abuse and neglect.
• Boys born to teenage mothers are 13% more likely to be incarcerated later in life.
• Girls born to teenage mothers are 22% more likely to become teenage mothers themselves

Overall, a sad situation, one that would strain any family. Hopefully, some will benefit from the increased awareness of the problems of teen pregnancy due to this situation. 

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