Archive for March, 2014

Why Some Colds Won’t Go Away

Thursday, March 27, 2014 // Uncategorized

An informative article on a common malady.

Your Health

Sick Again? Why Some Colds Won’t Go Away

Some people get back-to-back colds, infected by a new virus

By

Sumathi Reddy
  • March 24, 2014 7:02 p.m. ET

    Rhinoviruses are the main cause of the common cold. Science Picture Co./Corbis

    About a month ago Sharon Gilbert was hit with a runny nose, sore throat and a cough. The whole snotty works.

    A few weeks later she thought she had recovered. Then her husband Derek got sick, and bam. “Suddenly I started getting all the symptoms [again] and it was worse,” said Ms. Gilbert, a 61-year-old writer in Charleston, Ill.

    In the winter that seems to have no end in many parts of the country, people like Ms. Gilbert have been plagued with the seemingly everlasting cold.

    That’s partly because the common cold can last longer than many people think—up to two weeks for the principal symptoms and perhaps weeks more for a cough that lingers even after the virus has been cleared away. There’s also the possibility of secondary infections such as bacterial sinusitis.

    And some patients might get back-to-back colds, doctors say. It isn’t likely people will be reinfected with the same virus because the body builds some immunity to it. But people can pick up another of the more than 200 known viruses that can cause the common cold, some of which are worse than others.

    The Cold Facts

    • Adults on average get two to five colds a year, mostly between September and May. Young children can get as many as seven to 10 colds.
    • More than 200 different viruses cause colds, and scientists continue to discover new ones.
    • Colds are most contagious about two days before symptoms start and in the early stages of illness.
    • The average cold lasts two to 14 days. Coughs can linger up to six weeks.
    • Exercise, reducing stress, getting good sleep and hand hygiene can help prevent getting a cold.

    Sources: National Institute of Allergy and Infectious Diseases; Common Cold Centre (Cardiff University); CDC.

    “When you hear people who have the cold that ‘won’t go away,’ those are typically back-to-back infections of which we see a lot of in the cold weather when people are cohorting together,” said Darilyn Moyer, a physician at Temple University Hospital and chairwoman-elect of the American College of Physicians Board of Governors.

    Influenza may get all the attention, but the common cold is the leading cause of doctor visits, according to the National Institutes of Health. Each year, people in the U.S. get about one billion colds, and 22 million school days are lost to the stubborn viruses.

    Experts say adults on average get two to five colds a year; school children can get as many as seven to 10. The elderly tend to get infected less because they’ve built up immunity to many viruses. And adults who live or work with young children come down with more colds.

    Don’t I know it. For more than a month now my family seems to be playing a game of pass-the-nasty-cold. My husband had a cold and lingering cough for weeks, which we suspect he gave to our infant. Finally I succumbed.

    We blamed the purveyor of all germs, our kindergartner. Just as we were all recovering, the infant started day care and brought home a virus and we’re all on round two of apparently a different cold.

    Experts say it’s possible that the carrier of germs—in this case our kindergartner—can infect others without having symptoms himself.

    “At any given moment if we were to swab you…we’d probably come up with five different rhinoviruses sitting in your nose but you’re not sick,” said Ann Palmenberg, a researcher at the Institute of Molecular Virology at the University of Wisconsin-Madison. Rhinovirus is the most common viral cause of the common cold, accounting for 30% to 50% of adult colds, and there are more than 150 strains of it.

    To get infected, the so-called ICAM receptors, which the rhinovirus attaches to in order to enter the nasal cells, need to be open, Dr. Palmenberg said.

    “Rhinos are out there all the time, it’s just a question of when you are susceptible,” she said. Factors such as stress, lack of sleep and people’s overall health can make them more likely to get infected. More than 150 strains or genotypes of the rhinovirus have been identified and researchers believe there are probably many more.

    Rhinovirus replicates best in the relatively lower body temperatures of the upper respiratory area, such as the nasal passages, sinuses and throat.

    Other viruses, such as the less-common adenovirus, can replicate and attach to receptors in the upper and lower respiratory tracts, causing a more serious illness.

    Other viruses—including the coronavirus, respiratory syncytial virus and enterovirus—have also been identified as causing cold symptoms. “The most confounding thing of all is that we still haven’t identified the cause of 20% to 30% of adult common colds,” said Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, part of the National Institutes of Health.

    Sometimes a cold that never seems to end could be a sign of something more serious. A cold may result in a sinus infection, bronchitis or pneumonia. And cold symptoms are at times confused with seasonal allergies.

    A usually dry cough that lingers after a cold is typically due to bronchial hyperreactivity or tracheal inflammation, doctors say. “After you go through an infection in your respiratory system, you can almost have a transient form of asthma where your bronchial tubes are very highly reactive and very irritated and inflamed,” said Dr. Moyer, of Temple University Hospital.

    A review of various studies, published last year in the journal Annals of Family Medicine, found that coughs on average last about 18 days. The report also said a survey of nearly 500 people found that most participants expected a cough should disappear in about a week and believed antibiotics from their doctor would help them. (A big no-no!)

    Some experts believe having one cold virus and a weakened immune system could make catching another virus easier. Because the epithelial linings in the nose are weakened when you have a cold, the broken down mucus-membrane barrier may be more prone to picking up another virus.

    But others suggest that proteins such as interferons, which are secreted during a cold to help fight the virus, may also boost resistance to getting infected by a second virus, according to Dr. Fauci, of the NIH.

    What can a person do to prevent or shorten a cold? Nearly everyone knows someone who swears by taking echinacea or zinc or downing packs of vitamin C.

    But doctors say the evidence isn’t conclusive that any of these remedies helps. Some research indicates that exercise and meditation could help prevent colds.

    The good news is spring is here, at least officially, so the worst of the winter cold season should be over. Come summer, however, a new batch of viruses emerge and you might find yourself saying hello to the pesky summer cold.

    Write to Sumathi Reddy at [email protected]

     

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    Human Growth Hormone Risks

    Wednesday, March 26, 2014 // Uncategorized

    People have long sought the fountain of youth.  There are those that take human growth hormone in the belief that it will retard or reverse the aging process.  As usual, they do so without realizing that there are risks associated with any medication.  It takes long term studies to determine what happens to people who take medications or supplements over prolonged periods of time.  This is an article from today’s Wall Street Journal which outlines some of the risks.

    In the Lab

    Scientists Warn of Risks From Growth Hormone

    Studies suggest healthy older people live longer with lower levels of HGH

    By

    Shirley S. Wang

    March 24, 2014 6:50 p.m. ET

    Analysts expect human growth hormone sales to climb 34% from 2011 to 2018. Associated Press

    Does human growth hormone have antiaging powers? Or does it contribute to heightened cancer risk and earlier death? The complex science in the area suggests the answer is yes to both.

    Growth hormone, a biochemical that helps stimulate cell growth and division, is given to children and teens with low natural supplies to increase their growth. Increasingly, healthy older individuals also are taking it to improve the appearance of skin, increase muscle tone and for other purported benefits.

    Taking growth hormone for antiaging purposes is hugely controversial in the medical community but nonetheless appears to be gaining popularity in parts of the world. The global market for human growth hormone, or HGH, will reach an estimated $4.7 billion by 2018, up from $3.5 billion in 2011, according to Global Industry Analysts Inc., a market research firm.

    New studies published this year, however, offer the strongest indication yet that lower levels of a compound related to growth hormone called insulin-like growth factor-1, or IGF-1, are related to longevity and lower risk of cancer as people reach old age.

    “These studies suggest that growth hormone for healthy aging might not be a good idea,” says Nir Barzilai, an endocrinologist at Albert Einstein College of Medicine in New York City who published one of the papers in the journal Aging Cell in February.

    That levels of testosterone, estrogen, growth hormone and other biological chemicals fall with age is well known among medical professionals. But whether replacing or supplementing hormones is good for the health of an aging individual is a complex question.

    One cautionary tale comes from estrogen replacement, once thought to benefit women post-menopause. Data from a large trial, the Women’s Health Initiative, indicated that giving estrogen to women 50 and older appeared to increase the risk of stroke and perhaps breast cancer.

    That’s because what’s good for young people biologically isn’t necessarily good for older adults. The same hormones may have a different effect across the life span and the outcome may be different, says Dr. Barzilai, also director of Einstein’s Institute for Aging Research.

    HGH prompts the liver and other organs to make IGF-1, which affects many tissues and organs in the body. Studies usually measure IGF-1 rather than growth hormone directly because IGF-1 levels remain more constant.

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    Does human growth hormone have “anti-aging” powers or does it contribute to heightened cancer risk and earlier death? In the Lab columnist Shirley Wang and Reynolds Oklahoma Center on Aging Director William Sonntag discuss on Lunch Break. Photo: Getty

    The Food and Drug Administration has approved many synthetic growth hormone products for treatment of people who need more in their systems. But since 2010 the agency has monitored people receiving treatment due to data suggesting that adults who were treated with HGH during childhood had a 30% increased risk of early death compared with the general population. The FDA continues to believe the benefits outweigh the risks in that population, according to its website.

    Also, even supposed antiaging benefits may not truly be healthy. There’s evidence that the increased muscle from growth hormone doesn’t actually increase strength. Growth of muscle alone due to HGH use won’t necessarily improve functioning if the well-worn neural pathways to the brain aren’t repaired.

    And growth hormone does stimulate cartilage growth, but this can actually cause carpal tunnel syndrome in older people, says William Sonntag, director of the Reynolds Oklahoma Center on Aging.

    There aren’t any randomized controlled trials—and probably won’t be for ethical reasons—that would provide more definite evidence of benefit or harm of use of IGF-1 in healthy older people.

    Few in the scientific community dispute that there are some modest benefits to increasing IGF-1 levels, such as tightening of the skin. There also appear to be cognitive benefits.

    Dr. Sonntag and his colleagues bred mice with the idea of removing an IGF-1 gene—and therefore lowering the amount of IGF-1—in their brains at various ages. They found that mice growing up with a normal amount of IGF-1 who had their IGF-1 levels reduced in later life showed cognitive impairment as a result.

    But the relationship between growth hormone and cognitive function is complex, Dr. Sonntag says. When the group studied mice that lived all their lives with low IGF-1 levels—as some people with genetic mutations are known to do—they showed no cognitive impairment.

    In fact, these mice didn’t show deficits of IGF-1 in the brain. Somehow, it seems, the brain tissue, which also makes IGF-1, compensated for the lower amount of IGF-1 levels circulating in the blood, researchers at Southern Illinois University of Medicine have shown.

    “Although on the surface it looks like reducing IGF-1 is going to be good for us, it’s a lot more complicated than that,” Dr. Sonntag says.

    There also are clear risks involved with higher levels of growth hormone, many scientists say. Among the strongest is cancer. Studies show that lowering IGF-1 by 50% decreases cancer risk significantly and that increased levels of IGF-1 are linked with higher cancer risk.

    Longevity is another area where low growth hormone levels appear to be better than high. Across many species, those with low lifetime IGF-1 levels, including mice, fruit flies and humans, live longer than those with higher levels, a number of studies have shown. But the data isn’t as clear about typically aging people who likely have normal levels of growth hormone growing up but experience age-related decline.

    A new study is among those offering better evidence that lower growth hormone is linked with longevity. Valter Longo, director of the Longevity Institute at the University of Southern California, and his team, published the study in Cell Metabolism in March.

    They found that in those aged 65 and older, people with higher IGF-1 levels showed a fourfold increased risk for cancer and 75% increase in overall mortality compared with those with lower levels.

    “Overwhelmingly the human data and the research and the science will say that, for the majority of people, [taking HGH is] just a bad idea,” says Dr. Longo.

    It doesn’t rule out the possibility that there’s some benefit for some individuals, but generally exercise, muscle training and eating better should be the focus of efforts to improve health, he says.

    Yet this treatment may induce a strong placebo effect.

    Dr. Sonntag recalls hearing from a retired salesman in his 80s who said he had been taking growth hormone and was feeling great because of it. The man also said he exercised regularly and watched his diet. He was in town to take his 101-year-old mother to lunch.

    Moreover, the man was taking pills to stimulate HGH production—which it does in children but not for older people, Dr. Sonntag says. “He had good genes. He was doing the right thing” with exercise and diet, the doctor says. But “he thought it was the growth hormone he was taking.”

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    Most Flu Asymptomatic?

    Tuesday, March 18, 2014 // Uncategorized

    This is interesting. Many people who have the flu have no symptoms and might be infecting other people who then develop symptoms.  this is the summary from Journal Watch followed by the abstract from Lancet.

    Influenza, whether of the seasonal or pandemic variety, is asymptomatic in most people with serologically confirmed infection, according to a study in the Lancet Respiratory Medicine.

     

    Researchers studied five successive cohorts of people in England during the 2006-2011 flu seasons. The cohorts ranged in size from 600 to 3500, and all members provided blood samples before and after each flu season. Their households were contacted weekly to identify flu-like illness and symptoms.

     

    On average, roughly 20% of the unvaccinated had serologic evidence of influenza infection, but up to three quarters of the infected were asymptomatic. The proportions did not vary significantly between seasonal and pandemic influenzas. The pandemic H1N1 strain was associated with less severe symptoms than the seasonal H3N2 strain.

     

    A commentator says an important unanswered question is how much the asymptomatic cases contribute to flu transmission

    Comparative community burden and severity of seasonal and pandemic influenza: results of the Flu Watch cohort study

    Summary

    Background

    Assessment of the effect of influenza on populations, including risk of infection, illness if infected, illness severity, and consultation rates, is essential to inform future control and prevention. We aimed to compare the community burden and severity of seasonal and pandemic influenza across different age groups and study years and gain insight into the extent to which traditional surveillance underestimates this burden.

    Methods

    Using preseason and postseason serology, weekly illness reporting, and RT-PCR identification of influenza from nasal swabs, we tracked the course of seasonal and pandemic influenza over five successive cohorts (England 2006—11; 5448 person-seasons’ follow-up). We compared burden and severity of seasonal and pandemic strains. We weighted analyses to the age and regional structure of England to give nationally representative estimates. We compared symptom profiles over the first week of illness for different strains of PCR-confirmed influenza and non-influenza viruses using ordinal logistic regression with symptom severity grade as the outcome variable.

    Findings

    Based on four-fold titre rises in strain-specific serology, on average influenza infected 18% (95% CI 16—22) of unvaccinated people each winter. Of those infected there were 69 respiratory illnesses per 100 person-influenza-seasons compared with 44 per 100 in those not infected with influenza. The age-adjusted attributable rate of illness if infected was 23 illnesses per 100 person-seasons (13—34), suggesting most influenza infections are asymptomatic. 25% (18—35) of all people with serologically confirmed infections had PCR-confirmed disease. 17% (10—26) of people with PCR-confirmed influenza had medically attended illness. These figures did not differ significantly when comparing pandemic with seasonal influenza. Of PCR-confirmed cases, people infected with the 2009 pandemic strain had markedly less severe symptoms than those infected with seasonal H3N2.

    Interpretation

    Seasonal influenza and the 2009 pandemic strain were characterized by similar high rates of mainly asymptomatic infection with most symptomatic cases self-managing without medical consultation. In the community the 2009 pandemic strain caused milder symptoms than seasonal H3N2.

    Funding

    Medical Research Council and the Wellcome Trust.
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    Electronic Medical Records, the Down Side

    Thursday, March 13, 2014 // Uncategorized

    Patients complain about the physician spending more time looking at the computer than at them.  The following article from Forbes examines the negative repercussions of  the latest attempt to improve medical record keeping.

    Op/Ed 3/04/2014 @ 10:37AM 4,259 views

    Technology Is Interfering With Your Doctor’s Visit – And It’s Driving Physicians Crazy

    In a recent Rand study commissioned by the American Medical Association, doctors said being able to provide high quality healthcare is the primary driver of their satisfaction. However, the study also found the number of factors contributing to dissatisfaction is becoming almost insurmountable.

    Electronic health records (EHRs), widely touted as technological tools to improve patient care, have in fact increased physicians’ workloads and administrative burdens. Additionally, as revealed in that same Rand study, physicians complained that their digital record systems are interfering with face-to-face encounters with their patients. Physicians recognize the over-hyped promise of EHRs – having relevant patient data at the time of visit – and the reality of incomplete information because lab, x-ray, and pharmacy systems are not interoperable. Couple the burden and disappointment of inadequate EHRs with the added obligation of entering data to a patient record at the rate of 30-40 keystrokes per patient, and physicians are left with much less time for real patient care.

    A doctor talks to a patient in a hospital. (Photo credit: iStock)

     

    Yet Washington appears to be convinced that technology is the answer to better care, even when physicians will tell you that better care depends on listening to and examining the patient through their history and physical – albeit technology has a role in diagnosis and confirmation of findings. As Kevin Pho, MD recently pointed out, and confirmed by many physicians we know, they often have to spend more time “checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients.”  More time in front of computers equals less time for patients.

    In fact, a study in the American Journal of Emergency Medicine found that emergency physicians spent 43 percent of their time entering data into a computer, compared to only 28 percent of their time spent talking to patients.  It went on to say that “during a typical 10-hour shift, a doctor would click a mouse almost 4000 times.”

    In his new autobiography[1], U.S. Defense Secretary Robert M. Gates makes reference to how the Defense Department was so enamored with technology that it undervalued its most important asset – human intelligence. Perhaps the federal government still has not learned this lesson on the domestic side. The Department of Health and Human Services values EHR technology and its role in the doctor’s office – referred to as meaningful use – as the standard of care; thereby undervaluing our most important asset – the physicians’ knowledge, education, training, and intelligence. The physician is demoted to a keyboard operator so that the government’s Holy Grail – personal information – can be entered into its massive database. Given its track record in protecting personal and confidential information, the public has much to fear from medical and health data collection by the federal government.

    But EHRs are saving money, so it’s worth it, right? Not exactly. The once predicted cost savings due to EHRs is somewhat in question today.  As Dr. Pho points out, a 2005 Rand Corporation analysis predicted that they would save $81 billion annually.  Admittedly, those numbers were overstated.

    Another area that impacts overall physician satisfaction is practice setting. The Rand study confirmed that physicians want to work with and for other physicians, as well as for hospitals. However, hospitals take away physicians’ clinical autonomy and try to control the content and time spent with each patient. Physicians, meanwhile, understand the need to treat each patient individually and not as just another number in the hospital’s panel of enrolled patients. Unfortunately, the trend is toward hospital employment with productivity quotas and severe limits on the time a physician may spend with the patient.

    Deloitte reports that the number of physicians directly employed by hospitals increased 45 percent from 2000-2010. Further complicating the picture is the fact that hospitals can lose up to $250,000 per year per employed physician. But this has not stopped the hospital systems’ bull-rush to employ as many physicians as possible. According to Rand, excessive oversight by the hospital system is a major contributing factor to physicians’ dissatisfaction and lost productivity. In fact, physicians find that the contracts they sign with hospitals turn out to be so unreasonable that a majority leave after their two- to three-year term expires. This creates significant continuity of care and access problems for the patients at the employing hospital system.

    Rand makes clear that money doesn’t drive physicians, but income stability and fair treatment from payors, including the government, substantially improve their satisfaction. Ask any patient care physician what his or her goal is, and the answer invariably will be, “To provide the best possible care and outcome for my patient.” And this is why the new era of government mandates, rules, and regulations is detracting from medicine’s primary mission. It is not about collecting the most patient information and personal data possible; it is and always has been about providing care and cure. Somehow this simple, yet basic principle has been lost along the way of building massive, impersonal systems with layer upon layer of red tape and hassle.


    [1] Robert M. Gates, Duty: Memoirs of a Secretary at War (New York: Alfred A. Knopf, 2014).

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    What Would You Do, Doctor?

    Tuesday, March 4, 2014 // Uncategorized

    A poignant essay from this week’s Journal of the AMA (JAMA) in which the physician, Dr. Rebekah Mannix, describes old school, paternalistic medicine versus new school, shared decision making.  She describes being torn between the two.  Her aside about the attitudes of recent graduates is spot on.” What do graduating residents worry about most when assuming their first professional job?6 The availability of free time. ”  I agree with her.  We don’t do our patients a service by sitting on the sidelines.  We have to have some skin in the game.

    A Piece of My Mind | March 5, 2014

    What Would You Do, Doctor?

    Rebekah Mannix, MD, MPH1
    1Division of Emergency Medicine, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts

     

    JAMA. 2014;311(9):911-912. doi:10.1001/jama.2014.910.

     

     

    The first time I remember hearing, or perhaps really feeling, this question came when I was a junior resident in pediatrics. By then I had assembled a small cohort of primary care patients for whom I truly felt responsible. With the initial shock and blind ignorance of intern year behind me, I had begun to understand my role in guiding my patients through a healthy childhood, or at least navigating through a complex medical system. One patient, Alek, was a sweet 4-year-old boy, whose parents had emigrated from Albania in the hopes of improving his medical condition. Alek was missing a small part of chromosome 4, which resulted in a host of problems including development delays, seizure disorder, vision problems, and chronic aspiration. He couldn’t speak and barely walked. He was happy, bubbly, and beloved. His mother and father would bring him to his clinic appointments dressed in their Sunday finest—he in a navy blue sweater with a cartoon character emblazoned on the front, his mother in a long flowery dress with boots, and his father in a tie. They always brought me some sort of gift, a box of candy or Alek’s preschool picture in the same navy blue sweater he wore to his appointments. I still have that picture in my desk.

     

    But now Alek was gravely, irretrievably ill. What started off as an ear infection progressed to meningitis, then a head bleed, then cardiopulmonary arrest. I had visited him frequently during his 1-month hospitalization, watching his parents slowly lose hope for the return of their sweet boy, their only child. Now, we sat in a team meeting, with the ICU attending, the neurology attending, the coordinated care attending, an ethicist, me, the Albanian interpreter, and the family. The situation was dire, the interpreter relayed to the family, there was little hope for recovery. The MRI and EEG done the night before bore no good news. Alek would likely never come off the ventilator. The question before the family was, do you want to redirect care, extubate him, and let “nature take its course”?

     

    And so, with this room full of senior physicians and experts, the family turned to me, their junior resident primary care physician, and asked, “What would you do, Doctor?”

     

    Having been a physician for only 1 year and not having suffered many personal losses or hardships of my own at that time, I paused, but only briefly. A question was asked, and I would answer it, with an untroubled assurance that 14 more years of life and medicine would later erode.

     

    “I would let him go.”

     

    I may have heard a quiet gasp from someone in the room. The ICU attending stared at me (with approval? with horror?). Alek’s parents nodded, reached out their hands to me, bowed their heads, and agreed to have the breathing tube pulled. He died later that day.

     

    Two months later, I saw the Albanian interpreter in the elevator. He told me that Alek’s parents weren’t doing so well. They felt like they had killed Alek by allowing the breathing tube to be pulled. I felt sick. One year later, when I was finished with residency, I got a call from Alek’s parents saying they had a new baby, and would I be her primary care physician. I still felt sick.

     

    Since Alek, I became much more circumspect in how I answered the question “What would you do?” Often, I would explain how every individual is different, laying out the pros and cons of the intervention in question. I would cite medical evidence, calculate risks, and defer decision-making to families when neither the evidence nor risks strongly favored a single course of action, even if I felt strongly about the best course of action. This, I felt confident, was patient-centered care. I understood and agreed that when dealing with “questions of value,” physicians should view their role as “facilitative rather than directive.”1 On any given emergency department shift, I could be heard reciting the following mantra to my patients and their families: “You are flying this plane. I am only helping you navigate.”

     

    My 84-year-old mother hates physicians like me. “Why don’t doctors tell patients what to do anymore?” She is stymied by the choices offered her and doesn’t feel a 10-minute office visit and the information relayed therein is an adequate surrogate for medical school and years of practice. More than occasionally, she will complain to me, “How should I know if I really need to have a heart catheterization or not” or “Why do I have to decide if it’s time to stop taking my blood pressure medications?” I reassure her that while the doctors are medical experts, she is the only “her” expert, and the medical decision-making has to be shared. Unconvinced, she shrugs. I further explain to her that medicine is no longer the paternalistic discipline it once was. She then asks, “What’s wrong with paternalism?”

     

    This generational divide likely cannot be breached. Gone, and thankfully so, are the days of House of God, where a medical “deity” decides the fate of his (yes, his) patients. We have certainly evolved from the days of this type of paternalistic medicine, this covert and mysterious practice of healing. In the modern era, the vast majority of physicians would never hide a cancer diagnosis from their patient, in contrast to mid-century medicine, when a physician survey demonstrated that 90% of physicians would not tell their cancer patients their diagnosis.2 But this open practice of medicine is not so easy, because now physicians are saddled with not only what to tell their patients but also how to tell them. And in an era of conflicting forces (increasingly complex patients vs 10-minute appointments, Google searches vs evidence-based medicine, cost-effectiveness vs personalized medicine), curating the how and what of disseminating information to our patients is almost mind-numbingly complicated.

     

    To add to this complexity, even our ethicists can’t decide what Alek’s parents were really asking me, let alone whether or not I should answer.1,3– 5 Were they asking for my expert opinion? Were they asking me to validate their own? Were they asking me just to decide for them? These questions are relatively new ones and have flourished in our era of patient-centered care. With decision-making and responsibility evenly distributed between physician and patient, physicians can let their patients carry more of the burden. We can choose not to answer, or sidestep, or redirect the question. But I wonder, is it just as paternalistic to reinterpret the question as it is to just answer it?

     

    Perhaps my mother’s disdain of the modern model of shared medical decision-making reflects something else missing from our current practice of modern medicine. Perhaps my mother subconsciously objects to what feels like diminished physician personal ownership and responsibility in our nonpaternalistic practice, our what I call “emotional work hours.” Our time is rationed, our care is rationed, and our emotions are rationed. What do graduating residents worry about most when assuming their first professional job?6 The availability of free time.

     

    Maybe the paternalistic era of medicine did offer our patients some advantages. Aside from the unwanted hierarchical implications, the word paternalism does imply not only a relationship between physician and patient, but also a deep responsibility of the physician to the patient. Perhaps when our patients ask us “What would you do, Doctor?” they are asking us to put some skin in the game, to really care about the outcome as if it were our own.

     

    Recently, I have been forced to witness modern medicine from the perspective of a family member. The truth is, I don’t know how nonphysicians, ie, most of our patients, navigate the medical system as well as they do. When my husband was diagnosed with pancreatic cancer, we faced an initial onslaught of choices that I was intellectually if not emotionally well equipped to make. I didn’t need or want much input from his primary care physician, and, in the decisive (and some would say impulsive) way that emergency medicine physicians often have, I chose a hospital, a surgeon, and an oncologist within a day or so of the diagnosis. We plunged forward, my husband with blind faith and me with manic purpose. Now that his disease has progressed, I need more help navigating the choices. We are lucky in that Dr K, my husband’s oncologist, is not only a kind and thoughtful man, but a man who really knows his stuff.

     

    So, as we sit in Dr K’s examination room, we hear a well-rehearsed litany of choices. There is the possibility of ablation for the hepatic metastases, followed by octreotide therapy. Resection may or may not be an option. VEGF and mTOR inhibitors may also be in play. Liver transplant is out. As we listen to our choices, I look at my husband, who appears perplexed. It’s too much for his layman’s ears, and despite the gravitas of the situation, his eyes are beginning to glaze over. I know what I would do, what I want to do. But that’s not what my husband wants to hear, what he needs to hear. I know it’s not fair and I feel sorry for Dr K, but I lean in anyway, and ask what needs to be asked: “What would you do, Doctor?”

    ARTICLE INFORMATION

     

    Section Editor: Roxanne K. Young, Associate Senior Editor.

     

    Corresponding Author: Rebekah Mannix, MD, MPH ([email protected]).

    Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported.

    REFERENCES

     

    1 +
    Truog  RD.  “Doctor, if this were your child, what would you do”? Pediatrics. 1999;103(1):153-154.
    PubMed   |  Link to Article
    2 +
    Oken  D.  What to tell cancer patients: a study of medical attitudes. JAMA. 1961;175(13):1120-1128.
    PubMed   |  Link to Article
    3 +
    Gutgesell  HP.  What if it were your child? Am J Cardiol. 2002;89(7):856.
    PubMed   |  Link to Article
    4 +
    Ross  LF.  Why “doctor, if this were your child, what would you do?” deserves an answer. J Clin Ethics. 2003;14(1-2):59-62.
    PubMed
    5 +
    Ruddick  W.  Answering parents’ questions. J Clin Ethics. 2003;14(1-2):68-70.
    PubMed
    6 +
    2011 Survey of Final-Year Medical Residents. http://www.merritthawkins.com/pdf/mha2011residentsurvpdf.pdf. Accessed January 12, 2014.
    Copyright ©2014 American Medical Association
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