February 8, 2010
Category: Medicine
There's a prosecution going on in Texas that sounds so corrupt, and could have such a chilling influence on the pursuit of quackery nationwide, that it cannot be ignored. I urge you to read the story in the Times, but here's a brief recap.
In Kermit, a small Texas town, two nurses at local hospital became concerned about the practices of one of the physicians, Dr. Rolando G. Arafiles, Jr. Among the alleged practices were the improper peddling of herbal medicines to hospital patients, and the performance of (sometimes unorthodox) surgical procedures without the appropriate privileges to do so. Anne Mitchell, RN, the nurse against whom charges are still filed, went to the hospital with her concerns and was fired, an act for which state reprimanded the hospital. Given the lack of response from the hospital, she went to the state medical board. When Dr. Arafiles found out that there was a complaint against him, he went to a local sheriff buddy of his, who tracked down the confidential report to the state medical board, and used the information in it to deduce the identity of the filers.
And then he charged them with a crime.
The alleged crime was a trumped up bullshit charge for misuse of state data---which is impossible, since the nurse used the hospital data to refer cases to the state medical board. I'm not a lawyer, but it's hard to see what could possibly be wrong with what Mitchell did.
In fact, the nursing code of ethics specifically requires nurses to advocate for patients, including going to higher authorities when necessary.
There is no "rule" that a code of ethics must square with all laws. In this case the ethical code probably does agree with the law, at least the spirit, and probably the letter.
Reading about the actions of these local officials is like watching Blazing Saddles---it's a small town, with a few people in control of everything, and willing to contort the meaning of the law into any shape they wish. If it weren't for the real people involved, it would almost be funny.
Read on »
Posted by PalMD at 1:22 PM • 21 Comments • 0 TrackBacks
February 4, 2010
Category: Medicine
I recently raised some questions about narcotic therapy contracts and my readers raised even more issues. Some of these questions deserve further discussion.
First, despite the examples I gave, when I'm speaking about narcotic contracts I am talking about people chronically on narcotics. I don't normally use contracts for people with self-limited problems. That doesn't mean these patients aren't susceptible to the same problems as long-term users of narcotics, but the thinking is (based on what data, I don't know) that people with a clear, self-limited, anatomic problem, such as a kidney stone or broken hip, are less likely to develop a substance use disorder (depending of course on their baseline susceptibilities to such problems). This assumption may be complete and utter bullshit, and certainly there are people who become addicted after using narcotics for self-limited problems. Still, it seems (from crappy, anecdotal experience) that it's people with vague, chronic pain that end up causing health care providers the most problems.
Second, despite reservations I may have, and other cogent points made by my readers, I'm not about to stop using this tool. It may be a blunt instrument, but it's what we've got for the time being. Even though we may recognize that these contracts may do more to protect providers than patients, and that narcotic use is not entirely volitional, these contracts serve an important purpose. They recognize that narcotics are not like other drugs. While someone may be dependent on insulin, they do not engage in illegal behaviors to obtain it, and they do not end up using it for that yummy insulin high. They do not grow to crave it.
Read on »
Posted by PalMD at 5:13 PM • 37 Comments • 0 TrackBacks
Category: Medicine
Medicine has traditionally been full of hierarchies. Employees' uniforms make their role easy to identify: one color for radiology techs, another for secretaries, etc. When I was a resident, medical students wore short white coats, residents long blue coats, and attendings long grey coats.
Medicine is also a traditionally male-dominated field, and despite the fact that a small majority of medical students are female, the higher academic and administrative positions are still male-dominated.
Nursing, on the other hand, is traditionally female. Nurses, despite their indispensable role in health care, are traditionally subordinate to doctors, a role made explicit by doctors giving "orders" and nurses following them.
Nurses have taken on a much more complex and diverse set of roles over the last several years. Critical care nurses and nurse anesthetists are some of the most highly trained and highly skilled of medical professionals.
So how come nursing students wear white, see-through scrubs?
Read on »
Posted by PalMD at 2:44 PM • 22 Comments • 0 TrackBacks
February 3, 2010
Category: Medical ethics • Medicine
I'm heartened by the discussions of medical ethics arising out of The Immortal Life of Henrietta Lacks. From reading and listening to interviews with writer Rebecca Skloot, and from my brief conversations with her, I know that medical ethics were very much on her mind during the ten years it took her to create the book. If you read the book, you will see that she was also very concerned that she not be just another exploiter of the Lacks family. That's one reason comments such as this one are disturbing----and at the same time not really disturbing at all. It helps to highlight the amount of distrust the scientific community has managed to bank.
(As a reminder, Henrietta Lacks was an African American woman who died of cervical cancer in the 1950s and whose cancer cells, taken without her explicit consent, became one of the most important tools of modern biology.)
We've all benefited from research made possible by Henrietta Lacks and countless others whose names have been forgotten. The amount of distrust we've banked with the public over the years is considerable, and will take a long time to mitigate. But there are many reasons to try to improve our trust balance sheet, not the least of which is our own self-interest.
But let's back up a bit and get a little deeper into how we understand medical ethics.
Read on »
Posted by PalMD at 4:54 PM • 9 Comments • 0 TrackBacks
February 1, 2010
Category: Medical ethics • Medicine
Treating patients with narcotic analgesics is not simple. Narcotics can be very effective at relieving pain, but they come with a whole set of problems, including risk of adverse effects such as nausea, constipation, and altered mental status; overdose; and dependence. As I've written before, narcotic-dependent patients can be a challenge to treat. One of the tools we use is the "narcotic contract", a document which explicitly states the rights and responsibilities of the health care provider and the patient (although in practice, it tends to put more emphasis on the rights of the provider and the responsibilities of the patient). Two typical examples of such contracts can be found here and here.
Read on »
Posted by PalMD at 2:12 PM • 39 Comments • 0 TrackBacks
January 31, 2010
Category: Medical ethics • Medicine
This is a special shout out to the doctors and scientists out there. Everything we do in our fields has repercussions, often unexpected ones. Because of this, we strive to practice ethically to help prevent or minimize negative repercussions.
This discussion comes up specifically as an epiphenomenon of the release of The Immortal Life of Henrietta Lacks (my full review can be found here.) How one reacts to this book would, I suppose, depend on your perspective. A neighbor of the Lacks's might react quite differently than a 22 year old doctoral student. And that's really the point.
This book should be required reading for young scientists and medical students. Ethical practice is important because it recognizes the fact that many negative outcomes are unexpected, and that we as physicians and scientists cannot always anticipate these negative outcomes.
It's good to see some of the comments appearing online about the book, even though many of these are from folks who haven't read it (it's being released on February 2nd). It's natural to become defensive when your beliefs are questioned. Some of the more interesting comments appeared at Ed Yong's place. To catch you up, HeLa is cell culture used in labs around the world. It was derived from a young woman named Henrietta Lacks, a woman dying of cervical cancer in a segregated hospital in 1950's America.
I have to say I completely disagree. Cell lines are derived from Humans on a regular basis, I use cells from a man who died from colon cancer and a young girl who had neuroblastoma. What exactly is the issue here? Would this fuss be made if she hadn't been black and poor? I doubt it.
Her cells were useful but they're not unique and why should her family get money for her cells when other families don't? I've read an article by the author of this book and it was self aggrandising overblown nonsense.
Trying to conflate the real racially motivated problems in the US with this type of cancer research is just insulting to everyone involved, in my opinion.
Read on »
Posted by PalMD at 1:02 PM • 7 Comments • 0 TrackBacks
January 30, 2010
Category: Narcissistic self-involvement
It's a cold day here in Lake Woebegone southeast Michigan. I'm looking out the kitchen window at the thermometer: +11 F, which is apparently the same -11 C. From my kitchen table, I can see the neighbors let out the dog, who seems unfazed by the cold. He's some sort of little fuzzy white dog and he's currently sniffing happily. It's not quite cold enough for the air to have that extra clarity you see when it gets really cold, but I'm still not rushing outside.
It's pretty cold upstairs. We probably need to replace more of the windows, and I'm not so sure about our insulation, so we were cozily nested deep under the covers, sleeping the way you do when the air is cold and the bed is warm. This is, until there was a little knock on the door, and suddenly a third body in the bed saying, "I'm hungry I'm bored can we play I'm hungry can I have waffles now how come you're not saying anything?"
So now I'm down at the kitchen table, watching the neighbor's dog sniff around the trees. I'm drinking and enjoying my coffee (I can quit any time, really), and waiting for my Irish oatmeal to finish cooking so that I can pour some Michigan maple syrup over it.
If you are not blessed to live in a part of the country that makes maple syrup, you need to go find some. I don't know what's in those other syrup bottles (OK, I do, I just don't like to think about it), but real maple syrup started out in a maple tree in the late winter/early spring when a Michigander pounded taps into his maples and hung buckets on them, collecting the sap (unless he has one of those fancy vacuum systems). He collected the buckets, poured them in a vat, and cooked it down, filtered it, and bottled it. Now I'm eating it.
At some point I'm going to head out into the cold and make my way to the hospital, but meanwhile, it's coffee and oatmeal time.
In other news, I've posted my review of The Immortal Life of Henrietta Lacks. I posted it over at another site because I'm experimenting with reaching out to other audiences. I already have one post about the book here, and I hope to post more, since this is one of the best medical history books I've read in a while.
Happy wintry Saturday!
Posted by PalMD at 8:44 AM • 15 Comments • 0 TrackBacks
January 27, 2010
Category: Medicine
"...It never was our guise
To slight the poor, or aught humane despise:
For Jove unfold our hospitable door,
'Tis Jove that sends the stranger and the poor..."
---Homer: The Odyssey, Translation by Alexander Pope
A few weeks ago,
Drugmonkey wrote a piece about perceptions of drug users. Specifically, the study looked at how mental health providers perceive people with substance use disorders depending on whether the patients were referred to being a "substance abuser" vs. having "a substance use disorder." These data revealed something interesting. Among the mental health professionals:
...those assigned the "substance abuser" term ... were significantly more in agreement with the notion that the character was personally culpable for his condition and more likely to agree that punitive measures be taken...
[...]
[they were more likely]...to convey internal causal attribution and personal culpability, a moral vs. medical solution, suggesting the character has volitional control and might be viewed as a "perpetrator"who is willfully engaging in the behavior and thus more deserving of punishment.
I would not be surprised if these results were reproducible in primary care physicians. People with substance use disorders can be difficult to care for even before we layer on our own prejudices. Anecdotally speaking, substance abusers can be needy, stubborn, and narcissistic. They can behave inappropriately and show little respect for boundaries. These behaviors set off a whole set of reciprocal behaviors in providers. If a patient demands a narcotic medication, the reaction is often to become angry and say "no" without responding to the underlying pathology (not, that is, the pathology of the back pain, but the narcotic dependence).
This phenomenon has been
documented in various ways over the years but I've found little in recent literature examining physicians' attitudes toward people with substance use disorders. Today, though, I found an interesting article just published in the journal
Addictive Behaviors which looked specifically at doctors' attitudes toward prescribing opiates in patients with a history of substance abuse. The study's findings resonated with me, and I suspect they would with many doctors.
Read on »
Posted by PalMD at 7:00 PM • 32 Comments • 0 TrackBacks
Category: Narcissistic self-involvement
I'm hard on hardware, apparently. My current computer, an hp tablet, is falling apart. I need to start thinking about replacement. Cost is the number one issue, so I was thinking about an Acer or a Dell Mini or similar product.
I use my computer all day, every day, for work and for writing. My hospital and my office use IT systems that requires Windows.
So, geeky folks, I need some suggestions. What have you folks found to be useful and economical?
Posted by PalMD at 1:46 PM • 35 Comments • 0 TrackBacks
PalMD is a practicing internist in the Great Lakes region of the U.S.. Aside from the great joy he finds in his family and his work, he likes communicating some of that joy to others. He has a special interest in the ways patients---and we are all patients at one time or another---are deceived by charlatans. He aims to change the world, one reader at a time. Previous writings can still be found 
