I've heard it said that the internet is 90 percent pornography and 10 percent bad medical advice.   The more I go down the rabbit hole of popular medical sites, the more I wonder if the balance is tipping away from sex.  There are plenty of absolutely bat-guano crazy quasi-medical websites, some of which actually advocate violence in support of their odd ideas.  Of more concern though are popular medical websites giving seemingly benign advice, much of which is wrong or so simplistic that wrong is too kind a word.

Dr. Mehmet Oz's website is popular.  It doesn't get as much traffic as WebMD or MayoClinic but between his website and TV show, he has a lot of reach and influence.  As I mentioned a few days back, I'm skeptical of much of what I've found so far at his website. Today I went over there and found an interesting link: 5 SURPRISING WAYS TO LIVE LONGER IN UNDER A MINUTE.

Before we explore his suggestions, let's talk a little bit about living longer.  As an internist, a big part of my job is helping people live longer and better.  If you want to get the most bang out of your longevity buck, there are a couple of ways to invest wisely.  Most Americans die of heart disease, stroke, cancer, or accidents.  Many of these deaths are preventable, and we've gotten pretty good at guiding people away from premature death.  Helping people stop smoking, controlling cholesterol and blood pressure, and treating diabetes are all relatively simple, inexpensive, and effective.  But these interventions require a real commitment by patients, and people are often looking for easier answers.  Dr. Oz provides those answers, despite their lack or utility or veracity.  According to Oz:

You can’t live forever. However, there are things you can do to live longer and in better health. Increasing longevity is much easier than you think. Here’s the really good part: all of these health habits can be accomplished in less than one minute.

First up, eat eggs.  He gives a number of reasons to eat eggs, many of which are unsupported, and none of which help prevent the main causes of death in Americans. His advice: "Under-a-Minute Tip: Boil a half-dozen eggs in the beginning of the week. Eat one a day and you’re on the road to making a dramatic difference in your health."  I like eggs just fine, but they are food, not medicine.  As part of a healthy diet, one based mostly on plant materials, they can be just fine, but for most Americans, adding an egg-a-day to the diet will not have a dramatically good effect on health.

Next he suggests taking chromium polynicotinate to help prevent diabetes. There is little data on this dietary supplement. Most of the data available for chromium are on the related substance chromium picolinate, and those data are not terribly favorable.  There are, however, strong data to support proper diet and exercise for the prevention of diabetes.

Third up, checking your heart rate.  His suggestion: "Take your resting heart rate before you get out of bed every morning. If it is high or keeps going up every month, see your doctor."  That's not a terribly helpful suggestion, but I'm always happy to see someone to go over cardiac health.

Next up, beets.  I do like beets, especially roasted with a little salt and pepper.  Many people don't think of beets, which are a great choice in trying to develop healthier eating habits.  But they aren't particularly miraculous.  They're just a veggie, despite Oz's claims about them "dilating blood vessels", whatever that may mean.  His tip? "You can drink your beets daily in a nutrient-packed beverage that also contains carrots, parsley and apples. It’s easy and inexpensive to make."  Or you could eat them as part of a balanced meal, one whose calories are supplied by different food groups in a satisfying and healthy way.

Finally, Oz reminds us that stress is bad, and that women like to hold stress in their head and face.  I have no idea what, from a medical perspective, that means, but he recommends self-massage, something I could never argue against, unless it were promoted as life-saving or longevity-enhancing.

It's disappointing to see an influential and obviously bright doctor giving out platitudes rather than real medical advice.  As Stan Lee apparently wrote, with great power comes great responsibility.  I wish Dr. Oz would wield his power more carefully.

Dr. Mehmet Oz is one of America's most influential doctors.  Just ask him.  He has a TV show and everything.  And in the past, much of his advice had been practical and mundane, the same advice you might hear from your own (perhaps less charismatic) physician.  But lately, he's been giving out frankly bizarre medical opinions.  Not all of Oz's recommendations are over-the-top strange, but even some of his less-bizarre stuff is hyperbolic to the point of being---in my opinion---deceptive.  Let's explore one example close to my heart, diabetes.  As an internist, one of my most important tasks is the prevention and treatment of diabetes.  I know something about it.  As a heart surgeon, Dr. Oz deals with one of the most serious complications of diabetes, coronary heard disease, so he must know a bit about it as well.

So I was a bit surprised to learn from his website that I've  been going after diabetes the wrong way.  Unknown to me is the "prevention powerhouse" of coffee and vinegar.  He recommends heavy consumption of these miracle foods to prevent diabetes and to help the liver and cholesterol, whatever that means.  Reading this, two questions come to mind (a few more, really, but two that we will focus on): is this plausible, and is this true?

There are a few epidemiologic studies that support the idea that coffee consumption is in some way associated with diabetes risk.  (For a bit of background on different types of studies, see here and here.)  There are a few bits of basic science that could explain this relationship, if it turns out to be causal.  But these large studies simply show relationships.  They have found that people who drink more coffee (regular or decaf) were less likely to develop diabetes during the study period.  Most of these studies tried to control for confounding variables (for example, caloric intake) but none of these truly shows cause and effects.

The two biggest potential problems here are recall bias and confounding variables.  Do people reliably report the data we ask them to?  We aren't directly measuring it, so this is critical.  Do coffee drinkers simply have smaller appetites?  Or other habits that reduce the risk of diabetes?  These studies give us an interesting starting point.  The next step to look for actual cause and effect would be a randomized controlled trial (which obviously could not be double-blind), that takes non-diabetics and randomly has half drink coffee and half abstain, and follows them over a several year period.   The idea that coffee can affect blood glucose metabolism and the development of diabetes is not nuts, but the available data don't allow us to go any further than that.

The data support the plausibility of the question of coffee and diabetes, but not the truth of the statement.   But let's pretend it is true.  The next questions are are how much risk reduction is there, and at what cost?

We know that some drugs and proper diet and regular exercise reduce the risk of diabetes.  How do these interventions compare with coffee or vinegar?  Is one of them 100 times more potent than the other?  One thousand?  One fifth?  And what are the hazards of caffeine consumption?  Not that great in general (and lessened by drinking decaf), but even small amounts of caffeine can cause significant acid reflux, sleep problems, heart palpitations, headaches.

What Dr. Oz is suggesting is using an unproven drug (coffee or dilute acetic acid) that isn't needed.  We have safe, effective ways to prevent diabetes.  Our biggest failure is in providing people with the education, health care, and other tools to follow through.

References

Salazar-Martinez E, Willett WC, Ascherio A, Manson JE, Leitzmann MF, Stampfer MJ, & Hu FB (2004). Coffee consumption and risk for type 2 diabetes mellitus. Annals of internal medicine, 140 (1), 1-8 PMID: 14706966

VANDAM, R., & FESKENS, E. (2002). Coffee consumption and risk of type 2 diabetes mellitus The Lancet, 360 (9344), 1477-1478 DOI: 10.1016/S0140-6736(02)11436-X

Tuomilehto, J. (2004). Coffee Consumption and Risk of Type 2 Diabetes Mellitus Among Middle-aged Finnish Men and Women JAMA: The Journal of the American Medical Association, 291 (10), 1213-1219 DOI: 10.1001/jama.291.10.1213

van Dam, R. (2006). Coffee, Caffeine, and Risk of Type 2 Diabetes: A prospective cohort study in younger and middle-aged U.S. women Diabetes Care, 29 (2), 398-403 DOI: 10.2337/diacare.29.02.06.dc05-1512

Pereira MA, Parker ED, & Folsom AR (2006). Coffee consumption and risk of type 2 diabetes mellitus: an 11-year prospective study of 28 812 postmenopausal women. Archives of internal medicine, 166 (12), 1311-6 PMID: 16801515

Dam, R., Dekker, J., Nijpels, G., Stehouwer, C., Bouter, L., & Heine, R. (2004). Coffee consumption and incidence of impaired fasting glucose, impaired glucose tolerance, and type 2 diabetes: the Hoorn Study Diabetologia, 47 (12), 2152-2159 DOI: 10.1007/s00125-004-1573-6

The ICU can be a terrifying place for an intern.  Of course, the patients are probably a bit more frightened, but then, many of them are unconscious.  Rounds are endless in the ICU; new admissions, work rounds, teaching rounds, evaluations for transfer, afternoon rounds, lasix rounds (don't ask), all punctuated by CPR codes on the floor, and your own patients trying their hardest to die.

One of the more sobering ICU experiences is the gastrointestinal (GI) bleed.  One night while making some sort of middle-of-the-night rounds, I saw a patient sitting up in bed watching TV.  She was middle aged, hair done but mussed from plasticized hospital pillows, and quite awake.  I grabbed her chart and stopped in, happy to have someone conscious to talk to.  She came to the hospital when she noticed dark black stools, and in the ER she was found to have a low blood count.  But she looked fine, and given how busy our ICU was, I wondered how the hell she warranted a bed.

We chatted casually for a bit about nothing in particular, she as happy as I to have someone to talk to, and in mid-sentence her eyes rolled back and her telemetry alarms went off.  Her blood pressure tanked, her heart rate soared, and she was clearly in shock.  Just like that: fine one moment, dying the next.  Thankfully, we saved her, but that taught me a valuable lesson: every GI bleed is potentially life-threatening, at least until you have a good idea about what's going on inside the patient.

The gut, from mouth to anus, is a continuous tube, and a long one.  Blood can come from any part of it, but some problems are more common and some more dangerous than others.  In general, we tend to divide GI bleeds into "upper" (from the mouth to upper part of the small intestine) and "lower" (all the rest).

Human Digestive Tract

This division helps us develop a differential diagnosis, a list of possible causes of the problem.  In general, upper GI bleeding shows up in vomitus either as red blood or as vomit mixed with "coffee-grounds".  If the blood makes it all the way through, it generally turns black and comes out as black, tarry stool (melena).

Lower GI bleeding generally shows up as bright red blood from the rectum.  The list of potential diagnoses is huge, but a few of them are most common.  Upper GI bleeds are often the result of ulcers, and lower GI bleeds are often caused by diverticulosis, arteriovenous malformations, or growths, either benign or malignant.

Once we manage to stabilize a patient, which often involves transfusion of saline and/or blood, we can take a look into the stomach and the colon via endoscopy.  Usually we can find a cause, but in somewhere between 5-25% of cases, endoscopy doesn't give us an answer.

EGD, or esopaphagogastroduodenoscopy, allows direct visualization of the upper GI tract.  Not only can an expert take a good look around, but she has many tools for stopping ongoing bleeding, including cauterization and injection of drugs.  All of this can be done without opening up a patient.

The same specialist can do a colonoscopy, where a scope is passed from the rectum all the way to the cecum, where the small intestine meets the large.  But these two procedures leave a lot of gut unexplored.  Sometimes an specialized EGD can be used to look a little bit further into the small bowel, but for the most part, the small bowel is a dark zone when it comes to direct visualization.   If the bleeding is bad enough, and a source isn't found by scope, the surgeons can dig in and try to locate and stop the bleeding, but people with hemorrhagic shock are not the easiest to operate on.  They can develop blood clotting disorders, and start bleeding from literally everywhere.

The gold standard for identifying severe, obscure GI bleeding is angiography.  A catheter can be threaded into the arterial system, dye can help localize bleeding, and then the bleeding can be stopped using various angiography-related techniques.  This is very invasive, and only useful during severe bleeding. We have two other high-tech, relatively non-invasive tools to look for obscure GI bleeding: tagged red blood cell scan, and capsule endoscopy.  In tagged RBC scans, RBCs are literally tagged with a radioactive isotope and if there is enough bleeding, the radioactive RBCs can be detected by the appropriate equipment.  This technique has several limitations.  Another technique is capsule endoscopy.  This one is pretty cool.

In capsule endoscopy, the patient swallows a small capsule with a camera inside.  This is then, um, recovered, and the films viewed.  It can be quite successful.  Another new technique, called "push enteroscopy", can also be quite effective, but requires very specialized training and a lot of time.

As I proofread this piece (not all that carefully...why change now?) I'm wondering what the point here is, and I suppose it's this:

The human body is full of surprises, and so is human invention.  In my career I've watched several people bleed to death, and I'll never be able to erase those memories.  Properly-developed medical technology saves lives, and techniques available today would have saved some of the people I've seen die, people whose blood drawn into a syringe looked  like dilute cranberry juice before their hearts stopped, people who complained about how cold they felt as they died of shock.

References

CAVE, D. (2005). Obscure Gastrointestinal Bleeding: The Role of the Tagged Red Blood Cell Scan, Enteroscopy, and Capsule Endoscopy Clinical Gastroenterology and Hepatology, 3 (10), 959-963 DOI: 10.1016/S1542-3565(05)00716-0

PENNAZIO, M. (2004). Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: Report of 100 consecutive cases Gastroenterology, 126 (3), 643-653 DOI: 10.1053/j.gastro.2003.11.057

In most scientific disciplines, medicine included, hypotheses start with observations.  When John Snow became curious about a London cholera outbreak, he looked for patterns and found that many cases centered around a local well.  While he didn't have a clear idea what caused cholera, he suspected the water as a source, and tested his hypothesis by having the pump handle removed, which appeared to help stem the epidemic.  Eventually it was discovered that that a bacterium was the cause of cholera and that is was transmitted in drinking water contaminated by feces.

More modest hypotheses are the grist of the science mill.   Researchers may observe a new trait in a fruit fly and hypothesize that it is due to a novel genetic change.  They then do the hard work of looking for correlations and associations, and the bench work involved in pursuing an answer.  In medicine, testing a hypothesis at the bench is followed by testing on real people, a significant scientific and ethical shift.

There are a myriad ways that medical science can go awry, and as in much of human thinking the root of many of these mistakes is our own fallible brains.  We see patterns, and when we see patters, we often assume that post hoc, ergo propter hoc, that is, if one event precedes another, it is the cause.  When you take the tinder of this human tendency, and ignite it with human emotion, we can end up consumed by medical catastrophes.

Fellow Scientopia blogger Female Computer Scientist tipped me off to a piece in The Scientist, one that demonstrates how a father's desperation and a doctor's desire to please led to a terrible medical decision.  The article tells the story of the Johnson's, whose autistic son developed intractable behavior problems.  The family pursued all of the usual conventional medical approaches, purposely avoiding much of the autism quackery that so many others fall prey to.   As their son worsened, Mr. Johnson started doing his own research---and stumbled onto something interesting:

He discovered the work of a trio of physician/researchers at the University of Iowa who had successfully treated patients with Crohn’s disease and ulcerative colitis using a nematode parasite found in the intestines of pigs—Trichuris suis, the pig whipworm. Both are autoimmune disorders in which the immune system essentially attacks the intestinal walls. Stewart also found data that pointed to a link between some autism symptoms and inflated levels of proinflamma​tory cytokines, an apparent result of the immune system attacking glial cells in patients’ brains.¹ Putting these bits of information together, Stewart wrote a short review paper and presented it to Hollander. His central hypothesis was that parasitic worm infection would modulate Lawrence’s immune system and calm inflammation that was causing his disruptive behaviors.

This hypothesis---that autistic behaviors can be modulated by parasitic infection---is not as insane as it sounds.  Rabies increases aggressive behavior in animals, causing them to bite and spread the virus.  The parasite Toxoplasma has been hypothesized to change human behavior. But in the Johnsons' case, an unbroken chain of faulty assumptions led them to try something foolish.

The basic syllogism is this:

1. Inflammatory diseases can be treated by a parasite.
2. Autism is an inflammatory disease.
3. Autism can be treated by a parasite.

First, can "inflammatory diseases" really be treated with pork whipworms?  The studies are unimpressive.  The few studies done found some minor statistically significant improvement when whipworm infestation was tested against placebo.   The inflammatory response generated by parasitic infection is a bit of a blunderbuss.  Compare it to something like infliximab, a monoclonal antibody very successfully used in Crohn's disease that targets a specific immune molecule and doesn't involve ingesting worm larvae.

Many diseases fall under the category of "inflammatory", and inflammation is a complicated process, one that can't be nailed down as something to be turned "on" or "off".  This makes analogies between one inflammatory disease and another problematic.

Is autism an "inflammatory disease"?   One study cited in The Scientist looked at a very small sample of autistic people, without a control group, and found evidence of inflammation in their neural tissue.   There  is no clinical evidence that autism has an "inflammatory" cause that can be affected by immunomodulation with, say, corticosteroids which are a non-specific immunologic treatment effective in many inflammatory diseases.

Given that statements one and two are false, number three is ridiculous.  But the Johnsons were understandably desperate and tried worm therapy.  At low levels of infestation, they saw little improvement, but at high infestation levels, there was a change:

The Johnson family anxiously awaited the effects of the full dose of TSO on Lawrence’s violent behavior. Within 10 weeks of the higher-dose treatment, the autistic boy stopped smashing his head against walls. He stopped gouging at his eyes. The paralysis and frustration that held him and his family prisoners in their own home lifted. The freak outs ceased. “It wasn’t gradations,” remembers Stewart, who had always kept meticulous notes on Lawrence’s disorder and the interventions they had attempted. “It just went away. All these behaviors just disappeared.” Elated, Stewart called Lawrence’s doctor, Eric Hollander. “He was stunned, because all of that behavior set was gone,” Stewart says. “He was speechless, as I was.”

As Lawrence's previous behaviors demonstrated, there was a certain unpredictability to his disease.  He sometimes worsened, sometimes improved, and in cases like this, we are even more easily fooled by our post hoc ergo propter hoc thinking.   There is no way of knowing, in this single case, whether or not worm infestation had a clinical effect on autism.

I suspect this story is going to continue on two separate paths. Quacks are going to take it and run, marketing expensive whipworm therapy to desperate parents.  Real scientists and clinicians are going to take a step back, and examine the possible role of inflammation in autism on the one had, the the possible role of parasites in various inflammatory diseases on the other.  The work will be hard, slow, and lead to many dead ends, but eventually we will learn important scientific facts.

The slow pace of science can be torture for those who are suffering, but turning individuals into uncontrolled experiments helps neither the patient nor science as a whole.  We treat lab rats better than that.

References

SUMMERS, R., ELLIOTT, D., URBANJR, J., THOMPSON, R., & WEINSTOCK, J. (2005). therapy for active ulcerative colitis: A randomized controlled trial Gastroenterology, 128 (4), 825-832 DOI: 10.1053/j.gastro.2005.01.005

MAYER, L. (2005). A novel approach to the treatment of ulcerative colitis: Is it kosher? Gastroenterology, 128 (4), 1117-1119 DOI: 10.1053/j.gastro.2005.02.038

Vargas, D., Nascimbene, C., Krishnan, C., Zimmerman, A., & Pardo, C. (2005). Neuroglial activation and neuroinflammation in the brain of patients with autism Annals of Neurology, 57 (1), 67-81 DOI: 10.1002/ana.20315

Not to be a nudge, but you could vote for me for a Medgadget Medical Weblog Award in one (or both, presumably) of two categories: Best Medical Blog, or Best Literary Medical Blog.  Voting will be open until the 13th.

I got a call at the office yesterday from Mrs. Pal.

"PalKid woke up flushed and has a fever.  I think she may have strep."

"So take her to the pediatrician."

"Really?"

Every trip to the pediatrician with PalKid is an adventure, but not the sort where you find gold at the end of a rainbow.  She is afraid to mention a sore throat because she's afraid of having her throat swabbed.  The entire experience usually ends with everyone exhausted, covered in snot an tears, and cranky.

"Well, if you really think she's got strep, bring her over to my office and we'll swab her," I said, wondering how much I might be underestimating my ultimate regret.

"Good luck with that.  We're on our way."

The staff at the office couldn't have been nicer to her, and manged to swab her throat with only a little bit of drama.  After confirming my wife's diagnosis, I called in some antibiotics and wondered how the rest of us might be feeling later.

It didn't take long for my wife's fever to hit, and this morning she woke up with a sore throat and a muffled voice that whispers "strep" to primary care docs.

So morning rounds are done, both at the hospital and at home, and I'm sitting in front of a roaring fire warming up, getting ready to read a book.  I figure I have about four more hours before everyone's motrin wears off.

Not to be a nudge, but you could vote for me for a Medgadget Medical Weblog Award in one (or both, presumably) of two categories: Best Medical Blog, or Best Literary Medical Blog.  Voting will be open for another ten days.

A real doctor?

Currently, over 48% of medical school graduates are women.  Seven percent of medical school students are African American.  About 8% report Hispanic or Latino ethnicity.  So, while medical school classes increasingly look like a typical suburban high school in my part of the country, they do not look much like the US population at large.  If you grow up in a Hispanic community and speak Spanish, you may have a hard time finding a doctor who speaks your language.  If you are African American, you may have a hard time finding a doctor with potentially similar experiences to yours, and finding an empathic, understanding doctor is already difficult enough.  Some of this is mitigated by the possibility that ethnic minority doctors may choose to practice in ethnic minority neighborhoods, but this has its own difficulties, including salary differences.

A newly released study reports on a significant disgrace in medicine, one which sheds some light on salary disparities in medicine.  This study found the gender gap for starting physicians' salaries is growing, with new male physicians averaging nearly $17,000 more annually than new female physicians in 2008.   This was a significant rise from the late 1990's when the gap was only about $3000, much of which disappeared when controlled for significant variables.

The gender gap in doctors' pay has been studied in the past, and has often been attributed to women working few hours, or choosing lower paying specialties, such as primary care.  But during the time of the study, women increasingly shunned primary care in favor of higher paid specialties.  Family status, although not followed explicitly, seemed a poor explanation, as the study looked only at starting salaries, and previous studies showed only small effects of family status.  This data would have been nice, but is it truly relevant?

When looking at pay discrimination, there are always multiple factors that can be used to "explain" gender differences in pay.  Do women physician, when looking for their first job, offer to work less in order to raise a family they may or may not have?  Or do potential employers simply assume that women doctors will not work as much as men?  Or does our society simply put a lesser value on women as highly-trained professionals, and paint over this judgement with various and interchangeable excuses?

The gender ratio in medicine is rapidly approaching parity, and may exceed it soon.  As more women practice medicine, will the profession become ghettoized?  Will we feel even more comfortable balancing our health budget on the backs of physicians?

That's a lot of questions without answers, but the gap is growing, and we can no longer feign ignorance.

References

Lo Sasso, A., Richards, M., Chou, C., & Gerber, S. (2011). The $16,819 Pay Gap For Newly Trained Physicians: The Unexplained Trend Of Men Earning More Than Women Health Affairs, 30 (2), 193-201 DOI: 10.1377/hlthaff.2010.0597

Not to be a nudge, but you could vote for me in one (or both, presumably) of two categories: Best Medical Blog, or Best Literary Medical Blog.  As some incentive, I'll repost a poem that was the runner up for the first annual Charles Prize for Poetry last fall.

Song for my father, II

“Say Ahh,” you said
as you pressed my tongue down
with the back of a spoon.

I can still taste the cold metal,
feel your warm hands, impossibly large
palpating my neck.

Doctor, father.

“No need to bother the doctor,” you said.
Your eyes showed no hint of bother.

So we went back to the bathroom
as I watched you set a new blade in your razor
hold a warm cloth to your face
lather yesterday’s whiskers.

I wondered where the old blade went.
A small slot in the back of the cabinet,
a mystery, like your newly shaved face,
betraying little of what was beneath.

Your copy of Cecil’s looks old,
like you.
The cover worn, the pages yellowed.
But you, a younger you on every page
Underlines, margin notes
expressions of wonder.

Maybe your face was stoic then
but you loved the mysteries
I can read it in every pen stroke.

It must have been a fountain pen.
I’ve always loved fountain pens
But I found them on my own.

You handed me your stethoscope
the rubber stiff with age
and said, “Go for it”
a smile breaking out,
cracking through an old psychiatrist’s
habitual stoicism.

“Daddy, my throat hurts.”

Sure, I think,
as I hold the spoon against her tongue
and palpate her impossibly small neck.

“I think a kiss will fix it,
no need to bother the doctor.”

She seems to agree.