September 21, 2012 | 10:11 am

On Medicine and Absolution

Posted by Albert Fuchs, M.D.

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… or Reflections on Yom Kippur

“My heart is blighted like grass, and withered, for I forget to eat my bread.”
– A patient’s prayer, Psalm 102

[None of the anecdotes in this post are descriptions of any specific patient. They are amalgams of many patients. Specific details have been distorted or invented to preserve anonymity.]

I diagnose and treat medical problems. I love doing it. Sometimes I make a big difference in someone’s life. More often, I just reassure them that they’re going to be OK. Or I give them advice about what they need to do to live healthier. But what I do has limits, and people frequently bring me problems that are well beyond my ken.

A business man comes to me for chest pain. He feels guilty because he has been misleading his business partner in a negotiation.

A wife has vague urinary symptoms after her affair of several years ends.

A middle aged man comes to me for insomnia. His endless work responsibilities have caused him to miss important events with his kids.

Of course, they each believe they may have a medical problem, so I examine them and order the appropriate tests. I rule out coronary disease, and infections, and hormonal problems. I call them with the good news. The tests are all normal. But they are not relieved. Their symptoms persist or even worsen.

I think I must be missing something. I send the business man to a cardiologist, the wife to a urologist, the father to a sleep specialist. More diagnostic tests are ordered. They are all normal. Good news, right? No. They are not reassured. Their symptoms continue and with every unrevealing test result they seem to give their symptoms more attention.

All primary care doctors see lots of these cases. These patients are seeking care in the wrong marketplace. They don’t have a medical problem. Their conscience is bothering them. They’re not sick; they’re guilty. They do not require medicine. They seek absolution.

But I have no prescription for that, no advice for attaining forgiveness, for undoing wrong deeds. Perhaps I should send them to a psychologist. I ask some questions looking for symptoms of depression or anxiety disorder. I come up empty. They’re mentally healthy, yet they are miserable.

What’s the medical specialty that helps people who’ve done wrong? What’s the service industry that undoes guilt? I’m no expert, but as far as I can tell, the only methodical approaches to this are in organized religions. My colleagues and friends who are psychologists and psychiatrists may object. But it seems to me that mental health professionals can only clarify the patient’s goals and feelings, clarify if the ethical damage can be undone, and work through the feelings. That’s a lot, but it doesn’t strike me as what these patients are craving. They want to atone. Organized religions have a formula for that.

I’m not here to tell you to go to church. And I’m certainly not going to delve into theology or suggest that any religion’s recipe for forgiveness is true in a fundamental or exclusive sense. I’m just suggesting that if you know you’ve done something wrong, and you feel terribly about it, maybe you don’t need a doctor. Maybe you need a minister, a priest, or a rabbi.

Like I said, I love what I do. I can fix some medical problems, and I can help prevent others. I can help you live more days and make those days healthier. But there is more to life than that. Sometimes there is also wrongdoing, and guilt, and redemption. For that, I have no training. Forgive me.

Learn more:

Forgiveness (Wikipedia)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

September 14, 2012 | 11:59 am

Ninth hantavirus case linked to Yosemite

Posted by Albert Fuchs, M.D.

Yosemite National Park
Photo credit: CDC

In 1993 in the Four Corners region of the US Southwest a woman developed a cough and progressive shortness of breath and died shortly thereafter. A few days later, her fiancée, a young physically fit man developed similar symptoms was rushed to a hospital and also died. A series of laboratory tests failed to identify any known infectious agent. The Centers for Disease Control and Prevention (CDC) Special Pathogens Branch was notified. Further testing revealed a previously unknown strain of hantavirus. The new strain would eventually be named Sin Nombre hantavirus (perhaps the most paradoxical name I’ve ever encountered).

In Asia and Europe hantavirus infections in people cause a very different illness marked by hemorrhagic fever and kidney failure. This new illness in the US marked by progressive respiratory failure was named Hantavirus Pulmonary Syndrome (HPS). HPS has early symptoms that are very similar to the flu: fever, fatigue, and muscle aches in the thighs and back. About half the patients also experience headaches, chills, nausea, vomiting, and diarrhea. Four to 10 days after the initial symptoms a cough and progressive shortness of breath develop. The lungs fill with fluid. About one third of patients with HPS die.

Since 1993 there have been very few (587) cases of HPS nationwide. The hantavirus strains in the US, like elsewhere, are carried by rodents. Sin Nombre hantavirus is carried mostly by the deer mouse in the western and central US and Canada. People are infected with hantavirus through contact with infected rodents, or their urine and droppings. Hantavirus in the US cannot be transmitted from person to person.

This summer hantavirus claimed the spotlight because of a number of cases linked to Yosemite National Park. Nine visitors to Yosemite have become sick from hantavirus, the most recent this week. Most of them camped in tent cabins in Curry Village in early July. These cabins have since been closed. Three of the nine have died.

The park, along with state and national health agencies, have attempted to contact all campers who have visited Yosemite this summer to advise them to seek care promptly if they develop flu-like symptoms. There is no specific treatment for hantavirus, but prompt admission to intensive care can help support patients on ventilators until the illness resolves. The patients who have survived seem to have recovered completely.

For those of us who haven’t been to Yosemite recently, the CDC advises that the best way to avoid hantavirus is to keep your home and nearby structures (garages, sheds) free of rodents. The links below have some common-sense suggestions.

Our family’s rodent control strategy involves an attractive feline named Pancho. Perhaps we should make her available to the National Park Service.

Finally, with Rosh Hashannah a few days away, I wish my readers a year of prosperity and joy, and no exposures to dangerous untreatable viruses.

Learn more:

Hantavirus in Yosemite: Ninth case reported in another visitor (LA Times)
August 2012 – Yosemite National Park Outbreak Notice (CDC)
Hantavirus (CDC information page)
Tracking a Mystery Disease: The Detailed Story of Hantavirus Pulmonary Syndrome (CDC)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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September 7, 2012 | 10:46 am

Still no evidence that organic food is healthier

Posted by Albert Fuchs, M.D.

Make mine with pesticides. Photo credit: Wikimedia Commons

“It’s not what you don’t know that hurts you, it’s what you know that isn't so.” -- attributed variously to Mark Twain and to Will Rogers

Many popular ideas are popular not because they're right but because of a widespread failure of skepticism. For example, in the 1970s the idea that wide lapels really make you look great was widely adopted without rigorous testing.

Organic food has grown to a $26 billion industry in the last couple of decades largely on public good will. This industry was perfectly poised at the intersection of several of our irrational biases – our fear of “chemicals”, our assumption that natural is better than artificial, and our suspicion of technology that alters living things. Surely our food must be healthier without all those industrial “chemicals”, we told ourselves as we spent sometimes twice as much for organic produce.

My regular readers know that I’ve written previously (links below) that there is no proof whatsoever that organic food is healthier than conventional food. In the current issue of the Annals of Internal Medicine, the question is finally given some rigorous examination.

Since the adjective “organic” is sometimes bandied about carelessly, we should have a general consensus about what it means. Organic plants are grown without synthetic pesticides or fertilizers and are not genetically modified. Organic livestock is raised without growth hormones or routine (i.e. preventive) antibiotics. Organic livestock is fed organically produced feed and is provided access to the outdoors and freedom of movement. Organic food is also generally manufactured without additives or irradiation.

The authors of the paper retrieved every peer-reviewed study that compared either organically and conventionally grown food or the people eating these foods. 240 of these studies were found and their findings were reviewed. The results were strikingly blah, prompting a flurry of media coverage (links below).

The studies found no difference in health outcomes between people eating organic and conventional food. Two studies found higher pesticide levels in the urine of children eating conventional food compared to organic food, but these levels were well below those that cause health problems. There were also no consistent meaningful differences in nutrient levels between the two groups.

I have long been suspicious that organic produce has higher risks for bacterial contamination since the alternative to synthetic fertilizer is fertilizer from animal waste. This also turns out to be unfounded. Bacterial contamination of food was similar in both groups.

There was one small but tantalizing difference. Bacterial contamination of meat was similar in frequency in both farming methods, but bacterial contamination with bacteria resistant to three or more antibiotics was significantly more common in traditionally grown chicken and pork than organically grown animals. That doesn’t prove that the humans who eat that meat are more likely to get sick or that their illnesses would be harder to treat, but it suggests that routine use of antibiotics in livestock has risks which require further study.

There may be lots of other good reasons to buy and eat organic food. Some people think organic food tastes better, and of course that is best left to each one’s palate. Others assert that organic farming practices are better for the environment. But organic farming consumes more resources and uses much more land per food produced, so if most of us ate organic food much more of the environment would be taken up for farming than is currently. There are also ethical reasons to refrain from supporting farming practices that treat animals cruelly. I’m not suggesting that we should not eat organic food, only that we should not do it with the expectation that it is healthier.

So for now, I’ll take my apple with pesticides. Oh, and those lapels are still groovy, no matter what other people say.

Learn more:

Are Organic Foods Safer or Healthier Than Conventional Alternatives?: A Systematic Review (Annals of Internal Medicine)
Why Organic Food May Not Be Healthier For You (NPR Morning Edition)
Study Questions How Much Better Organic Food Is (Associated Press)
Organic food no more nutritious than non-organic, study finds (NBC News)
My previous posts about organic food:

When the Stool Hits the Sprouts
Would You Like Some Salmonella With That?

For a very informative description of the benefits of modern farming, as well as other technical revolutions that make modern life possible, I highly recommend “The Rational Optimist: How Prosperity Evolves” by Matt Ridley.

Tangential Miscellany

Dr. Kevin Pho, the very well known physician blogger and outspoken advocate of social media in medicine, published my post about the coming flood of newly-insured patients. If you didn’t read it when I posted it three weeks ago, you might want to take a look. Check out the comments, too. Many of them are, shall we say, vigorously opposed to my point of view.

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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