Give Doctors a Break

In a heartless op-ed in yesterday’s paper, an anesthesiologist argues that medicine shouldn’t be a part-time endeavor. Dr. Sibert makes a firm introduction: “I’m a doctor and a mother of four, and I’ve always practiced medicine full time,” she boasts. “When I took my board exams in 1987, female doctors were still uncommon, and we were determined to work as hard as any of the men.”

Her premise:

With a growing shortage of doctors in America, we can no longer afford to continue training doctors who don’t spend their careers in the full-time practice of medicine.

She’s half-right, I think; the costs of medical education are too great for doctors to be pulling back on normal work hours or quitting their work entirely, willy-nilly. Besides, perhaps a tougher or more persevering group of would-be physicians might have used their coveted med school slots to better end and, ultimately, helped greater numbers of people.

The problem is this: What happens when a doctor gets sick? Or her child? Or partner or spouse? Most of us who’ve gone to med school, men and women both, do or should plan for coping with the inevitable decline of our parents and older family members. But there are some unfortunate circumstances that can make full-time work a challenge for months or even years.

I suspect the author has been fortunate in her career and health.

When a doctor or a dependent becomes seriously ill, she needs a supportive environment. She needs a workplace that allows her to take time off completely, or to work part-time for a while and possibly for a period of years, in a way that doesn’t engender resentment among her colleagues.

In a system without slack, doctors may feel pressured to work under too much duress, when they themselves are facing serious health or family problems. As things stand, I’ve witnessed doctors who’ve abused alcohol, been unkind to colleagues and disrespectful toward patients, and cut clinical corners as ways of coping with too much work, too little free time, and too little sleep.

Sometimes, the reasons why a doctor needs to cut back on her hours or work may not be evident to her colleagues. She may keep her good reasons to herself. With patients, explaining the details of one’s own illness, or a child’s, seems unprofessional, in general, although I do think that when a doctor becomes so fragile that she may not be able to return to work, her patients have the right to know that much, if they depend on her.

As for me, what I’ll say here is this: The day I stopped practicing medicine, nearly five years ago, was one of the saddest days of my life.

Medicine still is a macho field, as Dr. Sibert reveals in her op-ed. This is a shame, because the physicians’ shortage is real. In the long run, the system – which amounts to doctors in supervisory positions, like division and department chiefs – should soften up.

A flexible, more realistic system would allow doctors, in whom the system has invested so much, and who have invested so much of themselves, to take time off when they need it, and flexibility in their schedules, so they can continue in their careers after prolonged illness.

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A Recipe for Fresh, Low-Fat Blueberry Muffins

This morning I noticed we had too many blueberries in the fridge. So while my husband went out for a run, I opened the windows wide (to cool the apartment), turned on the oven and made some fresh breakfast food.

fresh muffins, Sunday morning

It had been two decades or so since I’d baked anything like these. My recollection, mainly from my suburban childhood, was that muffins involved a fair amount of work; we used to pull out a mix-master with beaters, a flour-sifter, and all sorts of stuff that then had to be cleaned. That was far too much work for me this morning.

So I simplified and halved an old recipe I’d hand-written sometime back in my Moosewood years. And I adjusted it so there’d be less sugar, and swapped whole milk for skim.

Preparation time: 8 – 15 minutes, depending on your proficiency in the kitchen; Baking time: 30 minutes

Ingredients (for 8 small muffins):

1/4 cup softened butter (vegetable oil is OK, too; some people say that improves the texture and taste of the baked goods, but I’m not convinced and try to minimize chemicals in my cooking.)

2/3 cup sugar

1 large beaten egg

1/4 cup skim milk

1/4 teaspoon salt

1 teaspoon baking powder

1 cup flour (I used organic, which I happened to have, and didn’t bother sifting it)

optional: cinnamon, ~ 1/4 teaspoon

ripe blueberries, about 2 cups, washed

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Preparation:

1. Preheat the oven to 375 degrees (F)

2. Use a fork to smash the butter at the base of a deep, medium-sized bowl;

3. Add the beaten egg and mush everything together;

4. Add in the sugar, stir with a fork or large spoon;

5. Add the milk, swirl everything together with the spoon;

6. Add the salt and baking powder, mix thoroughly at this point to evenly distribute the salt and powder;

7. Add the flour, and mix again.

(This step completes a basic muffin batter.)

8. Now, add the fruit.* For blueberries: With extra-clean hands, grab a fistful of washed blueberries and squeeze them into the batter for flavoring. Then add in the remaining whole berries and mix those around, gently.

9. Insert paper cupcake holders into the holes of an oven-proof muffin tray. Drop about 1/3 cup of batter into each cup, not overfilling.

10. Bake for 30 minutes at 375 degrees in the center of the oven.

11. Remove from the oven. (If you’re compulsive, as I am: insert and withdraw a toothpick with a quick in-out stroke; if the muffins are cooked, raw batter won’t stick. If batter does stick to the toothpick, put the muffins back in the oven for 5 minutes or longer, until they’re done.)

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If you follow these instructions, you can make fresh muffins with minimal equipment and little to clean up. You can freeze and store the muffins, no problem, once they’ve cooled.

*There are countless fruit variations and other add-ins you might use. This morning I prepared half of the batter using a ripe, diced banana and a fistful of cut-up walnuts.

Considerations:

Not everything I cook is nutritious. And while I don’t advise eating muffins regularly, as these are essentially confections, I figure if you’re going to serve these to your family, it’s better that they be prepared with fresh ingredients and a minimum of chemicals, sugar, salt and fats. These have some relative advantages over similar breakfast treats:

These lack preservatives;

They’re roughly half the size of typical store-bought muffins (countering the super-sized effect);

They’re made with skim milk instead of whole milk;

They have approximately 2/3 the usual amount of sugar.

Besides, they came out great!

Of course, dear readers, I’d like to know what are the true nutritional benefits in blueberries, and what happens to their putative anti-oxidant properties once they’ve been baked for 1/2 an hour. But I don’t think anyone knows, for sure.

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Quotes on Oncology, Via Forbes, and a Spiraling Helix

Forbes kept a close eye on the annual ASCO meeting in Chicago. On THE MEDICINE SHOW, Forbes’ Matthew Herper provides a précis of a speech by outgoing ASCO President Dr. George Sledge.

Here are my two favorite parts:

“So what happens when, a few years from now, a patient walks into a doctor’s office and hands a physician a memory stick loaded with gigabytes of personal genomic data?” Sledge asks. His answer: the flood of data will help doctors and patients, but things will get “very, very complicated.”

and

…Doctors will need real-time access to clinical data from all practice settings. This in turn will require interoperable databases using common terminology. Health information technology should offer on-the-spot decision support to oncologists and patients facing the increasingly complex tapestry revealed by modern genomics. It should provide individualized, ready access to a clinical trials systems. It should support appropriate coverage and reimbursement for services. And it should aggregate data so that we can learn from every patient’s experience.

DNA orbit animated smallWhat he’s saying, in a nutshell, is that oncologists will need to know science and have access to effective HIT to interpret and act upon the ever-growing pile of info on cancer genetics as it applies to people in general and individual patients. I recommend the full read.

An added perk in the MEDICINE SHOW piece is a terrific, gyrating DNA model courtesy of Wikipedia (@Forbes!).

For an additional twist (PM, 6/7), turns out Wikipedia offers a mutable Medicine Show of its own.

What goes around…?

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Human Milk For Sale, Where’s the FDA?

The June issue of Wired carries a feature on the Booming Market for Human Breast Milk. You can read about the under-the-counter and over-the-Internet sale of “liquid gold” with a typical asking price in the range of $1 to $2.50 an ounce.
Here’s a taste, from the article:

…“rich, creamy breast milk!” “fresh and fatty!”… Some ship coolers of frozen milk packed in dry ice. Others deal locally, meeting in cafés to exchange cash for commodity…

Late last year, the FDA issued a warning about feeding your child human milk from strangers. Still, the stuff’s barely regulated.

milk containers, Wired Magazine, June 2011

As much as I think it’s a good idea for women to breast feed their babies as best they can, I was pretty shocked to learn about this unregulated industry.  Mainly because if a woman who donates milk is infected with a virus, like HIV or HTLV-1, the milk often contains the virus. The infant can absorb the virus and become infected. Feeding human breast milk from an unknown donor is kind of like giving a child a blood transfusion from a stranger, unchecked by any blood bank.

I’m not sure why Wired ran this story, which is admittedly interesting. Maybe it’ll push the FDA to take a more aggressive stance on this matter, as it should.

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Considering Aromasin for Healthy Women, and the New Breast Cancer Prevention Study

I’m minding the annual meeting of the American Society of Clinical Oncology from a distance this year.

So far, the big breast cancer story syncs with a NEJM paper published yesterday on-line, on the use of exemestane (brand name: Aromasin, manufactured by Pfizer) to prevent invasive breast cancer. These patent-protected pills block the body’s normal production of estrogen.

The main finding was that for women deemed “at risk” for developing BC – as defined by the investigators – the incidence of cancer was significantly reduced when they took Aromasin as compared to a placebo. At a median observation point of 35 months, there was no observed effect on the women’s survival.

What’s right about the study: it’s prospective, randomized and large, including over 4560 women. The results are clear in terms of percents and relative risks: There was a 65% relative reduction in the annual incidence of invasive breast cancer (0.19% vs. 0.55%) and a hazard ratio of 0.35 (with confidence interval 0.18 to 0.70; P=0.002). So they’ve got strong stats.

Estrogen, typically depleted but not absent in post-menopausal women, can promote growth of breast cancer cells. From the paper’s first section: “Aromatase inhibitors profoundly suppress estrogen levels in postmenopausal women and inhibit the development of breast cancer in laboratory models.” So the findings are plausible, which helps, too.

The first problem (or non-problem, really) is there were only 43 cases of invasive BC in total; there wasn’t much cancer, or its reduction, in either arm of the study in terms of absolute numbers. This makes the divergent percents reported seem far less impressive. Second, and more importantly – the long-term consequences of taking this relatively new estrogen-inhibiting drug, in terms of women having thinner bones, possibly more cardiovascular disease, diminished libido and other side effects, are unknown.

Already there are two drugs marketed to prevent breast cancer in some women: tamoxifen and raloxifene. These drugs, also anti-estrogens, have significant side effects including blood clots, and few women choose to take them as prophylaxis for breast cancer. The new study suggests Aromasin is better because it’s got fewer side effects; Pfizer’s idea is that it’s a safer option for women who want to reduce their risk of developing BC.

But what caught my attention is who qualified for this trial: Most healthy women over the age of 60 – that’s a whopping, growing population of potential Aromasin-takers, besides the relatively small number of women with known pathology such as precancerous or stage 0 breast cancer (conditions like LCIS and DCIS, for which a preventive drug seems justifiable) or high risk-conferring BRCA-1 or -2 mutations.

Reading over the trial’s eligibility, I had to wonder, how could anyone think it reasonable to treat all women over the age of 60 with an estrogen inhibitor? And who populated the IRBs that approved this protocol? (Imagine if oncologists were to propose testing the effects of chemical castration in thousands of men over the age of 60; few would support such a trial, although in all likelihood androgen ablation would reduce the incidence of prostate cancer in men.)

The NEJM article lists support for the work from the Canadian Cancer Society Research Institute, the Canadian Institutes for Health Research, Pfizer, and the Avon Foundation. Among my many questions, I’d like to know what exactly what fraction of the study’s support came from Pfizer. The Journal (and every) should break this down for a published non-advertisement: If Pfizer provided 5% or 50% or 95% of funding for the trial, readers should be informed, as should women who might choose to take this drug and their doctors who might prescribe it.

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A New E. Coli Outbreak, Hemolytic-Uremic Syndrome, and Eating In or Out

There’s a newly-identified E. coli strain that’s causing a serious illness called hemolytic uremic syndrome (HUS). The recent cases, mainly in northern Europe, have been attributed to eating raw vegetables like cucumbers, lettuce and tomato. So far, authorities aren’t sure of the exact source.

Like any stomach bug, these bacteria can cause diarrhea, fever and other symptoms related to the gut. When people develop HUS, the kidneys fail and they may need dialysis. (Uremic Syndrome refers to uremia, when toxins normally cleared by the kidneys circulate in the bloodstream and cause problems in other body parts.)

blood smear reveals fragmented red blood cells (schistocytes), image from Wikimedia Commons

The “H” in HUS is for hemolytic, which describes how red blood cells are destroyed in the bloodstream. This occurs sometimes from effects of a bacterial toxin, such as might happen upon ingestion of a toxic strain of E. coli bacteria. This condition results in jaundice – a visible yellowing of the eyes and skin, and anemia – a paucity of red blood cells.

According to NatureNews, the culprit’s genome has been sequenced. It encodes broad-spectrum beta-lactamases. This means these toxic E. coli will, in general, resist antibiotics that exert their antiseptic powers by means of beta-lactam rings.

What’s my take-home message, as a home-maker and mom?

If I were traveling in areas affected now, I wouldn’t panic or change my plans. But I would avoid eating salad and any raw fruits or vegetables that can’t be peeled. I’d be mindful of foods like guacamole and salsa with fresh cilantro or other imperfectly-washed ingredients. Better to order cooked food, especially in restaurants where you don’t know who’s rinsing the greens.

The same rules apply at home, except that I’ll eat salad and fresh vegetables that I’ve prepared diligently.

Hand-washing after touching any part of a toilet, bathroom sink or faucet is always wise. The point is to avoid accidentally putting germs in your mouth that come from animal or human feces.

Yuck.

My next post will be on another topic, entirely.

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