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Category Archives: Opinion/Editorial

Rapid Home HIV Testing: Times are Changing

May 17, 2012 Dr. Pullen

With the FDA advisory panel recommending approval of the home rapid HIV test using saliva on a mouth swab the U.S. is making a significant change in tactics in screening for HIV. I have been in clinical practice for all but the very earliest of the history of HIV. I was a resident from 1980-1983, and in practice in the Army from 1983-1987. I remember the first patient of mine diagnosed with HIV was a woman who was just a few years post a blood transfusion for a bleeding duodenal ulcer, and who died within months of her diagnosis of multiple opportunistic infections.

In practice in WA since 1987 I’ve tried to obey the letter and spirit of the law requiring pre and post testing counseling for patients receiving HIV testing, and have grumbled that this state law pushed into place by the gay-rights lobby at a time when little effective treatment was available and serious concerns about confidentiality and discrimination were major concerns. Now that highly effective treatment for HIV is available the advantages of early HIV diagnosis would seem to make any barriers to testing for HIV counterproductive. An easy to use, affordable, reasonably accurate HIV test is a big change to the current status-quo, where considerable emphasis is placed on protection of the patient via counseling regarding results, and places more value on more widespread testing, early diagnosis and opportunities for prevention of spread of HIV.

Tests have been available for years for use by individuals to obtain their own specimen and mail it away to a test facility for confidential testing without accessing a physician or medical care provider. These have not been widely used. If the home oral swab rapid test comes to market it is very likely to be much more widely used. I fully agree with the FDA advisory panel that the benefits of this test will outweigh its risks. Still we should not ignore the risks. I see the benefits and risks as outlined below:

Benefits Risks

More HIV positive patients identified Rare false positives may lead to poor decisions

Prevention of some cases of HIV Rare false negatives may lead to not getting blood test

Low financial barrier to HIV testing Some patients may not get appropriate test results counseling

Convenience of HIV testing What unintended consequences to expect

I anticipate that in mass market use the false positive rate and the uninterpretable results rate will be higher than the extremely low rates in the test populations used in the initial studies, but even so I expect the use of a readily available home saliva HIV test will be one more step toward earlier diagnosis and slowing of the rate of spread of HIV in the U.S.

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Obesity, Smoking, Death and Medication Use

May 3, 2012 Dr. Pullen

Somehow I was not in the least surprised when I came across a Huffington Post article showing which states in the US have the highest rates of medication use. Why am I not surprised? Intuitively I suspected that these are the states with the highest rates of obesity and smoking. Look back to a prior post on how obesity has surpassed smoking as the leading preventable cause of death in America. Every one of the top 9 most medicated states is in the highest tier of rates of obesity. What medical conditions lead inexorably to the use of multiple medications? Think diabetes, hypertension and chronic pain. All of these conditions are directly related to obesity in many cases. Also think heart and lung diseases like asthma, COPD and coronary artery disease, all well documented to be related to both smoking and obesity. Here are the 9 “most medicated states” from the Huffington Post article with the CDC 2011 rate of obesity in parentheses. For interest I’ve also put the state’s rank in terms of smoking incidence from the CDC data.
State (Retail Rx per capita) Rate of obesity Smoking Rate (national rank)

West Virginia (18.4) >30% 25% (tie for 8^th highest)
Tennessee (16.9) >30% 25% (tie for 8^th highest)
Alabama (16.9) >30% 25% (tie for 8^th highest)
Kentucky (16.5) 30% 29% (alone w/top rate)
Arkansas (16.4) >30% 26% (6 way for 2^nd)
South Carolina (16.3) 25%-29% 24% (4-way tie for 12^th)
Mississippi (15.9) >30% 26% (6-way tie for 2^nd)
Iowa (15.3) 25%-29% 22% (3-way tie for 17^th)
Missouri (15) >30% 26% (6-way tie for 2^nd)

For reference there are nine states with 2009 rates of obesity > 30% of which 7 are here in the top 9 most medicated states. The national average rate of smoking is 21% and all 9 of the states with the highest rates of medication use are in the top 17 states for rates of smoking.

I cannot access the SDI data to see what the rates of obesity are in the states with the lowest incidence of obesity are but here are some other health related statistics and their relationship to a relative lower obesity rate.

1) Colorado is alone as the only state in the US with a 2009 rate of obesity at <20%. Why doesn’t Colorado rank at the very top for the lowest for death rates in adults? Possibly because of a smoking rate of 20% (tie for 28^th highest leaving it pretty good but with a death rate of 709/100,00 (11^th best).

2) The fifteen states with obesity rates from 20-25% (the best except for Colorado) are listed below in alphabetical order:

Death rate (rank) Smoking Rate (rank)

a) Alaska 742 (2oth) 24% (Tie for 12^thhighest)

b) California 660 (4^th) 15% (50^th highest, i.e. 2^nd lowest)

c) Connecticut 691 (8^TH) 18% (tie for 38^th highest)

d) Hawaii 590 (1^st) 16% (49^th, i.e. 3^rd lowest)

e) Idaho 723 (16^th) 18% (tie for 38^th highest)

f) Minnesota 675 (5^th) 17% (tie for 44^th highest)

g) Montana 786 (33^rd) 20% (tie for 29^th highest)

h) New Jersey 717 (14^th) 18% (tie for 38^th highest)

i) New York 676 (6^th) 19% (tie for 32^nd highest)

j) Oregon 748 (22^nd) 18% (tie for 38^th highest)

k) Rhode Island 749 (23^rd) 20% (tie for 28^th highest)

l) Utah 659 (3^rd) 11% (51^st highest, i.e. lowest)

m) Vermont: 721 (15^th) 18% (tie for 38^th highest)

n) Virginia 762 (25^th) 19% (tie for 32^th highest)

o) Wyoming 773 (29^th) 21% (tie for 21^st highest)

Looking at this data you may note that 4 of the 5 states with the lowest death rates are in the 15 states with the lowest rates of obesity, and that none of them are worse than the 44^th highest smoking rates. (only Arizona is missing, in the next 25%-29% obesity rate and at a tie for 21^st in rate of smoking) You may also note that the only two states in the top 15 for lower obesity rates ranking in the bottom half for death rates have smoking rates ranking at 21^st and 29^th.

Contrast this with the five states with the highest death rates:

West Virginia with >30% obesity and 25% smoking rate (tie for 8^th highest)
Mississippi with > 30% obesity and 26% smoking rate (tie for 2^nd highest)
Oklahoma with >30% obesity and 26% smoking rate (tie for 2^ndhighest)
Alabama with > 30% obesity and 25% smoking rates (tie for 8^th highest)
Louisiana with >30% obesity and 26% smoking rate (tie for 2^nd highest)

In contrast the states with the lowest death rates have the opposite statistics for obesity and smoking rates:

Hawaii with 20-24% obesity and 16% smoking rate (3^rd lowest).
Arizona is the exception in these states with 25-29% obesity and a smoking rate of 21% (right at the national average and ranking in a 6 way tie for 20^th highest in the U.S.
Utah with in the 20-20% obesity and the lowest smoking rate in the U.S. at 11%.
California with 20-24% obesity and 16% smoking, second only to Utah.
Minnesota with 20-24% obesity and in a tie for 4^th lowest smoking rates at 17%.

It appears that states where citizens choose not to smoke and trend to be less obese have both lower rates of medication use and lower death rates. My guess is that the observation of lower death rates and lower rates of medication use are the result of lower rates of diabetes, hypertension, COPD, cardiovascular disease in these same states. Yes these other health markers also trend directly with obesity and smoking rates.

So what can you as an individual learn from this? Get fit, avoid obesity and don’t smoke. No surprises here.

Periodontal Disease and Atherosclerosis: Another Observational Study Conclusion Disproved

April 19, 2012 Dr. Pullen

Another widely accepted dogma that comes from observational studies alone was shown to be just our eyes fooling us when surprisingly this week the American Heart Association released an unusual scientific statement with the conclusion that the evidence does not support gum disease as a risk factor or as a cause of cardiovascular disease. For over 20 years it has been widely believed that periodontal gum disease is a risk factor and a cause of coronary heart disease and stroke. The story of how the dogma that poor oral health became nearly universally accepted as a risk factor of cardiovascular disease is worth looking at because it exposes the risks of accepting data from an observational study as true just because it seems to make sense and conform to what we also see in practice.

Essentially all of the evidence used to support the belief that gum disease is a risk factor or a cause of atherosclerosis was from observational studies. In an observational study it is observed that condition A is present more often in people with condition B than in persons without condition B. Many studies showed that patients who had heart attacks are more likely to have bad oral health than patients who have not had heart attacks. This is far different from saying that gum disease causes heart attacks. In an extensive evaluation of all of the studies showing a relationship between gum disease and cardiovascular disease a panel including both dentists and physicians concluded that the evidence simply does not support the conclusion that there is a causative relationship. The problem appears to be that several other risk factors for cardiovascular disease are also put patients at risk for gum disease. These include tobacco use and low socioeconomic status, as well as age and diabetes mellitus. In a controlled study these confounding variables would be considered and “controlled” for in any analysis. In an observational study this is much more difficult to take into account

The association of periodontal disease and atherosclerosis was so in synch with our bedside observations that it was intuitive to accept the association as dogma. For me at least it never occurred to seriously question the relationship. This was in part because of the widespread acceptance of the test hsCRP (highly sensitive C-reactive protein), a test for low-grade systemic inflammation as an independent risk factor for coronary disease. It was easy to infer that because periodontal disease is a chronic inflammatory condition, can lead to bacteremia, and is a potential cause of systemic inflammatory marker elevation, that is “just made sense” that it is a cardiovascular risk factor.

I hope this 20 year walk down the path of least resistance is one I and others will remember when presented with an observational study purporting to show a relationship. Although I tell patients frequently that just because one factor precedes or coexists with another that it does not automatically follow that one causes the other, I too am obviously guilty of falling into this trap.

Sometimes as a medical community we are criticized for insisting on controlled, randomized, blinded studies to prove efficacy of our treatments, tests and procedures. It can be an expensive, time consuming and sometimes frustratingly tedious process. Still, without solid scientific controlled studies we will be at risk of taking what seems to make sense as factual. Bleeding sick patients was accepted as dogma in centuries prior to use of the scientific method, and we need to beware believing everything we see.

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Overdiagnosis in Breast Cancer?

April 5, 2012 Dr. Pullen

Overdiagnosis was not a term I ever heard in medical school, and I suspect it is one that few or you had heard of much more than a year or two ago. Overdiagnosis is when a condition is diagnosed that is not causing any symptoms for a patient now, nor will it cause symptoms at a later time in their life. I wrote about overdiagnosis earlier after reading the excellent book, “Overdiagnosed: Making People Sick in the Pursuit of Health” by H Gilbert Welch.

This book nicely discusses the issues of overdiagnosis in both chronic disease and in cancers. The long-held assumption that all malignancies left untreated progress, spread and lead to death is simply not true. We are learning that many types of cancer have unpredictable courses. Prostate cancer is the most notorious of these, with good evidence showing that most prostate cancers are ones patients live with asymptomatically whether they know about them or not and die of something else without ever having symptoms of the prostate cancer. This is the primary issue behind the recent USPSTF “D” recommendation against routine PSA screening in asymptomatic men. There is strong evidence that some percentage of renal cell cancers, some types of breast cancer and thyroid cancers not infrequently regress or remain indolent and never lead to symptoms.

The recent evidence suggesting frequent overdiagnosis in breast cancer is very disturbing. An April 3 article in the Annals of Internal Medicine in a large retrospective review in Norway infers a 15-25% incidence of overdiagnosis in women found to have breast cancer on mammographic screening. They used every other year screening, and suggest that for every 2500 women screened 6-10 cases of overdiagnosis occurred, 20 women were diagnosed with breast cancer that was not overdiagnosis, and 1 death related to breast cancer was prevented. We have strongly encouraged women to get annual mammograms for years. Personal anecdotal experience can make us even more confident that we are doing the right thing. I have had many patients diagnosed with early breast cancer by mammogram over the last 20+ years, and until recently had not had any women over age 40 that I can recall diagnosed with advanced stage breast cancer who had been getting their annual mammograms. It was very intuitive and tempting for me to believe that I was saving many lives and preventing much morbidity by aggressively pursuing early breast cancer diagnosis. I know that I have put many women through emotionally stressful and uncomfortable additional testing, biopsies, and breast cancer treatment. It is concerning to think that I may be subjecting some of these women to overdiagnosis and unnecessary treatment, but until we as a society actively address the issue of overdiagnosis and try to find ways to figure out which early cancers found on screening can be managed with active surveillance and which need curative treatment we are left with the inevitable overdiagnosis dilemma. This will involve asking a cohort of women with various very early cancers to be observed for progression prior to intervention. Whether this is going to be acceptable is not clear. We need to do the same thing for men with early prostate cancer. We are following lots of men with prostate cancer, but as far as I know not in a formal study that will give us help in knowing which cancers can be safely followed. For now I’m doing nothing different except keeping my eyes wide open to further research and recommendations.

Much of what we do in medicine today is aimed at early diagnosis of asymptomatic disease, and overdiagnosis is a very valid concern any time we are screening for asymptomatic disease. The recent changes in criterion for hypertension, diabetes and hypercholesterolemia are leading us to the preventative treatment of many diseases that are of themselves asymptomatic. The whole issue of overdiagnosis is going to be fascinating to follow over the next decade or two.

You may also enjoy: PSA Controversy Continues

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Coping With Grief: Eat, Sleep and Carry On

March 29, 2012 Dr. Pullen

I am far from an authority on coping with grief, but as a family physician of almost 30 years and having some personal experience with grief I feel that sharing some of my experience may be useful. I’ve had a fairly simplistic approach to grief for a long time, and am not completely sure how I came to this point, but it has worked for me and it seems to be well received and appreciated by patients. At least some of this came from the pastor who was a part of my residency program when my first wife died near the end of my third year. I seem to recall talking about this with Becky Sullivan MD, my residency director and mentor during my early years of practice in Puyallup. Still I think the crystallization of this triad of needs to be met during times of grief is something I came to understand and verbalize by talking to many patients over many years.
I believe a major key to getting through a time of great loss is to find a way to take care of our basic physical and emotional needs. I think of these as, “Eat, sleep and carry on.”

Eat: I too often see patients in acute grief with superimposed upper abdominal pain that I am certain is from gastric hyperacidity and not eating. Simply forcing yourself to eat can go a long way towards getting through a period of grief without complicating peptic ulcers or gastritis. I tell patients that they don’t have to be hungry, don’t have to feel like eating, and don’t even have to eat an extremely healthy diet. They just have to force themselves to chew and swallow a reasonable amount of food three times a day. Tradition in many communities, religions and cultures bears out the importance of eating. It is a nearly universal custom for family, friends and relatives to bring meals to the bereaved.

Sleep: Sleep is very difficult for many people in times of great stress or grief. In my opinion this is one of the most important times for physicians to prescribe sleep aides. It is tough to maintain your sanity and move through the rituals, responsibilities and duties expected when you are reasonably rested. In a sleep deprived state this is nearly impossible. Don’t be afraid to ask your physician for help if sleep is a problem after a major loss.

Carry On: This is my way of saying that forcing yourself to participate in at least some of your usual daily activities is very helpful in regaining some sense of normalcy. If you stay home all day, only see others who are also grieving, and don’t force yourself to carry on with your usual life activities it is too easy to become all-consumed by your grief. If you exercise normally continue to exercise. If you go to church continue to go to church. If you are in a service club, a book club, a bowling league, or other routine activity try to get back into that activity reasonably quickly. It can really help as a distraction and start to lead to a feeling that life can and must go on after the loss.

There is much more to managing grief, and I’m certainly no psychologist. Still, the advice to eat, sleep and carry is a good base on which to base your recovery.

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Generic Lexapro Finally: Understanding Isomers

March 15, 2012 Dr. Pullen

With the FDA approval yesterday of Teva’s generic Lexapro (escitalopram) I’m taking this opportunity to remember my years as a chemistry major at Bowdoin College and talk about a subject that is fascinating and not really that complicated. The movement toward the use of isolated isomers (also called sterioisomers or enantiomers ) as medication seems to be an accelerating trend in recent years.
A compound is defined by its chemical structure. The number of each type of ato, and the bonds between the atoms define the compound. For many drugs every molecule is shaped the same. For others the shape of the molecule can assume mirror image conformations, i.e. a left-handed and a right-handed shape. In medications the useful isomers are those with an asymmetric (chiral) center where there are two mirror image options for the shape of the chemical bonds to assume. These are technically called enantiomers, but are most commonly called R and S isomers. S stands for the Latin “sin” for left, R for the Latin rectus for right. (There are two other nomenclature methods for designating isomers, one using +/-, another using D/L, but these are seldom used in medicine and are mentioned so if you see them you won’t wonder if I am making all this stuff up.) A mixture of both the L and S isomers is called a racemic mixture. The FDA has developed a detailed approach to isomers that makes an interesting read for those of you with a scientific interest.

Fits great

Wrong Hand to Fit

The way most drugs work in the body is that they attach to a receptor site. If the receptor site is shaped in way that the left or right handed molecule fits well, and the other shape does not fit well, the one that fits well is going to the active drug. Think of this like hands and a glove. Your right hand fits nicely into a right-handed glove. Your left hand does not easily fit. The same is true for your left hand and a left-handed glove.

For other things like your head, any hat the right size fits because our heads are symmetric (relatively), with no isomeric variations.

In some cases the less active isomer is truly inactive. In other cases it appears that the “pure” active isomer has advantages as a medication. The not-so-surprising observation that drug companies somehow seem to discover that one isomer of their blockbuster drug is really the active isomer just before the patent expires on the original isomer mix leads some of us to be skeptical about the benefits of isomers. Still the trend toward isomers as medications seems to be real, so it is useful to understand what an isomer is, and why sometimes it may not be worth the added expense of buying the brand name isomer when the isomeric mix product is an inexpensive generic. Here are a few of the more popular isomers used as medication with a little Dr. Pullen commentary:

Lexapro vs citalopram: Lexapro was brought to market by Forest Laboratories just prior to the patent expiration of Celexa, the racemic citalopram product. The argument that Lexapro has less side effects and works faster is much harder to define than with a product like Nexium where more objective endpoints like ulcer healing, gastric pH, etc are available, but in my experience most patients to equally well on generic $4./month citalopram vs. Lexapro at $138.24/ month (Costco pricing). With the approval of Teva to exclusively market generic Lexapro for 6 months their price will be somewhat lower than brand name Lexapro, but in 6 months expect much lower prices from competitors. If the price approaches the $4. cost of citalopram generic Lexapro is likely to be very commonly used.

Nexium vs Omeprazole: Nexium has been a blockbuster drug for AstraZenica for years. This was a brilliant marketing move, by AstraZenica, again just prior to Prilosec (the original brand name for omeprazole) going generic. In order to market a “better” drug, Nexium was marketed as a 40 mg esomepraxole (left handed isomer) and compared to the 20 mg dose of omeprazole. It was shown to be very slightly faster acting. Now that you understand isomers does it surprise anyone that by taking the active isomer or omeprazole and using 4 times the dose of esomeprazole that is in racemic omeprazole the it is slightly faster acting? Not me. Is it worth the cost premium (Costco omeprazole 20 mg = $11.75/ 30 capsules vs. Nexium 40 mg = $202.75 / 30 capsules). Probably never.

Albuterol vs Xopenex: Unlike the prior two isomers, Xopenex is the R isomer not the S isomer of albuterol. There are some patients where the racemic mixture in albuterol causes more cardiac stimulation like racing heartrate than the R-albuterol isomer in Xopenex. This makes Xopenex preferable for some patients, but most patients do just fine on albuterol.

There are lots of other drugs sold as isomers, but this is enough to give you examples, and hopefully enough reason to be skeptical of claims of superiority for isomers sold as new expensive branded drugs.

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How Good Is Peyton Manning Going To Be?

March 11, 2012 Dr. Pullen

Does Muscle Weakness Improve After Disc Surgery?

For an NFL fan arguably the best thing that could happen to your team is to sign Peyton Manning and have him perform at or near his pre-injury level. The corollary is that one of the worst things to happen to your team would be to take a huge salary cap hit to get a Peyton Manning with such weak throwing arm that even with his experience and determination he is unable to excel or that he is re-injured and unable to play. The opportunity to get a superbowl champion, 4-time MVP, and future hall of fame quarterback who suddenly has become available to lead your team to a championship makes it easy to overlook the nature of spinal nerve injuries and cervical spine surgery.

The excitement and media heyday surrounding Peyton Manning neck surgery and his recent free agency prompted me to post about the nature of weakness from spinal nerve injury, and what can be expected in terms of recovery of strength and function. The real issues come down to two questions:

Is the nerve injury he has sustained to his cervical nerve root significant enough to cause irreversible weakness that will render him unable to perform at a level close to his previous superstar status. How much more recovery of strength can he expect.
Is he going to be able to hold up to the trauma he will be subject to as an NFL quarterback?

Let’s look at these one at a time.

How much of Manning’s arm weakness can he recover?: The real key to how successful Mr. Manning is going to be in his comeback hinges on the degree of chronic nerve injury he has sustained. Most of the time once a spinal nerve had been injured leading to muscle weakness, if the weakness persists for very long the damage is permanent. It is not clear how long Manning had been having weakness prior to his single-level fusion procedure, but it is certainly concerning that he had undergone at least 2 prior microdiscectomy procedures and that with a player as valuable to his team and generally competitive as Manning it seems unlikely that he chose to stop playing and have surgery at the first sign of weakness.

So what is the chance of a full recovery of motor function, i.e. strength, for Manning and how is this likely to affect his effectiveness as at throwing a football? I expect it to be more significant than may be widely appreciated. I cannot find it reported anywhere just which cervical level Manning had fused, so I don’t know which cervical nerve root is damaged. The most common cervical levels for disc injury are the C5-6 and the C6-7 levels. The cervical discs and nerves are labeled for the two vertebrae they are between. There are 7 cervical vertebrae, so the C6 nerve root exits

Brachial Plexus Diagram

between the C5 and the C6 vertebrae, and the C7 nerve root exits between the C6 and the C7 vertebrae. The anatomy is further complicated because the nerves to each muscle in the shoulder and arm get stimulation from several spinal nerve roots. This is because the cervical nerves come together in a complicated conglomeration of nerves called the brachial plexus. The nerve roots enter the plexus and fibers from several nerve roots joint to exit the plexus as peripheral nerves. Each muscle gets stimulation from one of these peripheral nerves. Key muscles in the throwing process include the triceps, the pectoralis major and minor, the latissimus dorsi, the deltoid, the biceps, the biceps radialis, and others. Each of these muscles in innervated by a specific peripheral nerve, and most of these receive varying amounts of innervations from the C5, 6, 7 and 8 nerve roots.

Certainly Manning has had access to the best available therapy to try to regain muscle strength. Still muscles just don’t work without nerve stimulation. This is called trophy, or trophic stimulation. Muscles that lose their innervations undergo atrophy (no trophy) and become smaller and lose their function. (think of polio and spinal cord injury victims) No amount of exercise, therapy or effort can make a muscle without innervations work. So if Manning still has arm weakness six months after his fusion surgery it is likely he will be left with at least some degree of muscle weakness. Six months post surgery he is not likely to get much more strength back. Certainly therapy can help other muscles become stronger and assume some of the roll of the muscles that have lost strength, but for Manning to function at a level required of a top level NFL quarterback I predict he will need to be able to throw the a football at very close to his prior strength.

How Vulnerable Is Manning To Recurrent of Further Injury?: How serious are the concerns that Peyton Manning will be at risk of additional levels of disc injury due to already existing disc injuries and the additional stress on the disc levels adjacent to a fusion. I expect that the fusion is going to hold up pretty well, and not itself be highly vulnerable to becoming unstable. The issue is really whether he develops disc herniations at the levels above and below the fusion, and whether he develops narrowing of the spinal canal (spinal stenosis) related to scar tissue or exuberant bone growth in the area of the fusion or at adjacent disc levels. NFL quarterbacks are sacked an average of twice a game, an although Manning is very experienced and may be able to minimize the number or sacks and hits he receives, undoubtedly he will be hit and his neck will be put in harm’s way in the course of an NFL season. I anticipate that these are going to be future issues for Manning, but that they are not likely to be the reason he is or is not successful in his short term comeback.

I anticipate that Peyton Manning’s success or lack of success at his comeback is going to hinge on how much arm strength he has remaining. This will be apparent to fans by the time the season comes, and he really has had enough time to strengthen his muscles by now. Teams expecting him to become a great deal stronger than he is right now are likely to be disappointed.

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Post Hoc Ergo Propter Hoc: All Is Not As It Appears

March 10, 2012 Dr. Pullen

I like some Latin phrases that have become part of our language. See an earlier post Carpe Diem. ”Ad hoc” is a commonly used moniker meaning literally “for this”, but the term “post hoc,” or more properly “post hoc ergo propter hoc,” (Latin for after the fact, therefore because of the fact) is used to describe the tendency to infer a causal relationship to what happens after something to the preceding event or action. The whole debate about MMR and autism is because the MMR vaccine is given to 1-year-old children and the first signs of autism are usually noticed in the few months after the usual time to give MMR. This post hoc ergo propter hoc assumption is a big part of the reason that when you look at the list of side effects of any medication on the manufacturer’s prescribing guideline nearly every commonly encountered symptom is listed. When you look at the comparison of side effects of the drug being tested and compare this to the incidence of the side effects of placebo control, it is amazing how commonly “side effects” of placebo occur. I jokingly tell patients who come in for evaluation of a problem just as it seems to be resolving that I wish I had seen them yesterday. Then I could have taken credit for a cure. The tendency to assume that what happens in the period of time shortly after an intervention is the direct result of and caused by the intervention is natural although not always correct.

This same issue occurs with everything from surgeries to chiropractic care. I remember in medical school that one student in our class was traumatized by the sudden death of his patient right in the middle of his first time alone with a patient for a physical exam. Did he do something to cause her death? Almost certainly not, but still he was likely pretty anxious the next few times he did a physical exam.

The natural course of many self-limited illnesses makes post hoc ergo propter hoc relationships very common. If you have a sinus infection that is going to last 10 days, but you see the doctor on day 8 and get an antibiotic, are told the medication should help within 2-3 days, when you recover in 2 days it is natural to credit the recovery to the antibiotic. If you get a headache the day after you start a new medicine, or a rash when you have been on the medication for a few days then post hoc. The relationship is assumed.

This issue is discussed very nicely in a recent article in Forbes by Henry Miller:

The Data on Drugs’ Side Effects Must be Reliable

As a medical resident at a major cancer center some years ago, I was responsible for administering a 4 a.m. intravenous dose of a drug that was part of the patient’s treatment protocol. I stood by the patient’s bedside, groggily flicking and tapping the syringe to get the last tiny air bubble out of the drug before injecting it.

Just as I was about to push the plunger to administer the drug, the patient died — just stopped breathing and expired. There was a “do not resuscitate” order, so sadly, that was that. The time was 4:01 a.m.

Had I more quickly removed the air bubbles and administered the drug at exactly 4 a.m., the patient would have died within seconds of receiving it. As a result, the investigators on the treatment protocol, the maker of the drug, federal regulators and I would all have suspected that the drug was the proximate cause of death. Read more

This post hoc issue plays havoc with everything from medication side effects reporting to patient’s expectations for treatment. I think it is an import concept to keep in mind when we try make sense of what we observe in live and medicine.

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Why Patient’s Don’t Have Advance Directives?

March 5, 2012 Dr. Pullen

I was reading my American Family Physician at the YMCA this weekend, and found an article “Implementing Advance Directives” that prompted me to come home and write this post. I have to admit that I should need to more often and earlier with many of my patients. I need to have a better plan for helping patients successfully and confidently choose to complete both a living will and a durable power of attorney. A living will outlines you preferences for decisions you want made on your behalf in various circumstances if you are unable to verbalize you own preferences. A durable power of attorney legally authorizes someone to make health care decisions for you in the circumstances where you are unable to make them for yourself. These two documents complement each other. I’ve too often tried to maneuver the minefield of coming to decisions for a patient’s care when they have failed to make their preferences clear and implement a durable power of attorney giving one individual the power to execute those choices. Then an out of town relative shows up to save the day, or a sibling dispute over how to deal with Dad’s terminal illness care happens. This type of thing is all too common, and makes a stressful time for everyone. Making your preferences known, putting it in writing, and designating a legal power of attorney helps your loved ones avoid this unnecessary messy and at times ugly scenerio. Both of these documents are crucial to both you and your family to assure that your wishes for decision making about your health are carried out according to your wishes.

Why don’t I do a better job? I suspect it is a combination of factors. I think the first is that this is rarely high on a patients list of topics they want to discuss at an office visit. It is easy to put off this discussion when seemingly more pressing issues are the patient’s expressed reason for the office visit. Even at physical exam visits, or in the medical coding lingo “preventative care” or “health maintenance” visits, it is alluring to focus on topics that lead to a longer or healthier life rather than a better death experience. Here is the list of the physician-related barriers to completion of an advance directive listed in the AFP article:

Discomfort with the topic.
Lack of institutional support.
Lack of reimbursement.
Lack of time.
Waiting for the patient to initiate the discussion.

In my case it is certainly not discomfort with the subject, and I am not intentionally waiting for the patient to bring up the subject, but lack of time and reimbursement undoubtedly play a role.

In addition most patients really don’t need my help in working through this decision process if they address the issue before there is a crisis. Although there are cultural, personal and ethnic variables that shape our decision making, most of my patients can really quite quickly and easily work through the process of completion of both a very functional living will and a durable power of attorney without my assistance. So why doesn’t everyone just do it themselves? Here are the barriers listed in the AFP article that are patient related:

Fear of burdening others, i.e. family or friends.
Health Literacy
Lack of interest or knowledge of the subject.
Spiritual, cultural or racial traditions.
Waiting for their physician to initiate the discussion.

So how can you just “Do it yourself?” It’s really easy. Obvoiusly since you are reading this article you have access to the internet, and everything you need is just a few clicks away. I encourage you, if you have not already completed these documents, to DO IT NOW:

Down load your state’s Advance Directives at the caringinfo.org site. This is really easy and you can get everything you need by selecting your state from the list here.
Many states have a form called a POLST form. This stands for physician orders for live sustaining treatment. If you use a search engine like Google, and you type in your state + POLST form you will easily find a form to download if your state has a POLST form. You can get the Washington State form to download easily at WA POLST download. Many physician offices have these available, just ask your doctor.
For some people a form to help you ascertain your values on this subject and to make your values clear to the individual you choose to have your medical power of attorney is helpful. The University of New Mexico Institute for Ethics has published online a non-copyright protected form for you to download. Some patients will find it helpful to attach this to their advance directive as guidance to their proxy in making decisions in line with their values.

There you have it. You have no more valid excuses to keep you from completing your own advance directive and living will. Once you complete it be sure to not keep it a secret. Give a copy to your physician, to the person you choose as your DPA, and keep a copy handy at your home. Don’t be a victim of your own procrastination or discomfort with this topic. If you find it helpful ask questions on the subject up with your personal physician. Be sure to let them know you have these documents completed.

In my best cheer-leading mantra: You can do it! Go – Go – Go!

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Selfishness and Suicide

March 5, 2012 Dr. Pullen

Is suicide the epitome of selfishness? I was initially taken aback when a person I completely respect told me how angry he was about a colleague who had committed suicide, telling me how selfish he though the person had been. I had not thought of suicide as a selfish act previously, but have thought a good deal about it since.

I see patients, parents, grandparents, siblings, friends and lovers concerned about suicide in the office from time to time. Other times I am the one concerned about suicide in patients I think may be at risk. Suicide is I a big and growing concern in the U.S. these days and I thought this would be a good time to write about this topic to share some statistical information and some thoughts. I hope to stimulate a forum for comments and sharing of thoughts in the comments below.

First some thoughts:

I think of suicide as the ultimate in selfish behavior most of the time. The purported victim leaves behind many other victims of their act. Family, loved ones, friends, associates and their whole community are left to grieve, often filled with guilt over the lost soul. Don’t ever think of suicide as leaving the world better off without out your presence, you will leave far more sadness and grief behind that if you live.
Never be afraid to ask anyone if suicide is a concern. They may lie and say no, but often people with suicidal intent will admit their concern if directly and empathetically asked.
If you have concerns about suicide for yourself or someone else ask for help. There are 24-hour crisis lines available, your physician, pastor, or other professional is obliged and usually happy to try to help.
Never think of a half-hearted suicide attempt as a way to find help. Miscalculations or other mishaps can make a suicidal gesture (not really meaning to kill yourself, but really asking for help) into a successful suicide all too often.

First some thoughts:

I think of suicide as the ultimate in selfish behavior most of the time. The purported victim leaves behind many other victims of their act. Family, loved ones, friends, associates and their whole community are left to grieve, often filled with guilt over the lost soul. Don’t ever think of suicide as leaving the world better off without out your presence, you will leave far more sadness and grief behind that if you live.
Never be afraid to ask anyone if suicide is a concern. They may lie and say no, but often people with suicidal intent will admit their concern if directly and empathetically asked.
If you have concerns about suicide for yourself or someone else ask for help. There are 24-hour crisis lines available, your physician, pastor, or other professional is obliged and usually happy to try to help.
Never think of a half-hearted suicide attempt as a way to find help. Miscalculations or other mishaps can make a suicidal gesture (not really meaning to kill yourself, but really asking for help) into a successful suicide all too often.

Next some statistics that I find interesting and informative:

N 2007 suicide was the 10^th leading cause of death in the U.S.
Although persons of all ages may commit suicide young men and the elderly are by far at highest risk. The incidence of suicide in adolescents ages 15-19 is 6.9/100,000, in young adults 20-24 is 12.7/100,000 and in adults 65 and older 14.3/100,000. In the age range 15-19 males are 5x as likely as females, and in 20-24 males are 6x as likely as females to die of suicide.
Access to firearms is a major risk for successful suicide. Children in homes with firearms are 10x as likely to die of suicide as children in homes without firearms.
Both men and women die of firearms related suicide but males are especially at risk. 56% of male suicides involve firearms vs. 30% of females. Males are also more likely to die of suffocation than females at 24 vs.21%.
Females are far more likely to die of poisoning at 40% vs. 13% than males.
Gay young men are especially at risk for suicide. See comments below.

Risk factors for suicide include:

Prior suicide attempts
Mental health problems
Drug or alcohol abuse
Separation or divorce
Physical or sexual abuse
Being young and gay. Several studies show higher risks of suicide in gay male adolescents. Risk estimates range from 2-10x. (1,2)
Returning veterans of the recent Iraq and Afghanistan wars are at risk.

So what can we do to keep suicide from affecting those near us? I suggest a few things.

If you choose to have firearms in your home, take rigorous precautions to keep them away from adolescents. Recognize this as a major risk factor.
Even if you do not suspect any concern, make the topic a regular subject to bring up with your child. Be sure they understand that suicide is not acceptable, and that you are very willing to help them in any way if suicide becomes remotely a concern.
Take any suicidal hints or references very seriously.
Keep prescription and non-prescription medications well away from youth. Buy non-prescription drugs in small quantities or keep larger quantities locked away.
Never think of suicide as beneficial to others. It is strictly a selfish exit from life, and leave behind others to struggle with your loss as well as all of their own problems. It makes nothing better.

I’d love to hear comments from readers. Leave a comment below.

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