Archive for: June, 2010

How did we get here?

Jun 15 2010 Published by under Fatherhood, Medicine

My wife is an accomplished professional. She loves her profession, and she's damned good at it. But she is officially "unemployed", and it kills her every time she has to put that down on a form. So how is it that she came to be unemployed?

When we met, MrsPal and I were both working full time---more than full time, actually. I'd have to say she was actually working quite a bit harder than I was. After we were engaged, an opportunity arose for her to cut back on her grueling schedule, but to do it she would have to quit her job entirely. For a variety of reasons, that is what she chose to do.

She became pregnant shortly after we were married, and it was not a pregnancy that would have mixed well with work. Over the years, by default, I have become the primary wage-earner in the family, and she has become the primary at-home parent and manager of the household (i.e. the one who does everything). Various conversations online and off have led me to wonder exactly how we came to this particular pattern.

We met fairly early in my career. I had spent the better part of my life in training, and MrsPal was already a veteran teacher. At that point, we could have made a conscious decision to appoint one of us the primary wage earner. We didn't. We allowed ourselves to carry on working our usual pace, but I know she was wondering how to balance her home life and career. I was not subjected to as much of a conundrum as it was always assumed that as a doctor I would keep doctoring. As a society, we have decided to compensate teachers (about 75% of whom are women) far less than doctors, so there were significant practical concerns. We also don't value pregnancy and early parenting enough to allow people to do it without significant risk to their job.

As my readers know, I love writing about fatherhood, but my ability to be a father depends entirely on my wife's decision to stay at home and work her ass off.  Sure, we could have chosen for her to keep her job, but that would have meant a huge sacrifice in income.  And at the time we established this pattern, it wouldn't have really crossed my mind.  Now, though, I think about it quite often.  Like many couples, we argue about the division of labor in our household.  It's a difficult problem,  trying to make both partners feel their work is equally valued in spite of cultural norms.  I don't have the answer, but it's important to acknowledge that it's a problem; a problem of society, and a problem of individuals such as myself who allow their spouses to feel less than well-compensated for their work.

I'll admit to some discomfort writing about an issue that involves me so personally, and that indicts me as part of the problem.  But someone's got to, right? And thank you, MrsPal, for being a great partner.  I'll keep trying to be one as well.

23 responses so far

Plumbing the depth of quackery at HuffPo

Jun 14 2010 Published by under Medicine

One of the questions addressed in this space is, "what makes a particular condition susceptible to quackery?"  Some of the common features we've seen over time are:

  1. Diverse and protean symptoms: fatigue, "brain fog", diffuse pain, and other vague symptoms are often used as diagnostic criteria for controversial entities such as morgellons and chronic Lyme disease.
  2. Lack of diagnostic certainty: there are no definitive tests to make the diagnosis of chronic Lyme disease or morgellons (or fibromyalgia for that matter) making objective diagnosis difficult. 
  3. Children affected: autism affects children (and of course their parents) and our natural desire to protect children makes us vulnerable.

There are a number of ways that quacks can churn out their product using just these three trends.  When a patient suffers from generalized fatigue or malaise but a good work up fails to reveal a specific problem, a real doctor will listen carefully and take a cautious wait-and-see approach.  A quack will rush into action, applying unproven treatments and even making up their own diseases. 

Making up a disease may sound easy but if you want people to really buy it, you need to follow a few principles.  You have to make it sound plausible to lay people, and you have to create the best kind of lie---the one based on a nidus of truth.

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33 responses so far

Gardasil for Guys: a good idea, sort of

Jun 09 2010 Published by under Medicine

I was catching up again on my favorite periodical (Morbidity and Mortality Weekly Report---the Dengue Fever story is Awe.Some.) I came across the official recommendations for Gardasil for males. Gardasil is the vaccine produced by Merck that can protect women against infection by four strains of human papilloma virus (HPV). The vaccine has been shown to prevent genital warts and pre-cancerous lesions caused by the virus. The vaccine, in conjunction with Pap tests, has the potential to significantly reduce the incidence of cervical cancer.
Of course, HPV infections do not arise spontaneously on the female cervix. In heterosexuals, HPV is passed between male and female partners, but men, not having a cervix, do not suffer the same consequences. They do, however, get genital warts and sometimes develop penile, anal, and oral cancers due to HPV. Men who have sex with men are at even higher risk than men who strictly have sex with women.
So there are several potential advantages to vaccinating men against HPV: it can protect them against genital warts and certain cancers; and it can protect their partners. In October of 2009, the FDA approved the HPV vaccine for use in males. An analysis by the Advisory Committee on Immunization Practices (ACIP) published in a recent MMWR gives us some guidance into the use of the vaccine in males.

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31 responses so far

Pandemic flu vaccine and Guillain Barre

Jun 08 2010 Published by under Medicine

As we ramped up for the H1N1 influenza pandemic last year, one of the worries expressed by the public and by the alternative medicine establishment was Guillain Barre Syndrome (GBS). As explained by neurologist Steven Novella, GBS is a serious auto-immune neurologic disease that causes weakness. It is often preceded by a relatively mild upper respiratory or gastrointestinal illness. In 1976, when a novel swine flu appeared and spread quickly through a military reservation in the U.S. This was a pattern seen in the 1918 pandemic, and the government moved to stem a potential serious pandemic. As it turned out, the pandemic fizzled, but the vaccine was associated with a bump in the incidence of GBS (10 excess cases per 1 million vaccinations).

Since that time, influenza vaccination has been associated with a small increase in GBS, approximately 1 case per million vaccinations. It's not clear that this relationship is causal, but because of this history, it's not just the altmed crowd who is interested in this question. The CDC and other agencies have taken an aggressive approach to monitoring the safety of the pandemic influenza vaccine including a possible associations with GBS. The CDC tasked its Emerging Infections Program (EIP) with active surveillance for problems. The EIP sought out cases of GBS through an extensive network of providers and calculated the risks associated with GBS and pandemic flu vaccination.

The preliminary results of this investigation were released this week in my favorite periodical, the Morbidity and Mortality Weekly Report. The CDC found an excess in GBS cases of 0.8 per million vaccinations, similar to previous (post-1976) years.  This is a low number, and correlation does not require causation, but it's important to compare this small risk with the risk of influenza itself.  As the CDC summarized:

The 2009 H1N1 vaccine safety profile is similar to that for seasonal influenza vaccines, which have an excellent safety record. Vaccination remains the most effective method to prevent serious illness and death from 2009 H1N1 influenza infection; illness from the 2009 H1N1 influenza virus has been associated with a hospitalization rate of 222 per 1 million and a death rate of 9.7 per 1 million population.

This is good news.  In spite of the hype from the altmed industry, we managed to vaccinate a lot of folks and prevent a lot of flu, with very few significant adverse events.  

32 responses so far

"Porn isn't violence, and if you try to take it from me I'll slap you"

Jun 07 2010 Published by under Medicine, Politics

I'm not sure what to write about this, but I feel a need to write something. There has been an interesting and infuriating discussion going on at Jason and Zuska's blogs.

Jason, whose posts on learning and cognition rock, started the discussion with an examination of a small amount of scientific literature on pornography. He's young, so he might not be aware of the extensive literature going back at least 25 years, including writings of Dworkin, MacKinnon, and many others. There's a lot of it, some of which I've read, but not for a very long time.

He starts by wading into a deep swamp of patriarchy without the appropriate flashlight.

Let's make a few things clear: I am not taking sides in the issue of whether or not pornography should be censored or restricted (but most forms of censorship make me very uncomfortable). This is meant to review some of the research that's been conducted on whether or not there is a reliable causal relationship between pornography and various Bad Things.

Jason is young and naive, and probably suffers a bit from the incredulity of privilege. You cannot lay down words on a critical topic such as porn and claim that you are not taking sides. The act of addressing it with certain words and certain biases is taking sides, and sophisticated readers are going to call you out on it right quick. I think that Jason truly believed there was a way to address this "purely" without being influenced by the patriarchal culture we live in. That would be nice.

Zuska countered with brief and characteristically incisive post pointing out that asking whether or not porn leads to sexual violence glosses over the fact that porn <i>is</i> sexual violence.  

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248 responses so far

Not just stupid, but dangerous

Jun 03 2010 Published by under Medicine

Joe Mercola's website has always been a "target-rich environment" for quack hunters. His rants against vaccines, his incorrect flu information, his support of homeopathy, and just about everything else at his website comes free of evidence and full of unfounded assertions (as well as some seriously side-splitting giggles).

But his latest post up at---where else?---the Huffington Post is patently dangerous. It is entitled, "Why You Shouldn't Drink Pasteurized Milk". If he had gone into the high caloric content of milk, the possible uses of alternative sources of calcium and other nutrients derived from milk, etc., it might have been an interesting piece. But instead it is a plea to drink "raw" (unpasteurized) milk. To those of you who already do this, I apologize for my next statement; it's aimed not at you but at professionals who should know better:


Pasteurization is the process of heating milk to a temperature that kills most of the pathogenic (disease-causing) bacteria. And milk, no matter where it comes from, is a great medium for growing pathogenic bacteria. Since pasteurization became common in the U.S., milk-related illnesses have dropped from about 25% of food-borne illnesses to almost none. That's a good thing. And that was back in the day when the milk came from small family farms, the very places that raw milk enthusiasts say we should get our milk from to avoid illness.

The toll from raw milk

According to the CDC:

During 1998--2005, a total of 45 outbreaks of foodborne illness were reported to CDC in which unpasteurized milk (or cheese suspected to have been made from unpasteurized milk) was implicated. These outbreaks accounted for 1,007 illnesses, 104 hospitalizations, and two deaths (CDC, unpublished data, 2007). Because not all cases of foodborne illness are recognized and reported, the actual number of illnesses associated with unpasteurized milk likely is greater.

Here is a brief rundown of what raw milk has done for us in the last few years:

  • Pennsylvania, 1994, 29 people sickened by Salmonella, more than half children under 7.
  • Pennsylvania, 1983, 57 people sickened by Campylobacter.
  • Washington State, 1999, 54 sickened by multi-drug resistant Salmonella from raw milk cheese
And that's just a sample.  We also have E. coli, Listeria, Brucella---raw milk makes people sick. Very few outbreaks have been conclusively linked to pasteurized milk (I found one report, but it lacked the rigor available with current genetic testing.)
The benefits of raw milk

From a rhetorical standpoint, it's not possible to prove a negative.  It may be that somewhere, somehow, some day, a preponderance of the evidence will show dirty milk to possess significant benefits unavailable from pasteurized milk.  If that does happen, there will presumably be a push to make raw milk safer via some technology, such as irradiation.  But current evidence shows no benefits from raw milk, and plenty of risk.  There are no benefits to weigh against these substantial risks.  Additionally, there are no recorded risks introduced by pasteurization.  So why not do it?
There is no rational, evidence-based response.  Consumers who choose to consume raw milk are taking big risks, but these risks are usually taken out of ignorance.  But when a doctor such as Mercola recommends it, it is a dangerous abuse of his power as a professional. It is reckless.  It is stupid.  It endangers public health.  He should be ashamed.
But of course, he has no shame.

37 responses so far

Narcotic treatment contracts and the state of the evidence

Jun 02 2010 Published by under Medicine


Not an opium poppy

I took this picture a couple of days ago. This poppy popped up as a volunteer in my front bed. It's about four feet tall and the flower is about 5 cm in diameter. It's not an opium poppy, but it could pass, and I've been looking for an excuse to use the picture.
Opium derivatives---and later, synthetic opioids---have probably been used for millennia for the relief of pain. Given human biology, they've probably been abused for just as long. Opiate use disorders are a daily fact for primary care physicians; the use of these drugs has become more and more common for chronic non-cancer pain. These medications are very effective in the treatment of pain, but come with a lot of undesired effects, not least among them the potential of developing a substance use disorder. They also have considerable street value, with Vicodin selling for $5-$10 per tablet on the illicit market.
But our options for the treatment of pain are not unlimited. Non-steroidal anti-inflammatory medications such as ibuprofen are not safe in all patients, and are not always effective. A multi-modal approach to the treatment of chronic pain can be very helpful, but many patients do not have access to this expensive treatment, and many more simply want instant relief, something which opiates can provide, but with a price.
The abuse of prescription opiates is on the rise. Continuing with Vicodin as an example, 9.3% of American 12th graders reported using Vicodin illicitly in a recent survey. From 1994 to 2002, the mention of hydrocodone---the narcotic in vicodin--in emergency center charts increased 170%. This is a big problem.
So we have two big problems: chronic pain, and narcotic abuse. How can we treat chronic pain and avoid contributing to substance use disorders and drug diversion? One strategy has been the use of so-called narcotic contracts, which we've discussed at length. But absent from that discussion was the evidence.
Before we look at this evidence, we must re-examine our reasons for using these contracts. In my own practice, we generally use them to protect ourselves from becoming involuntary drug dealers, and to prevent patients from abusing the narcotics we prescribe. So how are we doing with that?

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23 responses so far

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