Author Archives: Incision and Drainage

10.28.11
by

Healthy Eats



You are what you eat. I'm guessing you've heard this cliche before. But have you thought about what it means and whether it's true? Surely, "You are what you eat," doesn't mean that later today I'll morph into a frosted doughnut with Halloween sprinkles. What it does mean is that my body is built, mostly, on nutrients I consume. There are, of course, exceptions - women are born with all of the (non-surrogate) eggs they will have for their lives and medical devices do not use diet to sustain themselves. Tooth enamel and cerebral cortex neurons stay constant but, other than that, our bodies undergo constant turnover. And, as we all know, the substrate for that turnover is what we eat (so, if you had a turnover for breakfast, that turnover is used for turnover). And even those things in our bodies that are not directly the result of diet are affected by it. Your teeth, for example, are highly sensitive to the food you eat and its sugar content. So, food matters - and food quality affects health. But, eating well is expensive, right?

Consider a recently published University of Washington study that examined the cost of eating a diet compliant with the federal Dietary Guidelines for Americans, 2010 - which recommends increased dietary quantities of vitamin D, calcium, dietary fiber and potassium and less sugar and saturated fat. Using a survey to assess eating habits and then tallying retail prices at Seattle-area food suppliers, the study team tabulated the estimated dollars needed to get enough of some key nutrients, such as potassium. Based in part on the fact that such nutrients are plentiful in fresh produce and hard to find elsewhere, the researchers reported that meeting the guidelines would add to food costs. In fact, for one nutrient (potassium), an additional $380 was needed per person per year to meet recommended guidelines. On the other hand, for every 1% increase in dietary calories obtained from sugar and saturated fat, study subjects saved approximately $26 (sugar) to $102 (saturated fat) per person per year. Based on these findings, the authors concluded that, "Improving the American diet will require additional guidance for consumers, especially those with little budget flexibility, and new policies to increase the availability and reduce the cost of healthful foods."

This study certainly has limitations in terms of its scope and methods (including the fact that the calories and costs were estimated rather than directly observed), but it nonetheless supports the conventional wisdom that you have to be rich to eat a healthy diet. I argue, however, (and I'm not alone in this) that conventional wisdom is simply not true on this point. It is, of course, a lot easier to be a healthy eater if you have a fat wallet, but it's certainly possible without one. And while I agree with the basic tenet of AB 581(declaring access to healthy food items a basic human right), I don't think this issue should be left to legislation alone. For example, here is a quick recipe of tips for economic and nutritious eating.

Recipe for Eating Well on a Tight Budget.

·      Mix the following into your routine
o   Two parts buying local, fresh and in-season when possible.
o   Three cups planning nutritious meals that can be re-served another night.
o   One part frequent thick and hearty soups (these will cut back the urge to splurge).
o   Three carts of buying generic and in bulk and freezing perishables.
o   Six tablespoons of reading food labels. You'll be shocked at all the added sodium.
·      Cook this mixture slowly in a reduction sauce dedicated to cutting back on unrefined sugar, saturated fat and expensive and unnecessary vitamin supplements.
·      Finish with three thimbles of nutrition education.

It is in the finishing that the most enduring benefit will be found - for you and your family. In particular, we could be doing a much better job of teaching our children about food and nutrients and creating a life-long appreciation for their importance. As a father who delivers sprinkled doughnuts home on a bi-weekly basis, I am likely more delinquent on this point than many in Marin. So, for parents like me a great place to start the schooling sauté is at the North Bay Discovery Day. On November 5th, in an event sponsored by The Buck Institute, over 50 exhibitors will gather at Infineon Raceway, all tasked with helping to make science fun and accessible for kids.

Among the exhibitors is accomplished chef Ted Smith, founder of Kids Cooking for Life (KCL) which is a community program that focuses on educating children on food, cooking and (big bonus!) table manners.

The KCL exhibit (in partnership with Kaiser Permanente) on Discovery Day is called a "Whole Grain Adventure" and will feature fun and games (including a Fiber Race) and deliver the message "that whole grains (and the fiber they contain) are an essential ingredient of a healthful diet."

Ted Smith writes, "I strongly believe that you don't have to be wealthy to eat healthy. What I've learned as an owner-operator of restaurants in Chicago for over 23 years (and having served over 18 million customers) is this: fruits and vegetables are a lot cheaper than meat, seafood and poultry! And fruit and vegetables is where you find healthy eating."

And don't worry, a diet rich in produce will not turn you into a turnip.

For more info about Discover Day check out
http://www.buckinstitute.org/discoveryday


10.28.11
by

Healthy Eats



You are what you eat. I'm guessing you've heard this cliche before. But have you thought about what it means and whether it's true? Surely, "You are what you eat," doesn't mean that later today I'll morph into a frosted doughnut with Halloween sprinkles. What it does mean is that my body is built, mostly, on nutrients I consume. There are, of course, exceptions - women are born with all of the (non-surrogate) eggs they will have for their lives and medical devices do not use diet to sustain themselves. Tooth enamel and cerebral cortex neurons stay constant but, other than that, our bodies undergo constant turnover. And, as we all know, the substrate for that turnover is what we eat (so, if you had a turnover for breakfast, that turnover is used for turnover). And even those things in our bodies that are not directly the result of diet are affected by it. Your teeth, for example, are highly sensitive to the food you eat and its sugar content. So, food matters - and food quality affects health. But, eating well is expensive, right?

Consider a recently published University of Washington study that examined the cost of eating a diet compliant with the federal Dietary Guidelines for Americans, 2010 - which recommends increased dietary quantities of vitamin D, calcium, dietary fiber and potassium and less sugar and saturated fat. Using a survey to assess eating habits and then tallying retail prices at Seattle-area food suppliers, the study team tabulated the estimated dollars needed to get enough of some key nutrients, such as potassium. Based in part on the fact that such nutrients are plentiful in fresh produce and hard to find elsewhere, the researchers reported that meeting the guidelines would add to food costs. In fact, for one nutrient (potassium), an additional $380 was needed per person per year to meet recommended guidelines. On the other hand, for every 1% increase in dietary calories obtained from sugar and saturated fat, study subjects saved approximately $26 (sugar) to $102 (saturated fat) per person per year. Based on these findings, the authors concluded that, "Improving the American diet will require additional guidance for consumers, especially those with little budget flexibility, and new policies to increase the availability and reduce the cost of healthful foods."

This study certainly has limitations in terms of its scope and methods (including the fact that the calories and costs were estimated rather than directly observed), but it nonetheless supports the conventional wisdom that you have to be rich to eat a healthy diet. I argue, however, (and I'm not alone in this) that conventional wisdom is simply not true on this point. It is, of course, a lot easier to be a healthy eater if you have a fat wallet, but it's certainly possible without one. And while I agree with the basic tenet of AB 581(declaring access to healthy food items a basic human right), I don't think this issue should be left to legislation alone. For example, here is a quick recipe of tips for economic and nutritious eating.

Recipe for Eating Well on a Tight Budget.

·      Mix the following into your routine
o   Two parts buying local, fresh and in-season when possible.
o   Three cups planning nutritious meals that can be re-served another night.
o   One part frequent thick and hearty soups (these will cut back the urge to splurge).
o   Three carts of buying generic and in bulk and freezing perishables.
o   Six tablespoons of reading food labels. You'll be shocked at all the added sodium.
·      Cook this mixture slowly in a reduction sauce dedicated to cutting back on unrefined sugar, saturated fat and expensive and unnecessary vitamin supplements.
·      Finish with three thimbles of nutrition education.

It is in the finishing that the most enduring benefit will be found - for you and your family. In particular, we could be doing a much better job of teaching our children about food and nutrients and creating a life-long appreciation for their importance. As a father who delivers sprinkled doughnuts home on a bi-weekly basis, I am likely more delinquent on this point than many in Marin. So, for parents like me a great place to start the schooling sauté is at the North Bay Discovery Day. On November 5th, in an event sponsored by The Buck Institute, over 50 exhibitors will gather at Infineon Raceway, all tasked with helping to make science fun and accessible for kids.

Among the exhibitors is accomplished chef Ted Smith, founder of Kids Cooking for Life (KCL) which is a community program that focuses on educating children on food, cooking and (big bonus!) table manners.

The KCL exhibit (in partnership with Kaiser Permanente) on Discovery Day is called a "Whole Grain Adventure" and will feature fun and games (including a Fiber Race) and deliver the message "that whole grains (and the fiber they contain) are an essential ingredient of a healthful diet."

Ted Smith writes, "I strongly believe that you don't have to be wealthy to eat healthy. What I've learned as an owner-operator of restaurants in Chicago for over 23 years (and having served over 18 million customers) is this: fruits and vegetables are a lot cheaper than meat, seafood and poultry! And fruit and vegetables is where you find healthy eating."

And don't worry, a diet rich in produce will not turn you into a turnip.

For more info about Discover Day check out
http://www.buckinstitute.org/discoveryday


10.03.11
by

The Good, The Bad, The Ugly (Marin IJ)


You may have noticed that vaccines are back in the news. In fact, the last few weeks have brought several related stories, which as a vaccine advocate, I would categorize as the Good, the Bad and the Ugly (yes, vaccines and Clint Eastwood movies do have something in common!) These developments can be summarized as 1) Good; rotavirus vaccine benefits children and public health, 2) Bad; pertussis (whooping cough) vaccine wears off sooner than previously thought (after about three years) and 3) Ugly; the Human papillomavirus (HPV) vaccine was blindsided by hearsay from a U.S. presidential candidate. More plot details below...
Good: Rotavirus vaccine decreases health costs
Have you heard of rotavirus? As a medical student studying for the boards, I had trouble remembering what type of infection this bug caused until I learned the mnemonic R-O-T-A, which stands for "right out the a@*&#." That pretty much sums it up. Rotavirus is a leading cause of diarrhea, especially in children under the age of five. Tens of thousands of kids visit emergency departments each year because of rotavirus (which can cause life-threatening dehydration), and thousands more will require hospitalization for re-hydration. According to the CDC, just five years ago, rotavirus was responsible (annually) for approximately 55,000 to 70,000 hospitalizations and 20 to 60 deaths among young children. Even in mild cases, rotavirus is a bummer for everyone involved, except, that is, for the diaper industry.
The good news is that there are now two licensed vaccines against rotavirus (RotaTeq and Rotarix) and recent evidence suggests that they are working well. In the September 22nd issue of the New England Journal of Medicine (NEJM), researchers from the CDC reported the results of a 2001-2009 study comparing pre- and post-vaccination outcomes. Their results suggest that the vaccine (first widely available in 2007) resulted in an approximately one-half reduction in diarrhea-related ED visits and hospitalizations. Furthermore, the researchers calculated that the vaccine had likely prevented over 20,000 hospitalizations a year since 2007, resulting in a health care cost savings of over $90 million a year. I think you'll agree; that's a public health benefit we shouldn't be flushing away.
Bad (well, not totally bad): Pertussis vaccine wears off earlier than thought
Hopefully by now everyone knows that we are in the midst of a pertussis (whooping cough) epidemic - one in which (quite regrettably) Marin County has led the way. This epidemic is multi-factorial - it is due in part to natural disease fluctuation, but also related to significant rates of personal belief exemptions (PBEs) for vaccines and waning immunity in older kids and adults. We have suspected for some time that the typical schedule of acellular pertussis vaccination (in older kids and adults) does not provide adequate protection and very recent (and still unpublished) evidence from the 2010 pertussis outbreak seems to confirm this. Dr. David Witt (infectious disease) and Dr. Paul Katz (pediatrics) from San Rafael Kaiser Permanente recently studied over 15,000 kids under the age of 18 in Marin County and identified 132 confirmed cases of pertussis. Their preliminary results, presented two weeks ago at the American Society for Microbiology in Chicago, suggest several important trends; 1) vaccinated children (age 2-18) are less likely to get whooping cough than unvaccinated ones, 2) younger children (age 2-7) who are vaccinated are well protected against disease and 3) older kids (with a peak around age 12), even if vaccinated, are very susceptible. In fact, the risk for 12-year olds is approximately ten times higher than for 2-7 year olds. This, then, seems to be good justification for the idea of a pertussis booster shot (as now required by state law AB 354) for 7th-12th graders. Fortunately, and this is where the bad news is not really so bad, Marin County seems to be doing very well with these boosters. According to public health officer, Dr. Jason Eberhart-Phillips, "We are nearly there to full compliance in Marin at this time. Local education officials understand and value the health and well-being of their students! "

Ugly: The HPV vaccine flap
Genital warts are not a pleasant topic. Especially when you consider that the causative virus (HPV) is a major risk factor for cervical cancer. Cervical cancer is nasty, even for cancer, and it kills young women. If you have any doubt about how horrible this cancer can be, consider this description of metastatic disease from The Immortal life of Henrietta Lacks by Rebecca Skloot... "Henrietta's body was almost entirely taken over by tumors. They'd grown on her diaphragm, her bladder and her lungs. They'd blocked her intestines and made her belly swell like it was six months pregnant." Fortunately, HPV immunization offers significant protection (70% or so) against cervical cancer in addition to genital warts. But despite its well-documented safety (over 35 million doses given worldwide), the context of the topic (teenagers having sex) has fueled some political pushback.

On September 13, the day after a GOP presidential candidates debate, Michelle Bachmann claimed on several media outlets that the HPV vaccine was hazardous and could cause "mental retardation." Later, Bachman told Matt Lauer on the "Today" show that the HPV vaccine has "very dangerous consequences" and that it puts "little children's lives at risk." As it turns out, these statements were based, not on fact, but on a single anecdotal account from a woman who had talked to Bachmann at a campaign event. This sort of   "a person I knew had a..." approach to public health is not healthy. In fact, this tact by a public figure was so egregious that Dr. Arthur Caplan of the University of Pennsylvania Center for Bioethics, challenged Bachmann - offering her $10,000 of his own money (to be given to a charity of her choice) if she could, in Caplan's words, "produce a person within a week who had been made 'retarded' by the HPV vaccine, and if that claim could be verified by three doctors." It's been several weeks now and Caplan's challenge remains unanswered. I asked Dr. Caplan to summarize his opinion of the situation:

He says, "Bachmann decided to base her campaign on an anti-vaccination platform. To do so she had to claim that vaccines like the HPV vaccine to prevent cervical cancer are dangerous.  Her willingness to throw away women's lives for political gain is not only unworthy of a Presidential candidate it is morally despicable."
"As a recent study in NEJM on vaccines against rotavirus demonstrated," Caplan continues, "vaccines remain our best response to lethal and disabling diseases in children and adults. By continuing to allow politicians, celebrities and crackpots to spew utter nonsense about vaccine dangers the medical, scientific and media communities are complicit in compromising the health of the public both in the U.S. and worldwide.  Vaccines do have risks as do every other health intervention from alternative medicine, to aspirin, to anesthesia.  But, vaccines are among the safest and most effective tools we have to fight dread diseases.  The public should know that and hopefully my challenge to Bachmann will help make that happen."
Ugly situation indeed, but if it results in a better understanding of vaccines, including their minimal risk in the face of major benefits, it will lead to a prettier picture of public health.


10.03.11
by

The Good, The Bad, The Ugly (Marin IJ)


You may have noticed that vaccines are back in the news. In fact, the last few weeks have brought several related stories, which as a vaccine advocate, I would categorize as the Good, the Bad and the Ugly (yes, vaccines and Clint Eastwood movies do have something in common!) These developments can be summarized as 1) Good; rotavirus vaccine benefits children and public health, 2) Bad; pertussis (whooping cough) vaccine wears off sooner than previously thought (after about three years) and 3) Ugly; the Human papillomavirus (HPV) vaccine was blindsided by hearsay from a U.S. presidential candidate. More plot details below...
Good: Rotavirus vaccine decreases health costs
Have you heard of rotavirus? As a medical student studying for the boards, I had trouble remembering what type of infection this bug caused until I learned the mnemonic R-O-T-A, which stands for "right out the a@*&#." That pretty much sums it up. Rotavirus is a leading cause of diarrhea, especially in children under the age of five. Tens of thousands of kids visit emergency departments each year because of rotavirus (which can cause life-threatening dehydration), and thousands more will require hospitalization for re-hydration. According to the CDC, just five years ago, rotavirus was responsible (annually) for approximately 55,000 to 70,000 hospitalizations and 20 to 60 deaths among young children. Even in mild cases, rotavirus is a bummer for everyone involved, except, that is, for the diaper industry.
The good news is that there are now two licensed vaccines against rotavirus (RotaTeq and Rotarix) and recent evidence suggests that they are working well. In the September 22nd issue of the New England Journal of Medicine (NEJM), researchers from the CDC reported the results of a 2001-2009 study comparing pre- and post-vaccination outcomes. Their results suggest that the vaccine (first widely available in 2007) resulted in an approximately one-half reduction in diarrhea-related ED visits and hospitalizations. Furthermore, the researchers calculated that the vaccine had likely prevented over 20,000 hospitalizations a year since 2007, resulting in a health care cost savings of over $90 million a year. I think you'll agree; that's a public health benefit we shouldn't be flushing away.
Bad (well, not totally bad): Pertussis vaccine wears off earlier than thought
Hopefully by now everyone knows that we are in the midst of a pertussis (whooping cough) epidemic - one in which (quite regrettably) Marin County has led the way. This epidemic is multi-factorial - it is due in part to natural disease fluctuation, but also related to significant rates of personal belief exemptions (PBEs) for vaccines and waning immunity in older kids and adults. We have suspected for some time that the typical schedule of acellular pertussis vaccination (in older kids and adults) does not provide adequate protection and very recent (and still unpublished) evidence from the 2010 pertussis outbreak seems to confirm this. Dr. David Witt (infectious disease) and Dr. Paul Katz (pediatrics) from San Rafael Kaiser Permanente recently studied over 15,000 kids under the age of 18 in Marin County and identified 132 confirmed cases of pertussis. Their preliminary results, presented two weeks ago at the American Society for Microbiology in Chicago, suggest several important trends; 1) vaccinated children (age 2-18) are less likely to get whooping cough than unvaccinated ones, 2) younger children (age 2-7) who are vaccinated are well protected against disease and 3) older kids (with a peak around age 12), even if vaccinated, are very susceptible. In fact, the risk for 12-year olds is approximately ten times higher than for 2-7 year olds. This, then, seems to be good justification for the idea of a pertussis booster shot (as now required by state law AB 354) for 7th-12th graders. Fortunately, and this is where the bad news is not really so bad, Marin County seems to be doing very well with these boosters. According to public health officer, Dr. Jason Eberhart-Phillips, "We are nearly there to full compliance in Marin at this time. Local education officials understand and value the health and well-being of their students! "

Ugly: The HPV vaccine flap
Genital warts are not a pleasant topic. Especially when you consider that the causative virus (HPV) is a major risk factor for cervical cancer. Cervical cancer is nasty, even for cancer, and it kills young women. If you have any doubt about how horrible this cancer can be, consider this description of metastatic disease from The Immortal life of Henrietta Lacks by Rebecca Skloot... "Henrietta's body was almost entirely taken over by tumors. They'd grown on her diaphragm, her bladder and her lungs. They'd blocked her intestines and made her belly swell like it was six months pregnant." Fortunately, HPV immunization offers significant protection (70% or so) against cervical cancer in addition to genital warts. But despite its well-documented safety (over 35 million doses given worldwide), the context of the topic (teenagers having sex) has fueled some political pushback.

On September 13, the day after a GOP presidential candidates debate, Michelle Bachmann claimed on several media outlets that the HPV vaccine was hazardous and could cause "mental retardation." Later, Bachman told Matt Lauer on the "Today" show that the HPV vaccine has "very dangerous consequences" and that it puts "little children's lives at risk." As it turns out, these statements were based, not on fact, but on a single anecdotal account from a woman who had talked to Bachmann at a campaign event. This sort of   "a person I knew had a..." approach to public health is not healthy. In fact, this tact by a public figure was so egregious that Dr. Arthur Caplan of the University of Pennsylvania Center for Bioethics, challenged Bachmann - offering her $10,000 of his own money (to be given to a charity of her choice) if she could, in Caplan's words, "produce a person within a week who had been made 'retarded' by the HPV vaccine, and if that claim could be verified by three doctors." It's been several weeks now and Caplan's challenge remains unanswered. I asked Dr. Caplan to summarize his opinion of the situation:

He says, "Bachmann decided to base her campaign on an anti-vaccination platform. To do so she had to claim that vaccines like the HPV vaccine to prevent cervical cancer are dangerous.  Her willingness to throw away women's lives for political gain is not only unworthy of a Presidential candidate it is morally despicable."
"As a recent study in NEJM on vaccines against rotavirus demonstrated," Caplan continues, "vaccines remain our best response to lethal and disabling diseases in children and adults. By continuing to allow politicians, celebrities and crackpots to spew utter nonsense about vaccine dangers the medical, scientific and media communities are complicit in compromising the health of the public both in the U.S. and worldwide.  Vaccines do have risks as do every other health intervention from alternative medicine, to aspirin, to anesthesia.  But, vaccines are among the safest and most effective tools we have to fight dread diseases.  The public should know that and hopefully my challenge to Bachmann will help make that happen."
Ugly situation indeed, but if it results in a better understanding of vaccines, including their minimal risk in the face of major benefits, it will lead to a prettier picture of public health.


09.21.11
by

Michelle Bachmann’s Assault on Public Health (Art Caplan)


Michele, My Warning Bell about Vaccine Fear-Mongering
Public Health
Arthur Caplan, 09/20/2011

Read more: http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=5543&blogid=140#ixzz1YbeEpERW

Greg Kaebnick, the editor of the Hastings Center Report (and, full disclosure, a former student of mine!) kindly invited me to offer some comments on my decision to publicly challenge Congresswoman and presidential candidate Michele Bachmann's comments on the safety of the HPV vaccine. I am happy to do so. It lets me tell a story that might be of interest to the bioethics community and to offer a few comments about my own thinking about the public work in which some bioethicists engage.
Yesterday, Bachmann abandoned her claim that the vaccine was dangerous, saying she was only repeating a story she had been told. Of course, rumor-mongering is hardly a defense. Moreover, she has apparently decided to make an antivaccination stance a key part of her campaign to dislodge Texas Governor Rick Perry from his position as the GOP's leading presidential candidate.
In running against vaccines, Bachmann is willing to dissemble and lie about vaccine safety to try and score political points. She is also apparently willing to sacrifice the lives of young women in the U.S. and around the world to cancer, as well as others who may die of whooping cough or flu to her political ambition by impugning the safety and efficacy of vaccines and vaccine mandates. This stance should not only disqualify her from selection as the GOP candidate for any national office, but it should also lead her Minnesota constituents to think about whether she belongs in Congress at all.

The HPV flap to date

 On Tuesday, September 13, the day after the GOP presidential candidates debate, Bachmann claimed on various media outlets that the HPV vaccine was dangerous and could cause "mental retardation". Bachman told Matt Lauer on the "Today" show that she had met a woman who said her daughter had "suffered mental retardation from the vaccine." She went on to say that the HPV vaccine has "very dangerous consequences" and that it puts "little children's lives at risk."
The whole off-the-wall discussion during the debate about Perry's push to promote the HPV vaccine through an executive order had me angry. Bachmann's fear-mongering about vaccine safety to gain an edge on Perry pushed me over the edge. Within hours, I wrote an impassioned column trying to get the facts straight. I posted it on my Facebook page and tweeted it as well. The column got some attention, and I got a number of requests for radio and print interviews about it on Tuesday.
On Wednesday I happened to see a Facebook post by my friend and former colleague at the University of Minnesota, Steve Miles. He, too, was angry about Bachmann's lies about vaccine safety and had posted this item: "I am offering $1,000 for the name and medical records release of the person who Michele Bachmann says became mentally retarded as a consequence of the HPV. Please share this message."
The American Academy of Pediatrics also issued a strong statement, and a few commentators and fact-checking items in the newspapers noted that her remarks were not true. Still, I worried that the stench of fear was going to linger around vaccines yet again, and I decided I should take on Bachmann's untruths, too. I did not want Bachmann to give more fuel to anti-vaccinators or to risk the lives of children whose parents might not get them vaccinated because of fears she was continuing to stoke.
Although I thought Steve's $1,000 wager would get some attention, I thought we needed to up the ante. We needed a gimmick to debunk the Bachmann blarney. So I tweeted and e-mailed my own challenge: If Bachmann could produce a person within a week who had been made "retarded" by the HPV vaccine, and if that claim could be verified by three doctors that she and I agreed upon, then I would give $10,000 of my own money to a charity of her choice. If not, she would give $10,000 dollars to a charity of my choosing.
I repeated the challenge on the radio interviews I had that Thursday morning and said the clock had started ticking. Pretty soon, my phone was ringing and e-mails were coming in from journalists. Steve let me know he did not agree with the terms of my challenge but that he was on board with me and would add his $1,000 dollars to it. So there was an $11,000 throwdown.
During interviews that Thursday, I pointed out again and again that there was no evidence at all that the HPV vaccine caused "retardation," that the CDC/VAERS Web site had never received any such report, that there had been no report I knew of in any other country in the world of any such side-effect despite more than 35 million doses administered, and that it was reprehensible that the same sort of fear-mongering that was causing infants to die of pertussis, flu, rotavirus, measles, and polio around the world was being offered up about HPV vaccine by a serious contender for the presidency of the United States.
I then received a request for an interview on "Anderson Cooper 360" on CNN about my challenge. The power of TV in American culture is still impressive. After the Anderson Cooper interview, the issue of Bachmann's vaccine fear-mongering became national news, splashed all over the print, radio, and Internet. Bachmann was being held accountable, and lying about vaccine safety was costing her. By Saturday she had dropped in the polls.
Her campaign has not responded to Steve or me. An NPR reporter told me that her press person said she would not respond because she had not received "a letter" from me challenging her views about the HPV vaccine. That response is absurd on its face.

On taking a public stand

Part of the reason I was angry about Bachmann's comments is that I have been working on vaccine ethics long enough to be acutely aware of the harm caused by vaccine misinformation. In 2004, I had been asked by a Pennsylvania official for help in determining how best to allocate the then-scarce supply of flu vaccine. I told him I did not know anything about vaccines, but that I was sure some bioethicists were working in this area. It turned out that I could not find any to recommend.
I began wondering why that was, since vaccines are the single most effective medical intervention ever mounted against disease, with at least one major scourge of humanity, smallpox, eliminated due to vaccines and another, polio (which I had as a child), close to eradication. Long story short, I ended up launching a project at Penn on vaccine ethics and a related project, which I run with the able help of Jason Schwartz.  I signed up for a course on how to make vaccines; sat in on lectures on vaccine issues; and met Paul Offit, of our Children's Hospital and department of pediatrics, who had been waging a one-man war against anti-vaccination propaganda for years. I got deeply involved in the subject and wound up publishing quite a bit on vaccines in general and on HPV vaccine in particular.
Having been involved in a highly visible way in other situations where politicians, zealots, or advocates have tried to advance misinformation in the name of a political or medical goal - including the Terri Schiavo case, the battle over federal funding of embryonic stem cell research, the claim that a Belgian man had "woken up from a 23-year coma" to use facilitated communication to reveal the horror of his experience, and crackpot offers of cures with untested adult stem cell therapies, among others - I knew a few things about the importance of speaking up, the need to have scholarship in place to back up one's comments, and the price that often has to be paid for doing so.
The need to speak from an ethical perspective in public forums and outlets about inaccurate, misleading, or outright false claims about bioethical issues should be self-evident. While it is important to publish one's views in the peer-reviewed literature and to share them in the seminar room, it is equally important for those who have the skills and the facility to communicate with broader audiences to do so. Like economics, political science, climate science, agriculture, and engineering, bioethics is not a purely theoretical field. To do what nearly all of those in the field claim it seeks to do - advance patient interests, enhance the prospect for justice for the least well-off, correct abuses of patient and subject rights - some in the field must engage in policy and public dialogue. At the same time, of course, if one is going to speak up, then it is important either to have published on the matter or to have mastered the relevant subject area at least to the point where one is comfortable teaching and lecturing about it.
The danger in advancing civic debate and public understanding is that your own peers will not know your scholarly work on a topic and will see any highly visible public activity as self-promotional pandering - or at best as popularizing, although that is little better on the academic scale of value. The duty to get involved surely overwhelms the price.
It is also true that entering the public arena means interaction with the media. Time and again, I have seen my comments distorted, misstated, or simply misused, even by highly respected journalists. It has already happened in the HPV vaccine story. The Internet only makes matters worse, given its immense power of repetition.
I think my decision to call out Michelle Bachmann on her comments about vaccine safety and vaccine mandates with my $10,000 challenge was the right one. I believe it is having the effect I intended. The lack of evidence behind nearly all of the claims of vaccine dangers and risks remains in the news. There may even be a better understanding of what is involved in creating different types of vaccine mandates. And women and men in America may be more willing to get their children vaccinated against a disease that kills and maims thousands and to support efforts to get the HPV vaccine to poor women worldwide to prevent many of the hundreds of thousands of deaths that occur every year from cervical cancer.
If vaccination is going to be a key part of the winnowing process of those who want to be president, then the framing of that debate has been reset in a much more positive mode.
Arthur Caplan is the Emanuel & Robert Hart Director of the Center for Bioethics and Sidney D. Caplan Professor of Medical Ethics at the University of Pennsylvania, and a Hastings Center Fellow. Follow him on Twitter @ArthurCaplan.
Caplan's references and writings on vaccines:
Boom and bust-have we learned what we need to from the flu vaccine shortage?" Johns Hopkins Advanced Studies in Medicine, 2005: 522-3.
"Off the grid: Vaccinations among home-schooled children," The Journal of Law, Medicine & Ethics, 35, 3, 2007: 471-77. (with D Khalili).
"Lessons from the failure of human papillomavirus vaccine state requirements", Clinical Pharmacology and Therapeutics, 82, December, 2007: 760-3, (with JL Schwartz, RR Faden and J Sugarman).
"Leveraging Genetic Resources or Moral Blackmail? - Indonesia and Avian Flu Virus Sample Sharing," American Journal of Bioethics, 7, 11, 2007: 1-2 (with DR Curry).
"Ethics" in: S. Plotkin, W. Orenstein and P. Offit, eds., Vaccines, 5th ed., 2008: 1677-1684 (with JL Schwartz).
"Genital warts: mountains or molehills?" The Lancet Infectious Diseases, 8, 5, 2008; 277-8 (with SC Hull).
"A proposed ethical framework for vaccine mandates: Competing values and the case of HPV", Kennedy Institute of Ethics Journal, 18,2, 2008: 111-124. (with RI Field).
"Is Disease eradication unethical?" The Lancet, 373, 2009: 2192-3.
"Disease eradication -  a response," The Lancet, 374, 2009: 1144 (letter).
"The case for vaccinating boys against HPV," Public Health Genomics, 12, 2009:362-7 (with S Hull).
"Unlicensed Pandemic a (H1N1) Vaccines: Explicit ethical rules of the road are needed in public health emergencies," The Lancet, 2009: 375, 2010 444-45.
"Physician attitudes toward influenza immunization and vaccine mandates," Vaccine, 28, 2010: 2517-22 (with J Desante and A Behrman, F Shofer).
"Influenza vaccination of healthcare personnel," Infection Control and Hospital Epidemiology, 31, 2010: 987-995 (with TR Talbot, H. Babcock, D Cotton, LL Maragakis, GA Poland, DJ Weber).
"Clinical trials of drugs and vaccines in poor nations -- ethical challenges and ethical solutions," Clinical Pharmacology and Therapeutics, 88, 5, 2010: 583-4.
"Health care worker support of an influenza vaccine mandate at a large pediatric tertiary care hospital" Vaccine, 29, 9, 2011: 1762-9 (with K Feemster, S Coffin, P Offit, C Feudtner and M. Smith).
"Vaccination: facts alone do not policy make," Health Affairs, 30, June 2011: 1205-8.
"Ethics of vaccination programs," Current Opinion in Virology, 1, 2011: 1-5. (with Jason Schwartz).
"Time to mandate influenza vaccination in healthcare workers," The Lancet, 378, 2011: 310-311.
"Vaccination refusal: ethics, individual rights and the common good," Primary Care Clinics Office Practice, 2011, in press. (with Jason L Schwartz)
Posted by Susan Gilbert at 09/20/2011 11:36:03 AM |
09.21.11
by

Michelle Bachmann’s Assault on Public Health (Art Caplan)


Michele, My Warning Bell about Vaccine Fear-Mongering
Public Health
Arthur Caplan, 09/20/2011

Read more: http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=5543&blogid=140#ixzz1YbeEpERW

Greg Kaebnick, the editor of the Hastings Center Report (and, full disclosure, a former student of mine!) kindly invited me to offer some comments on my decision to publicly challenge Congresswoman and presidential candidate Michele Bachmann's comments on the safety of the HPV vaccine. I am happy to do so. It lets me tell a story that might be of interest to the bioethics community and to offer a few comments about my own thinking about the public work in which some bioethicists engage.
Yesterday, Bachmann abandoned her claim that the vaccine was dangerous, saying she was only repeating a story she had been told. Of course, rumor-mongering is hardly a defense. Moreover, she has apparently decided to make an antivaccination stance a key part of her campaign to dislodge Texas Governor Rick Perry from his position as the GOP's leading presidential candidate.
In running against vaccines, Bachmann is willing to dissemble and lie about vaccine safety to try and score political points. She is also apparently willing to sacrifice the lives of young women in the U.S. and around the world to cancer, as well as others who may die of whooping cough or flu to her political ambition by impugning the safety and efficacy of vaccines and vaccine mandates. This stance should not only disqualify her from selection as the GOP candidate for any national office, but it should also lead her Minnesota constituents to think about whether she belongs in Congress at all.

The HPV flap to date

 On Tuesday, September 13, the day after the GOP presidential candidates debate, Bachmann claimed on various media outlets that the HPV vaccine was dangerous and could cause "mental retardation". Bachman told Matt Lauer on the "Today" show that she had met a woman who said her daughter had "suffered mental retardation from the vaccine." She went on to say that the HPV vaccine has "very dangerous consequences" and that it puts "little children's lives at risk."
The whole off-the-wall discussion during the debate about Perry's push to promote the HPV vaccine through an executive order had me angry. Bachmann's fear-mongering about vaccine safety to gain an edge on Perry pushed me over the edge. Within hours, I wrote an impassioned column trying to get the facts straight. I posted it on my Facebook page and tweeted it as well. The column got some attention, and I got a number of requests for radio and print interviews about it on Tuesday.
On Wednesday I happened to see a Facebook post by my friend and former colleague at the University of Minnesota, Steve Miles. He, too, was angry about Bachmann's lies about vaccine safety and had posted this item: "I am offering $1,000 for the name and medical records release of the person who Michele Bachmann says became mentally retarded as a consequence of the HPV. Please share this message."
The American Academy of Pediatrics also issued a strong statement, and a few commentators and fact-checking items in the newspapers noted that her remarks were not true. Still, I worried that the stench of fear was going to linger around vaccines yet again, and I decided I should take on Bachmann's untruths, too. I did not want Bachmann to give more fuel to anti-vaccinators or to risk the lives of children whose parents might not get them vaccinated because of fears she was continuing to stoke.
Although I thought Steve's $1,000 wager would get some attention, I thought we needed to up the ante. We needed a gimmick to debunk the Bachmann blarney. So I tweeted and e-mailed my own challenge: If Bachmann could produce a person within a week who had been made "retarded" by the HPV vaccine, and if that claim could be verified by three doctors that she and I agreed upon, then I would give $10,000 of my own money to a charity of her choice. If not, she would give $10,000 dollars to a charity of my choosing.
I repeated the challenge on the radio interviews I had that Thursday morning and said the clock had started ticking. Pretty soon, my phone was ringing and e-mails were coming in from journalists. Steve let me know he did not agree with the terms of my challenge but that he was on board with me and would add his $1,000 dollars to it. So there was an $11,000 throwdown.
During interviews that Thursday, I pointed out again and again that there was no evidence at all that the HPV vaccine caused "retardation," that the CDC/VAERS Web site had never received any such report, that there had been no report I knew of in any other country in the world of any such side-effect despite more than 35 million doses administered, and that it was reprehensible that the same sort of fear-mongering that was causing infants to die of pertussis, flu, rotavirus, measles, and polio around the world was being offered up about HPV vaccine by a serious contender for the presidency of the United States.
I then received a request for an interview on "Anderson Cooper 360" on CNN about my challenge. The power of TV in American culture is still impressive. After the Anderson Cooper interview, the issue of Bachmann's vaccine fear-mongering became national news, splashed all over the print, radio, and Internet. Bachmann was being held accountable, and lying about vaccine safety was costing her. By Saturday she had dropped in the polls.
Her campaign has not responded to Steve or me. An NPR reporter told me that her press person said she would not respond because she had not received "a letter" from me challenging her views about the HPV vaccine. That response is absurd on its face.

On taking a public stand

Part of the reason I was angry about Bachmann's comments is that I have been working on vaccine ethics long enough to be acutely aware of the harm caused by vaccine misinformation. In 2004, I had been asked by a Pennsylvania official for help in determining how best to allocate the then-scarce supply of flu vaccine. I told him I did not know anything about vaccines, but that I was sure some bioethicists were working in this area. It turned out that I could not find any to recommend.
I began wondering why that was, since vaccines are the single most effective medical intervention ever mounted against disease, with at least one major scourge of humanity, smallpox, eliminated due to vaccines and another, polio (which I had as a child), close to eradication. Long story short, I ended up launching a project at Penn on vaccine ethics and a related project, which I run with the able help of Jason Schwartz.  I signed up for a course on how to make vaccines; sat in on lectures on vaccine issues; and met Paul Offit, of our Children's Hospital and department of pediatrics, who had been waging a one-man war against anti-vaccination propaganda for years. I got deeply involved in the subject and wound up publishing quite a bit on vaccines in general and on HPV vaccine in particular.
Having been involved in a highly visible way in other situations where politicians, zealots, or advocates have tried to advance misinformation in the name of a political or medical goal - including the Terri Schiavo case, the battle over federal funding of embryonic stem cell research, the claim that a Belgian man had "woken up from a 23-year coma" to use facilitated communication to reveal the horror of his experience, and crackpot offers of cures with untested adult stem cell therapies, among others - I knew a few things about the importance of speaking up, the need to have scholarship in place to back up one's comments, and the price that often has to be paid for doing so.
The need to speak from an ethical perspective in public forums and outlets about inaccurate, misleading, or outright false claims about bioethical issues should be self-evident. While it is important to publish one's views in the peer-reviewed literature and to share them in the seminar room, it is equally important for those who have the skills and the facility to communicate with broader audiences to do so. Like economics, political science, climate science, agriculture, and engineering, bioethics is not a purely theoretical field. To do what nearly all of those in the field claim it seeks to do - advance patient interests, enhance the prospect for justice for the least well-off, correct abuses of patient and subject rights - some in the field must engage in policy and public dialogue. At the same time, of course, if one is going to speak up, then it is important either to have published on the matter or to have mastered the relevant subject area at least to the point where one is comfortable teaching and lecturing about it.
The danger in advancing civic debate and public understanding is that your own peers will not know your scholarly work on a topic and will see any highly visible public activity as self-promotional pandering - or at best as popularizing, although that is little better on the academic scale of value. The duty to get involved surely overwhelms the price.
It is also true that entering the public arena means interaction with the media. Time and again, I have seen my comments distorted, misstated, or simply misused, even by highly respected journalists. It has already happened in the HPV vaccine story. The Internet only makes matters worse, given its immense power of repetition.
I think my decision to call out Michelle Bachmann on her comments about vaccine safety and vaccine mandates with my $10,000 challenge was the right one. I believe it is having the effect I intended. The lack of evidence behind nearly all of the claims of vaccine dangers and risks remains in the news. There may even be a better understanding of what is involved in creating different types of vaccine mandates. And women and men in America may be more willing to get their children vaccinated against a disease that kills and maims thousands and to support efforts to get the HPV vaccine to poor women worldwide to prevent many of the hundreds of thousands of deaths that occur every year from cervical cancer.
If vaccination is going to be a key part of the winnowing process of those who want to be president, then the framing of that debate has been reset in a much more positive mode.
Arthur Caplan is the Emanuel & Robert Hart Director of the Center for Bioethics and Sidney D. Caplan Professor of Medical Ethics at the University of Pennsylvania, and a Hastings Center Fellow. Follow him on Twitter @ArthurCaplan.
Caplan's references and writings on vaccines:
Boom and bust-have we learned what we need to from the flu vaccine shortage?" Johns Hopkins Advanced Studies in Medicine, 2005: 522-3.
"Off the grid: Vaccinations among home-schooled children," The Journal of Law, Medicine & Ethics, 35, 3, 2007: 471-77. (with D Khalili).
"Lessons from the failure of human papillomavirus vaccine state requirements", Clinical Pharmacology and Therapeutics, 82, December, 2007: 760-3, (with JL Schwartz, RR Faden and J Sugarman).
"Leveraging Genetic Resources or Moral Blackmail? - Indonesia and Avian Flu Virus Sample Sharing," American Journal of Bioethics, 7, 11, 2007: 1-2 (with DR Curry).
"Ethics" in: S. Plotkin, W. Orenstein and P. Offit, eds., Vaccines, 5th ed., 2008: 1677-1684 (with JL Schwartz).
"Genital warts: mountains or molehills?" The Lancet Infectious Diseases, 8, 5, 2008; 277-8 (with SC Hull).
"A proposed ethical framework for vaccine mandates: Competing values and the case of HPV", Kennedy Institute of Ethics Journal, 18,2, 2008: 111-124. (with RI Field).
"Is Disease eradication unethical?" The Lancet, 373, 2009: 2192-3.
"Disease eradication -  a response," The Lancet, 374, 2009: 1144 (letter).
"The case for vaccinating boys against HPV," Public Health Genomics, 12, 2009:362-7 (with S Hull).
"Unlicensed Pandemic a (H1N1) Vaccines: Explicit ethical rules of the road are needed in public health emergencies," The Lancet, 2009: 375, 2010 444-45.
"Physician attitudes toward influenza immunization and vaccine mandates," Vaccine, 28, 2010: 2517-22 (with J Desante and A Behrman, F Shofer).
"Influenza vaccination of healthcare personnel," Infection Control and Hospital Epidemiology, 31, 2010: 987-995 (with TR Talbot, H. Babcock, D Cotton, LL Maragakis, GA Poland, DJ Weber).
"Clinical trials of drugs and vaccines in poor nations -- ethical challenges and ethical solutions," Clinical Pharmacology and Therapeutics, 88, 5, 2010: 583-4.
"Health care worker support of an influenza vaccine mandate at a large pediatric tertiary care hospital" Vaccine, 29, 9, 2011: 1762-9 (with K Feemster, S Coffin, P Offit, C Feudtner and M. Smith).
"Vaccination: facts alone do not policy make," Health Affairs, 30, June 2011: 1205-8.
"Ethics of vaccination programs," Current Opinion in Virology, 1, 2011: 1-5. (with Jason Schwartz).
"Time to mandate influenza vaccination in healthcare workers," The Lancet, 378, 2011: 310-311.
"Vaccination refusal: ethics, individual rights and the common good," Primary Care Clinics Office Practice, 2011, in press. (with Jason L Schwartz)
Posted by Susan Gilbert at 09/20/2011 11:36:03 AM |
09.19.11
by

Too Many Tasks (Marin IJ)


I'm sitting down to write on an important topic. I should check my email. Right, where was I? An important topic for students, parents, professionals, and, well, just about everyone. Who's texting me? Oh shoot; I need to finish that Amazon order. I forgot to call the plumber. And the dog needs to go out. Did I feed my daughter's Brazilian water frog? I should check my email. Wait, focus. Important topic. Interesting topic. And it's critical that everyone understand the limitations and risks associated with it. I really should check my email. Multi...must check email! ...Tasking.
Like many people in our digitalized and sensory-loaded world, I'm a fervent multi-tasker. Email, bills, scheduling, patient-care, child-care, pet-care, Twitter-care, fantasy sports; I can do it all. And I can do it all at the same time! At least so I thought. Just checked my email for the fourth time this paragraph. My wife wants to know if we can go to a school fundraiser tonight. My boss is trying to schedule a tennis match. I wonder which QBs are available on the cbsportsline waiver wire? Expedia has a new fare alert for me. $299 bucks to fly to Omaha! Sweet. Contrary to the ethos I've prided myself on, in a world of information overload, constant data processing can actually "smog," "asphyxiate," and starve away productive time. In fact, multi-tasking may threaten efficiency more than aid it. 
Skeptical? Well, stay with me here (your stock portfolio and Facebook newsfeed can wait), and consider evidence from cognitive testing. Researchers looking at individuals performing two or more tasks at once have found that, quite consistently, people complete tasks faster if they do them serially (one, then the other) rather than in parallel (start one, start the other, back to the first, and so on). In fact, loss of efficiency has been estimated to be around half-a-second per task switch and up to twice the sum of the time needed to complete two tasks in order. So, for example, if it takes me two minutes to check and respond to my email and three minutes to order a new mattress online, it would take me up to ten minutes to do the two tasks "at the same time" (switching back and forth between tasks with a delay with each switch). But if I did the tasks serially (i.e. focusing on one task and completing it before moving on to the next), the two tasks should take me only five minutes.
Now, as we all know, multi-tasking is more or less a fact of life. Most of us are forced to multi-task some or all of the time, both at work and at home. A busy shift in the Emergency Department (ED) is an excellent example of this, and one that I'm quite familiar with. I spend my days talking with patients, performing physical exams, entering orders, documenting, calling consultants, communicating with nursing and other personnel, performing procedures, making referrals, all while trying not to neglect an important task like prescribing the correct medication. Studies of ED physicians demonstrate that their tasks will be interrupted four to fourteen times per hour, or every four minutes or so. An observational study of nurses reported that ED nurses (at work) multitask 34% of the time. Each and every single one of the interruptions that ED providers experience could have disastrous consequences. (This is why we have developed safety mechanisms like timeouts and checklists.)
But of course, some multi-tasking is unavoidable. Our patients surely appreciate that we break away from a routine task, like charting, to tackle another more critical task, such as providing acute resuscitation. And, keep in mind that some "multitasking" is not harmful. For some people, listening to music while driving or studying is not really multi-tasking at all but rather a multi-sensory approach to a task. This habit may or may not affect efficiency and performance. People are (according to cognitive studies) able to train themselves to block out distractions when performing an assignment. Note that I say "distractions" and not tasks. Tasks, especially ones that require working memory - very short term memory designed to aid in completion of short term tasks - will be more efficiently completed in order and cannot be blocked out as part of a multisensory approach. Working memory is ephemeral and highly sensitive to interruptions. We all experience this as those "I lost my train of thought" moments.
Can you minimize brain stalls and achieve a healthy level of multi-tasking? Maybe, but first you have to set aside dedicated time to think, focus, and plan. Creativity benefits from focus and people who have planned or rehearsed tasks beforehand are less likely to suffer delays. Here's another tip: try to resist over-dosing on jolts of satisfaction ("dopamine squirts") associated with compulsive behavior - like checking email every 2.4 minutes. And when possible, finish what you started  - NOW - rather than deferring it to the "later" bucket. Working memory is temporary and what may seem unforgettable right now is actually quite forgettable in 15 minutes. Finally, experiment with focus adjuncts - meditation or paying attention to your breathing may help, as might noise-erasing headphones (which, my wife lovingly has dubbed "wife- and kid-erasers"). Of course, a lot of the modern world cannot be easily "noise-erased," but if you make an effort to slow down, especially with important endeavors, your reward, ultimately, will be higher efficiency and fewer mistakes.
Well, phew, I've made it through this task. Hope you did too. How many unread emails do I have? That frog must be absolutely starving. Now, if you'll excuse me, I've got a few other things to do...


09.19.11
by

Too Many Tasks (Marin IJ)


I'm sitting down to write on an important topic. I should check my email. Right, where was I? An important topic for students, parents, professionals, and, well, just about everyone. Who's texting me? Oh shoot; I need to finish that Amazon order. I forgot to call the plumber. And the dog needs to go out. Did I feed my daughter's Brazilian water frog? I should check my email. Wait, focus. Important topic. Interesting topic. And it's critical that everyone understand the limitations and risks associated with it. I really should check my email. Multi...must check email! ...Tasking.
Like many people in our digitalized and sensory-loaded world, I'm a fervent multi-tasker. Email, bills, scheduling, patient-care, child-care, pet-care, Twitter-care, fantasy sports; I can do it all. And I can do it all at the same time! At least so I thought. Just checked my email for the fourth time this paragraph. My wife wants to know if we can go to a school fundraiser tonight. My boss is trying to schedule a tennis match. I wonder which QBs are available on the cbsportsline waiver wire? Expedia has a new fare alert for me. $299 bucks to fly to Omaha! Sweet. Contrary to the ethos I've prided myself on, in a world of information overload, constant data processing can actually "smog," "asphyxiate," and starve away productive time. In fact, multi-tasking may threaten efficiency more than aid it. 
Skeptical? Well, stay with me here (your stock portfolio and Facebook newsfeed can wait), and consider evidence from cognitive testing. Researchers looking at individuals performing two or more tasks at once have found that, quite consistently, people complete tasks faster if they do them serially (one, then the other) rather than in parallel (start one, start the other, back to the first, and so on). In fact, loss of efficiency has been estimated to be around half-a-second per task switch and up to twice the sum of the time needed to complete two tasks in order. So, for example, if it takes me two minutes to check and respond to my email and three minutes to order a new mattress online, it would take me up to ten minutes to do the two tasks "at the same time" (switching back and forth between tasks with a delay with each switch). But if I did the tasks serially (i.e. focusing on one task and completing it before moving on to the next), the two tasks should take me only five minutes.
Now, as we all know, multi-tasking is more or less a fact of life. Most of us are forced to multi-task some or all of the time, both at work and at home. A busy shift in the Emergency Department (ED) is an excellent example of this, and one that I'm quite familiar with. I spend my days talking with patients, performing physical exams, entering orders, documenting, calling consultants, communicating with nursing and other personnel, performing procedures, making referrals, all while trying not to neglect an important task like prescribing the correct medication. Studies of ED physicians demonstrate that their tasks will be interrupted four to fourteen times per hour, or every four minutes or so. An observational study of nurses reported that ED nurses (at work) multitask 34% of the time. Each and every single one of the interruptions that ED providers experience could have disastrous consequences. (This is why we have developed safety mechanisms like timeouts and checklists.)
But of course, some multi-tasking is unavoidable. Our patients surely appreciate that we break away from a routine task, like charting, to tackle another more critical task, such as providing acute resuscitation. And, keep in mind that some "multitasking" is not harmful. For some people, listening to music while driving or studying is not really multi-tasking at all but rather a multi-sensory approach to a task. This habit may or may not affect efficiency and performance. People are (according to cognitive studies) able to train themselves to block out distractions when performing an assignment. Note that I say "distractions" and not tasks. Tasks, especially ones that require working memory - very short term memory designed to aid in completion of short term tasks - will be more efficiently completed in order and cannot be blocked out as part of a multisensory approach. Working memory is ephemeral and highly sensitive to interruptions. We all experience this as those "I lost my train of thought" moments.
Can you minimize brain stalls and achieve a healthy level of multi-tasking? Maybe, but first you have to set aside dedicated time to think, focus, and plan. Creativity benefits from focus and people who have planned or rehearsed tasks beforehand are less likely to suffer delays. Here's another tip: try to resist over-dosing on jolts of satisfaction ("dopamine squirts") associated with compulsive behavior - like checking email every 2.4 minutes. And when possible, finish what you started  - NOW - rather than deferring it to the "later" bucket. Working memory is temporary and what may seem unforgettable right now is actually quite forgettable in 15 minutes. Finally, experiment with focus adjuncts - meditation or paying attention to your breathing may help, as might noise-erasing headphones (which, my wife lovingly has dubbed "wife- and kid-erasers"). Of course, a lot of the modern world cannot be easily "noise-erased," but if you make an effort to slow down, especially with important endeavors, your reward, ultimately, will be higher efficiency and fewer mistakes.
Well, phew, I've made it through this task. Hope you did too. How many unread emails do I have? That frog must be absolutely starving. Now, if you'll excuse me, I've got a few other things to do...


09.19.11
by

Work Does Not Have to Hurt (Marin IJ)



This Labor Day, as we honor workers, let us also celebrate workplace safety. Well, perhaps workplace safety is not so much something we celebrate, as it is something we should expect. And if you consider where we've come from, remarkable progress has truly been made. Over one hundred years ago, Upton Sinclair's novel The Jungle depicted the truly awful working conditions of the early 20th century Chicago meatpacking industry. For example, consider the job of "beef-boner"..."Your hands are slippery, and your knife is slippery, and you are toiling like mad, when somebody happens to speak to you, or you strike a bone. Then your hand slips up on the blade, and there is a fearful gash. And that would not be so bad, only for the deadly contagion. The cut may heal, but you never can tell." Grimy and grim. And workplace danger was not restricted to beef boners - in year 1913 alone, the Bureau of Labor Statistics (BLS) documented 23,000 industrial deaths among a workforce of 38 million, equivalent to a rate of 61 deaths per 100,000 workers. And there were likely thousands more that went un-documented. Even thirty years ago, in the 1980s, after vast improvements in working conditions and safety, over 7000 people a year died on the job.

Last week, the BLS released the data for 2010, reporting 4,547 fatal work injuries, a rate nearly twenty fold improved from 1913. Of the year 2010 deaths, 1,766 were transportation related, 808 from assaults (including self-inflicted), 732 from being struck by an object, 635 from falls, 409 from toxic exposures and 187 from fires and explosions. Occupation-wise, the greatest magnitude of deaths was seen in transportation/material moving (1,115) and construction/mining industries (760). A somewhat surprising third were management occupations (533) - including 29 (no longer) top executives.

So nowadays, as you can see, workplace deaths are rare enough that they are fastidiously tracked - in fact you can find a description of specific events on the OSHA website (this, by the way, is only recommended for Faces of Death aficionados). Cleary, further improvements in work safety are possible but nonetheless, non-fatal injuries on the job are a problem of much greater frequency. According to 2009 BLS data, there were over 3.2 million workplace injuries or illness reported in the private sector alone. These include 195,150 back injuries and 212,760 falls. Ouch. In all, days-away-from-work approached one million in 2009 (this was actually an 11% decrease from 2008). As one might expect, high risk professions include those with significant lifting/physicality requirements - such as patrol officers, nursing aides, orderlies and attendants, delivery truck drivers, construction laborers, and janitors and cleaners.

No profession, however, is immune from on the job injuries. Even pillow softness testers must suffer some risk- although it is not immediately evident to me what this might be. Hazards exist in the offices and hallways around us. To help keep you safe in these environments, I canvassed the web (www.workplacesafetytips.org/) and Dr. Scott Levy, Chief of Occupational Medicine at San Rafael Kaiser, for some safety tips.

1) Boot the boxes...
And other clutter out of the hallway and walkways. Tripping over your own box of files would not only be embarrassing, it could also be quite painful.

2) Don't carry anything higher than your eye level or read while walking.
Can't see where you are going? Carrying a heavy load? Not noticing Wobbly Wanda and her cup of very hot tea. Ruh-oh.

3) Don't run unless someone's life is at stake.
Stieg Larsson, author of The Girl with the Dragon Tattoo, died prematurely because the elevator was broken and he ran seven flights of steps to make a meeting on time. His heart couldn't take the stress of always being in a rush. Can yours?

4) Look before you sit.
Seems simple, but a chair is not always that clear of a target to hit - especially if you're distracted. A bruised bum or a bum back could be your penance for poor sitting technique.

5) Think Ergonomically
A properly designed (ergonomic) workstation can help minimize work place injuries. This fact becomes quite obvious when people with very different proportions attempt to use the same workspace.

6) Something's in the air around here
Besides hazards that lead to musculoskeletal injuries, consider other sources of injury. Strong scented colognes and perfumes can easily aggravate allergies and trigger asthma attacks.

7) Wellness is not for Wussies.
Consider starting or joining a workplace wellness program.  There's a lot of evidence that having a healthier workforce will lead to fewer injuries.

8) Light Matters
Don't overlook the importance and relevance of your office lighting. Traditional fluorescent light bulbs flicker very rapidly and can lead to increased fatigue - not to mention irritability.

9) Control the Urge to Multi-Task
This is a tough one - and I'm as guilty as the next over-stimulated employee. More on this another time, but just know that serious multi-tasking does not help you to be more effective, in fact it can be quite detrimental. You are much more likely to forget something important (such as driving on the right side of the road) if your mind is flipping back and forth between two activities.

In sum, advises Dr. Levy..."Although office injuries will never drop to zero despite our best efforts, there are ways to minimize the numbers.  Developing an ongoing program where office hazards are continually monitored will lead to improved staff morale in addition to the obvious benefit of an overall safer workplace."

Indeed, work does not have to hurt.

09.19.11
by

Work Does Not Have to Hurt (Marin IJ)



This Labor Day, as we honor workers, let us also celebrate workplace safety. Well, perhaps workplace safety is not so much something we celebrate, as it is something we should expect. And if you consider where we've come from, remarkable progress has truly been made. Over one hundred years ago, Upton Sinclair's novel The Jungle depicted the truly awful working conditions of the early 20th century Chicago meatpacking industry. For example, consider the job of "beef-boner"..."Your hands are slippery, and your knife is slippery, and you are toiling like mad, when somebody happens to speak to you, or you strike a bone. Then your hand slips up on the blade, and there is a fearful gash. And that would not be so bad, only for the deadly contagion. The cut may heal, but you never can tell." Grimy and grim. And workplace danger was not restricted to beef boners - in year 1913 alone, the Bureau of Labor Statistics (BLS) documented 23,000 industrial deaths among a workforce of 38 million, equivalent to a rate of 61 deaths per 100,000 workers. And there were likely thousands more that went un-documented. Even thirty years ago, in the 1980s, after vast improvements in working conditions and safety, over 7000 people a year died on the job.

Last week, the BLS released the data for 2010, reporting 4,547 fatal work injuries, a rate nearly twenty fold improved from 1913. Of the year 2010 deaths, 1,766 were transportation related, 808 from assaults (including self-inflicted), 732 from being struck by an object, 635 from falls, 409 from toxic exposures and 187 from fires and explosions. Occupation-wise, the greatest magnitude of deaths was seen in transportation/material moving (1,115) and construction/mining industries (760). A somewhat surprising third were management occupations (533) - including 29 (no longer) top executives.

So nowadays, as you can see, workplace deaths are rare enough that they are fastidiously tracked - in fact you can find a description of specific events on the OSHA website (this, by the way, is only recommended for Faces of Death aficionados). Cleary, further improvements in work safety are possible but nonetheless, non-fatal injuries on the job are a problem of much greater frequency. According to 2009 BLS data, there were over 3.2 million workplace injuries or illness reported in the private sector alone. These include 195,150 back injuries and 212,760 falls. Ouch. In all, days-away-from-work approached one million in 2009 (this was actually an 11% decrease from 2008). As one might expect, high risk professions include those with significant lifting/physicality requirements - such as patrol officers, nursing aides, orderlies and attendants, delivery truck drivers, construction laborers, and janitors and cleaners.

No profession, however, is immune from on the job injuries. Even pillow softness testers must suffer some risk- although it is not immediately evident to me what this might be. Hazards exist in the offices and hallways around us. To help keep you safe in these environments, I canvassed the web (www.workplacesafetytips.org/) and Dr. Scott Levy, Chief of Occupational Medicine at San Rafael Kaiser, for some safety tips.

1) Boot the boxes...
And other clutter out of the hallway and walkways. Tripping over your own box of files would not only be embarrassing, it could also be quite painful.

2) Don't carry anything higher than your eye level or read while walking.
Can't see where you are going? Carrying a heavy load? Not noticing Wobbly Wanda and her cup of very hot tea. Ruh-oh.

3) Don't run unless someone's life is at stake.
Stieg Larsson, author of The Girl with the Dragon Tattoo, died prematurely because the elevator was broken and he ran seven flights of steps to make a meeting on time. His heart couldn't take the stress of always being in a rush. Can yours?

4) Look before you sit.
Seems simple, but a chair is not always that clear of a target to hit - especially if you're distracted. A bruised bum or a bum back could be your penance for poor sitting technique.

5) Think Ergonomically
A properly designed (ergonomic) workstation can help minimize work place injuries. This fact becomes quite obvious when people with very different proportions attempt to use the same workspace.

6) Something's in the air around here
Besides hazards that lead to musculoskeletal injuries, consider other sources of injury. Strong scented colognes and perfumes can easily aggravate allergies and trigger asthma attacks.

7) Wellness is not for Wussies.
Consider starting or joining a workplace wellness program.  There's a lot of evidence that having a healthier workforce will lead to fewer injuries.

8) Light Matters
Don't overlook the importance and relevance of your office lighting. Traditional fluorescent light bulbs flicker very rapidly and can lead to increased fatigue - not to mention irritability.

9) Control the Urge to Multi-Task
This is a tough one - and I'm as guilty as the next over-stimulated employee. More on this another time, but just know that serious multi-tasking does not help you to be more effective, in fact it can be quite detrimental. You are much more likely to forget something important (such as driving on the right side of the road) if your mind is flipping back and forth between two activities.

In sum, advises Dr. Levy..."Although office injuries will never drop to zero despite our best efforts, there are ways to minimize the numbers.  Developing an ongoing program where office hazards are continually monitored will lead to improved staff morale in addition to the obvious benefit of an overall safer workplace."

Indeed, work does not have to hurt.

08.24.11
by

A Back to School Basic



The phrase "Back to school," can elicit a wide range of thoughts. Emotional responses include excitement, nerves, and in the case of my wife a profound "Thank Goodness!" My daughter, about to enter first grade, has a somewhat different opinion. "Can my American Girl go instead?". No matter what, this is the time of year of making back to school plans and lists. Pencils, erasers, coloring books and computer accessories. Notebooks, crayons, backpacks and brown bag lunches. Scissors, sanitizer and glue sticks. Gym clothes, clean underwear and shoes that fit. Feel like something important is missing? Well if you are a 7th-12th grader without an up to date pertussis (whooping cought) booster, than yes, something important is missing. In fact, this something is critically important - as you may not be allowed to attend school without it.
Last year, the state legislature passed AB354, which mandates an up to date pertussis booster (as part of the Tdap immunization) for all 7th-12th students. Based on this new law and immunization records, an estimated 5,000 students in Marin will need to move the Tdap shot to the top of their back to school list, or else there may just not be a school to go back to. Now, if you or your children are in this group, this requirement likely seems like a hassle, and it is. But, there is a good reason. I'll take a moment to explain...

Vaccination efforts during the past century have made certain childhood diseases so rare that they seem like remnants of an uncivilized past. Few of us have actually seen a new case of polio or measles, so it's easy to be lulled into thinking that these ailments are so antiquated they couldn't possibly cause trouble again. Unfortunately, this is just not true. The diseases that we vaccinate against are not extinct; they are lurking, waiting for enough people to drop their guard. If you think that I am an alarmist, consider these recent outbreaks: polio in Nigeria, measles across the U.S. and whooping cough in Marin County.

We are currently in the midst largest pertussis outbreak in 40 years - with ten deaths in California alone. Nationwide, measles is back - with a confirmed 156 cases in the first half of this year - the most since 1996. These outbreaks should remind us that we aren't as safe from vaccine preventable diseases as we may think. Pertussis, for instance, is a highly contagious lung infection that can affect both children and adults and classically causes a "whoop" after coughing. In the days before DTP (diptheria-tetanus-pertussis) immunization, pertussis killed thousands of infants every year - often because the cough was so severe that it caused them to start bleeding in the brain. Thankfully, with the advent of widespread vaccination, the number of infections declined 99% between the 1930s and the 1980s and the death rate plummeted to single digits by the 1990s. In the last ten years, however, we've seen a resurgence of this infant-killer. Nationwide in 2005, there were over 25,000 cases of pertussis reported to the CDC; 21 of these were in Marin County. There are several explanations for pertussis' comeback, but mostly it can be blamed on under-immunization. The protection afforded by the pertussis vaccine tends to wear off three to five years after vaccination, thus even children who have received the recommended DTaP series (five shots between the ages of 2 months and 6 years) are at risk for contracting the disease later.  Because of herd immunity (immunity that occurs when the vaccination of part of the community - or herd - provides protection to unvaccinated individuals) many parents think that their children are protected against pertussis (and other diseases) even if they are not fully vaccinated. Unfortunately, the more parents who believe this and exercise the (personal belief) exemption to mandatory vaccination, the more likely it is that herd immunity will fail. This is why a group of pediatricians in Philadelphia have published a manifesto to those who "absolutely" refuse to immunize: "by not vaccinating your child you are taking selfish advantage of thousands of others who do vaccinate their children ... We feel such an attitude to be self-centered and unacceptable." These pediatricians would be appalled with vaccination rates in Marin - according to the California Department of Public Health, the Marin County kindergarten immunization rate is 84.7%, significantly below the state rate of 92.1%. And while we have long suspected that un-immunized children are at greater risk of disease, we now have solid evidence of this. Two papers published in 2009 by a team of researchers from Colorado document significantly increased risk of pertussis (twenty-three fold risk) and varicella (nine-fold) in children whose parents refuse these immunizations.

So, what can we do to ward off a further surge in preventable infectious disease? Well, a great place to start is at the top of that back to school list. Fortunately, efforts are in play to make this as hassle free as possible. The Marin County Department of Health and Human Services is partnering with the Marin County Office of Education, San Rafael Kaiser Permanente, the Marin County School Nurses' Association and the Marin Medical Reserve Corps to offer five vaccine clinics in school sites around the county just before the start of classes. At these clinics the vaccine will be offered at no cost to Kaiser members and the many students who qualify for free vaccine under federal rules and at a maximum will cost $32. Dates are August 15th, 16th, 17th, 19th and 22nd. For more information and details visit http://www.co.marin.ca.us/tdap.
08.24.11
by

A Back to School Basic



The phrase "Back to school," can elicit a wide range of thoughts. Emotional responses include excitement, nerves, and in the case of my wife a profound "Thank Goodness!" My daughter, about to enter first grade, has a somewhat different opinion. "Can my American Girl go instead?". No matter what, this is the time of year of making back to school plans and lists. Pencils, erasers, coloring books and computer accessories. Notebooks, crayons, backpacks and brown bag lunches. Scissors, sanitizer and glue sticks. Gym clothes, clean underwear and shoes that fit. Feel like something important is missing? Well if you are a 7th-12th grader without an up to date pertussis (whooping cought) booster, than yes, something important is missing. In fact, this something is critically important - as you may not be allowed to attend school without it.
Last year, the state legislature passed AB354, which mandates an up to date pertussis booster (as part of the Tdap immunization) for all 7th-12th students. Based on this new law and immunization records, an estimated 5,000 students in Marin will need to move the Tdap shot to the top of their back to school list, or else there may just not be a school to go back to. Now, if you or your children are in this group, this requirement likely seems like a hassle, and it is. But, there is a good reason. I'll take a moment to explain...

Vaccination efforts during the past century have made certain childhood diseases so rare that they seem like remnants of an uncivilized past. Few of us have actually seen a new case of polio or measles, so it's easy to be lulled into thinking that these ailments are so antiquated they couldn't possibly cause trouble again. Unfortunately, this is just not true. The diseases that we vaccinate against are not extinct; they are lurking, waiting for enough people to drop their guard. If you think that I am an alarmist, consider these recent outbreaks: polio in Nigeria, measles across the U.S. and whooping cough in Marin County.

We are currently in the midst largest pertussis outbreak in 40 years - with ten deaths in California alone. Nationwide, measles is back - with a confirmed 156 cases in the first half of this year - the most since 1996. These outbreaks should remind us that we aren't as safe from vaccine preventable diseases as we may think. Pertussis, for instance, is a highly contagious lung infection that can affect both children and adults and classically causes a "whoop" after coughing. In the days before DTP (diptheria-tetanus-pertussis) immunization, pertussis killed thousands of infants every year - often because the cough was so severe that it caused them to start bleeding in the brain. Thankfully, with the advent of widespread vaccination, the number of infections declined 99% between the 1930s and the 1980s and the death rate plummeted to single digits by the 1990s. In the last ten years, however, we've seen a resurgence of this infant-killer. Nationwide in 2005, there were over 25,000 cases of pertussis reported to the CDC; 21 of these were in Marin County. There are several explanations for pertussis' comeback, but mostly it can be blamed on under-immunization. The protection afforded by the pertussis vaccine tends to wear off three to five years after vaccination, thus even children who have received the recommended DTaP series (five shots between the ages of 2 months and 6 years) are at risk for contracting the disease later.  Because of herd immunity (immunity that occurs when the vaccination of part of the community - or herd - provides protection to unvaccinated individuals) many parents think that their children are protected against pertussis (and other diseases) even if they are not fully vaccinated. Unfortunately, the more parents who believe this and exercise the (personal belief) exemption to mandatory vaccination, the more likely it is that herd immunity will fail. This is why a group of pediatricians in Philadelphia have published a manifesto to those who "absolutely" refuse to immunize: "by not vaccinating your child you are taking selfish advantage of thousands of others who do vaccinate their children ... We feel such an attitude to be self-centered and unacceptable." These pediatricians would be appalled with vaccination rates in Marin - according to the California Department of Public Health, the Marin County kindergarten immunization rate is 84.7%, significantly below the state rate of 92.1%. And while we have long suspected that un-immunized children are at greater risk of disease, we now have solid evidence of this. Two papers published in 2009 by a team of researchers from Colorado document significantly increased risk of pertussis (twenty-three fold risk) and varicella (nine-fold) in children whose parents refuse these immunizations.

So, what can we do to ward off a further surge in preventable infectious disease? Well, a great place to start is at the top of that back to school list. Fortunately, efforts are in play to make this as hassle free as possible. The Marin County Department of Health and Human Services is partnering with the Marin County Office of Education, San Rafael Kaiser Permanente, the Marin County School Nurses' Association and the Marin Medical Reserve Corps to offer five vaccine clinics in school sites around the county just before the start of classes. At these clinics the vaccine will be offered at no cost to Kaiser members and the many students who qualify for free vaccine under federal rules and at a maximum will cost $32. Dates are August 15th, 16th, 17th, 19th and 22nd. For more information and details visit http://www.co.marin.ca.us/tdap.
08.24.11
by

Meditations on Placebo (Marin IJ)




I've had placebo on the mind recently. This preoccupation started at the gym after a discussion with a self-described "Zennie," who tried to convince me of the benefits of meditation - particularly for priming athletes for peak performance. This woman, herself a practitioner of "muga-mushin," (Japanese for "no mind, no self"), asserted that an athlete could benefit more from careful visualization than from actual practice. I was skeptical; I have to believe Kobe Bryant's jumper is better served by physical practice than mental repetition. And this is when I started thinking about the placebo effect - the well-described sugar pill phenomenon in which patients experience significant improvement from sham treatments. It occurred to me that perhaps the mind-body benefits seen with placebos were not all that different than those achieved via meditation. And, I began to wonder, could meditation be used to consciously invoke the placebo effect?

Medical literature has, over and over again, demonstrated the power of placebo. Last year, for instance, a Newsweek cover story examined remarkable placebo treatments for depression - so remarkable that they are making it difficult for drug makers to prove the advantages of new anti-depressant medications. (The placebo response has become so robust in clinical trials that the drugs cannot outperform it.) Similarly, a recent Harvard study of asthmatics found 45% improvement in symptoms with a fake inhaler and 46% improvement with impostor acupuncture - compared to 50% with an actual treatment (albuterol).  Beyond just "tricking the brain to feel better," placebo treatments seem capable of causing actual neurological and physiological (bodily response) changes.

Even more startling was a recent study of patients with irritable bowel syndrome (IBS - a chronic gut condition characterized by pain and bowel irregularities). This study utilized an "open-label" placebo - in other words a placebo treatment without deception. In the investigation, led by Ted J. Kaptchuk and colleagues and published in December of 2010, eighty IBS patients were given either 1] no additional therapy or 2] treatment with what they described to the patients as "placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes." Self-reported symptom scores were assessed at 0, 11 and 21 days after the initiation of treatment. The results demonstrated significant improvements in symptom severity and relief in the placebo group.

Now, this study was a small one, with possible confounders (such as unreliability in patient symptom reporting) but certainly is provocative and promising. For years, physicians have struggled with placebo treatments - because they assumed that trickery was necessary for them to work. Trickery puts doctors in an uncomfortable position - having to choose between two ethical principles - beneficence (helping the patient) and autonomy (helping them make informed decisions). To freely prescribe placebo without the troublesome concealment component opens up a clear pathway for placebo treatments for many conditions - depression, asthma, chronic pain, IBS, addiction, hypertension, and more.  Now, I should be clear, there are limits to the physiologic possibilities for placebo. We can't expect mind-over-matter to work with a bleeding limb or widely metastatic cancer.

Nonetheless, the ramifications of the IBS study, if borne out in subsequent studies, are huge - the placebo effect may not require deception at all. Perhaps it's been mischaracterized for decades and perhaps conscious attempts at self-healing should
be carefully examined and mainstreamed. And this brings me back to meditation. Could meditation function like a placebo treatment for some conditions? I do not see why not. I'm no expert in Buddhism or meditation and I do not meditate (small children in the home would seem to make that nearly impossible). Still, I know there are a lot of different types of medication from a number of religious and spiritual traditions. And for the sake of this topic, I think we can agree that each shares an emphasis on channeling attention and achieving a still, rather than muddied and churning, mind. With that context, here's some substantiation for meditation. First, and anecdotally, from my gymnasium Zennie...

- She successfully used meditation to limit sweating on a very hot day, reporting that she "was able to not sweat, save for a light sweat film on the face (nothing under the arms or chest.)" This, by the way, is not a recommended approach to dealing with the heat.

-She successfully used meditation to prepare for extreme 24-hour straight sessions on the rowing machine achieving "no pain, total relaxation in the moment and no tension." This by the way, is not a recommended fitness regimen.

Not sold? Here's what the medical literature has to say...

-Functional MRI studies by Richard Davidson at University of Wisconsin demonstrate that meditation can have measurable effects on certain regions of the brain (such as in the process of consciously cultivating empathy).

-Other studies suggest that meditation can help young adults cope with stress and can improve information-processing in adults.

-Studies of flu vaccine efficacy suggest that meditation can help boost the body's immune response.

There is still much research to be done and I suspect that meditation is just one of a number of means of achieving better health through mind-body synching. Exercise, healthy relationships and optimism, for instance, may benefit the body through similar mechanisms. While the methods may vary, the physiologic mechanisms are likely similar. But, more on this another time. For now, I need to get back to the couch for some six-pack abs training - visualizing crunches is so much more comfortable than the real thing!



08.24.11
by

Meditations on Placebo (Marin IJ)




I've had placebo on the mind recently. This preoccupation started at the gym after a discussion with a self-described "Zennie," who tried to convince me of the benefits of meditation - particularly for priming athletes for peak performance. This woman, herself a practitioner of "muga-mushin," (Japanese for "no mind, no self"), asserted that an athlete could benefit more from careful visualization than from actual practice. I was skeptical; I have to believe Kobe Bryant's jumper is better served by physical practice than mental repetition. And this is when I started thinking about the placebo effect - the well-described sugar pill phenomenon in which patients experience significant improvement from sham treatments. It occurred to me that perhaps the mind-body benefits seen with placebos were not all that different than those achieved via meditation. And, I began to wonder, could meditation be used to consciously invoke the placebo effect?

Medical literature has, over and over again, demonstrated the power of placebo. Last year, for instance, a Newsweek cover story examined remarkable placebo treatments for depression - so remarkable that they are making it difficult for drug makers to prove the advantages of new anti-depressant medications. (The placebo response has become so robust in clinical trials that the drugs cannot outperform it.) Similarly, a recent Harvard study of asthmatics found 45% improvement in symptoms with a fake inhaler and 46% improvement with impostor acupuncture - compared to 50% with an actual treatment (albuterol).  Beyond just "tricking the brain to feel better," placebo treatments seem capable of causing actual neurological and physiological (bodily response) changes.

Even more startling was a recent study of patients with irritable bowel syndrome (IBS - a chronic gut condition characterized by pain and bowel irregularities). This study utilized an "open-label" placebo - in other words a placebo treatment without deception. In the investigation, led by Ted J. Kaptchuk and colleagues and published in December of 2010, eighty IBS patients were given either 1] no additional therapy or 2] treatment with what they described to the patients as "placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes." Self-reported symptom scores were assessed at 0, 11 and 21 days after the initiation of treatment. The results demonstrated significant improvements in symptom severity and relief in the placebo group.

Now, this study was a small one, with possible confounders (such as unreliability in patient symptom reporting) but certainly is provocative and promising. For years, physicians have struggled with placebo treatments - because they assumed that trickery was necessary for them to work. Trickery puts doctors in an uncomfortable position - having to choose between two ethical principles - beneficence (helping the patient) and autonomy (helping them make informed decisions). To freely prescribe placebo without the troublesome concealment component opens up a clear pathway for placebo treatments for many conditions - depression, asthma, chronic pain, IBS, addiction, hypertension, and more.  Now, I should be clear, there are limits to the physiologic possibilities for placebo. We can't expect mind-over-matter to work with a bleeding limb or widely metastatic cancer.

Nonetheless, the ramifications of the IBS study, if borne out in subsequent studies, are huge - the placebo effect may not require deception at all. Perhaps it's been mischaracterized for decades and perhaps conscious attempts at self-healing should
be carefully examined and mainstreamed. And this brings me back to meditation. Could meditation function like a placebo treatment for some conditions? I do not see why not. I'm no expert in Buddhism or meditation and I do not meditate (small children in the home would seem to make that nearly impossible). Still, I know there are a lot of different types of medication from a number of religious and spiritual traditions. And for the sake of this topic, I think we can agree that each shares an emphasis on channeling attention and achieving a still, rather than muddied and churning, mind. With that context, here's some substantiation for meditation. First, and anecdotally, from my gymnasium Zennie...

- She successfully used meditation to limit sweating on a very hot day, reporting that she "was able to not sweat, save for a light sweat film on the face (nothing under the arms or chest.)" This, by the way, is not a recommended approach to dealing with the heat.

-She successfully used meditation to prepare for extreme 24-hour straight sessions on the rowing machine achieving "no pain, total relaxation in the moment and no tension." This by the way, is not a recommended fitness regimen.

Not sold? Here's what the medical literature has to say...

-Functional MRI studies by Richard Davidson at University of Wisconsin demonstrate that meditation can have measurable effects on certain regions of the brain (such as in the process of consciously cultivating empathy).

-Other studies suggest that meditation can help young adults cope with stress and can improve information-processing in adults.

-Studies of flu vaccine efficacy suggest that meditation can help boost the body's immune response.

There is still much research to be done and I suspect that meditation is just one of a number of means of achieving better health through mind-body synching. Exercise, healthy relationships and optimism, for instance, may benefit the body through similar mechanisms. While the methods may vary, the physiologic mechanisms are likely similar. But, more on this another time. For now, I need to get back to the couch for some six-pack abs training - visualizing crunches is so much more comfortable than the real thing!



07.28.11
by

Summer Sweating (Marin IJ)



Summer is officially in effect. It's time for Beer-bques, beach bumming, and picnicking in the rapidly browning grass. There are many things to love about summer, but one thing few of us love is summer sweat. Yes, for many, summer is the season of sweating. Now, we all know that perspiration plays an important bodily function. By coating our bodies with moisture, it promotes evaporative heat loss and keeps us from over-heating and shriveling like slugs in the sun. Still, most folks don't think that sweating is cool. Sweat stains on t-shirts and salty dribbles down the forehead (not to mention clammy hands and soggy feet) are embarrassing and distracting. Or, perhaps you're like me and sweat profusely whenever you visit the doctor's office - in my case to the point of disintegrating the disposable paper sheet on the examining table; an odd response, indeed, for someone who works in the medical field.

Luckily, I have a sweat expert in the family. My wife Angela is a contributing writer for the International Hyperhidrosis Society (www.sweathelp.org), the foremost provider of support and informational resources to the world's community of excessive sweaters (that is people who sweat a lot, not those who excessively wear sweaters). Hyperhidrosis is an actual medical condition characterized by excessive sweating above and beyond what is needed to keep the body cool. Those with hyperhidrosis may sweat four or five times more than normal - regardless of external conditions - and their sweating is so extreme that it interferes with daily life. Now, someone with that level of lather should probably seek professional help, but for the rest of us who just want to curtail the average summer slather, here, adapted from the work of my in-home sweat consultant, are some tips.

  • First of all, remember that sweat plays a critical role in keeping you cool in hot temperatures. The key to keeping your body's air conditioning working properly is hydration. Drink early, drink often, and drink again. Limiting fluid intake is most definitely not a healthy approach to sweat suppression. You can help your natural cooling system by using a vaporizer or atomizer to spray a light mist of water under your arms. As the water evaporates your body will naturally cool.

  • Dress for summer sweat-ccess. Wear loose, lightweight, and light-colored clothing. Choose natural, breathable fabrics, such as cotton, or hi-tech fabrics designed to "wick" moisture away from your skin.

  • Sun-damaged or burned skin is not as effective at dissipating body heat and can have lasting consequences. Protect your skin and stay cooler by avoiding the peak sun hours. Sunscreen is a hot topic right now, and you should know that there is quite a bit of misleading advertising out there and not all sunscreens are created equal. New FDA regulations have been issued, but companies have at least one year to comply with these sensible new standards. Nonetheless, you should stay sunburn safe if you stick to sunscreens that are 1) SPF 15 to SPF 50, 2) have both UVA and UVB protection and 3) make sure to re-apply frequently.

  • If you sweat profusely from your forehead and/or face, consider wearing a wide-brimmed or long-billed hat. As with your clothing, your hat should be lightweight and light-colored. Coolibar hats, among others, have earned a "seal of recommendation" from The Skin Cancer Foundation.

  • When it's hot outside and especially during summer exercise sessions, temperatures inside shoes and socks can reach 120 degrees Fahrenheit. Choose lightweight, breathable or ventilated shoes or sandals and use sweat absorbing inserts (such as Summer Soles). When wearing socks, choose pairs that wick moisture away from your feet such as those designed for athletes and hikers. Absorbent foot powders and antiperspirants can also be used on feet to minimize sweating and moisture buildup.

  • Bust armpit wet marks by changing your antiperspirant routine. Choose a soft-solid formula and apply antiperspirant to underarms once in the morning and again prior to bedtime. Application twice daily--and especially before bedtime--has been shown to be more effective. Gently massaging the antiperspirant into the skin may be useful. You can consider using a stronger over-the-counter antiperspirant such as Certain Dri or Secret Clinical Strength (active ingredients; aluminum chloride and aluminum zirconium trichlorohydrex). To avoid irritation, only apply antiperspirant to completely dry skin. If you suffer from an annoyingly sweaty face, consider applying an antiperspirant along your hairline. Follow the application tips mentioned above, but test the product on a tiny area of skin first to make sure that it won't cause irritation.


Wow, thanks honey, that's a lot of good perspiration inspiration. Before we wick away this topic, however, I should note that there are quite a few serious medical conditions that are associated with sweating. These include, and are not limited to - infection, heart disease, adverse medication effects or overdose, thyroid or endocrine disease, and certain types of tumors. New patterns of sweat, or sweat associated with other concerning symptoms (like the feeling of a rhino stomping on your chest) should trigger you to seek medical evaluation.

And finally, to reiterate, if you think you suffer from excessive sweating (hyperhidrosis) or your sweat is not adequately controlled by over the counter products, you should talk to a dermatologist about other treatment options. These include: prescription antiperspirants, iontophoresis (machines like Fisher Galvanic and Drionic) and Botox injections. Dr. John Maddox, chief of dermatology at San Rafael Kaiser, told me that the time to seek help for sweating is when it "becomes such an everyday problem that it affects life and work - such as not being able to type because one's hands slip off the keyboard." I suppose, for me that means I shouldn't ever pursue a career as a professional patient. As for those of us who find themselves sweating more in the summer... "Regular sweat in the summer time?" says Dr. Maddox, "Don't sweat it!"





07.28.11
by

Summer Sweating (Marin IJ)



Summer is officially in effect. It's time for Beer-bques, beach bumming, and picnicking in the rapidly browning grass. There are many things to love about summer, but one thing few of us love is summer sweat. Yes, for many, summer is the season of sweating. Now, we all know that perspiration plays an important bodily function. By coating our bodies with moisture, it promotes evaporative heat loss and keeps us from over-heating and shriveling like slugs in the sun. Still, most folks don't think that sweating is cool. Sweat stains on t-shirts and salty dribbles down the forehead (not to mention clammy hands and soggy feet) are embarrassing and distracting. Or, perhaps you're like me and sweat profusely whenever you visit the doctor's office - in my case to the point of disintegrating the disposable paper sheet on the examining table; an odd response, indeed, for someone who works in the medical field.

Luckily, I have a sweat expert in the family. My wife Angela is a contributing writer for the International Hyperhidrosis Society (www.sweathelp.org), the foremost provider of support and informational resources to the world's community of excessive sweaters (that is people who sweat a lot, not those who excessively wear sweaters). Hyperhidrosis is an actual medical condition characterized by excessive sweating above and beyond what is needed to keep the body cool. Those with hyperhidrosis may sweat four or five times more than normal - regardless of external conditions - and their sweating is so extreme that it interferes with daily life. Now, someone with that level of lather should probably seek professional help, but for the rest of us who just want to curtail the average summer slather, here, adapted from the work of my in-home sweat consultant, are some tips.

  • First of all, remember that sweat plays a critical role in keeping you cool in hot temperatures. The key to keeping your body's air conditioning working properly is hydration. Drink early, drink often, and drink again. Limiting fluid intake is most definitely not a healthy approach to sweat suppression. You can help your natural cooling system by using a vaporizer or atomizer to spray a light mist of water under your arms. As the water evaporates your body will naturally cool.

  • Dress for summer sweat-ccess. Wear loose, lightweight, and light-colored clothing. Choose natural, breathable fabrics, such as cotton, or hi-tech fabrics designed to "wick" moisture away from your skin.

  • Sun-damaged or burned skin is not as effective at dissipating body heat and can have lasting consequences. Protect your skin and stay cooler by avoiding the peak sun hours. Sunscreen is a hot topic right now, and you should know that there is quite a bit of misleading advertising out there and not all sunscreens are created equal. New FDA regulations have been issued, but companies have at least one year to comply with these sensible new standards. Nonetheless, you should stay sunburn safe if you stick to sunscreens that are 1) SPF 15 to SPF 50, 2) have both UVA and UVB protection and 3) make sure to re-apply frequently.

  • If you sweat profusely from your forehead and/or face, consider wearing a wide-brimmed or long-billed hat. As with your clothing, your hat should be lightweight and light-colored. Coolibar hats, among others, have earned a "seal of recommendation" from The Skin Cancer Foundation.

  • When it's hot outside and especially during summer exercise sessions, temperatures inside shoes and socks can reach 120 degrees Fahrenheit. Choose lightweight, breathable or ventilated shoes or sandals and use sweat absorbing inserts (such as Summer Soles). When wearing socks, choose pairs that wick moisture away from your feet such as those designed for athletes and hikers. Absorbent foot powders and antiperspirants can also be used on feet to minimize sweating and moisture buildup.

  • Bust armpit wet marks by changing your antiperspirant routine. Choose a soft-solid formula and apply antiperspirant to underarms once in the morning and again prior to bedtime. Application twice daily--and especially before bedtime--has been shown to be more effective. Gently massaging the antiperspirant into the skin may be useful. You can consider using a stronger over-the-counter antiperspirant such as Certain Dri or Secret Clinical Strength (active ingredients; aluminum chloride and aluminum zirconium trichlorohydrex). To avoid irritation, only apply antiperspirant to completely dry skin. If you suffer from an annoyingly sweaty face, consider applying an antiperspirant along your hairline. Follow the application tips mentioned above, but test the product on a tiny area of skin first to make sure that it won't cause irritation.


Wow, thanks honey, that's a lot of good perspiration inspiration. Before we wick away this topic, however, I should note that there are quite a few serious medical conditions that are associated with sweating. These include, and are not limited to - infection, heart disease, adverse medication effects or overdose, thyroid or endocrine disease, and certain types of tumors. New patterns of sweat, or sweat associated with other concerning symptoms (like the feeling of a rhino stomping on your chest) should trigger you to seek medical evaluation.

And finally, to reiterate, if you think you suffer from excessive sweating (hyperhidrosis) or your sweat is not adequately controlled by over the counter products, you should talk to a dermatologist about other treatment options. These include: prescription antiperspirants, iontophoresis (machines like Fisher Galvanic and Drionic) and Botox injections. Dr. John Maddox, chief of dermatology at San Rafael Kaiser, told me that the time to seek help for sweating is when it "becomes such an everyday problem that it affects life and work - such as not being able to type because one's hands slip off the keyboard." I suppose, for me that means I shouldn't ever pursue a career as a professional patient. As for those of us who find themselves sweating more in the summer... "Regular sweat in the summer time?" says Dr. Maddox, "Don't sweat it!"





07.28.11
by

Be Ready to Get Ready (Marin IJ)


For many of us, "disasters" are unexpected daily travails - a missed connecting flight, a blown hot water heater on the day the in-laws arrive, or, worst of all perhaps, the DVR failing to record True Blood. These, indeed, are events that are difficult or impossible to plan for, but they're trivial compared to true disasters like Hurricane Katrina. The thing about actual disasters is, that while they're quite common across the world at large, they're (thankfully) rather rare in one's personal experience. I recall just two in my lifetime - the 1989 Loma Prieta quake and the Y2K computer glitch. Oh wait, Y2K turned out to be as bland as a saltine, so let's make that just one. With such infrequency, it's easy to become complacent about potential threats lurking in our environment - namely floods, fires and quakes. This is true even among first responders (like me); after all, it's hard to maintain focused preparation for an event that may never happen, and if it does, it will likely be with little warning. As Kevin J. Kitka, an emergency physician in Joplin, Missouri and a responder to the region's recent EF-5 tornado wrote, "You never know that it will be the most important day of your life until the day is over." Most of us in the Bay Area have learned to live with the possibility of another major earthquake. We take comfort in strict building codes and governmental readiness on the local and state level. But while complacency is comfortable, it can be dangerous. Skeptical? Consider what happened earlier this year in Christchurch, New Zealand.
"One minute we were sitting [and] contemplating a gentle walk to the Art Gallery," writes Dr. Elizabeth Mowat, a Brit visiting Christchurch this past February. "[The] next minute the immense glass front of the hotel was looming precariously towards us then crashing down around us with nowhere to hide!" "I was talking on Skype one minute," writes another witness "and the next the screen went blank and computers were crashing onto the ground all around me. I ran to the doorway, but the floor was shaking so much I couldn't stand, so I just got down into the foetal position and started praying."
In sum, the Christchurch earthquake killed 182 and caused major infrastructure damage, leaving areas of the city virtually uninhabitable. It was a minor tremble on the devastation scale compared to what happened in Japan and Haiti, but nonetheless crushing to Kiwis - especially because it seemed like they had a handle on earthquake preparedness. Christchurch had, after all, survived a larger quake (7.1) in September of 2010 with no causalities, and the city's building codes, EMS response strategy, and public education programs have served as a model for other fault-centric locales. Take, for example, their long-running quake preparedness TV commercial focused on "Fix. Fasten. Forget." The ad starred two comic characters that just couldn't seem to figure out proper safety procedures (like fastening the water heater). One envisions a Kiwi version of Beavis and Butthead, but nonetheless, the message seems to have resonated (with over 90% of surveyed residents recalling it.)
So how come, despite all this, Christchurch suffered horribly? What went wrong? Well, mostly, it was bad luck: the quake struck in midday when many people were out and about, it occurred along a rather obscure fault (one not thought to be high risk), and it caused significant ground liquefaction (similar to what happened to the SF marina in 1989). It was thought that any cataclysmic earthquake in Canterbury (the region on the South Island where Christchurch is located) would radiate out from the Great Alpine Fault. Yet both recent quakes occurred along other faults and in highly populated areas that were not fully prepared. Helen Clark, the former prime minister of New Zealand, acknowledged this not long after the quake. "Clearly the level of building resilience in Christchurch was not up to, in every case, dealing with this shallow and quite severe shock. I guess it will be back to the textbooks now to see what further work needs to be done to really ramp up New Zealand's resilience."

So, what lessons can we in the Bay Area take from the Christchurch experience? 1) In a seismically active region such as ours, expect the unexpected and realize that you may not be as secure as you suppose. Says Dr Jason Eberhart-Phillips, public health officer for Marin County, "The 182 deaths resulting from this relatively small [Christchurch] magnitude event should heighten public awareness of the need to get ready for the much larger quake that is expected in the Bay Area in coming years." Hence, 2) a few minutes of preparation now could serve you quite well in an actual disaster. A good place to start is with a simple family disaster plan and with disaster supplies (check out getreadymarin.org for classes and manuals). The Red Cross also has an excellent supply checklist (www.redcross.org) including basics like non-perishable food, flashlights, and diapers - enough for three days. And, as a Christchurch witness states, "Have plenty of bottled water, when it stops coming out of the tap it is not nice to consider the consequences."
Other sensible additions include medications (a week supply,) extra batteries, cash and a crank radio. In the Bay Area you would probably want to tune into KCBS 740 or KGO 810. Keeping your car's gas tank half full at all times and having a back-up (non-electrical) charging mechanism for your phone are other practical tips. Finally, let's recognize that day-to-day disasters will still occur and in times of need, having a back-up DVR can make an awful lot of sense.
07.28.11
by

Be Ready to Get Ready (Marin IJ)


For many of us, "disasters" are unexpected daily travails - a missed connecting flight, a blown hot water heater on the day the in-laws arrive, or, worst of all perhaps, the DVR failing to record True Blood. These, indeed, are events that are difficult or impossible to plan for, but they're trivial compared to true disasters like Hurricane Katrina. The thing about actual disasters is, that while they're quite common across the world at large, they're (thankfully) rather rare in one's personal experience. I recall just two in my lifetime - the 1989 Loma Prieta quake and the Y2K computer glitch. Oh wait, Y2K turned out to be as bland as a saltine, so let's make that just one. With such infrequency, it's easy to become complacent about potential threats lurking in our environment - namely floods, fires and quakes. This is true even among first responders (like me); after all, it's hard to maintain focused preparation for an event that may never happen, and if it does, it will likely be with little warning. As Kevin J. Kitka, an emergency physician in Joplin, Missouri and a responder to the region's recent EF-5 tornado wrote, "You never know that it will be the most important day of your life until the day is over." Most of us in the Bay Area have learned to live with the possibility of another major earthquake. We take comfort in strict building codes and governmental readiness on the local and state level. But while complacency is comfortable, it can be dangerous. Skeptical? Consider what happened earlier this year in Christchurch, New Zealand.
"One minute we were sitting [and] contemplating a gentle walk to the Art Gallery," writes Dr. Elizabeth Mowat, a Brit visiting Christchurch this past February. "[The] next minute the immense glass front of the hotel was looming precariously towards us then crashing down around us with nowhere to hide!" "I was talking on Skype one minute," writes another witness "and the next the screen went blank and computers were crashing onto the ground all around me. I ran to the doorway, but the floor was shaking so much I couldn't stand, so I just got down into the foetal position and started praying."
In sum, the Christchurch earthquake killed 182 and caused major infrastructure damage, leaving areas of the city virtually uninhabitable. It was a minor tremble on the devastation scale compared to what happened in Japan and Haiti, but nonetheless crushing to Kiwis - especially because it seemed like they had a handle on earthquake preparedness. Christchurch had, after all, survived a larger quake (7.1) in September of 2010 with no causalities, and the city's building codes, EMS response strategy, and public education programs have served as a model for other fault-centric locales. Take, for example, their long-running quake preparedness TV commercial focused on "Fix. Fasten. Forget." The ad starred two comic characters that just couldn't seem to figure out proper safety procedures (like fastening the water heater). One envisions a Kiwi version of Beavis and Butthead, but nonetheless, the message seems to have resonated (with over 90% of surveyed residents recalling it.)
So how come, despite all this, Christchurch suffered horribly? What went wrong? Well, mostly, it was bad luck: the quake struck in midday when many people were out and about, it occurred along a rather obscure fault (one not thought to be high risk), and it caused significant ground liquefaction (similar to what happened to the SF marina in 1989). It was thought that any cataclysmic earthquake in Canterbury (the region on the South Island where Christchurch is located) would radiate out from the Great Alpine Fault. Yet both recent quakes occurred along other faults and in highly populated areas that were not fully prepared. Helen Clark, the former prime minister of New Zealand, acknowledged this not long after the quake. "Clearly the level of building resilience in Christchurch was not up to, in every case, dealing with this shallow and quite severe shock. I guess it will be back to the textbooks now to see what further work needs to be done to really ramp up New Zealand's resilience."

So, what lessons can we in the Bay Area take from the Christchurch experience? 1) In a seismically active region such as ours, expect the unexpected and realize that you may not be as secure as you suppose. Says Dr Jason Eberhart-Phillips, public health officer for Marin County, "The 182 deaths resulting from this relatively small [Christchurch] magnitude event should heighten public awareness of the need to get ready for the much larger quake that is expected in the Bay Area in coming years." Hence, 2) a few minutes of preparation now could serve you quite well in an actual disaster. A good place to start is with a simple family disaster plan and with disaster supplies (check out getreadymarin.org for classes and manuals). The Red Cross also has an excellent supply checklist (www.redcross.org) including basics like non-perishable food, flashlights, and diapers - enough for three days. And, as a Christchurch witness states, "Have plenty of bottled water, when it stops coming out of the tap it is not nice to consider the consequences."
Other sensible additions include medications (a week supply,) extra batteries, cash and a crank radio. In the Bay Area you would probably want to tune into KCBS 740 or KGO 810. Keeping your car's gas tank half full at all times and having a back-up (non-electrical) charging mechanism for your phone are other practical tips. Finally, let's recognize that day-to-day disasters will still occur and in times of need, having a back-up DVR can make an awful lot of sense.
06.15.11
by

Twitter Comment on Circumcision Column

You know you've really made it big when Flanny Pants is sending article ideas via Twitter.
See below

John Flanagan
You should publish a similar article about fighting breast cancer in women by excising breasts (100% defense) goo.gl/0Rwal
 
This is a ridiculous and farfetched comparison. But, let's consider it nonetheless. Let us say that a woman, of her right mind, decides to get a bilateral mastectomy. She does so because she does not plan to have children and because she carries the BRCA gene and has seen her mother and sister die from breast cancer. Should she be forbidden from making this decision? Under the bioethical principle of autonomy the answer is no - so long as she is aware of the risks and benefits and is a competent decision maker. Should we recommend mastectomy as a public health effort - no - and that was not the point of my column on infant male circumcision. 
06.15.11
by

Twitter Comment on Circumcision Column

You know you've really made it big when Flanny Pants is sending article ideas via Twitter.
See below

John Flanagan
You should publish a similar article about fighting breast cancer in women by excising breasts (100% defense) goo.gl/0Rwal
 
This is a ridiculous and farfetched comparison. But, let's consider it nonetheless. Let us say that a woman, of her right mind, decides to get a bilateral mastectomy. She does so because she does not plan to have children and because she carries the BRCA gene and has seen her mother and sister die from breast cancer. Should she be forbidden from making this decision? Under the bioethical principle of autonomy the answer is no - so long as she is aware of the risks and benefits and is a competent decision maker. Should we recommend mastectomy as a public health effort - no - and that was not the point of my column on infant male circumcision. 
06.15.11
by

A butchering of bioethics (Marin IJ)



There's a truly heinous procedure - a cruel punishment wrought against newborns. Virtually every newborn in this country is subjugated to this bloody assault, one that severs an attachment with the mother. What is this horrific act and how can it possibly be legal? It's the butchering of the umbilical cord after birth. Ok, butchering isn't really a fair description. The clamps are sterile and the procedure is usually not very messy. And I think we can all agree that, while cutting the umbilical cord may be an invasive procedure, it is nonetheless necessary. It would be ridiculous to forbid the cutting of an umbilical cord but not so far-fetched is the banning of another widespread newborn procedure - circumcision.
You've no doubt heard about the recently certified resolution that will appear on the San Francisco ballot this fall which would make the "genital cutting of male minors" illegal and punishable (for practitioners such as physicians and mohels) with a $1,000 fine or up to one year in prison. The initiative would make it unlawful in the city of San Francisco "to circumcise, excise, cut, or mutilate the whole or any part of the foreskin, testicles, or penis of another person who has not attained the age of 18 years." The sponsors of this bill have obtained the 7,700 city resident signatures necessary to place this statute on the ballot and the controversy is attracting comment from numerous cultural and media silos (including a rather distasteful comic, Foreskin Man, in which the villain is a scissors-wielding rabbi.)
Certainly, there are numerous ways to skin this story but, fundamentally, this is an ethical question. One of the core principles of biomedical ethics is autonomy - the ability of the patient to make informed decisions about his or her body and medical care. This is an essential principle - without it the experimental abuses of Nazi Germany and Tuskegee, Alabama might someday be relived. Newborn babies cannot, of course, make any decisions. They know how to cry, feed, sleep and fill up the diaper. That's about it. Making an informed decision about "genital cutting" is not in their wheelhouse. Thus, this decision falls to others. In the vast majority of instances, a child's parents are the appropriate decision-makers because they are both the progenitors of the new life as well as those most directly affected by its immediate fate. The rights of parents in this regard have not been explicitly defined. They are neither wielded through surrogacy nor autonomy but a combination of the two - I call it progenitonomy [the rights (under the law) of the progenitor]. Such rights, cannot, of course, be absolute. We do not allow, for instance, Jehovah's Witnesses to deny their children a life-saving blood transfusions and the news is rife with other circumstances where the state must step in to guarantee the health of a child whose parents or guardians have abdicated their progenitorship. Is the circumcision of newborn males such a situation? I think most of us would agree that is not. (Most, of course, not including 7,700 or so people in San Francisco.) But in the name of informed debate, let's examine the major risks and benefits of "genital cutting of male minors."
Benefit #1: Protection against infection - including urinary tract infections in infants, infections of the glans of the penis, and sexually transmitted diseases such as HIV. It's well established in the medical literature that uncircumcised men are at increased risk of infection due to the moist, germ-friendly environment under the foreskin. Note also that the infection-protection that circumcision provides is valuable not just to the individual and his sexual partners, but also to the public health at large. For example, the low rates of circumcision in Africa are thought to have contributed to the start of the AIDS epidemic and multiple studies have indicated that circumcision should be considered an effective "surgical vaccine" for HIV.
Benefit #2: Protection against penile cancer. Once again, well established. And while penile cancer is rare, it is worth noting that newborn circumcision provides 100% defense against it.
Benefit #3: Cultural and religious sensitivity. There is no denying that circumcision is of great importance to Jews and Muslims. It may also be of importance to some non-religious parents who live in areas with high rates of circumcision. Now, let's be clear - there are limits to a "cultural" benefit. Most would agree that forced female circumcision during the adolescent years goes well beyond any defensible level of moral relativism.
What then about the risks or potential harm?
Yes, circumcision is a painful procedure. By measuring heart rate and stress hormone release (cortisol) in infants, this somewhat obvious observation has been scientifically validated. But, then again, I can't imagine that penile cancer is pain free either. And, nowadays, various forms of anesthesia are routinely used for the procedure and this should mitigate concerns significantly. Complications of newborn circumcision are very rare, occurring much less than 1% of the time (actually 0% in a large Kaiser study published in 2006) and mortality is virtually unheard of (besides a few reported cases of in-the-home deaths of undiagnosed hemophiliacs). In terms of potential harm, circumcision is much less risky than other common parental decisions, such as foregoing routine vaccinations and placing earrings in youngsters.
So, where does this lead us? Circumcision is a common procedure that is safe yet potentially painful. It has some long-term health benefits, but not enough to consider it a recommended procedure on a medical platform alone. There is some possible harm, but is quite minor, and the real harm (for some) seems to be in the imagery it evokes. Ultimately, though, there does not appear to be any basis to deny parents the ability to make this decision for their child based on their own beliefs and circumstances. Thus, to punish practitioners for carrying out the progenitor's circumcision request is, to quote the chief of pediatric urology at UCSF (Dr. Laurence Baskin), "a bunch of nonsense." In fact, it is, quite simply, a butcher-like approach to ethics and medicine.




06.15.11
by

A butchering of bioethics (Marin IJ)



There's a truly heinous procedure - a cruel punishment wrought against newborns. Virtually every newborn in this country is subjugated to this bloody assault, one that severs an attachment with the mother. What is this horrific act and how can it possibly be legal? It's the butchering of the umbilical cord after birth. Ok, butchering isn't really a fair description. The clamps are sterile and the procedure is usually not very messy. And I think we can all agree that, while cutting the umbilical cord may be an invasive procedure, it is nonetheless necessary. It would be ridiculous to forbid the cutting of an umbilical cord but not so far-fetched is the banning of another widespread newborn procedure - circumcision.
You've no doubt heard about the recently certified resolution that will appear on the San Francisco ballot this fall which would make the "genital cutting of male minors" illegal and punishable (for practitioners such as physicians and mohels) with a $1,000 fine or up to one year in prison. The initiative would make it unlawful in the city of San Francisco "to circumcise, excise, cut, or mutilate the whole or any part of the foreskin, testicles, or penis of another person who has not attained the age of 18 years." The sponsors of this bill have obtained the 7,700 city resident signatures necessary to place this statute on the ballot and the controversy is attracting comment from numerous cultural and media silos (including a rather distasteful comic, Foreskin Man, in which the villain is a scissors-wielding rabbi.)
Certainly, there are numerous ways to skin this story but, fundamentally, this is an ethical question. One of the core principles of biomedical ethics is autonomy - the ability of the patient to make informed decisions about his or her body and medical care. This is an essential principle - without it the experimental abuses of Nazi Germany and Tuskegee, Alabama might someday be relived. Newborn babies cannot, of course, make any decisions. They know how to cry, feed, sleep and fill up the diaper. That's about it. Making an informed decision about "genital cutting" is not in their wheelhouse. Thus, this decision falls to others. In the vast majority of instances, a child's parents are the appropriate decision-makers because they are both the progenitors of the new life as well as those most directly affected by its immediate fate. The rights of parents in this regard have not been explicitly defined. They are neither wielded through surrogacy nor autonomy but a combination of the two - I call it progenitonomy [the rights (under the law) of the progenitor]. Such rights, cannot, of course, be absolute. We do not allow, for instance, Jehovah's Witnesses to deny their children a life-saving blood transfusions and the news is rife with other circumstances where the state must step in to guarantee the health of a child whose parents or guardians have abdicated their progenitorship. Is the circumcision of newborn males such a situation? I think most of us would agree that is not. (Most, of course, not including 7,700 or so people in San Francisco.) But in the name of informed debate, let's examine the major risks and benefits of "genital cutting of male minors."
Benefit #1: Protection against infection - including urinary tract infections in infants, infections of the glans of the penis, and sexually transmitted diseases such as HIV. It's well established in the medical literature that uncircumcised men are at increased risk of infection due to the moist, germ-friendly environment under the foreskin. Note also that the infection-protection that circumcision provides is valuable not just to the individual and his sexual partners, but also to the public health at large. For example, the low rates of circumcision in Africa are thought to have contributed to the start of the AIDS epidemic and multiple studies have indicated that circumcision should be considered an effective "surgical vaccine" for HIV.
Benefit #2: Protection against penile cancer. Once again, well established. And while penile cancer is rare, it is worth noting that newborn circumcision provides 100% defense against it.
Benefit #3: Cultural and religious sensitivity. There is no denying that circumcision is of great importance to Jews and Muslims. It may also be of importance to some non-religious parents who live in areas with high rates of circumcision. Now, let's be clear - there are limits to a "cultural" benefit. Most would agree that forced female circumcision during the adolescent years goes well beyond any defensible level of moral relativism.
What then about the risks or potential harm?
Yes, circumcision is a painful procedure. By measuring heart rate and stress hormone release (cortisol) in infants, this somewhat obvious observation has been scientifically validated. But, then again, I can't imagine that penile cancer is pain free either. And, nowadays, various forms of anesthesia are routinely used for the procedure and this should mitigate concerns significantly. Complications of newborn circumcision are very rare, occurring much less than 1% of the time (actually 0% in a large Kaiser study published in 2006) and mortality is virtually unheard of (besides a few reported cases of in-the-home deaths of undiagnosed hemophiliacs). In terms of potential harm, circumcision is much less risky than other common parental decisions, such as foregoing routine vaccinations and placing earrings in youngsters.
So, where does this lead us? Circumcision is a common procedure that is safe yet potentially painful. It has some long-term health benefits, but not enough to consider it a recommended procedure on a medical platform alone. There is some possible harm, but is quite minor, and the real harm (for some) seems to be in the imagery it evokes. Ultimately, though, there does not appear to be any basis to deny parents the ability to make this decision for their child based on their own beliefs and circumstances. Thus, to punish practitioners for carrying out the progenitor's circumcision request is, to quote the chief of pediatric urology at UCSF (Dr. Laurence Baskin), "a bunch of nonsense." In fact, it is, quite simply, a butcher-like approach to ethics and medicine.




05.30.11
by

Hands On

When Rene Ismael Martinez collapsed while playing soccer last November 7th, his friend and teammate, Luis San Ramon, could think of just one thing: Rene's young children and what they would do without their dad. The thought was grimly real; 44-year-old Rene had just suffered a sudden cardiac arrest. This notion would be enough to paralyze most people - freezing them like a driver at a red light. But not Luis, he managed to block out the background noise so he and another teammate could attempt to resuscitate Rene. The other man was Alejandro Higareda, the assistant director of operations at Marin Academy High School; trained in CPR and basic life support as a pre-requisite for his job. Alejandro knew to perform chest compressions fast and deep, sternum to backbone while keeping count in his head and giving direction to Luis (who was providing rescue breathing) and others. This powerful CPR, the force of which at first worried some onlookers, proved to be life-saving. Later described by one of the responding paramedics from Novato Fire as "simply awesome," Alejandro's forceful chest compressions kept blood circulating through Rene's body for the five or so minutes it took help to arrive. Alejandro was just doing what he'd been trained to do - with the help and support of bystanders who urged him on - and he had no idea how profoundly important his actions were for Rene.
This past May 19th at the First Annual Marin EMS Survivors' celebration, Rene Martinez walked onto the stage with Luis, Alejandro, and a crowd of paramedics, firefighters, doctors, nurses, and medical communications specialists (dispatchers and interpreters). It had been a little over six months since that day on the soccer field, and if we hadn't just heard the story, no one in the audience would have guessed that Rene had so recently suffered a cardiac arrest. Through an interpreter, Rene tearfully thanked everyone on stage for saving his life.
Rene is one of the lucky ones. Nationwide, over 200,000 people a year suffer a cardiac arrest and of these only 2-8% survive long enough to be discharged from the hospital. Some of these never fully recover brain function. But Rene regained mental faculties by the time he reached the hospital. I know, because I was there that day and asked his doctor, Bob Stein, how it could be that his patient, who had just suffered a prolonged cardiac arrest, was now awake and talking to the staff? I don't recall exactly what Dr. Stein replied, but I now know the explanation. Without a doubt, Rene's remarkable recovery was due to the simply awesome CPR he received from Alejandro. This CPR kept his brain oxygenated while his heart was stalled (weakly fibrillating like a SonicCare toothbrush low on batteries.) Thus, after the Novato Fire paramedics used an electronic defibrillator to re-start his heart (re-charging the battery, if you will), Rene's brain was able to quickly recover.
Rene Martinez was one of seventeen Marin residents who survived an out-of-hospital cardiac arrest last year. This number represents a 15% survival rate - much better (albeit with a small sample size) than national averages. But could it be better? What would it take to do better? A new hospital? Defibrillators in every home? No, nothing that drastic. All it would take is every citizen knowing how to do CPR (a simple, physical act that can be performed by a third-grader.) And now, it's easier to learn CPR than ever - as new evidence and guidelines suggest that hands-only CPR (that is without rescue breaths) is at least, if not more, effective in adult patients with cardiac arrest than traditional CPR with mouth-to-mouth breaths.
I asked our new County Public Health Officer, Dr. Jason Eberhart-Phillips, about the importance of bystander training for CPR. "Heart attacks," he wrote, "remain one of the leading causes of out-of-hospital death in Marin County. When heart attacks happen, bystanders who phone 911 and begin CPR can greatly increase the chances of survival. Effective chest compressions can move oxygen-rich blood to the heart and brain, keeping a victim alive until emergency responders arrive on the scene."
So, wondering how you can be prepared to be a hero among us like Luis and Alejandro? Or how you can feel confident that your fellow citizens would save you like they did Rene Martinez? It's simple, really. Rehearse. This is, as Malcolm Gladwell and many others have counseled, good advice for anyone, in any profession. Learn something, practice it, and when the time comes, memory will kick in. So, for those interested in learning proper CPR (this is yet one more thing that the movies do not get right), here are some options...
First, you can sign up for a basic life support course or encourage your employer to offer one (Alejandro is extremely appreciative that Marin Academy provided his training). Second, you can pay attention to where Automated External Defibrillators (AEDs) are kept - you will notice them in gyms, at malls, and in airports. And yes, there is an app for this too. Finally, this Saturday you can come out to one of multiple sites in Marin and receive free (non-certified) training in hands-only CPR and AED use from local EMTs, paramedics, nurses, and doctors. The training will take less than ten minutes of your time and just might help you save someone's life. As Alejandro Higareda will attest, this is both an opportunity and an honor, and one best informed by rehearsal.

********************************
Hands-Only CPR and AED Training. Presented by Marin County Emergency Medical Services. This Saturday, June 4th 10am-2pm. Locations include: Vista Point, Strawberry Village, Toby's Feed Barn, The Village, Red Hill Shopping Center, Town Center, Northgate Mall, Mill Valley Depot Plaza and Vintage Oaks at Novato.
Interested in volunteering to help the trainers? Call Karrie Groves at 415-473-3214.
05.30.11
by

Hands On

When Rene Ismael Martinez collapsed while playing soccer last November 7th, his friend and teammate, Luis San Ramon, could think of just one thing: Rene's young children and what they would do without their dad. The thought was grimly real; 44-year-old Rene had just suffered a sudden cardiac arrest. This notion would be enough to paralyze most people - freezing them like a driver at a red light. But not Luis, he managed to block out the background noise so he and another teammate could attempt to resuscitate Rene. The other man was Alejandro Higareda, the assistant director of operations at Marin Academy High School; trained in CPR and basic life support as a pre-requisite for his job. Alejandro knew to perform chest compressions fast and deep, sternum to backbone while keeping count in his head and giving direction to Luis (who was providing rescue breathing) and others. This powerful CPR, the force of which at first worried some onlookers, proved to be life-saving. Later described by one of the responding paramedics from Novato Fire as "simply awesome," Alejandro's forceful chest compressions kept blood circulating through Rene's body for the five or so minutes it took help to arrive. Alejandro was just doing what he'd been trained to do - with the help and support of bystanders who urged him on - and he had no idea how profoundly important his actions were for Rene.
This past May 19th at the First Annual Marin EMS Survivors' celebration, Rene Martinez walked onto the stage with Luis, Alejandro, and a crowd of paramedics, firefighters, doctors, nurses, and medical communications specialists (dispatchers and interpreters). It had been a little over six months since that day on the soccer field, and if we hadn't just heard the story, no one in the audience would have guessed that Rene had so recently suffered a cardiac arrest. Through an interpreter, Rene tearfully thanked everyone on stage for saving his life.
Rene is one of the lucky ones. Nationwide, over 200,000 people a year suffer a cardiac arrest and of these only 2-8% survive long enough to be discharged from the hospital. Some of these never fully recover brain function. But Rene regained mental faculties by the time he reached the hospital. I know, because I was there that day and asked his doctor, Bob Stein, how it could be that his patient, who had just suffered a prolonged cardiac arrest, was now awake and talking to the staff? I don't recall exactly what Dr. Stein replied, but I now know the explanation. Without a doubt, Rene's remarkable recovery was due to the simply awesome CPR he received from Alejandro. This CPR kept his brain oxygenated while his heart was stalled (weakly fibrillating like a SonicCare toothbrush low on batteries.) Thus, after the Novato Fire paramedics used an electronic defibrillator to re-start his heart (re-charging the battery, if you will), Rene's brain was able to quickly recover.
Rene Martinez was one of seventeen Marin residents who survived an out-of-hospital cardiac arrest last year. This number represents a 15% survival rate - much better (albeit with a small sample size) than national averages. But could it be better? What would it take to do better? A new hospital? Defibrillators in every home? No, nothing that drastic. All it would take is every citizen knowing how to do CPR (a simple, physical act that can be performed by a third-grader.) And now, it's easier to learn CPR than ever - as new evidence and guidelines suggest that hands-only CPR (that is without rescue breaths) is at least, if not more, effective in adult patients with cardiac arrest than traditional CPR with mouth-to-mouth breaths.
I asked our new County Public Health Officer, Dr. Jason Eberhart-Phillips, about the importance of bystander training for CPR. "Heart attacks," he wrote, "remain one of the leading causes of out-of-hospital death in Marin County. When heart attacks happen, bystanders who phone 911 and begin CPR can greatly increase the chances of survival. Effective chest compressions can move oxygen-rich blood to the heart and brain, keeping a victim alive until emergency responders arrive on the scene."
So, wondering how you can be prepared to be a hero among us like Luis and Alejandro? Or how you can feel confident that your fellow citizens would save you like they did Rene Martinez? It's simple, really. Rehearse. This is, as Malcolm Gladwell and many others have counseled, good advice for anyone, in any profession. Learn something, practice it, and when the time comes, memory will kick in. So, for those interested in learning proper CPR (this is yet one more thing that the movies do not get right), here are some options...
First, you can sign up for a basic life support course or encourage your employer to offer one (Alejandro is extremely appreciative that Marin Academy provided his training). Second, you can pay attention to where Automated External Defibrillators (AEDs) are kept - you will notice them in gyms, at malls, and in airports. And yes, there is an app for this too. Finally, this Saturday you can come out to one of multiple sites in Marin and receive free (non-certified) training in hands-only CPR and AED use from local EMTs, paramedics, nurses, and doctors. The training will take less than ten minutes of your time and just might help you save someone's life. As Alejandro Higareda will attest, this is both an opportunity and an honor, and one best informed by rehearsal.

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Hands-Only CPR and AED Training. Presented by Marin County Emergency Medical Services. This Saturday, June 4th 10am-2pm. Locations include: Vista Point, Strawberry Village, Toby's Feed Barn, The Village, Red Hill Shopping Center, Town Center, Northgate Mall, Mill Valley Depot Plaza and Vintage Oaks at Novato.
Interested in volunteering to help the trainers? Call Karrie Groves at 415-473-3214.