Gluten Free

Tour your local supermarket and you will be peppered by an exhaustive range of products labeled gluten free.

Gluten is a protein found largely in flours such as wheat, barley and rye.  It gives bread much of its elasticity.

Individuals with coeliac disease (a form of inflammatory bowel disease) are worsened by even small amounts of dietary gluten and total abstinence from the substance is critical. 

While this association is important it doesn't explain the near hysteria regarding gluten among foodies.  After all, the number of individuals with coeliac disease and gluten hypersensitivity  is less than one percent of the population. This hardly indicates the need to send gluten to a nutritional gulag.

Yet this is just what is happening, with more and more foods and services designated gluten free.  Consumers look for this branding and those items designated as gluten free fly off the shelf.

While some of the products have gluten removed, most (say peaches) are gluten free to begin with.  Shoppers oftentimes embrace these items for the first time believing  they are especially safe and healthy choices.

There are numerous gluten free sightings during the course of a usual day.  

For example, many restaurants proclaim that a number of their dishes are gluten free.  Ice cream parlors are gluten free.  A dentist advertises gluten free teeth cleanings.  Perhaps we'll even have gluten free condoms one day.







                                                                                                                                                                                                                                                                                                                   

No Thank You

A local clinic recently announced on the radio that they had begun to offer same day, early morning, late evening and weekend appointments.

Is this good news?  Probably not.

While patients will doubtless appreciate increased options, there are downsides to the strategy. 

Making it too convenient to be seen will likely result in many patients checking in for symptoms that would remit safely on their own in a few days.

While most patients will get good care off hours a good number will fall prey to false positive tests and run the risk of becoming medicalized (over diagnosed). These individuals would be better off staying home or at work.

Moreover, it is unlikely that patients would see their own doctor, making the visit tantamount to a walk in clinic visit, more expensive and less accurate.

From this perch, the marketing of extended hours, is more an homage to the bottom line, than a concern for patient care.

It's basically a case of clinic administrators, dressed in the robes of public service, looking for patients. 

To Tell The Truth

I learned a great deal about truth-telling from a young woman who had multiple admissions to the hospital for critically low potassium levels in her blood stream, making her vulnerable to serious and even fatal heart irregularities.

It was significant that her potassium levels remained normal after replacement in the hospital but regularly dropped to critical levels after discharge, bouncing her back into the hospital.

The evaluation of low potassium (hypokalemia) includes a number of sophisticated and esoteric tests which in her case were all normal.

A common cause, however, is the surreptitious abuse of laxatives, especially in patients with a background of anorexia nervosa.  In these individuals the key to confirming the laxative abuse is to firstly consider it after ruling out other causes with laboratory investigations.

My patient fervently denied the use of laxatives and she resented my probings into the matter.  She accused me of not trusting her which often left me, despite my growing belief that I had good reason not to trust her, with pangs of guilt, especially when she often appeared misunderstood or hurt.

Hospital visits became increasingly strained as feelings of guilt (she hit the guilt target flawlessly) and suspicion (I was virtually certain that she was not being honest) competed for my attention.

We were at an impasse.

I spoke to a colleague in psychiatry about the case, especially  as people with laxative abuse often have serious emotional distress.  

He asked me if I told her I did not believe her.  I had not, probably because it would have left me open to feelings of insensitivity.  But that was what he thought was needed and I determined to tell her I did not believe her, despite my anxieties about confrontation, on the next visit.

So the next day I visited her in her hospital room and told her  that I did not believe her and felt she had been secretly taking large doses of laxatives.

What followed was a thorough bombing, with everything within reach - lamps, glasses, books - flying at me as I fled the room.

It was not immediately apparent that truthfulness had served me well, but the next day I encountered a different person.  She was tearful, apologetic and confessed that she had been abusing laxatives.

She had a serious condition and I was relieved that we could finally begin treating her.  She was too.

This case reminds me of how amazing the truth can be, especially when it is painful.

On Touching

Touching has always been a way to express our love and humanity.  Its ability to heal has been recognized since physicians made house calls in caves.  

Royalty has used it to great advantage too, knighting with touches of the hand and sword.  Moreover, the "royal touch" of British and French monarchs, which was believed to cure a glandular form of tuberculosis, enhanced their position as purveyors of divine power for many centuries.

There is still plenty of touching in the 21st century but the practice is somewhat on hard times.  I am reminded of one of my patients, a grade school teacher, who was terminated after hugging a child who had fallen and scrapped her knee on the playground.  My patient was ultimately pushed out of the school district by parents and administrators who couldn't see the difference between compassion (which it was) and perversion.

The workplace is now largely free (you can thank Anita Hill) of unwanted gropings and touchings.

But at a price.

Fear of  sexual harassment is so widespread at work  that  tearful and overwhelmed individuals must oftentimes soldier on without the immense benefit of a pat on the shoulder or a discreet hug from a colleague.

In medicine, touch remains  one of physicians most powerful tools.  

I remember a woman on a rehabilitation unit who had unmanageable pain.  She was in great distress and the staff and I were at wits end.  Finally  I recalled an article suggesting that severe pain could be relieved by hair brushing.  After getting myself and the nursing staff to buy into the idea that this kind of touching could relieve severe pain, I ordered hair brushing for ten minutes every six hours, scheduling the brushing just like a pain pill.  The results were astonishingly good.

Doctors have many different ways of comforting patients utilizing touch.  In my case,  I placed my free hand on their right shoulder while examining various organ systems.  My belief is that this practice created a connection between us that was strong, resilient and therapeutic.

The smart physician can sometimes diagnose and treat patients effectively without ever touching or examining them.

The wise physician knows that the addition of a perfunctory physical exam (say aah) in such cases can result in speedier and more durable cures.

Placebos remain one of doctors most powerful tools and touch is arguably its quintessence.

Asking For Help

Primary care physicians often refer their patients to specialists, say a cardiologist,  for what is simply known as a consultation.  If the doctor or patient is unsatisfied with the consultation, a second consultant might be  brought in for what is called a second opinion.  On rare occasions,  an internist might refer a patient to another internist for advice and consultation.

While the primary doctor usually orchestrates the referral, patients sometimes do it themselves.

A second opinion might be invoked when someone has been advised to have a major operation.  Or, it might be invoked in an unusually complicated case where the primary physician and his/her consultants are out of ideas.

The selection of the doctor to give a second opinion can be fraught with biases.

Consider the following.  If the patient makes the choice, it is often influenced by family and friends who can be easily moved by the celebrity of a consultant, or their personal experience with him/her,  rather than objective performance measurements such as post operative complication rates.  

When the primary doctor picks the consultant, it is often someone in their own group.  This introduces a financial bias where keeping the fees in house might trump inviting a consultant from another organization, who might be more qualified to weigh in on the case.   

If the ordering doctor picks a colleague from their own group, there are at least two more important concerns. The doctor giving the second opinion might be reluctant to disagree with care rendered by someone who is in their personal, clinical and financial orbits.  Additionally,  there is the matter of herd mentality (common in groups and hospitals) where physicians, with social and clinical ties, tend to manage certain problems uniformly, making it less likely that alternative approaches will be considered.

Surprisingly, internists almost never ask internal medicine colleagues for formal consultation.  This is unfortunate since another internist, with a panoramic view of medicine, might be of much greater service in mysterious or complicated cases than a squadron of sub-specialists who tend to look at cases through a single lens. 

My years in medicine have shown me that a consultation or second opinion, centered in knowledge and a wide ranging experience, is often, in tough cases, more valuable than endless testing, which tends to get more and more  incoherent as time goes on. 

Sound judgement is vastly superior to rampant testing, which once unleashed,  tends to generate more smoke than light.

In good hands the second opinion (a third opinion is almost never a good idea) is often clarifying and reassuring for both patients and doctors.  Bias should be kept to a minimum and doctors and patients should work together in picking a consultant.

On Cleavage

It is almost inevitable that a physician will experience, over a long career, sexual arousal while seeing a patient.

In the vast majority of cases the feelings are rare, brief, without any violation of decency standards.

Many of us learned in our training that we might experience occasional erotic sensations  in the course of our clinical work.  We were assured that it was not abnormal to do so, though we were told we must never  act out any of those feelings.   To Wit, fleeting feelings were normal, prolonged feelings were a call for going on red alert.

Episodes of arousal are  usually biological, without emotional baggage, but they could indicate, presenting as a flirtation or seduction, a significant personality or psychological disorder.  

When the experience is anything more than ephemeral it becomes crucial to determine whether it is the doctor or patient launching Cupid's arrow.   In either case problems may go way beyond the exam room, permeating important relationships.  Psychiatric consultation can be of great benefit in sorting things out.

About twenty years into my practice I felt confident that sexual arousal in the exam room was not one of my problems.

But that changed one day when a new patient with a cough was brought into my office.  

Not only was she curvaceous but she had a full bosom with an an arresting cleavage.  Inchoate feelings of arousal started almost immediately and I found myself in a battle to not look at her chest, hoping my eyes would lock instead on to her eyes,  suggesting sincerity and caring rather than the embarrassing and over heated feelings I was struggling against.

Alas, my defenses crumbled when I examined her.

It was my habit to tell  patients what I was doing as I examined them: now I'm going to look at your throat, now I'm going to listen to your lungs.  Disaster struck when I came to listen to this patient's heart when I heard myself say, quite clearly and audibly - and now I'm going to listen to your breasts.

She gave no signal that she heard me though I felt certain she had.  Since she said nothing I decided not to open a can of worms and,  feeling exposed  and mortified, said nothing.

For the next twenty-two years, when coming to a  heart exam 
I would faithfully say, "and now I'm going to listen to your (pause, pause, pause, get it right) heart.

What did I learn?

I learned that  I was human and not always as in command of my feelings as I had imagined.  Moreover, I learned that patients can be generous in forgiving our frailties.  

Whatever feelings of attraction  I had for the patient were extinguished by the experience and our doctor patient relationship took an ordinary trajectory.

Retry

Dear Reader -

I sent out my last post, Televised Snake Oil, on 6/13/13.  I've since learned that some of you never received the post or had to go through some tricky gymnastics to view it.

It's not clear to me why this happened.

I will resend hoping the problem somehow auto corrects.

Blogspeak