Dr. Ben's Blog

Pushing placebos?

Leading and Managing People: What I Didn’t Learn in Medical School (second in a series)

Doctors are very often managers of at least small teams or groups of people. It starts in residency–a 2nd year resident manages interns and medical students, a 3rd year resident manages 2nd years, interns and students, and so on. Doctors in practice may manage a team including nurses, medical assistants, receptionists and/or secretaries, and perhaps advanced practice clinicians like nurse practitioners, physician’s assistants, and nurse midwives. Physicians in academic medicine may manage a research team.
The bottom line is that managing people is an important skill that most physicians need, and which is not typically taught during medical training.

I suspect that the same is true for many professionals in different fields, including law, dental and veterinary medicine, engineering and others.

Thanks to the Online Nursing Degree Directory…

for including my blog on their list of the top 100 academic medical blogs. Aside from the flattering inclusion of this blog, it’s a interesting list. I can’t say I’ve looked at all of them, but there are several blogs I’m already familiar with and like, and several more that I hadn’t been familiar with but which I’ve looked at and am glad to be aware of.

Executive function and ADHD

Executive function (EF) refers to a set of cognitive tasks or skills including planning and implementing strategies, performance monitoring, vigilant attention. It’s not a well-characterized concept, or one with a widely accepted definition. There is debate whether executive function is truly a single function or is a conceptual grab bag consisting of a number of different elementary cognitive functions. There are experimental results from cognitive task analysis and neuroanatomical/functional studies which bear on this issue.
The term executive dysfunction has started appearing in neuropsychological test results from some of my patients, often in association with a discussion of whether a patient has ADHD. Wanting to understand the concept of EF better, particularly as it relates to ADHD, I’ve been looking at a number of review articles. Most have been impenetrable to a non-specialist like me. I finally found one [Castellanos et al., Trends Cognitive Sciences, 10(3):117-123 (2006)] which, while dense, is at least comprehensible and is beginning to illuminate this area for me. This review specifically focuses on EF with regard to ADHD. It discusses the concept of EF and some of the experimental psych studies as well as neuroanatomic-functional evidence bearing on EF as an elementary unitary process vs a loose collection of elementary cognitive tasks.

If you’re interested in the topic and are willing to put in some effort, it’s worth reading.

Vitamin D in infancy and reduced risk of diabetes?

Evidence has been accumulating in bits and pieces for some time that vitamin D might reduce the risk of type 1 diabetes. The incidence of diabetes is higher further away from the equator; since vitamin D requires activation by a photochemical process, sun exposure increases the availability of active vitamin D. In addition, diagnosis of diabetes has seasonal variation, with maximum new cases in fall and winter, and a minimum during the summer. At the time of diagnosis of diabetes, serum vitamin D levels are lower than in matched controls. Finally, in a mouse model of type 1 diabetes (the nod or non-obese diabetic mouse), vitamin D supplementation decreased the number of mice developing diabetes. It is known that vitamin D affects several types of immune effector cells, so it’s quite plausible it might have an effect on triggering the autoimmune destruction of the pancreatic islet beta-cells.

HPV acquired often with first sexual partner

A study recently published in the Journal of Infectious Diseases (J Infect Dis. 2008; 197(2):279-82) looked at the incidence of genital HPV infection in women during their exclusive relationship with their first sexual partner. By the end of one year with that one partner, 28% of these young women had become infected with HPV. By the end of three years with the first and only partner, 50% were infected. These numbers were even higher if that first partner was “sexually experienced”.

This is a powerful argument for giving the HPV vaccine at a pretty young age–reliably before the first sexual experience.

More hazards of the Internet: self-treatment of sexually transmitted infections

Everyone looks for information online–that’s a given. So you might not be surprised to discover that patients who think they have a sexually transmitted infection might go looking for a treatment online, avoiding the stigma of telling a clinician what they think they have. A recent study from the UK looks at the availability of purported treatments for sexually transmitted infections online. With a well-defined search protocol intentionally limited to avoid an unmanageable number of results, they found 77 “treatments” from 52 different companies. [Not surprisingly, few of them had a good evidence base supporting efficacy or safety, though that wasn’t a focus of the study.] Few of the websites talked about side effects, contraindications or drug interactions, and few discuss partner treatment or prevention. [The authors of the study cynically wonder whether that is on purpose, so the purveyors of these products guarantee themselves additional sales when the index patient gets re-infected.]

So here we have another example of one of the most negative aspects of the Internet for medical care–the exploiting of scared patients who are afraid of embarrassment by selling them mostly ineffective “remedies” and the absence of simple, straightforward advice to reduce spread and prevent re-infection. Huge sigh.
Yet is there any way to prevent something like this? Education of everyone on how to safely and effectively use the web seems the only way–a worthy goal for many reasons, but a tall order to accomplish.

Autism continues to increase in California: more evidence that thimerosal is not the cause

Previously, autism data from California were published, demonstrating an increase in incidence roughly coinciding with an increase in the number of thimerosal-containing vaccines given to infants. This was interpreted as supporting the notion that thimerosal in vaccines was a cause of autism. Researchers from the California Department of Public Health recently published (Arch Gen Psychiatry. 2008;65(1):19-24) newer data, which shows that autism reports are still increasing rapidly in California, even more than five years after thimerosal is out of infant vaccines there. In addition, they show that both the increase in the absolute number of cases and the rate of increase of autism exceeded the increase in any other reportable developmental disability in the same age range and time period. The latter suggests that the increase isn’t due to a general increase in recognition and reporting of developmental delays.

It’s tragic to see that autism continues to increase. An explicit contradiction to the original indirect evidence that thimerosal was the culprit in autism, however, is reassuring with regard to the safety of vaccines.

ADDENDUM: I owe an apology to my readers and to parents of children with autism. The wording in my original post (since edited) was extremely insensitive and did not accurately convey my intent. I take no pleasure in the increasing rate of autism. I am happy to see evidence that the vaccines we’ve been administering are not at fault. Clearly, some people feel differently, despite a growing mass of evidence to that effect.

Several readers have posted strongly worded comments which I’ve not displayed for two reasons. Some include personal epithets which are not a useful form of dialogue. All include references to various studies purporting to prove an association between thimerosal and autism. These studies don’t address the epidemiological study I refer to in this post, or this approach to the question at all, and thus don’t seem germane. I will probably be writing more about this topic in the near future–stay tuned.

What’s the goal: Healthy habits vs weight loss?

Kathy Kater, a psychotherapist from Minnesota, has a very interesting letter in the BMJ, in response to a point - counterpoint on whether the obesity epidemic is exaggerated.
She makes the point that probably only a small portion of how our bodies maintain weight homeostasis consists of the modifiable factors diet and exercise. The larger portion is our genetic and physiologic makeup, leading to the thin person who eats everything and never gets fat, along with the heavier person who eats nothing but celery and does Stairmaster for hours a day, and still remains heavy. She cites studies attesting that exercise and good eating habits make you healthier regardless of your weight or body mass index. If this is the case, she posits, focusing on weight or BMI serves no useful purpose but creates a lot of negative self-image (which in the long run has been shown to reinforce obesity and bad lifestyle choices). She suggests that society would be better served by promoting healthy eating habits and appropriate exercise levels, and not obsessing about our numbers. Great food for thought (bad pun intended.)

Feel free to drop me an email and let me know what you think.

MRSA vaginal colonization: is vertical transmission to neonates a concern?

As methicillin-resistant Staph. aureus (MRSA) becomes more and more prevalent, we are wondering when to worry about it, and when not to (i.e. when it’s more likely a colonizer like sensitive Staph. aureus). A recent study (Andrews WW, Schelonka R, Waites K, Stamm A, Cliver SP, Moser S., Obstet Gynecol. 2008 Jan;111(1):113-8) from Obstetrics and Gynecology provides some reassurance about the presence of MRSA in the genital flora of pregnant women. In this study, the presence of MRSA was measured from routine anovaginal swabs obtained to look for Group B strep (GBS) colonization. MRSA is found in the vagina or anus during pregnancy in about 3.5% of women (total population studied, about 5800). To put this into context, about 15% of all women were colonized with Staph aureus regardless of antibiotic sensitivity, and 22% were colonized with GBS. Being colonized with GBS increased the likelihood of being colonized with any Staph aureus, and with MRSA specifically. [However, there is no implication of causality. Causation could flow in either direction, or colonization with both GBS and staph may reflect some underlying predisposition to colonization with gram positive organisms, for example.]

The most important result, however, is that the babies of MRSA-colonized women did not have invasive infections with MRSA. This is a huge reassurance, and allows obstetricians and midwives to let go of this concern and focus only on whether MRSA colonization has an impact on the mother directly (e.g. risk of episiotomy or Caesearean section incisions.)