NEWSBYTURI MCNAMEE

There’s a movie in which one of the characters is a sickly little boy who doesn’t go anywhere without his inhaler. When he gets short of breath, he takes a couple of hits off his inhaler, and within a minute or two he’s breathing easily again. Later in the movie it’s revealed that what’s actually in his inhaler is nothing more than aerosolized salt water. It’s a complete sham. Yet it still brought relief to this boy and his neurotic mother.

It’s a perfect example of the placebo effect -- benefit from a false treatment or intervention. It’s seen most commonly in situations where the symptoms are more subjective, such as pain or mood. In women, it's also seen in sex drive.

A recent study in the Journal of Sexual Medicine found that one in three women with diminished sexual desire who took a sugar pill as part of a control group reported an improvement in their symptoms. The study included 200 women diagnosed with female sexual arousal disorder; 150 of them took Cialis, the male erectile dysfunction drug, and 50 were chosen at random to receive placebo. Although the women taking Cialis showed no marked improvement in sexual arousal, a third of the women popping sugar pills reported restored sexual function. It seems that nothing had physically changed for these women, but psychologically a major shift had occurred.

As a medical educator, I try to encourage my residents to see beyond the next step in a patient’s care.  For example, before simply ordering a test, I challenge them to think of what they would do with the results.  If the test is negative, are we really reassured that there is no disease?  On the other hand, if it’s positive, will it help us in the treatment of this patient?  You’d be surprised at how often performing a test is not always the best thing to do.

So it’s with that mindset that I read about a new test for Alzheimer’s disease.  Via a spinal tap, we can now determine with a startling degree of accuracy whether Alzheimer’s is indeed present or not.

I wonder about the utility of this test, however, and also about how such a definitive diagnosis might make practitioners less vigilant in their workup of patients. At present, Alzheimer’s disease is virtually untreatable.  Would detecting the disease early make a significant difference in a patient’s health?  Additionally, Alzheimer’s is one of those illnesses to which it’s far too easy to attribute symptoms that may actually be harbingers of something more serious, not to mention treatable.  Worsening confusion?  It would be very easy to chalk it up to Alzheimer’s and not look for other conditions that could do the same thing.

Do you have your organ donor card signed yet? Do  you? I’m asking because I’d like to think that if more organs were available, stories like this wouldn’t happen, in which a very nice young man gets stricken with one of those awful, can’t-do-anything-to-prevent-it kind of diseases that is slowly destroying his liver.

His brother, also a very nice young man with a very nice young family, watches as his sibling wastes away for want of an organ. He has some testing done and discovers that he is a perfect match, and the two brothers travel to a well-respected transplant center to have a living-related liver transplantation.

The first brother, the recipient of 60% of his brother’s liver, is slowly recovering. The other brother, the donor, died, leaving behind a wife and three young children. The cause of death is still unknown, but given that it occurred in an otherwise healthy man 4 days post-operatively it stands to reason that the surgery may have had something to do with it.

In one of those “Oh my gosh I can’t believe they actually did that” moments of medical advancement, a group of researchers reported in the Lancet the successful regrowth of the entire articular surface of joints in rabbits.  In other words, the researchers made bunnies grow their own joint replacements.

Before you go taking granny’s walker away, bear in mind a few important points: They’re rabbits.  The same results may not be achievable in humans. The joints being evaluated were in their front legs, which – correct me if I’m wrong – don’t appear to be the major impact-bearing limbs in that particular species.

Further, the researchers looked at a very small number of these creatures (10 in the study group vs. 13 in two different control groups and one of the control groups contained three unfortunate bunnies who simply had their humeral heads removed, with no attempt at reconstruction.  The researchers astutely noted that “Defect-only rabbits limped at all times.”

I’ve just this very moment gotten my head above the surface after spending the better part of the last week and a half navigating the waters of the federal grant process.  The good news is that I think programs like mine are particularly well-suited to the grant for which we’re applying, and I’m quite optimistic about the outcome.  The bad news is that the process, and in the case of this grant the incredibly short turn-around time, may dissuade from applying the very programs that it’s meant to benefit.

The grant to which I refer is HRSA-10-277, the Affordable Care Act Primary Care Residency Expansion Program.  Announced June 17, 2010 and due July 19, 2010, this program offers $168 million to increase the number of primary care physicians by expanding enrollment in primary care residency programs.  Priority will be given to those programs who offer a minimum of six months of the residents’ training in a rural health clinic, community health center, community hospital, critical access hospital, or other community based settings.

Which sounds great, but I can’t help but wonder how programs so heavily invested in such priority areas could have the resources to come up with a 35-page grant in such a short period of time.  Do these places have grant writers?  Because there’s no way on earth I could have completed this grant application without my grant writer Donna.  Just none.  And most community health centers that I know of are so overextended and understaffed, the mere suggestion of adding a project of this size with such a precipitous deadline would probably be met with no small measure of laughter.

I received a call yesterday not unlike several calls I get at least yearly.  It was from a resident in an internal medicine residency program in another city—it seems his residency program is closing down and now he is in search of another.

I wince when I get these calls, not because I get them so frequently, but because a) this is an internal medicine residency that’s going down at precisely the time that we need more of them, b) given the caller’s clipped foreign accent, I’d wager he sacrificed body and soul to get that position, and c) the chances are good that he won’t find another spot.

But there is some good news. The U. S. Department of Health and Human Services recently announced federal funding for expansion of primary care residency programs.  The July 17th deadline for the grant is optimistic, if not unrealistic, but at least it’s an opportunity to make up for lost programs.  Our program is going to apply.  I can sleep in August.

The Accreditation Council of Graduate Medical Education (ACGME), charged with oversight of medical residency programs across the country, has finally publicized its take on the Institute of Medicine’s recommendations on resident working hours, and it’s an interesting work to consider.  The work week remains capped at 80 hours; however, what happens during those hours has changed.

For one, first-year residents are not to work longer than 16 hours.  Period.  No mandatory napping, just get the heck out of the hospital.  Upper-level residents are allowed to work up to 24 hours, and possibly four more if there are loose ends that need tying up.  While napping is “encouraged” during those shifts, the ACGME shied away from making it a requirement.

At the same time, the ACGME states that programs must design rotations so that there is a minimum of transitions in patient care, occasions that are fraught with potential for medical error.  They also are more specific about the degree of supervision required of residents based on their level of training.

I’ll admit it: I don’t like prescribing narcotics.

Don’t get me wrong, there are times when it’s clearly indicated. If you’ve got metastatic cancer or a fragment of femur poking out of your thigh, narcotics are probably right for you. It’s the less-obvious causes of pain for which patients request narcotics that make me and many other physicians squirm. The chronic back pain with a normal MRI. The old football injury. The migraines that seem to respond only to a specific brand and dose of painkiller. All are potentially and frequently legitimate, yet all are also among the many platforms from which narcotics abusers solicit their preferred prescriptions. And while most physicians really do want to help alleviate suffering, we also really don’t want to feed an addiction.

To protect ourselves and our patients, we try to monitor the use of prescription medications very closely. No more than a month at a time is dispensed. No refills are given if medications are lost or stolen. All prescriptions must come from one provider and be filled at one pharmacy. No exceptions. In practice, it makes the use of these medications a big pain in the tookus for both physician and patient.

There’s little doubt that America is facing a physician shortage that’s likely to worsen in upcoming years.  At present, there are thousands more slots for residency training of physicians than there are graduates of U.S. medical schools to fill them.  The remaining positions have historically been snapped up by internationally-trained medical graduates, or IMGs.  The competition for these remaining slots is fierce, and the process for even being considered for them is both arduous and expensive, especially for those whose medical education was not done in English.  Faced with this, many IMGs turn to careers in nursing or other healthcare-affiliated professions.  Others switch careers altogether.

A few, however, refuse to squander their medical training and set up illegal practices in communities with large immigrant populations.  According to this article, this appears to be especially true of Latin-American trained healthcare providers who, unlike IMGs from several other countries, are not taught medicine in English but in their native tongue, which makes the path to legal practice in the United States all the more cumbersome.  Moreover, there is an exceptional need in these communities for providers who are fluent in Spanish, a need which our current system of physician training has been unable to fill.  The Latin-American trained physicians are only too happy to help.

Addiction is a horrible thing for many reasons, with potentially disastrous outcomes for not only the individual afflicted but also for all those with whom he or she has contact.  Although the primary goal with addicts is to get them off their substance of choice, sometimes it’s not always possible.  With such individuals, some researchers have looked at strategies focused on damage control.

One area of damage being looked at is the use of street drugs as opposed to pharmaceutical grade drugs.  Perhaps not surprisingly, street drugs and the instruments of their delivery are frequently contaminated, often intentionally, leading to an entirely different series of health problems not directly related to the drug itself.  A group of researchers in England wondered whether they could get addicts to use less of the street drug if they provided the pharmaceutical-grade version with a healthcare professional’s supervision.

The answer: yes.  Of the 38 chronic heroin addicts to whom they provided supervised injectable heroin, 31 were using street heroin less than 50% of the time after 26 weeks.