Bernard Roizman, my science mentor- I spent many wonderful years in his lab

In 1910 Abraham Flexner wrote a report regarding the state of medical education.  The aftermath was stricter standards for admission, fewer medical schools, and an immediate, although, sadly, not long-lasting, impact on alternative medicine.

The Flexner report- demanding a scientific basis for patient treatment and medical education

A number of medical schools prior to the Flexner report offered courses in eclectic medicine, naturopathy, homeopathy, and other “alternative” approaches.  Flexner believed in the scientific approach, and was appalled at those who promoted non-vaccination. The medical schools that offered such “alternative” approaches were either closed, or they changed their curriculum to drop them.

The one alternative set of schools that did change were the osteopathic schools, which adopted the scientific method, but continued to offer “manipulation” in their curriculum. Today, the osteopathic physicians have equivalent training to medical physicians.

Sadly, we have now seen a reversal of science based thought as  states sanction non-scientific approaches to illness? Are we entering a new dark age in science and medicine? Have we left the renaissance period where science and engineering brought us so much, to go backward to the era of treatments that have no proven benefit or efficacy?

Listening to a recent podcast from Skeptics Guide to The Universe, and learned that homeopathy advocates using heat to treat burns.  You can find confirmation of this dangerous practice on-line.  Homeopaths, as well as other “alternative” approaches to medicine, have state-sanctioned practice.  Which means, in Arizona, if you become burned and go to a homeopath- they might give you a treatment that would kill you, but the state is sanctioning it.

The Scientific Method- missing from Alternative Therapy

The state of Arizona has a State appointed board of homeopathic physicians. The purpose is to “protect the health, safety and welfare of Arizona citizens by examining, licensing and regulating homeopathic physicians.”  If the state was really interested in protecting health and safety of Arizona then get rid of this board, and let the world know that homeopathy has no basis in science, will not add to your health, and there will be no licensed homeopathic physicians in Arizona.

In almost every state, there are boards to regulate homeopathic practice as well as, chiropractic boards, naturopathic boards- state sanctioned and licensed treatments that have little or no proven efficacy.

While that cost to the states is “a drop in the bucket” the cost to individuals is not. Many states mandate that chiropractic treatment be a covered benefit of insurance policies. When there is mandated treatment, insurance costs increase. If insurance companies could exclude chiropractic, homeopathic, and naturopathic treatments- the cost of policies would decrease. There is now a push for other “Complementary and Alternative Medicine” to be mandated by insurance companies, based on the premise that they mandate chiropractic.

But the costs do not end with your insurance policy. In our state we have chiropractors that team with ambulance-chasing lawyers.   Here is the scheme – you get in a car accident, and call the lawyer.  The lawyer has a group of people who will examine you, including chiropractors.  Once the case has settled, those bills are paid at a higher rate than customary fee. There is more money to be made by chiropractors that follow these lawyers than in practice (in practice if they are paid by insurance companies they have an adjusted fee, with the legal system, if a settlement is performed they can charge whatever they like).  Because the state sanctions “chiropractic” it is an allowed bill in settlement of automobile accidents, even though there is no evidence that chiropractic treatment has any benefit beyond massage therapy.

In Arizona, citizens pay for non-science based treatment not only through taxes that regulate their boards, but with increased insurance costs because the state mandates it cover a treatment that does not have any proven scientific benefit.  Increased automobile insurance costs because the chiropractic treatment is ultimately passed on to all drivers.

Perhaps the most dangerous chiropractic trend is the desire to certify some chiropractors to treat concussions.  Some chiropractors are advertising on their web sites – to quote: “If your child has suffered a head injury with or without loss of consciousness get them checked asap by your medical doctor or sports chiropractor.”  The treatment of concussions is a highly specialized neurologic diagnosis, that involves neuro-radiologists (radiologists that specialize in reading films of the nervous system), neurologists, and neurosurgeons. There is no evidence that chiropractic manipulation of the cervical spine or any spine helps with concussion. In fact, there have been 26 deaths attributed to chiropractic manipulation of the spine (and many non-published deaths- we have two). There is no role for chiropractors in the treatment of concussions, and yet having a state board gives them a false status among the general public.

In Australia, top scientists have asked the universities to reverse “the trend which sees government-funded tertiary institutions offering courses in the health care sciences that are not underpinned by convincing scientific evidence.”  By providing a degree in a “complementary medicine” one gives even more credibility to pseudoscience.  To counter this Nick Klomp, the dean of science faculty at Charles Sturt University in Wagga Wagga, New South Wales agreed that there was an issue and states that his training  is “all abut evidence based, science based,” – of course, that is like saying we give a degree in Santa Claus studies, and teach them to think critically.

Australian Skeptics like Rachel Dunlop fighting for science - and against ear candling

On a recent show by Dr. Oz, he asked people to ask their physicians why they don’t offer complementary treatments — the answer is obvious: we offer treatments that have are proven to help- it is a part of our medical ethics.  In our pillars of medical ethics we have beneficence – and that means we cannot offer a patient a treatment that will not benefit the patient. While conventional medicine has that as a pillar, apparently homeopaths, chiropractors, naturopaths, and others do not.  Their treatment is “belief based” with lots of confirmation bias from their patients.

The disconnect between politicians and science is quite old. In 1851 in Michigan a group of citizens successfully petitioned the state to fund a homeopathy school. This led to a major fight between the Board of Regents of The University of Michigan and the state legislature. Ultimately the state did fund one.  Science ultimately prevailed and the homeopathy school was closed. I leave you with this quote from Dr. Zina Pitcher at the time on the Board of Regents at The University of Michigan in 1851:

…shall the accumulated results of three thousand years of experience be laid aside, because there has arisen in the world a sect which, by engrafting a medical dogma upon a spurious theology, have built up a system (so-called) and baptized it Homœopathy? Shall the High Priests of this spiritual school be specially commissioned by the Regents of the University of Michigan, to teach the grown up men of this age that the decillionth of a grain of sulphur will, if administered homœopathically, cure seven-tenths of their diseases, whilst in every mouthful of albuminous food they swallow, every hair upon their heads, and every drop of urine distilled from the kidneys, carries into or out of their system as much of that article as would make a body, if incorporated with the required amount of sugar, as large as the planet Saturn?

University of Michigan Homeopathic School - closed thankfully post Flexner Report

In an era when states want to save money, and cut programs- perhaps the first programs that need to be cut are those that have no proven efficacy.  It would save a small amount of money in the state’s revenue- and its citizens would save much more when treatments of no value become of historical interest.

While there is a lot of controversy about what diet is best for a long and healthy lifestyle- there is no doubt about things that you can do to stay healthy into the golden years. We want them to be golden years, not rusty years.

So here are things that all of the medical community agrees with- and things that my 87 year old father do:

Lose weight– as you age most appetites decrease a bit, and habits change. If you lose weight it is a lot easier on your joints, your heart, and your back. Take advantage of the diminished appetite – my parents skip dinner most nights, or just have a snack. My dad has gone from 185 pounds when he worked to 150 pounds now — a nice slow weight loss over the last twenty years.

Exercise – one simple thing- walk every day. Thirty minutes – it makes a big difference. When I visit my parents my dad can out walk me. Both of my parents are as sharp as ever.

Keep your mind occupied. The golden years do not mean settling down and watching television. Keep up with something- my parents have a wide range of interests, my dad still serves on a board – and they always discuss politics (I might disagree with their views at times).

Simple formula: Eat less, walk a bit, and keep your mind occupied.

I’m glad my parents are happy and pretty healthy for being in their 80′s, and my son (18 months old now) has a great set of grandparents to enjoy (he’s their first grandchild).

My 87 year old dad, and his first grandson -JJ- keeps you young

One of my favorite chefs – Gordon Ramsay, talking about eggs and a few other things.

Scrambled eggs:

When I first started out in life working in a kitchen one of my jobs was to crack eggs and put them into a large container and then when someone ordered eggs they would be ladled onto a hot griddle and in a minute an order of scrambled eggs would be ready. Turns out, most kitchens make eggs the same way — a hot griddle, very little time, and a fast breakfast.

Fast food eggs are made over too hot a griddle yielding rubbery consistency

Two problems- the eggs have been heated so fast, that the proteins have lost most of their water giving the eggs the consistency of rubber and second, the eggs don’t taste that great.

When my patients who had LAP-BAND surgery complained that eggs became stuck above there band – it was quite clear- they were either making them to hot and fast, or getting them from a restaurant that was doing the same.

Here is the secret to all eggs — think of eggs like sex – you want it slow. When you were a kid, fast may have been ok but now you are an adult- time to earn how to make them.

The perfect scrambled egg has the consistency of custard or yogurt. They are not hard, rubbery, or dried out. Egg whites are a protein called albumin – and like all proteins, when given a high heat they tend to denature (our scientific term) — or lose their water and become curdled, hard, and more akin to eating a wad of bubble gum than the nice custard we desire.

Ingredients:

4 large Eggs
1 T butter – UNSALTED

First DO NOT whisk the eggs together ahead of time. Do this under some heat – and gently. Whisking eggs together begins a mechanical breakdown of the proteins that will result in more rubbery consistency.

Place a non stick fry pan on a low heat. Take a teaspoon of butter and gently coat the bottom of the pan. If the butter can melt – then place four eggs in the pan. Using a silicone spatula gently break the yolks and fold the eggs together. Gently stir the eggs – and every minute take the pan off the heat and continue to stir the eggs. Once the eggs “set” – or are a wet consistency when they are giving off a bit of steam – take them off the heat for the last time. Take the remaining 2 teaspoons of butter and fold them into the eggs. You will see the heat from the pan will continue to SLOWLY cook the eggs. As you stir in the butter the creamy texture of the eggs will form- once they are to that point, remove them from the pan and serve them.

At this point add salt and pepper to taste – not before. If you add salt to the eggs before the mechanical action of the salt, combined with the drying property will pull the water out of the eggs.

There you have it- the pefect scrambled eggs. Want to add some ingredients – I recommend Salsa instead of cheese- more flavor, and far fewer calories than fat.

Two servings if you are trying to lose weight and one serving if you want to gain weight.

In the nurse’s own words: “I had discovered (patient) had no clue about what they were about to participate in when they agreed to get a major invasive surgery. When I properly educated the patient using the allowed materials by my employer they became upset that the physician never explained details of the surgery or what had to be done after the surgery (complex lifetime daily self care).”

In a typical medical practice, or hospital – it would be the doctor or surgeon, the one with the medical degree, who would be responsible for educating the patient about surgery.  Nurses are trained, and hopefully well trained.  They are not, however doctors, or surgeons. While nurses, good ones anyway, forge relationships with patients, it is not the place of a nurse, with 6 years of experience, or 60 years of experience, to counsel a patient into hospice care, especially when the patient is scared or is lacking information about surgery. The surgeon is qualified to, and prepared to, explain thoroughly, as many times as necessary, any medical procedure a patient is undergoing. A surgeon will typically explain the surgery, and after care needs to the patient as well as the patient’s family.

Also worth noting is that there is procedure in place for initiating Hospice care. I am not affiliated with Banner Health, however, as is standard in most hospitals across the country, hospice care is not initiated by a nurse, and certainly not without the knowledge of the attending physician. I’ve been disillusioned by the huge outpouring of support the nurse has received. Not only do I have personal experience (that I share below) that’s shaped my opinion on this matter, I take offense to the supporters who have adopted the attitude that this nurse was fired because she upset the attending physician, and threatened the dollars attached to a transplant procedure.

Starzl did the first liver transplant years ago- saving many lives

Several years ago a friend of mine, Rod, was dying.  His liver was failing him. I remember seeing him the day before his transplant. At first I didn’t recognize him – he was stooped over, wearing baggy clothes, and only when he looked up and spoke to me did I recognize him.

In the years I knew Rod, he had gone from being a patient, to the handyman who worked on my house, to a friend. But now I looked at this man, and my clinical instinct told me he didn’t have but days left to live.

Rod’s words to his wife that day were, “I think I’m done.”  In his early 40’s, the man with a smile who would do anything for you, couldn’t face life anymore.  His jaundice skin was so itchy that he would jump in the swimming pool in the middle of the night (winter, no heater) – just to get some relief.  His ankles were four times their normal size from the edema.  His abdomen, normally flat, was puffed out because of all the ascites (water from a failing liver) in his belly.  He had no energy, and could only work a few hours a week.

The next day Rod’s pager went off. Mayo Clinic had a liver.

Four years later, Rod is working full time.  No jaundice, no swelling, no itching, legs and belly are back to normal.  He has some issues with the medicines he takes for rejection – but he has now seen one son finish high school, and the other one is as tall as he is.

When I think of people who have end-stage liver disease, I always think about Rod. I asked him what would have happened if someone had pushed him to hospice the day before the pager went off, or even a few months before that—he said he would have had it not been for the excellent education he received from Mayo, although at his low times he would have taken hospice.

HOSPICE OVER TRANSPLANT HOW A NURSE CAN STEER YOU

This brings us to the case of a registered nurse, who on her shift  this last year “educated” a patient about end of life care when they were waiting for a transplant. Some hail the nurse as one who stands up and informs people about end of life care. She said “I was caring for a dying patient whom I had discovered had no clue about what they were about to participate in when they agreed to get a major invasive surgery.”

Pre-transplant liver patients are some of the most ill patients you can see.  They tend to go from one crisis to the next, be it from bleeding, or infection, or jaundice, or liver failure.  Because of the scarce supply of livers, these patients are literally brought from the precipice of death.  Often prior to the transplant operation they need other operations, or procedures, just to bridge the gap. Imagine your worst illness, where you first thought you were going to die, then wished you would—imagine living like that for months. It takes grit, determination, and a supportive family, and a transplant team to help rally you.

So when this transplant patient would come into the hospital, in a crisis, but not yet ready for a transplant – and feeling horrible here comes this nurse – telling her that this was just the start, and giving pamphlets while telling her there is another way—death with dignity in a hospice.

The nurse isn’t a transplant educator, because she would know that you don’t take a patient who is critically ill and educate them about transplant. You wait until they are healthy, and have better mentation.  This was a “temp” nurse, filling in on this floor- self described as “specializing in cardiology, geriatrics, and end of live/palliative care.”

The next day when the surgeon came to see the patient, the surgeon became upset, and asked that the nurse be relieved.

Here is what this nurse did wrong:

(a) She isn’t a transplant educator, and therefore does not know about this procedure

(b) The materials she used which she describes as “When I properly educated the patient using the allowed materials by my employer they became upset that the physician never explained details of the surgery or what had to be done after surgery (complex lifetime daily self care).”un  The educational materials she referred to are summary materials, an adjunct. A small piece of what the patient will learn in the process of receiving a transplant.

(c)  She says “I was doing my job and protecting the patient’s rights to full disclosure about the surgery and their right to choose their course of care.” This was not the motive of this nurse, in my opinion.  There is a right time to educate a patient, and a wrong time to.  When the patient is very ill, but there is a procedure that will bridge them until they can obtain a transplant, is not the time. There is a whole group of classes transplant patients are REQUIRED to take, in the evaluation process for the new liver.  It is not up to this nurse, at this time to do this.  Her job was to watch over the patient that shift, not to steer this patient to hospice.

(d) This nurse also says nothing about going up the chain of command in the nursing structure.  She didn’t talk to her charge nurse, she didn’t talk to the supervising nurse on duty, nor did she talk to the nurse administrator on duty. This nurse took it upon herself to do this task. This is rogue behavior.  Had she gone up the chain of command she might have been educated – if she were to allow to be educated – about the educational process with transplant patients.

(e) There is always a role for end-of-life teaching and counseling. The best time to have those discussions is with a person who is feeling as well as they can, given a bad situation. The worst time to have those discussions is when the patient is feeling so ill that the thought of death is a fine release. She justifies her actions by her anecdotes of patients who “lying in hospital beds for weeks on end, suffering debilitating pain, air hunger, bed sores, muscle wasting, and their dignity is not respected – as their family members stood by horrified.”

(f)  This nurse then brought this to the public view – for sympathy, for political support, and does not admit to any wrong. She will get sympathy, and she frames the argument in that manner – but this points out that she believes she has nothing to learn, and the sole reason she was dismissed was because of greed, not because she can learn something from this.

(g) What this is NOT: this is not the case of a surgeon planning to do a transplant on a patient who is completely unaware of the circumstances.  As much as this nurse publicly attempts to frame the discussion in that manner, that simply does not happen with transplant patients.  Nor is this the case of a nurse providing a patient with informed consent about a procedure.  I’m a surgeon- while I nurse may obtain “consent” a piece of paper we ask patients to sign – if the patient has any questions, in over 20 years of surgery, the nurse always calls the surgeon to answer them.  A nurse cannot give informed consent – the surgeon can.  It is not uncommon for patients, the day of or before to have more questions – we, as surgeons are obligated and willing to answer them.

In surgery, we have four pillars of ethics: Autonomy, Nonmaleficience, beneficence, and justice.

 Autonomy 

Autonomy is that as a physician we have ethical obligations, and expectations to our patients. People are truly free to choose their treatment but must have the information that is required to make that choice. Because of innovation and research, it is the surgeon’s obligation.  In the case of transplants there are protocols, classes, a whole range of education that has been proven, over many years, to work well for education. The educational process has been tested, to the point where some public school systems have adopted the methods of this education. One cannot get educated from a busy nurse on a floor who has a self-described bias to hospice, and provides some cursory reading material.

Autonomy is not a nurse, without a background in the field, steering a patient to hospice.

Nonmaleficience

Nonmaleficience is that we do not use our skill and knowledge to harm a patient. There is risk associated with every surgical procedure, but that risk isn’t “doing harm” unless that procedure has NO HOPE of benefit. Transplants have a well-proven track record – over 85% at one year versus certain death without it. Hospice has 0% one-year survival.

 Beneficence

Beneficence is our duty to act in the best interests of the patient. We must always intervene for the comfort and well being of the patient.  Here is the hitch – it is not up to the surgeon to determine this. It is judged by the patient.  It is our goal to ease pain and suffering, it is not our goal to cause it. While this nurse publicly frames it so she can lay claim to beneficence – she cannot.

 Justice

Justice is the final pillar of ethics. This is how we decide how organs are dispensed. This is how we go to fight for the rights of our patients and not our self-interests. This is why I’m blogging about this act of  what I consider a rogue nurse.

The Arizona State Nursing board has asked that this nurse undergo a psychiatric evaluation.   The state has an obligation  to know if this is the act of an illiterate nurse, or someone who will tend to rogue behavior beyond the bounds of the profession. The board is rightfully concerned that she brought this into public, and instead of this nurse learning  how transplant education works, this nurse vows to change the system so any nurse can steer a patient from transplant to hospice. Where is the line between steering a patient to hospice and taking it into your own hands  – there is one, and does this nurse know that line?

Florence Nightengale - a hero, worked for her patients, not to send them to hospice

There is some misplaced sympathy for this nurse.  She states her license was revoked – it wasn’t she was simply referred to the board of nursing- an appropriate reaction. She thinks it is that referral that doesn’t get her a position – it isn’t, it was her action that proves it.  She thinks she was in the right- when she was so wrong.

Some sympathy comes from those who think it was the surgeon and the hospital who maintained the goal of  more dollars from procedures.  Funny thing about Banner Hospitals, they are considered, by many of my peer physicians, the most doctor-unfriendly and nurse-friendly hospital systems. For the record, I am not on staff at any Banner Hospital. And to be more clear, many of my friends are surgeons, and I know of no surgeon who wants to operate on someone who is terminally ill and without hope.

The perception that we surgeons are simply in it to “cut” and for “greed” is a sad perception that we need to correct. Until then, of my many colleagues, never have I met one who would do such a thing.

On a Happier Note: 

Today I am happy that my friend Rod is four years out with his new liver. I am happy that Rod didn’t have that nurse talking him into hospice care. Rod was as sick as any of them, had been hospitalized a dozen or more times before his transplant, and had many surgeries prior to the transplant.  Rod didn’t have an easy transplant, but he survived.  I am happy that Rod saw me become a father, and that he has become the uncle of my son. I know that Rod’s wife, his parents, his sons, and other friend are happy that Rod got his liver I’m glad Rod is here and is not someone we say “boy, Rod would have loved to see my son,” – as we put flowers on his grave.  Because you know what- if Rod had met that nurse, at the right time- he would have probably gone for hospice.  It would not have been death with dignity that would have been an unnecessary execution.

"There is no dignity in death." Dr. Gregory House - I agree

Comments for this post have been closed. Thank you everyone for participating in this discussion.

Bourdain calls out Deen

Paula Deen who crafted a remarkable, high profile career with her Southern style of cooking, delivered with Southern style charm, announced her diagnosis of  adult onset diabetes (type 2). Now the judgments are pouring in: her food and lifestyle led her to this diagnosis and the pundits are asking for her to “repent.”

As a physician let me be clear here:

Paula Deen’s diabetes is not a deserving fate for what she cooked, it is more a matter of genetics than anything else. For those who are unlucky enough to have the genetic code that predisposes them to diabetes, the odds are they will become its victim, as they get older.  Even the most “in shape” individual, who eats “right” who has the genetics for diabetes can no more avoid that than you can avoid a car accident  if someone misses a stop sign because they are texting.

Perhaps I am jaded – as someone who researches diets and performs weight loss surgery- I’m reminded that HL Mencken said that physicians are not suppose to offer repentance but absolution.  But a body never lies, and while we don’t know the “right” diet,  we do know that  certain foods can kill you.

While the news enjoys the pseudo-feud going on between Deen and one of my favorite writers-chef Anthony Bourdain, we in medicine hope that Paula Deen is using her celebrity to benefit millions who are diagnosed with diabetes. She is also cashing in a check from a sponsoring company;  isn’t that the American way?

The real quote from Bourdain is one anybody can respect, “Honestly, I have no ill will toward her personally. I respect anybody who’s had a trajectory like hers. But I don’t like the brand. If her shtick is food that’s going to rush you along your way to diabetes, then it’s not a brand I particularly like. I am the last person in the world to be advocating for any kind of healthy eating or lifestyle. The only distinction between us, actually, is that my show comes with a parental advisory and hers doesn’t.”

I won’t endorse Paula Deen’s cooking as “healthy” and most of it would cause blood sugar to rise higher than it should.  Food can kill you, but it cannot cure you. Hopefully Paula Deen will use her celebrity to advocate for diabetes education and awareness.  I also wouldn’t mind if she would come out with a few recipes that won’t raise the blood sugar as much as twinkie pie. And just to be fair– eating a little less of poison doesn’t mean it is being “moderate” it just means you are being less stupid. Besides- you can’t eat just one. So, Ms. Deen- lets see some new recipes.

Until then, I’ll be watching Bourdain eat camel cheeks in some far away place, wishing I was there with him.

]]> http://yourdoctorsorders.com/2012/01/paula-deens-diabetes-a-physicians-perspective/feed/ 2 http://yourdoctorsorders.com/2012/01/when-a-surgeon-needs-surgery/ http://yourdoctorsorders.com/2012/01/when-a-surgeon-needs-surgery/#comments Wed, 18 Jan 2012 18:18:59 +0000 The Doc http://yourdoctorsorders.com/?p=1638

Sometimes surgeons need surgery

Sitting in the chair, mouth open – thankfully numb from the anesthetic – thankful that the surgeon had years of experience.  Of course mine wouldn’t be a simple case – it is the rule of our profession, we never give our colleagues straightforward medicine or surgery to deal with.

It started out innocently- eating popcorn, and a bit of the husk became stuck between my teeth.  Didn’t know it, didn’t feel it, and after flossing it didn’t manifest itself.

A few days later there was pain, swelling, and half of my face was swollen. Calling my friend and dentist, he came in and opened up my gum, removed the offending husk that had worked its way into my gum, and drained the purulent material. Thinking it cleared up nicely with his procedure and the antibiotics – there was no need to return (never treat yourself).

Routine follow up x-rays a year later – “Terry, I need you to see someone.”

My referral was made and the kindly Dr. Robertson, with his southern drawl said, “Well, its stable now, but you have a little hole in the bone, and we will need to put some bone in there, and that tooth will need to come out.  If we don’t, it will be nothing but trouble.”

That was two years ago.  Time just slipped by – and every now and then the tooth would bother me… “Old Number 4” I would call it.

One weekend my golfing buddy, Steve, said he might not make it because he was having some oral surgery done. He made it- and I asked him about it.  Now my golfing buddy is a lawyer, who does nothing but defend physicians (not malpractice) – so he knows who is naughty and nice.

“How did it go?” I asked.

“Amazing, this guy is so talented. I needed these implants and he is slick.”

“Who did you use?”

“Dr. Robertson.” My guy – the guy I hadn’t seen in two years, the guy my friend, and dentist recommended.

By now “old number 4” was loose, and getting more painful.  A few times I thought I could easily pull it out. At my trip to see my dentist he took x-rays and said, “Really, you need to get this fixed. I mean, this can infect your heart, and the hole has gotten larger than I have ever seen in doing this for 30 years.”

Appointment made, and Dr. Robertson, just as kind as always was ready for the extraction. “This might hurt a bit.” The tooth almost fell out.  But what was left was a large cavity of bone destruction.

You can always tell when a surgeon has a challenge- they get quiet, they concentrate, and they calmly ask for things.  Calmness in a surgeon means confidence, perhaps a challenge, but confidence, and even a joy in something complicated. That is the surgeon you want,  not one who yells, screams and makes the crew upset.  On the other hand, I didn’t want to be on the receiving end of a challenge.  Dr. Robertson instructed the staff to snap a few photographs.  More bone was asked for- suture was asked for, and I heard him sigh, and then he began to talk about his trip to Alaska again – the challenge was met, he had prevailed, and now back to routine.

The photographs he took showed a large defect in my jaw up to, but not including my sinus. The amount of bone he used was  twice as much as he uses on a routine “difficult” case.  It was a huge hole- and at the final photograph showed beautiful work with some great stitches.

“You might be a little sore, so use a lot of ice chips, some ibuprofen, and I’ll write you a prescription for some Vicodin.”

Never used the Vicodin.  The hole healed nicely.

Four months later

A number of x-rays later, and two teeth cleanings- the bone had healed well. Time to place the implant.

Nervous about this because they said they may need sedation, and that didn’t appeal too much. Still, with my designated driver (my wife) off I went.

As he was working and chatting away, he stopped, and calmly asked for some more bone. Asked for a few more tools and then said he needed to do something different. After a minute he relaxed, and explained the extra work he did.

As he was asking for the equipment I thought of all the advertisements for dentists that did implants. Almost on every corner, and knew that most of them didn’t have one-tenth the experience as my surgeon. That knowledge gave me calmness.

Never more does a surgeon appreciate the skilled and experienced hands of a fellow surgeon when a patient.  As a teacher of surgeons, and one who has occasionally been asked to review other surgeons- there are not too many surgeons that impress me.  Too often I have watched surgeons in operating rooms and made that mental note that this would not be one I would choose – while they might be ok, and give good care in an emergency, but not my first choice. But here, as a patient, I was happy that my case – while a challenge, was with someone who was experienced, had good hands, and a calm demeanor.

Dr Robertson - skilled hands, for which this surgeon is thankful

Dr. Donald Robertson practices periodontics and implants in Phoenix.  My insurance didn’t cover the cost of the procedures, and I happily paid out of pocket. No free services were given for this post, and the purpose of this post was not to solicit for him, but to tell of my experience.  However, I would happily recommend him to any friend or colleague.  His office number is 602-242-2588.

The Paleolithic diet presumes that foods eaten during the stone-age (Paleolithic era from 2.5 million years ago to 10 thousand years ago) are optimal foods for humans. The Paleolithic (Paleo) diet includes grass fed beef and other lean meats, fish, shellfish, fruits, vegetables,  eggs, nuts, but no grains, no dairy, no salt, no refined fats (butter or margarine) and no sugar or high fructose corn syrup.

Fanatical Diet (Lifestyle types)
There are three things one should never discuss in polite company, religion, politics, and diet. Getting into an argument with proponents of diets is like a democrat trying to convince a republican that Obama is ok. Each side will quote their own studies, statistics, and population studies. But the key to scientific study of the various diets is not what we presume from correlation, but from what we learn when that diet is placed into patients – in this case, the laboratory values of those who have the diet.

Diet proponents become fanatical about their diet (lifestyle) to the point of religious fervor. Seeking to prove that their diet is backed by science, proponents use population studies with associations that are only suggestive and not proof of causation. These associations become propaganda as the associations are repeated over and over, morphing from a suggestion to “proof.”

The Flaws of population studies or Correlation does not equal causation
The foundation of many diets are based on the correlation of what a population eats and what diseases they suffer from. In the Paleo diet the assumption about what they ate and the diseases they suffered from is a spurious correlation at best, and far from causation.

Population studies are flawed, as often we find that we don’t know as much about the population as the data might suggest. Take the Pima Indians of the Southwest. In 1990 a paper came out stating that the Pima Indians had a low incidence of fatal coronary heart attacks in spite of having a high rate of diabetes. The Pima Indians were called among the most studied populations, with an NIH post in Phoenix, and lots of studies showing the highest rate of diabetes in the world. When the population was examined more carefully, the Pima Indians had plenty of heart disease.

Step back from the most studied group in the United States with great statistics and physicians trained in modern medicine and then imagine making conclusions about what Chinese eat, or Mediterranean’s, or French. Those assumptions are more flawed, as are the statements about what diseases they do or do not have. Now step back further trying to determine what people of the Stone Age ate, what diseases they had, and we leave the tenuous role of suggestion and enter the role of outright guessing. Even if we have reasonable data (and often we don’t – even for the best studied people in the United States) the correlation between what people eat as a cause for what diseases they have is a fundamental flaw. Correlation does not equal causation.

The Best Diet or Lifestyle is?
When it comes to the best diet plan for a person – we just don’t know enough to say that one is better than another. There isn’t enough evidence to state that the Paleolithic (also called Paleo) diet is better than the Ornish, Southbeach, Pritiken, or pick one, or better than how you currently live your life.

We cannot broadly say that any given diet will prevent heart disease, cancer, arthritis, or even obesity. When someone tells you a diet can prevent such, they have gone from the realm of science to the realm of bs.

The Paleo Diet Premise:
The Paleo diet premise is that we should avoid certain foods because our body is not evolved to process those foods, and if it does process them it will lead to the chronic diseases of modern man – heart disease, strokes, cancer. Cavemen didn’t have those diseases, so we should eat like cave men. Of course, we don’t know about what diseases that cavemen had – especially when it comes to organ and soft tissue diseases, we just have a few fossils that we examine and look for evidence of known diseases. Would coronary artery disease show up in a fossil – nope? Would cancer show up in the fossil – bone cancer would (kind of a rare cancer) or cancer that went to the bone might – but it would be hard to tell if the fossil evidence.

We do know, from many hunter-gathering societies, that they live a short life, and not long enough to develop the diseases we associate with aging. All a person has to do to pass on their genes is make it into puberty, and to be effective to nurture the young, into the 30′s, and to see grandchildren and help child raising – into the early 40′s. That is what a simple civilization needs. After that, in any primitive society, the elderly become a burden – perhaps to be placed on an ice flow. People who live into their 40′s and 50′s may die of cancer, heart disease, or obesity- but they will have passed on their genetic code.

The Evolution of Homo Sapiens:
When Homo Erectus came out of Africa, they encountered a world that was much more varied in food sources than Africa. The brain of the human (H. sapiens) evolved, becoming much larger, and utilizing far more energy than the brains of the Australopithecus – about 10 percent more. More than any other species, humans evolved a brain that required more calories- and our brain metabolism accounts for up to 25% of our energy needs. Bigger brains and its increased requirements mean a richer diet- and modern hunter gathering species derive about half of the energy from animal foods – in contrast with other primates that have far fewer animal foods. While our ancestors the Australopithecus dined on plant foods, and had large mouths to grind up fibrous plants – humans are built, with smaller faces and jaws, to dine on energy rich animal foods.

The reconstructed skull of Lucy, Australopithecus- large jar and muscles for eating plants

The Human skull is larger, larger brain- and jaws for more energy rich foods

Humans were successful, as the fossil record shows, because they were “flexible” eaters, using a wide variety of dietary strategies. If there were a lot of Elk, then we ate elk- berries, we picked berries. To state that our digestive system evolved only to eat some few items found in the Stone Age – has been disproven on the face of it. Our ancestors in Africa didn’t encounter Arctic char, whales, seals, salmon – and yet when they moved from that warm climate to the frozen north, they adapted quite well to a very high fat diet of primarily animal based diet that was clearly not available in Africa. The findings of starch grains from wild plants in grinding tools from sites in Italy, Russia, and the Czech Republic from the mid-upper Paleolithic era suggest that the production of flour was present 30,000 years ago.

Contrary to what Paleo proponents state: people made flour 30,000 years ago

How to eat like a caveman
There are some things about the Paleo diet that people avoid:

Excess sugars including fructose
Excess Omega 6 oils – including soy
Processed wheat, grains, and gluten
Dairy

What is the scientific evidence for this? It’s the simple premise that modern man has lifestyle illness from altering food, taking in too many calories, and if we would return to our ancestors roots (pun intended) we would avoid these highly processed foods and not suffer from the holy trinity of diabetes, obesity, heart disease, and maybe even cancer. There is not a single shred of evidence to support the premise of this diet.

An entire dietary regimen has been formed with plenty of books and websites to guide you through this. It has become so popular that the question becomes not the flawed premise for the diet, but rather how the diet would compare to other diets. If you want to eat like a caveman, then shop on the outside of your grocery store.  Everything on the inside of your grocery store is generally processed foods, and everything on the periphery of the grocery store is generally not processed.  On the periphery you will find the vegetables, fruits, meat counter, fish counter – although you might get in trouble with dairy, and before you check out they might have a cookie or two – or there might be a bakery (a big no no among the non-Geico types). But lets be clear- whatever the caveman could get that they could eat- they would eat, and if a caveman were to be around today- wait, we have them – well, they eat Poptarts.

In one real scientific study patients with known heart disease who were randomized to either the Mediterranean-like diet (based on whole grains, low fat dairy products, fish, fruit, and vegetables) or the Paleolithic diet (no grains or dairy but plenty of lean meat, fish, fruits, vegetables, root vegetables, eggs, and nuts) and those who undertook the Paleolithic diet were satisfied with less food. There was also a decrease in leptin in the Paleolithic group by 31% and by 18% in the Mediterranean group.

There have been other studies that show that people who go with this diet have improved laboratory values – less triglycerides, lower blood pressure, some weight loss, that the diet has a better glycemic index (the food doesn’t increase blood glucose levels as much). This diet compared to a standard diabetic diet did better. Those studies are short term, with small numbers of individuals, and hints of laboratory values.

So before one assumes I am putting this diet plan into the trash bit along with Ornish- there is clearly some data here that shows good nutritional sense in the food.

While highly processed carbohydrates transiently increases blood glucose levels more than whole grains – it does not mean that bread is bad for a person. At least we don’t know enough about this to state that today. Clearly, people who eat a lot of flour based products can get fat quickly, and getting off the bread and bakery products will help reduce weight, decrease hemoglobin A1C levels, decrease triglycerides, and overall be healthy.  Some people need to be told to never eat them again – as some alcoholics must never drink again- and some people are able to moderate them so they do minimal damage to the body.

Only a few studies have examined the effects of the Paleolithic diet on laboratory values that we associate as increased risk for disease – but again, those were laboratory values, not a long-term follow up for disease.

The premise for the Paleo diet may be flawed, but here are the parts of the Paleo diet that most would agree with:

(a) Highly processed grains – white flour, rolled oats- do cause a rapid increase in blood glucose levels and the body responds to that by increasing triglycerides and ultimately fat.
(b) Fish – as long as it is not contaminated with mercury, is a protein source that is high in Omega 3 fatty acids, which have been shown to be beneficial. If you have some great fish three or four meals a week it works out well.
(c) Vegetables and fruits are the basis for most diets- thus a vegetarian could participate in a Paleo diet easily. Too many people do not eat enough fruits or vegetables or look to them as snacks.
(d) The trend away from cattle feedlots and desire to have grass fed rather than grain fed beef. Grain fed beef is fatter and more prone to being infected with Salmonella or E.Coli than grass fed beef.  There is a wider variety of taste with grass fed beef, and most who find grass fed beef end up preferring its flavor. Grass fed beef is best cooked with Sous Vide cooking.
(e) If you eat more calories than you burn you will gain weight. But it is more than just calories – it is also the types of calories. Eating high glycemic index foods mean you will spike glucose pushing it into cells, where it will be quickly transformed and stored as fat. Low glycemic index foods will be slowly burned  - thus, calorie for calorie with the Paleo diet plan you will tend to burn the fuel from the food as opposed to store it.
(f) If you eat a majority of your food with highly processed grains instead of whole grains you will have a faster rise in blood sugar. Some attribute this rise to increased obesity and an increased load on the pancreas.

Overall- this is not a bad diet program. Nothing in it would appear to cause nutrient deficiencies and there is some preliminary evidence that this diet keeps a person more satisfied with less food. It is a low-carbohydrate diet, and those diets, in comparison to other diets, tend to produce faster and longer weigh loss.

Here are a few scientific references- I’m sure we will add more as time goes on

Low incidence of fatal coronary heart disease in Pima Indians despite high prevalence of non-insulin-dependent diabetes. RG Nelson, ML Sievers, WC Knowler, BA Swinburn, DJ Pettitt, MF Saad, IM Liebow, BV Howard, and PH Bennett
Circulation. 1990;81:987-995

Food for Thought: Dietary change was a driving force in human evolution. Wm R Leonard. Scientific American. December 2002: 107-114.

A Paleolithic diet is more satiating per calorie than a Mediterranean-like diet in inviduals with ischemic heart disease. Jonsson, et. Al. Nutrition & Metabolism 2010, 7:85

Thirty thousand-year-old evidence of plant food processing. A Revedin, et al Proc. Nat. Acad. Sci, November 2010: 107:18815-18819

Dr. Esselstyn noted the risk of heart disease in rural China was low in the 1970’s – and presumed that they didn’t have a “western diet.” Now there are two flaws in his population statistics: First in the 1970’s in rural China most individuals were starving to death – it was the end of the cultural revolution and any source of food that could be found and eaten was. The second issue is if you examine data from The China Study you will see that heart disease mortality was lowest in the rural communities that were able to eat more meat. In The China Study (again, I promise this will be a topic later) – they used mortality statistics from the time during the end of the Cultural Revolution. Rural China was starving then, all trees had been used for fuel, there were virtually no birds left (combination of deforestation and hungry humans) and rice was used for the army.

Dr. Esselstyn then talks about Norway during World War 2, when they were occupied by the Nazi Germany, and how that heart disease diminished as the Norske were forced to eat a plant based diet. That was a great assumption to make, but when examining the data from Norway there are a few interesting factoids – Meat consumption dropped 60% but fish increased 200 per cent. Vegetables and potatoes increased but sugar decreased by half. And when the data is put to a microscope in 1942 and 1943 when mortality declined, animal proteins were still higher than before the war. It appears that Norway suffered from increasing fish (great source of Omega 3 fatty acids) and foraged for foods such as wild greens, grew and ate a lot of potatoes, but had a low amount of sugars and almost no margarine (I don’t know a respectable Norwegian today who cooks with margarine). The sad part of the war was the increase of mortality from infectious diseases – especially pneumonia (my mother’s cousin who fought for the resistance died of this, as did many of his comrades).

Norway in WW2 ate a lot of fish- and this roe was popular

He followed these patients for up to 12 years – his numbers are confusing as he started with 24 patients and six dropped out (leaving 18). One of the 18 died from his heart disease (leaving 17). At ten years there were 11 patients. They did angiography and reported a regression of 11 lesions with 14 remaining stable.

Angiogram- xray - of a plaque. Not enough to do surgery on though

When any study talks about a “cardiac event” it means to most of us a heart attack. If you have a small lesion in a coronary artery and then that lesion accumulates a blood clot that is what a heart attack is. The blood clot (from platelets – a sticky component of blood that helps you clot ) blocks the flow of blood to the heart muscle. If the clot blocks blood flow for a long time then the heart muscle dies and you have a myocardial infarction, if it opens up then all you have is a heart attack. This has little to do with the size of the lesion, and more to do with the complex chemistry of the coagulation system. Hence, taking aspirin a day or Plavix is more beneficial.

The other major problem with the study is that these individuals were on lipid lowering medications. Dietary reduction of lipid level (Cholesterol and lipoproteins such as VLDL, HDL) is about ten per cent on average, but never more than twenty per cent. However, lipid-lowering medications – such as Crestor – can remarkably lower levels of the lipids. In addition, lipid-lowering medications are best for reducing inflammation. They are anti-inflammatory to blood vessels, meaning in addition to lowering the lipids and cholesterol, their main effect is to reduce the chance of having a “coronary event.”

Crestor shown to be effective at decreasing the plaque in arteries

One of my cousins, preventing heart disease and eating fat

There is a lot of pseudoscience in medicine, and the reason that we have medical treatments that are quackery is because of the industries built around them.  This was made evident by the recent issues with the HCG diet. Contrary to what reasonable people would think, the new FDA ban on over-the-counter HCG did not shut down the industry built around HCG. The FDA states “HCG has not been demonstrated to be effective adjunctive therapy in the treatment of obesity. There is no substantial evidence that it increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or “normal” distribution of fat, or that it decreases the hunger and discomfort associated with calorie-restricted diets”

There is an entire HCG diet industry kept alive by those who make their living promoting this weight loss method.  What has gone away is the ability of non-physicians to sell the drops, tablets, troches – all HCG must be prescribed by a physician. Within two miles of my home there are five places that advertise HCG diet. None of these places is a physician’s office. Whether the FTC or FDA cracks down on these is another matter.

These weight loss clinics sell the HCG –either by breaking the law and prescribing without a license, or they are finding a physician who will write the script without seeing the patient.   For a physician to write a prescription without seeing a patient is not only bad medicine it is unethical- and, at least in Arizona, would probably result in the physician being sanctioned by the medical board.

Because the FDA has, without equivocation, stated that HCG is not useful for weight loss, proponents of HCG are now circulating “articles” of “studies” showing that HCG works. But the HCG controversy provides a microcosm of how proponents of woo-woo medicine (medicine that is based on pseudoscience) use “studies” to promote their treatments.

The article that should have put the nail in the coffin of HCG was written in 1976 in the Journal of the American Medical Association. The paper was a study of 202 patients treated with either HCG or saline placebo.  The physicians administering the medicine did not know if they gave the patient HCG or if they gave the patient the saline (salt water). The patients did also not know.  All patients were placed on the 500 calorie diet.  At the end of the study, there was no difference between those who were given HCG and those who were given placebo in terms of weight loss. There was also no difference in fat loss. There was no evidence that those who had received HCT were more or less satisfied, and the dropout rate was the same. Thus, they could not prove what the advocates of HCG said- that people who use HCG along with the diet will feel better and adhere more to the diet, and that there was no more or less fat loss among those patients. This was the article that, temporarily, put the nail in the coffin for HCG.

The reasons physician-scientists consider this article a good article are: (a) The study was randomized so the patients did not know what they were getting.  This eliminates bias of the patient. (b) The physicians did not know what the patients were getting – eliminating the bias of the physician (c) The results were reviewed by non-bias staff (d) the study was prospective- meaning the subjects were followed ahead of time so the authors could not manipulate the data either way. (e) the article appeared in a journal that is peer reviewed, meaning editors read the article for its content, have the ability to ask the authors to submit raw data, and can spot bias.

That article, along with others, put away the HCG diet industry for a while, until 2007. In 2007 a book was written about HCG – by Kevin Trudeau, called “The Weight Loss Cure ‘they’ don’t want you to know about.”  The Federal Trade Commission fined Trudeau 37 million dollars for making false statements in this book. Oddly enough book is still sold, and many of the “HCG weight loss coaches” make money selling it.  The book is bunk, by the way – total, complete and utter nonsense promoting HCG.

This silly book resurected a bad diet

Contrast the great article in JAMA with an article that the HCG coaches are currently recommending, by Dr. David Bryman, an osteopath from Scottsdale, who published a non-randomized study with a higher protein low calorie diet- showing the HCG had more weight loss (The Bariatrician – 2010 Vol 25, page 11). The problems with this study are several: first there is no randomization, second there is no control, third there is no blinding, and fourth there is a clear bias, fifth the article is retrospective  – so it can come to the conclusion it likes. The article is worthless.

Having “journals” gives people who practice pseudoscience (be it chiropractic, acupuncture, homeopathy) a sense of legitimacy. Sadly, those journals do not follow scientific principles of research, evidence or science-based medicine.

Confirmation bias is a bias hard to overcome. This is seen in the HCG diet industry. If you attribute weight loss to HCG, then everyone who loses will confirm your bias that it was the HCG.  It is clear that it is the diet – whether it is a high protein 800 calorie, or the original 500 calorie diet, that will provide the weight loss.  However, the people who sell it, or the books and meal plans, are convinced that the HCG is doing the work- in spite of the lack of science supporting their claim.  Much like acupuncture, or homeopathy – if someone believes it, and then is confirmed by placebo effect, it is difficult to overcome that bias.  Add in that a part or all of one’s living is made by some pseudo-scientific endeavor and the pseudoscience becomes a religion.

It is difficult to convince someone their “experience” is not accurate or even that their “experience” isn’t what they think it is.

HCG shows the ultimate “placebo” effect.  A placebo is a pill or injection that has no active substance in it – commonly a sugar pill or a saline injection.  Placebo comes from Latin, meaning “I shall please.”  To test whether a chemical, hormone, or some agent works, you have to test it against a placebo. Some people, 35-55% of them, with some diseases, will have an equal effect with a placebo as with the hormone tested (in this case HCG). Placebo works best with nebulous things that cannot be measured- like appetite. As was shown in the JAMA study when HCG was compared with saline injections, there was no difference.  HCG works by placebo effect.

The problem is that HCG is not a placebo.  HCG is a hormone, one that has effects that can be long lasting and harmful. We don’t know if the hormone has a tumor promoting effect as other hormones do (estrogen with breast and uterine cancer and testosterone with prostate cancer, HCG may have tumor promoting effects – it certainly can increase venous thrombosis). The other problem is physicians who prescribe this are giving legitimacy to a treatment that does not work, and can cause harm. They are also placing themselves at risk by stating they have evaluated a patient

As with all pseudoscience- there are people who firmly “believe” in this without a shred of legitimate evidence. Proving that having a degree (MD, DO, RN) does not make one a skeptic, and clearly degrees do not teach people how to think and apply the scientific method. Many in pseudoscience use the logical fallacy of an appeal to authority – e.g.- a doctor prescribed the HCG, and a nurse is my coach so it must be good.

In terms of the other scams in medicine- Homeopathy is one that actually has a board sanctioned by the State of Arizona. It isn’t odd that Arizona is so backward, after all, it is the wild west. But I like the quote from Dr. Zina Pitcher, when the State of Michigan tried to force the University of Michigan to have a homeopathic school:

…shall the accumulated results of three thousand years of experience be laid aside, because there has arisen in the world a sect which, by engrafting a medical dogma upon a spurious theology, have built up a system (so-called) and baptized it Homœopathy? Shall the High Priests of this spiritual school be specially commissioned by the Regents of the University of Michigan, to teach the grown up men of this age that the decillionth of a grain of sulphur will, if administered homœopathically, cure seven-tenths of their diseases, whilst in every mouthful of albuminous food they swallow, every hair upon their heads, and every drop of urine distilled from the kidneys, carries into or out of their system as much of that article as would make a body, if incorporated with the required amount of sugar, as large as the planet Saturn?

The power of the purse did cause the school to come to the University of Michigan, although eventually the Supreme Court did state that the Regents of The University of Michigan were not answerable to the legislature.  The homeopathic school was merged into the medical school in 1920′s – and homeopathy was gone for a while. Sadly- it is back.