That twin thing

When four look-alike teenaged girls share the same household, ohmygosh. The energy, the decibel level, the drama.

I caught an episode this week of “Four of a Kind,” the Lifetime series about Calli, Kendra, Megan and Sarah Durst, identical quadruplets who live in Buffalo, Minn., and are in their senior year of high school.

Camera crews followed the girls and their mother, Naomi Durst, as they traveled to North Dakota State University to check out the campus. They met a cute guy, toured the dorm rooms, climbed an indoor rock wall and squabbled in the minivan on the way home. In the second half of the episode, they organized a fashion show to raise money for cancer care and learned the value of teamwork.

Like many siblings, especially those who are close in age, they don’t always relish the togetherness. At one point Kendra declares, “If we all end up at the same college, I’m going to lose my mind.”

Deep down, though, I suspect they share a bond like no other. It’s just that the path to independent adulthood can be rocky for any adolescent, and even more so when there are four of you. In many ways I totally get it because I’m a multiple too. I’ve had a fraternal twin sister ever since… well, ever since the day I was born.

Humanity has always regarded multiples with a certain amount of fascination. (Look at all the attention generated by one of the latest videos to go viral on YouTube, a clip of infant twin boys babbling with each other.) In ancient times, twins and triplets were variously thought to be magical or demonic, depending on specific cultural beliefs. These days society has a much better understanding of multiple births but it seems we’ve clung tightly to the attitude that multiples are special.

Studies abound about twins, and they make for compelling reading. Researchers have tracked pairs of identical twins, who share an identical genetic makeup, in an attempt to tease apart the influence of nature vs. nurture. There’s been considerable debate about twin psychology and the best way to guide twins from childhood into adulthood. Should you dress them alike? Should you keep them together in school or should you separate them – and if so, at what age? Twins have even been studied for their alleged powers of telepathy, although the evidence is shaky at best and may simply indicate the presence of a strong emotional bond between some twins.

For the record, my twin sister and I don’t look very much alike, other than sharing a family resemblance. Our personalities aren’t especially similar either; for one thing, she’s smarter and much more hard-working than I am. But we are very, very close. So close that when she broke her wrist in three places several years ago and spent half the night in an emergency room, I was up half the night too, even though I was 100 miles away and didn’t know about her ordeal until the next day.

It wasn’t always like that. Like the Durst quadruplets, we often bickered in our teens. This is an age when adolescents are trying to forge their own identity and it can be more challenging for multiples, especially when the rest of the world still perceives them as a single unit. All through high school, my twin and I were constantly compared – our grades, our clothes, our hair, our likes and dislikes. Classmates and even some teachers seemed to develop a mental block when it came to telling us apart. It was probably inevitable that there would be a certain amount of sibling rivalry (although the rivalry was never serious and has long since disappeared).

Multiply that times four and you get Calli, Kendra, Megan and Sarah Durst. Although “Four of a Kind” critics have called the girls immature, noisy and and obnoxious, I’m inclined to cut them a lot of slack. Constantly being seen as “the Durst quadruplets” may have been fun in second grade but it can wear thin by high school.

The girls are not, in fact, merely ”the Durst quadruplets.” When you look closely, they clearly have slight physical differences. They also have distinct personalities and interests. That their individuality is starting to emerge shouldn’t be a big surprise or sideshow curiosity to anyone; it’s the necessary emotional and psychological process of becoming an adult, albeit writ on a more complicated scale.

One of the things we owe to the study of twins, triplets and other multiples is how these processes, from language development to the influence of parenting skills, unfold from infancy through childhood and into adulthood.

Calli, Kendra, Megan and Sarah might squabble with each other right now and long for the day when they can escape each other’s orbit, but take it from another multiple: Ten years from now, or 20 years from now, they’ll have the separate identity they crave. And more than likely, they’ll realize that having a twin, or being a twin times two, is one of the coolest things ever.

Photo: Wikimedia Commons

Facebook for grownups

It appears to be the top health news story of the week already: The American Academy of Pediatrics published new guidelines Monday to help pediatricians be on the lookout for depression, cyberbullying and other concerns associated with use of the social media.

It’s about time. There’s been considerable debate over whether Facebook, chat rooms and other online activities are good or bad for kids’ health. The AAP’s clinical report, which appears in the latest issue of the Pediatrics journal, cites a Common Sense Media poll indicating 22 percent of adolescents log on to their favorite social media site more than 10 times a day and more than half visit one of the social sites, such as Facebook, at least once a day.

The risks include harassment, indiscreet behavior, potential exposure to inappropriate photos and information, and “Facebook depression,” the feeling that all your friends are more popular and having more fun than you are.

These are all very real concerns. The cut-and-thrust of the social scene among pre-teens and adolescents can be quite ferocious, with plenty of potential for kids to get into trouble. But what I want to know is: Should there be guidelines for adults too?

Adults are presumably more mature, more experienced and better equipped to navigate the social media. Or are they?

Unwise behavior knows no age limit. Adults can be stalked or bullied on the Internet too, or captured in a moment of indiscretion with possible repercussions for their career and/or personal and professional relationships. (Consider a study published last year in the Journal of the American Medical Association, which polled medical students anonymously about their online experiences and found episodes of profanity, sexually suggestive comments, discriminatory language, depictions of drunkenness and illegal drug use, and violations of patient confidentiality.)

Depression and low self-esteem know no age limit either. Although social sites such as Facebook can be a wonderful way for depressed adults to connect with the rest of the world, they sometimes end up feeling worse if they perceive they’re not measuring up to everyone else’s page on Facebook. And let’s not even get into the emotional intricacies of friending. If you’re the competitive sort, you might feel like a loser if other people have way more friends than you. Even well-adjusted adults can feel a slight pang of rejection if someone doesn’t respond to their friend request or, worse yet, decides to unfriend them. (Been there.)

Nuances such as tone and facial expression can be lost online, creating misunderstandings and hurt feelings. When people have a significant emotional investment in online friendships, it can be upsetting when there are disagreements or when a debate gets personal. In one of the online communities I belong to, I’ve seen several instances of people becoming deeply offended or getting angry and storming offline after a discussion got too intense.

Even without these psychological minefields, the Internet and the social media sites have another unfortunate effect: They can easily become a vast sinkhole into which the minutes and hours disappear without a trace. Adults are just as prone as kids to frittering away their time on Facebook and chat sites, parked in a chair, not getting enough physical activity and staying up late into the night.

There’s also the potential for spreading inaccurate and possibly harmful health advice through Facebook discussions and other online interaction.

The social media aren’t just for kids. In fact, a study last year by the Pew Research Group found that social networking is growing the fastest among the older demographic. From April 2009 to May 2010, social networking among adults age 50 and older grew from 22 percent to 42 percent. An estimated one-fourth of people over age 65 are now online.

Should physicians be formulating guidelines for adult use of the Internet? Perhaps not. But they’d be smart to recognize what a force it can be, for both good and ill, in the lives of grownups as well as kids.

HealthBeat photo by Anne Polta

Asthma, allergies and anxiety

Asthma and allergies often disrupt people’s lives in significant ways, forcing them to cope with daily uncertainty.

When the Allergy and Asthma Network Mothers of Asthmatics recently conducted an online survey on the impact of asthma, the results were more than a little eye-opening. Half of the respondents reported two or more unscheduled doctor visits during the preceding year, and 43 percent reported one or more trips to the emergency room. Nearly 20 percent also were hospitalized due to asthma at least once in the preceding year. Alarmingly, 15 percent of the survey participants had at least one asthma episode that was nearly fatal.

The report appears in the latest edition of Allergy and Asthma Today. The survey involved 409 individuals and was only available online, which may have skewed the results compared to the overall population. Nevertheless, it portrays the often difficult reality of living with and trying to manage a chronic disease.

Among some of the findings:

- Challenges are often multiple and differ from one person to the next. Some had trouble paying for their medications or getting their prescription filled with the medication prescribed by the doctor. Others reported missing many days of school or work because of asthma.

- Obtaining medication was an issue for many. Among the most common barriers: being unable to get a prescription filled or refilled, needing authorization from an insurance provider, and having to accept a substitute because the medication isn’t on the formulary. In some cases, the pharmacy no longer stocked certain brands.

- Although most of the survey participants had health insurance, they also incurred frequent out-of-pocket expenses associated with managing their asthma. Nearly one-third said they spent more than $1,000 a year on medications, devices and tests, along with co-pays and deductibles.

One of the findings that really stood out was the number of survey respondents who didn’t have an asthma action plan, a written and individualized plan to help them manage their asthma and prevent future episodes. Of those who reported a visit to the ER or a hospitalization within the previous year, 25 percent didn’t have an asthma action plan. Survey participants on Medicaid or Medicare were the least likely to have a written asthma plan. Specialty care didn’t seem to improve these statistics; among those who had seen a pulmonologist or allergist within the previous year, 27 percent had no asthma action plan.

The majority of the survey participants did have a plan, the magazine article points out. But it notes that even with an asthma action plan, many people still struggle with day-to-day life with asthma:

Some of it’s just the nature of asthma. You don’t go from having outrageous symptoms to no symptoms overnight. Many of these families are in the learning curve – the worst is behind them, but there’s still a ways to go. Others, well, they’re stuck. Stuck in access-to-care issues; stuck with missed work or school days; stuck with ever-changing healthcare rules made by people who don’t treat asthma patients every single day. Stuck going to appointments with doctors only to have someone else change the prescriptions they just learned how to use.

In an accompanying news release, Nancy Sander, president and founder of Asthma and Allergy Network Mothers of Asthmatics, says there’s still “a long way to go” to improve care for asthma. “Proven best practices such as completion of a proactive asthma action plan are still not widely adopted, and uncertainty is a major force in the lives of patients and their families,” she said.

I’m guessing a survey of people with diabetes, chronic obstructive pulmonary disease or any other chronic condition would reveal similar struggles. It’s not easy living with something chronic, especially when people don’t feel they have enough tools or information to help them.

I suspect it isn’t an accident that a new and completely unrelated study, this one of women who had undergone treatment for early-stage breast cancer, found that inadequate information often is associated with excessive worry about cancer recurrence. This particular study, which involved 1,837 women and was conducted by the University of Michigan Comprehensive Cancer Center, found women were less likely to worry if they understood the clinical information, received help with their symptoms and had a coordinated plan of care.

When clinicians focus on the problem at hand, it can be at the expense of the bigger picture. There’s probably no way to remove the anxiety or daily hassles of chronic disease, but wouldn’t patients be better off if they had the tools to help them feel more prepared?

Photo: Wikimedia Commons

Deceptive little pills

One Sunday afternoon several years ago, my then preschool-aged niece decided to host a tea party for her dolls and stuffed animals. The beverage: thimble-sized sips of flavored cough syrup.

Her parents found her lying groggy on the floor of her bedroom closet, surrounded by dolls and toys. A quick phone call to the Hennepin Regional Poison Center at Hennepin County Medical Center reassured them she would be OK, although she was drowsy for the rest of the day.

A spoonful of sugar is supposed to help make the medicine go down. But is this a good thing or a bad thing?

These days it’s often hard to even tell the visual difference between pills and candy, let alone how they taste. This point was driven home for me when I checked out “Choose Your Poison,” an online quiz devised by the California Poison Control System to increase consumer awareness of look-alike medications and candy.

It’s more challenging than you’d think. I’m embarrassed to report that when I took the interactive quiz, my score wasn’t very good. Granted, it’s hard to distinguish orange ibuprofen capsules from orange-flavored breath mints solely on the basis of a photograph. But who knew a piece of bubble gum and a chewable antacid tablet could look so similar? Or that rat poison might be mistaken for mini sweet and sour candies?

(This cool little quiz is also available as an iPhone app.)

If even adults can’t always tell the difference, how could a 3-year-old?

What’s concerning is how the line is increasingly being blurred, often in the name of making medications more palatable to children who need to take them – grape- and cherry-flavored cough medicine, for instance, or kiddie vitamins that resemble Gummi Bear candies. They look, smell and even taste good to kids.

Prescription and over-the-counter medications unfortunately are one of the leading sources of accidental poisoning among children. And as the episode with my niece demonstrates, kids often don’t stop with one swig or one pill if the medication is sweet and nicely flavored. Overdose, sometimes with serious consequences, can be the result. Only three months ago the FDA issued a warning about benzonatate, a prescription cough medicine that looks like candy and has led to accidental overdose and death among children.

Some tips from the experts with the Minnesota Poison Control System: Teach children never to take medication unless it’s given to them by a parent. Keep all medication, including vitamins, in a secure storage place, preferably one that can be locked. Because children often like to imitate adults, don’t take medication in front of them. And don’t ever refer to medicine as candy or lead children to believe medicine is similar to candy.

This isn’t exactly a new issue. Kids like to explore and put things in their mouth, especially if it’s sweet. Medication’s frequent resemblance to candy has always made it somewhat tempting. There was a time, though, when medicine was more likely to look and taste, well, medicinal. In making it more pleasant so it’s easier for children to take, have we exchanged one problem for another?

Photo: Wikimedia Commons

Noteworthy 2.0

A roundup of some noteworthy news and information recently arriving in the inbox:

 - Ongoing news coverage of the radiation plume dispersing from a quake-damaged nuclear power plant in Japan may have many U.S. citizens reaching for potassium iodide just in case. The tablets can be taken to reduce the risk of radiation-related damage to the thyroid, and are readily available without a prescription. Not surprisingly, sales of potassium iodide have been on the upswing, especially on the West Coast among those worried about exposire to drifting radiation.

In response, the Professional Compounding Centers of America issued a news release this week containing words of caution: Inappropriate self-dosing with potassium iodide can end up doing more harm than good. The PCCA explains that potassium iodide is meant to be used in cases of direct exposure to nuclear radiation. Misuse can lead to iodine toxicity, with symptoms ranging from sore teeth and gums and a metallic taste in the mouth to negative effects on the thyroid itself. The bottom line: Talk to your pharmacist or doctor first before deciding you need to stock up on potassium iodide.

- Itching may not seem like a big deal, clinically speaking. But chronic itching is linked to many medical conditions and can be difficult for sufferers to live with. Now there’s a new scientific effort to learn more about itch. The Washington University School of Medicine in St. Louis has opened what’s believed to be the world’s first Center for the Study of Itch. The center will bring together scientists and clinicians to study the mechanisms of itch and identify better treatments for it.

Itch has long been thought to be a lesser form of pain, but recent research has discovered that itch signals actually travel to the brain on a separate neurological path than pain. An itch-specific receptor, the gastrin-releasing peptide receptor, also has been identified. Researchers at the Center for the Study of Itch want to collect skin biopsies to develop a clinical research database and biobank that will help them identify genetic susceptibilities for chronic itch. They also plan to conduct clinical trials of potential therapies and treatments.

- Today marks World Tuberculosis Day and a global effort to focus attention on TB. There’s both good and bad news. Deaths from tuberculosis worldwide have declined by 35 percent since 1990 and the prevalence of TB has declined 14 percent from 1990 to 2009. New diagnostic technologies also have been developed for detecting multidrug-resistant TB.

But according to the U.S. Agency for International Development, tuberculosis continues to be a major public health threat, especially among the urban poor. There are more than 9 million new cases of tuberculosis worldwide annually and 2 million deaths.

Statistics from the American Lung Association are especially concerning: Worldwide, one-third of the population is currently infected with TB. Although rates in the U.S. are now the lowest on record, the decline has slowed, and drug-resistant TB is emerging as a serious challenge. Noteworthy research projects under way are aimed at better understanding the mechanisms of tuberculosis infection, identifying new therapies and developing a vaccine.

- Here’s some news for college students: The University of Minnesota has launched the Rothenberger Institute, an organization dedicated to improving the health and well-being of college students by offering online courses developed by public health experts. The flexible content will give students several options for learning – audio, computer-based and print.

Course modules will address issues such as sleep, exercise, stress and alcohol use. The goal is to help this age group become better prepared to do well in school and make a successful transition into adulthood. The Rothenberger Institute is named after James Rothenberger III, who taught at the University of Minnesota and was a national expert on health issues, as well as an early champion of Internet-based learning.

Courses are currently offered at U of M campuses in the Twin Cities, Duluth and Crookston, as well as Minnesota State University at Moorhead, Vermillion Community College and Inver Hills Community College. The Rothenberger Institute also has begun working with high schools, where college-bound seniors can take the courses for college credit.

- Finally, a word about National Poison Prevention Week, which is being observed this week. More than 2 million poisonings, most of them accidental, are reported to poison control centers in the U.S. each year. More than 90 percent of them occur in the home, and the majority of non-fatal poisonings occur among children under age 6.

Prevention is the best strategy. Adults are urged to keep household cleaners, disinfectants, solvents and other toxic substances locked up and out of children’s reach. Don’t forget about cosmetics and medicines. Many children are poisoned each year by perfume, nail polish, soap and prescription and over-the-counter medications.

After cancer, now what?

There was good news recently on the cancer front: More Americans are surviving cancer than at any other time in history.

According to a report from the National Cancer Institute and the U.S. Centers for Disease Control and Prevention, there are now 11.7 million people – almost one out of every 20 Americans – who’ve had cancer at some point in their lives. Their numbers have grown by 2 million in the past decade and almost quadrupled since 1971.

It’s both heartening and concerning. Heartening because a cancer diagnosis no longer automatically means someone’s life is over; concerning because the health community still seems mostly unprepared for how to help people live as well as possible after cancer.

In a way, the snail’s-pace progress toward quality survivorship care isn’t surprising. For decades the focus was simply on successfully getting patients through cancer treatment. What happened to them afterwards was a lesser priority. Research has been slow to develop a reliable body of information on the long-term and late effects of cancer treatment and on how people fare physically, emotionally and socially after treatment.

It has only been in the past decade or so, for instance, that cancer-related cognitive dysfunction, more familiarly known as chemo brain, has been officially recognized, even though patients have been talking about this unfortunate side effect/aftereffect for years. Through recent research, we now know more about it than we used to but there’s still much that’s unknown. It’s not clear if chemo brain is due to cancer itself or if treatment, specifically chemotherapy, is to blame. It’s not known if some patients are more vulnerable to it or what, if any, risk factors there might be. Although it’s often believed the cognitive dysfunction will eventually go away, we don’t really know this for sure; perhaps with the passage of time, survivors simply adapt to it.

Doctors and patients also are often at sea when it comes to followup care. How often do cancer survivors need to be monitored? What risks and long-term or late effects should they be on the lookout for?

Consider Dr. Sam LaMonte, a surgeon from Florida who underwent radiation therapy in 1991 for head and neck cancer, only to develop blockages in both his carotid arteries 15 years later – apparently a late complication from the radiation. In an article that appeared in the winter issue of Cure magazine, Dr. LaMonte says he was “dumb as a door” about the potential risk for late effects from radiation.

Late effects often emerge beyond when survivors may be looking for treatment-related problems, and it’s this lack of awareness that sends LaMonte into spasms of frustration. It also keeps him busy trying to educate health care professionals and survivors. He wants patients to know that, while radiation may have saved their lives, it may also have turned them into time bombs.

But more importantly, LaMonte stresses, many late effects can be treated or lessened if survivors are monitored, and their primary care physicians know what to look for.

Evidence-based clinical guidelines for survivorship care are still in their infancy. Moreover, the information doesn’t always filter down to those who need it, especially to primary care doctors at community clinics where many former cancer patients continue to receive most of their ongoing care. It has been more than five years since the Institute of Medicine released its landmark report, “Lost in Transition,” on the shortcomings in post-cancer care in the United States, and there’s scant sign of any significant improvement.

To complicate things, the survivor population is extremely diverse. Of the 11.7 million Americans currently alive after a cancer diagnosis, the majority – 7 million – are over the age of 65. The largest groups are women who’ve had breast cancer (22 percent) and men who’ve had prostate cancer (19 percent). These numbers tend to obscure the fact there are millions of younger survivors whose needs might be quite different from those of older people. They also obscure the many different types of the disease we call cancer. Someone who has undergone aggressive chemotherapy and a bone marrow transplant faces an entirely different set of future health risks than someone who has had a combination of surgery and radiation, or surgery alone. There’s not going to be a one-size-fits-all strategy to helping people live as well as possible after a diagnosis of cancer.

The good news is that the state of knowledge is clearly far better than it used to be. A few months ago the Minnesota Medical Association even devoted an entire issue of its magazine, Minnesota Medicine, to survivorship care. The road is still long, however, and if the new survivorship statistics are any indication, the need to address this issue is becoming more urgent with each passing year.

The evidence on empathy

Empathizing with patients often can help make them feel better, at least emotionally. But can it also result in measurably better outcomes in their health?

A new study from the Academic Medicine journal has put another brick in the wall of evidence shoring up the value of empathy. The research involved 891 patients with diabetes and 29 family physicians who were treating them. The doctors were asked to complete an assessment evaluating where they were on an empathy scale: high, moderate or low. Then they were compared against patient outcomes.

As you might have guessed, patients whose doctors had a high empathy score were significantly more likely to have better control of their diabetes than patients whose doctors were low in the empathy department.

Why, then, is it often so hard to convince physicians that being nice to their patients is more than just touchy-feely psychobabble? wonders Stephen Wilkins, a former health care executive and consumer behavior researcher who blogs about doctor-patient communication at Mind the Gap. He writes:

The problem with empathy research is that no one, including doctors, seems to be paying attention as attested to the fact that nothing has changed. Research documenting the therapeutic value of empathy goes back at least 20 years. Despite the evidence, it seems that physicians are no more empathetic today than when people first started researching empathy.

I’m not sure I would agree that nothing has changed. Health care organizations are paying attention to customer service and patient satisfaction in ways we didn’t see 10 or 15 years ago. Although there are still more than a few health care professionals who haven’t gotten the message, or who think empathy doesn’t matter that much, the majority seem to at least be making an effort.

The bigger question, it seems, is how to successfully instill empathy in the first place, and how to maintain it amid the increasing pressures of the health care work environment.

Is empathy something that can be taught to medical students? To some extent, the answer is yes. Communication skills are part of the curriculum at virtually every medical school in the U.S. Part of the process of becoming a doctor, after all, is learning how to effectively interact with the human beings who are your patients.

What’s disturbing is some of the evidence suggesting that medical students often begin to lose their empathy by the third year of their training. A study that appeared in September 2009 in Academic Medicine created quite a stir when it was published. The authors tracked matched cohorts of more than 400 students through medical school, from their first day to the end of their final academic year, and found a significant decline in empathy scores after the third year. The decline was greater for males than for females, and also was greater for students in technology-oriented specialties.

Not coincidentally, the third year of medical school is when students really begin to dive into hands-on patient care and start experiencing the reality of practicing medicine. This, along with the demands of the training process, may be what erodes empathy, the study’s authors wrote. Their findings are echoed in a number of previous studies examining everything from sleep deprivation among medical students to abusive training environments.

This issue doesn’t seem to be confined to the United States. A recent Twitter conversation in the U.K. raised similar points. Among some of the observations: Even with an emphasis on the importance of empathy and good communication, medical students often don’t put these skills into practice. For many students, distancing themselves from patients can in fact become a necessary coping mechanism. “If you felt every bad outcome you wouldn’t survive your MS3 year in [the] US,” a student tweeted. Someone else observed, “Committed people keep empathy, but some do lose it.”

Empathy can be even more challenging once students graduate from medical school and enter the real world of day-to-day medical practice with all its paperwork and the twin pressures of time and productivity.

So what’s the real issue here? Is it that doctors remain unconvinced that empathy makes any difference in their patients’ health? Or does it lie in the difficulty of sustaining an empathetic state of mind day in and day out in the demanding environment of patient care – and if so, how can this be changed?

Image: “Consolation,” Odette Sculpture Park, Windsor, Ontario; courtesy of Wikimedia Commons

Addicted at the bedside

It was the kind of story that gives you chills: A nurse at Abbott Northwestern Hospital in Minneapolis allegedly stole fentanyl meant for a patient undergoing a kidney procedure, telling the patient to “man up” and endure the pain.

According to news coverage last month, Sarah Casareto admitted in a criminal complaint that she has had dependency issues with narcotic pain medication.

An isolated incident? Maybe not. Earlier this month a registered nurse from Superior, Wis., pleaded guilty in federal court to taking Dilaudid, a prescription painkiller, from patients at a Twin Cities hospital. News accounts said Maria Mihalik allegedly posed as an employee to enter Mercy Hospital and used a syringe to siphon Dilaudid from patients’ IV drip bags.

The news from St. Cloud this week was more of the same: An unidentified nurse at St. Cloud Hospital was suspended after allegedly removing pain medication from patients’ IV bags and replacing it with saline or air. In the process, at least 23 patients were infected with bacteria.

As if this weren’t enough, last week’s episode of “The Mentalist” involved a drug-addicted anesthesiologist who killed a colleague by whacking him in the head with a golf club. The fictional motive: The doc was about to be outed for stealing pain meds from the hospital pharmacy and using them for herself.

The public might be excused for wondering exactly how widespread it is for health care professionals to abuse prescription drugs, especially narcotics.

Figures are hard to come by. The best estimate I could find was that about 10 to 15 percent of health care workers have substance abuse problems involving alcohol and/or prescription drugs. This level is the same as or slightly higher than the general population. It also means that 85 to 90 percent of health care professionals – in other words, the vast majority – don’t abuse drink or drugs.

But regardless of the incidence, the stakes are extremely high because of the potential for putting patients in danger.

Some of the addiction-related issues facing health care professionals are unique. For one thing, it’s far easier for them to obtain drugs, especially narcotics. This article, which appears at DrugAddictionTreatment.com, tells the story of Debbie, a 40-something nurse from Michigan who struggled with alcoholism and then turned to prescription painkillers for chronic back pain:

“It’s kind of like a roller coaster ride. One isn’t enough and you’re doing two [painkillers],” Debbie said. “Before you know it, you’re having to medicate yourself just to go to sleep.”

Debbie also pointed out that exposure to drugs can be a problem for those who are predisposed to addiction genetically or have experienced addiction in the past. “If you’re an addict, eventually your drug of choice is whatever is in front of you,” she said.

The fact that so many prescription drugs, especially painkillers, are commonplace in hospital, clinic and pharmacy settings also can lead some health care professionals into trying them out of curiosity, the article notes.

For nurses in particular, addiction is “an occupational hazard,” according to a paper published a few years ago in the American Journal of Nursing. The author, Patricia Maher-Brisen, spent 10 years with the Statewide Peer Assistance for Nurses program in New York. She describes some of the workplace factors that can contribute to nurses’ likelihood of becoming addicted: working night shifts or rotating shifts, working excessive overtime, working with critically ill patients, and the occupational risk of back and muscle injuries and pain. She cites research suggesting that emergency-room nurses are more than three times as likely to use marijuana or cocaine as nurses in other departments.

Maher-Brisen also makes a critical distinction: It’s not a crime to be addicted. The wrongdoing lies in putting patients at risk and engaging in unethical and criminal behavior, she writes:

Diversion is a crime, and when it occurs the police may be called in to investigate and make an arrest. Nurses have been arrested for falsifying records and forging prescriptions.

Practicing nursing while impaired by alcohol or other drugs is a form of professional misconduct. Nurses who practice while impaired report that they live in fear of being caught.

It’s often just a matter of time before a patient, colleague, or manager reports the problem to the administration.

Here are some more key facts about addiction among health care professionals: Doctors seem to be more likely than the general public to misuse prescription drugs but their overall drug of choice tends to be alcohol. Anesthesiologists are the exception; they’re more likely to abuse injected opioids, which are especially potent. Although most states provide intervention and monitoring for addicted physicians, there’s a shortage of programs for other professionals such as nurses and nurse anesthetists, with the result that many of these people are undertreated and sometimes die from their addictions.

With proper treatment, many addicted health care professionals can go back to work. Some might need to change the focus of their practice, however, and a small minority might never be fit to return to patient care.

To their credit, the three Minnesota hospitals where nurses were caught allegedly stealing drugs from patients were quick to act. They also were quick to go public and to share what they knew with patients who might have been affected. Drug misuse at this level rarely springs up overnight, however, and it makes one wonder how long these nurses continued to care for patients before their drug problems became apparent. Could – or should – someone have intervened sooner?

Maybe this is an opportunity for everyone in the health care community to take a long, hard look at how they identify, deal with and support colleagues who are addicted.

Photo: Wikimedia Commons

Primary care’s image problem

From the doctor’s point of view, is primary care rewarding or is it just plain boring?

Medical student Suchita Shah spent five weeks awhile back doing a clinical rotation at a primary care and general internal medicine clinic.

She blogged about the experience a few months ago. Then her blog entry was picked up at Kevin, MD, one of the leading voices in the medblogging world, which is where I discovered it. It seems to sum up many of the issues ailing primary care these days: namely, that many (maybe even most) medical students no longer seem to find it worth their while.

Shah writes:

It was awesome because I was the “doctor.” I essentially had full responsibility for each patient. From calling him in from the waiting room to deciding what medications he needed and at what dose, and everything in between, he was my responsibility. After I saw the patient, I’d present the case to my attending for a few minutes, we’d discuss and he’d teach for a minute and modify my plan a little if necessary, then the real doctor would go in and say hello and sign the orders I had suggested. I was my patient’s health care provider – a phenomenal feeling and an awesome transition in that I now think of myself as a capable clinician-in-training.

But that’s why I found primary care to be boring. I could do it. As a 3rd-year medical student. The cases I saw were by and large obesity, hypertension, diabetes and hyperlipidemia. A little tweaking of drug doses here and there, lots of education about lifestyle changes, plenty of questioning to assess for target organ damage, referrals for specialist followups… and far too much of “staying the course.”

Medical students and doctors like to be challenged and this wasn’t challenging, she writes. “And if this is what most of family medicine/primary care is like… I don’t want to do it for the rest of my life.”

Houston, I think we have an image problem.

To be sure, there’s a lot that’s frustrating these days for primary care physicians. There’s the paperwork, the crummy reimbursement, the pressure to churn patients through the exam room. But are these reasons to disdain the entire field of family medicine or general internal medicine?

The responses to Shah’s guest blog were interesting. “ALL of medicine is boring. And/or frustrating, time-consuming, aggravating or headache-inducing. Welcome to the real world,” one physician wrote.

From another doctor:

really? as a med student, u really feel like u have mastered primary care medicine? as a professor of medicine, i have a reference point, and i can assure u that u have not.

If you spend much time reading blogs and online discussions among medical students, however, the attitude that primary care is unexciting is far from unusual. And it’s not clear how much of this is based on reality and how much is perception.

It’s true that primary care doesn’t pay as well as most of the specialties. For medical students lumbered with enormous educational loans, career decisions often come down to the financial realities. It doesn’t seem to be only about the money, though; there also seems to be a perception that primary care itself isn’t interesting enough or worthwhile enough to be the focus of one’s career.

An article published a couple of years ago by the Association of American Medical Colleges reflects on why this is so. The devaluing of primary care isn’t new, and it often starts in medical school with a so-called hidden curriculum that devotes fewer resources to learning primary care, fewer good opportunities for students to experience primary care firsthand, and often even subtle discouragement or disdain by medical school faculty, the article explains.

But the article also hits on another factor: the high expectations of many medical students for a career that’s both intellectually and financially rewarding. These students, after all, are quite elite – very bright, very hard-working, competitive and achievement-oriented, with high aspirations for their future – and this sometimes leads to feelings of entitlement. When this is the mindset, primary care often simply can’t compete, especially if students perceive (mistakenly) that it’s easy enough for any rookie to do.

Primary care obviously isn’t suited for everyone. In the final analysis, students need to choose a specialty that’s a good fit for them, and the American health care system needs a good supply of specialists as well as primary care doctors.

But it would be too bad if students wrote off primary care on the basis of a limited experience that may not have been representative.

It looks as if Shah may have completely missed what makes primary care interesting and challenging, a physician commenter wrote: “Every patient encounter is an opportunity to discover something and someone new. I chose primary care partly because I didn’t want every patient of the day to be a life and death situation. I am happy to be brilliant once or twice a day and very much enjoy discovering what makes each of my patients tick, what they love and hate and why they make the health choices they do. I love to hear about their jobs and hobbies and families, their grief and their joy. I can always find a way to plant a small seed of better health in each of their lives. I love my job!”

Update: Results from Match Day on Mar. 17 show an uptick in the number of medical students obtaining residencies in primary care. The National Resident Matching Program reports that the number of U.S. medical school seniors matched to a residency in family medicine rose by 11 percent this year. There was an 8 percent increase in the number of matches to internal medicine and a 3 percent increase in pediatric matches.

The numbers are a little bit misleading because the overall number of residency training slots in primary care has been increased. Family medicine programs, for instance, are offering 100 more positions this year. The number of Match Day applicants for all specialties also is up overall.

According to this year’s Match Day statistics, dermatology, orthopedic surgery, otolaryngology, plastic surgery, radiation oncology, thoracic surgery and vascular surgery remain the most competitive specialties for applicants.

Match Day helps determine where fourth-year medical students will spend the next three to five years completing their residency training. It’s usually predictive of the student’s ultimate choice of specialty.

Photo: Wikimedia Commons

Putting radiation in perspective

The images of the destruction in Japan from last week’s major earthquake and tsunami have been horrifying. But as wrenching as they are, at least we can see them. Not so with radiation that may be leaking from a quake-damaged nuclear power reactor.

Radiation is like a stealth warrior. You can’t see, hear or feel it. Those with the highest and most immediate exposure, such as nuclear power plant workers, tend to show the effects within hours, days or weeks. But for most of the population, the health effects from lower-level exposure might not manifest themselves until 20 or 30 years later.

Rather scary? Well, yes. Here are a few facts, however, to help put things in perspective: The radiation risk to the Japanese public is low, at least for now. People can limit their exposure further simply by staying indoors. The health risk from radiation exposure depends on the type of radiation, the amount and length of exposure, as well as one’s cumulative lifetime dose.

From a New York Times article explaining the potential effects of radiation exposure from the disaster in Japan:

The more likely risk for the public is that of low-level exposures, which can increase the risk of cancer many years later. Again, the danger depends on the length of exposure and what types of radioactive materials to which one is exposed.

Some radioactive materials are readily absorbed by the body and linger there. Iodine, for example, goes to the thyroid gland, and strontium to the bone, and they emit radiation inside the body that over time can lead to cancer or leukemia. Other radioactive materials, like tritium, pass quickly through the body.

The article also notes that one of the main long-term risks isn’t from direct exposure per se. It’s from radioactive fallout that can enter the food chain, contaminating streams and offshore ocean water, for instance, or orchards, vegetable gardens and pastures.

Although many people are frightened of radiation, there’s an important point to keep in mind: We’re all exposed to radiation every day, primarily from natural and background sources. And for the average American, the single biggest source of exposure isn’t from nuclear power plants or clouds of radioactive fallout; it’s from medical imaging. Experts have calculated that CT scans and nuclear medicine account for more than one-third of the total radiation exposure and three-fourths of the medical imaging radiation exposure among the U.S. population.

How much radiation do you think you absorb on a daily basis? Here’s an online calculator from the EPA that helps you estimate your risk. (You’ll need to know the local altitude; Willmar is about 1,100 feet above sea level.) You can also keep track of your lifetime dose of medical-related radiation with this calculator from Xrayrisk.com, a site sponsored by the American Society of Radiologic Technologists. It includes the basics such as chest X-rays and dental X-rays, along with CT scans, nuclear medicine and interventional procedures. For more information on therapeutic radiation involved in cancer treatment, click here.

Photo: Associated Press