Richard G. Petty, MD

A Cause of Disease

Edward Bach.jpg

“Disease of the body as we know it, is a result, an end product, a final stage of something much deeper. Disease originates above the physical plane, nearer to the mental. It is entirely the result of a conflict between our spiritual and mortal selves. So long as these two are in harmony, we are in perfect health: but when there is discord there follows what we know as disease.”      

–Edward Bach (English Physician and Creator of the Bach Flower Essences, 1886-1936)   

Grapefruits, Medicines and Medical Correspondents

Mark Twain once said:
“Be careful of reading health books, you might die of a misprint.”

I was thinking about that as I was watching a TV show earlier.

I have spoken before about the frustration of many of us about the quality and accuracy of some media medical correspondents. Though every show has a disclaimer about the importance of discussing any issue with a health care provider, it is really unfortunate to present inaccurate data that could needlessly alarm people.

I will immediately put my hand up and say that I have done more than my share of media work, not just in the United States and Great Britain, but also in countries from Finland to Australia and twenty or thirty more in between. And I may well have misspoken at some time or other. Even the most well intentioned people sometimes make slips, and it is especially easy when you are in a studio and you know that the clock is counting down.

But that stress makes it all the more important to have accurate material prepared in advance so that slip-ups don’t happen.

Today’s piece was about a story that pink grapefruit may not interact with some medications. The correspondent rightly said that any type of grapefruit may interact with some medications, but then said that there was an interaction in the stomach. This is not correct and could be very confusing.

The issue is that grapefruit juice may induce the enzyme complex cytochrome P450 3A4 in the liver and intestine. So if you or a medication that is metabolized by the enzyme, grapefruit juice may lower the plasma level of the drug, making it less effective. This is another example of the importance of telling your health care provider about ANYTHING that you eat or drink, in addition to listing any herbs and supplements that you take.

Here is a list of some of the more common medicines metabolized by cytochrome P450 CYP3A4:

Grapefruit juice

A Shocking Study

I have been teaching medical students and doctors since the 1970s. But there have recently been times when I have despaired about the way in which so many young doctors no longer engage in common courtesies with their patients.

I just spoke to someone who had visited a new family physician. She was fresh out of her residency, and her residency director has something to answer for. She did not make eye contact or shake hands, and could not remember the person’s name. When the patient extended her hand the doctor became confused because she was focused on her laptop.

I know that I can be accused of being old fashioned, but that shocked me, as did a recent report that medical students at a highly rated school are going to be getting classes in empathy and talking to people. This was announced with great fanfare. My question: why on earth do intelligent people need to be taught how to communicate? And if they have a problem in that area, first, how did they get accepted into that excellent medical school? During the years that I was involved in medical school admissions, I would have not have given a high score to someone with poor interpersonal skills. Second, why are the students’ teachers not modeling communication skills?

So first I heard about the extraordinary manner of the primary care physician. Then it was the self-congratulation that accompanied the announcement that students were going to be taught how to speak to people.

And then this.

A study in the Archives of Internal Medicine that left me shaking my head.

The researchers from Northwestern University’s Feinberg School of Medicine found that Doctors do not address patients by name in half of first-time visits, even though nearly all patients want this common courtesy.

There has been research on what doctors should wear but little about how they should greet patients or what patients actually expect. Most good physicians have relied upon empathy and common sense to guide them. This study focused on finding out what patients think is an appropriate greeting. He also analyzed a sample of interactions between doctors and patients during first-time visits.

The researchers collected information from 415 phone surveys in which people were asked how they expect to be greeted by a doctor. Researchers also viewed and analyzed more than 120 videos of primary care visits in which the doctor and patient met for the first time.

They found that 78 percent of survey respondents wanted the physician to shake their hands. Nearly all patients wanted to be greeted by name, including 50 percent by their first name, 17 percent by their last name and 24 percent by both their first and last name. Most patients, about 56 percent, wanted physicians to introduce themselves using first and last names, while 33 percent expected last name and 7 percent expected first name.

The researchers found a striking difference between expectations voiced in the phone surveys and the actual interaction between doctors and patients in the videos. While 83 percent of doctors shook hands in the videos, only half addressed the patient by name.

Obviously everyone has their own communication style, but the researchers recommend that doctors should incorporate a greeting strategy that uses first and last names for both doctor and patient. Doctors also should plan to shake a patient’s hand, but need to be sensitive to body language or other nonverbal cues that may indicate whether a patient does not want to or is not physically able to reciprocate or respond.

How we use names or handshakes will also change over time.

Why does this business of doctor-patient communication matter so much?

It is not simply a point of courtesy, though that would not go amiss. The real issue is that relationships are the heart of healing. Relationships might not be so important to the person performing some technical service, but for healing they are essential. If I need to get my car fixed, it is nice if the mechanic wants to talk, but it is not essential. He can treat my car as the hunk of metal and moving parts that it is.

But healing is different from treatment. Healing demands a relationship, intention and a shared vision. An interaction that will create something that is greater than the sum of the parts. A polite, personal greeting creates a first impression that can affect the chance of developing a therapeutic relationship. Ignoring the normal rules of social interaction sets the tone for everything that comes afterwards. It is respectful to use a person’s name and on a purely practical level, helps ensure that you are seeing the right person! More than once I have been given the wrong chart before meeting a person for the first time.

Interestingly, accrediting organization quite rightly emphasize that communication is a critical skill for physicians. Sadly many medical schools put such a huge emphasis on academic attainments that some people enter the medical profession without natural communication skills, and their training does little to help them get better at it. But this skill may not come naturally to all doctors, so it’s important to offer guidance on different aspects of communication such as greetings

My students will tell you something that I have said a thousand times: “You have spent a lifetime developing people skills. You have learned how to talk to Aunt Mabel, how to feel when you are in a dangerous environment and how to deal with that guy at the bar who is becoming annoying. These are very valuable skills. Why did you check them at the door on the day that you entered medical school?”

One of my mentors once lamented, saying that 90% of medical students would have been better served by a technical college than a medical school, because they had no curiosity, no desire to move the field forward and no wish to engage with the people who came to see them. And that was in England, where there is socialized medicine. I did not want him to be right, but he probably was. In fact he was right about a great many things, which is why he was nominated for the Nobel Prize in Medicine on three occasions.

If medical schools want to turn out healers rather than technicians, then it is clear that medical students and doctors have to be helped to learn basic communication skills.

One of the many reasons that so many holistic therapists and practitioners of Integrated Medicine are popular is that they do understand the importance of good communication. Not because of research, but because that is their natural way of being.

What have your interactions with doctors been like?

How do you like them to greet you?

“True communication is remembering that everything is relationship — that, regardless of the appearance, no one stands alone.”
–Hugh Prather (American Spiritually-oriented Counselor and Writer in the Field of Personal Growth and Relationships)

“Once a human being has arrived on this earth, communication is the largest single factor determining what kinds of relationships he makes with others and what happens to him in the world about him.”
–Virginia Satir (American Family Therapist, 1916-1988)

How Doctors Think. Or Not.

I recently reviewed a fascinating book at the Amazon website. It is called “How Doctors Think,” and it was written by the ever-thoughtful Jerome Groopman from Harvard.

To save you having to look through all the reviews to find what I said, I thought that it would be useful to say something about the book and why I have some reservations about Jerome’s analysis.

Most doctors are highly educated, hard working people who most of the time try to do their best. Yet in our blame culture there are places in America where you can’t get a specialist to treat you: they have all been driven out of business by lawyers representing unhappy clients. The question of why this has come to pass has occupied the minds of the American medical profession for three decades.

Jerome believes that the key problem is that doctors make the same kind of errors in thinking that the rest of us do. We all – and not just doctors – jump to conclusions; believe what others tell us and trust the authority of “experts.” Clinicians bring a bundle of pre-conceived ideas to the table every time that they see a patient. If that have just seen someone with gastric reflux, they are more likely to think that the next patient with similar symptoms has the same thing, and miss his heart disease. And woe betides the person who has become the “authority” on a particular illness: everyone coming through his or her door will have some weird variant of the disease. As Abraham Maslow once said, “If the only tool you have is a hammer, you tend to see every problem as a nail.” To that we have to add that not all sets of symptoms fall neatly into a diagnostic box and that uncertainty can cause doctors and their patients to come unglued.

Up to this point the book is very good as far as it goes but I do not think that the analysis is complete.

I have taught medical students and doctors on five continents, and this book does not address some of the very marked geographic differences in medical practice and the book is “Americano-centric.”

The first point is that the evidence base in medicine is like an inverted pyramid: a huge amount of practice is still based on a fairly small amount of empirical data. As a result doctors often do not know want they do not know. They may have been shown how to do a procedure without being told that there is no evidence that it works. As an example, few surgical procedures have ever been subjected to a formal clinical trial. Although medical schools are trying to turn out medical scientists, many do not have the time or the inclination to be scientific in their offices. In day-to-day practice doctors often use fairly basic and sometimes flawed reasoning. A good example would be hormone replacement therapy. It seemed a thoroughly good idea. What could be better than re-establishing hormonal balance? In practice it may have caused a great many problems. Medicine is littered with examples of things that seemed like a good idea but were not. Therapeutic blood letting contributed to the death of George Washington, and the only psychiatrist ever to win a Nobel Prize in Medicine got his award for taking people with cerebral syphilis and infecting them with malaria. The structure of American medicine does not support the person who questions: consensus guidelines and “standards of care” make questioning, innovation and freedom very difficult. A strange irony in a country founded on all three.

The second major factor in the United States – far more than the rest of the world – is the practice of defensive medicine: doctors have to do a great many procedures to try and protect themselves against litigation. This is having a grievous effect not only on costs, but also on the ways in which doctors and patients can interact.

Third is the problem of demand for and entitlement to healthcare. We do not have enough money for anything: but what is enough if the demand for healthcare continues to grow as we expect? And if people are being told that it is their right to live to be a hundred in the body of a twenty year-old? Much of the money is directed in questionable directions. There are some quite well known statistics: twelve billion dollars a year spent on cosmetic surgery, at a time when almost 40 million people have no health insurance. There are some horrendous problems with socialized medicine, but most European countries have at least started the debate about what can be offered. Should someone aged 100 have a heart transplant? Everyone has his or her own view about that one, but it is a debate that we need to have in the United States.

Fourth is the impact of money on the directions chosen by medical students and doctors starting their careers. Most freshly minted doctors in the United States have spent a fortune on their education, so they are drawn to specialties in which they can make the most money to pay back their loans. In family medicine and psychiatry, even the best programs are having trouble filling their residency training programs. Many young doctors are interested in these fields, but they could die of old age before they pay off their loans.

Fifth is the problem of information. It is hard for most busy doctors in the United States to keep up to date on the latest research, and many are rusty on the mechanics of how to interpret data. So much of their information comes from pharmaceutical companies. Many of the most influential studies have been conducted by pharmaceutical companies, simply because they have the resources. But there have been times when data has therefore appeared suspect. Industry is not evil, but companies certainly hope that their studies will turn out a certain way, and the outcome of any study depends on the questions asked and the way in which the data is analyzed. And like any collection of people, it is easy to fall into a kind of groupthink. There are countless examples of highly intelligent individuals who all missed the wood for the leaves.

Another related problem is that many scientists are now also setting up companies to try and profit from the discoveries that they have made in academia. Most are working from the highest motives, but sometimes there are worries about impartiality. So once again, the unsuspecting physician may add data to the diagnostic mix without knowing its provenance. There have recently been a number of high profile examples of that.

I ended my review by saying that I hope that every doctor and patient in America should read it, and I stand by that, with the caveats and comments that I have added to the mix.

Medicine and Creativity

The Lancet medical journal has just published this year’s themed issue on the topic of ‘Creativity and Medicine’.

If you click on the link, you will be taken to a digital edition of the special issue. The digital edition is an exact facsimile of the print copy and is available for one month. You can turn pages just as you would with a print edition and even print off the pages for your own personal use.

The Lancet is one of the journals that you will find in the "Journal" listing on the left of this blog.

Many of the articles are extremely interesting and thought provoking: "Writing and healing;" "Development of children’s creativity to foster peace;" "Healing through art therapy;" "Theatre – a force for health promotion;" "Hospital clowns;" "Healing architecture; " "Healing gardens;" "Chance favors the prepared mind" and "What can the arts bring to medical training?" were some of my favorites, and give you a good flavor of what’s in store for you.

You will also see how this fits very precisely with a true Integrated Medicine.

One caution: it IS a medical journal and there are one or two articles near the back that are not for the squeamish.

With that caveat, there is much food for thought in these articles, and the Lancet deserves our thanks for making them available for free. Even if it is only for a month!

Predicting Response to Medicines

Much as we would all like to rely upon natural and non-invasive approaches to treatment, there are times when pharmaceuticals also have their place.

A common question is whether there are any good ways to predict who will respond to what treatment and whether we can predict the risk of side effects. Unfortunately the answer is that although we are getting better, and the research base if growing rapidly, there is still a lot of trial and error in prescribing.

An exciting and relatively new area is called pharmacogenetics: using our genetic make-up to allow us to tailor treatments to each of us individually. Over the last few months there have been a lot of media reports about being able to use simple blood tests to predict who will respond to antidepressants. (As an example, see this report from the Washington Post).

Unfortunately these reports, though undoubtedly well meaning, have not told the whole story. You might be interested to see a brief article about this interesting topic that helps put things in perspective.

Though there are some highly reputable institutions that are trying to help provide genetic testing not only for drug responses but also to predict the risk of developing certain illness, unfortunately there are also plenty of rogues who prey upon the worried and unwary. I was recently shown pages and pages of all kinds of tests on an individual: genetic tests; biochemical tests; allergy tests and all kinds of unorthodox tests using every imaginable type of gizmo, from magnets to devices claimed to measure the aura.

Not surpringly, the individual was thoroughly confused by this vast morass of information. The best thing to do was to tear it all up and to start again with the simple question: "What do you think is wrong?" Deep down inside, she knew the answer.

I have spent years working in and running laboratories, so I am not shy about using science and technology.

Science and technology must be our servants and not our masters.

“During my eighty-seven years, I have witnessed a whole succession of technological revolutions. But none of them has done away with the need for character in the individual or the ability to think.”
–Bernard Mannes Baruch (American Financier and Government Official, 1870-1965)

“We must learn to balance the material wonders of technology with the spiritual demands of our human race."
–John Naisbitt (American Futurist and Author, 1929-)

“Humanity has passed through a long history of one-sidedness and of a social condition that has always contained the potential of destruction, despite its creative achievements in technology. The great project of our time must be to open the other eye: to see all-sidedly and wholly, to heal and transcend the cleavage between humanity and nature that came with early wisdom.”
–Murray Bookchin (American Ecologist, 1941-)

Advertising Medicines

Web Mistress (that still sounds a bit rude) Carol Kirshner has just alerted me to something very important.

It looks as if there is going to be more oversight of direct-to-consumer advertising of medicines.

She posted this on Thursday:

"According to an article published today by Reuters the General Accountability Office (GAO) has published a report that the Food and Drug Administration (FDA) needs to improve their monitoring of direct-to-consumer drug advertising. Specifically, the FDA should issue warning letters more quickly when misleading advertisements appear.

The GAO findings are based on an examination of 19 letters issued in 2004 and 2005 which took, on average, 8 months to send out. The GAO asserts that by the time the companies received the letters, most had already discontinued the ads. Additionally, the GAO found that even after the letters were received, some companies continued to break the rules on the same medications.

The GAO report found that the pharmaceutical industry spent 4.2 Billion dollars on DTC ads in 2005. This is almost double the amount spent in 1997. Breakdown of other spending includes 7.2 Billion dollars promoting directly to doctors and 31.4 Billion dollars spent on R&D.

Logic would seem to suggest that if spending on DTC advertising continues to grow exponentially, monitoring will become even more difficult. There will simply be too much volume to keep up with given the current resources of the FDA. In fact, the FDA has tried to proffer this as an explanation for the lapses. According to the article, the GAO is standing firm that the FDA could do more."

The first thing to say is that the vast majority of pharma companies do a great job of providing clear and accurate information, and I know of several for whom patient welfare always trumps the bottom line. But clearly there have been some problems.

Second, is that consumers need to be aware that the inofmration in the advertisements may no longer be 100% accurate, so check before you take anything. One of the reasons for creating this blog was so that I could be responsive to questions and quick to provide new information as it appears.

I also have a number three point, and it is something that surprises many of my friends and colleagues in the United States. Direct-to-patient advertising is prohibited almost everywhere else in the world. The rationale for that prohibition is most definitely not to disempower people! It is that careful prescribing of medicines is becoming an ever more complex art and science.

Regular readers may remember a report about the lamentable level of training of British doctors in how to prescribe and combine medicines. And British doctors do not have the added burden of patients asking for medications by name.

Some years ago I was at a meeting at which I was told a statistic that 92% of American doctors will prescribe a medicine if tha patient asks them to, while the figure throughout Europe was less than 20%. I’ve never been able to find any documentation for those figures, though they were given to me by a senior executive in a pharma company.

If those figure are anywhere near the truth they would worry me: there are just so many inter-individual differences in response to treatment and so many potential interactions between medicines, herbs and supplements. Explaining them all to someone who hasn’t been trained in phamacology can be tough.

Trust me! I’ve been teaching medical students, residents, junior attendings, pharmacists and nurses since the 1970s. All have biomedical backgrounds, but teaching them all the ins and outs of modern pharmacology can be a Labor of Hercules!

So this is absolutely not a criticism of members of the public asking about things that they have seen on TV or the internet. Neither is it a criticism of 99% of the pharmaceutical industry.

I think that it’s great for people to ask for what they want, the problem is this: How many doctors and nurses are able to say no?

And also to explain their reasons clearly?

Isn’t it just an extra stressor for patients and prescribers alike?

Medical Terminology and Clear Communication

During the Second World War, there was so much worry about the possibility that Axis spies had penetrated the United Kingdom, that there was a whole campaign entitled, “Careless Talk Costs Lives.”

We sometimes see a similar problem in medicine, and in particular in psychiatric practice when we use terms that may cause great and unnecessary distress.

When somebody is unwell, it is hard for them and for their family to take everything in. research has shown that people only remember accurately 30-40% of what a doctor, nurse or therapist says to them. That is why I recently wrote the piece on clarity of communication.

Another problem is vocabulary. It is calculated that a medical student has to learn aorund 6,000 new words during his or her training. Young doctors and nurses often forget that what they mean by a word is often very different from what a non-medic may mean. That is why we try hard to define eveything on this blog.

You might be interested to look at an example on the Psychiatric Resource Forum blog. This one discusses paranoia. It’s an important word, but one which means something diferent to the specialist from its common use in conversation.

I think that it is valuable for you to be armed with as much information as you can, and I plan to continue highlighting terms that can lead to distress and misunderstanding.

Irritable Bowel Syndrome, Mood Disorders, the Serotonin Transporter and Integrated Medicine

Whenever we run into two common conditions, it’s easy to imagine links where none really exists. Three years ago some colleagues from Oxford reported on a person with bipolar disorder and irritable bowel syndrome, and commented that the association was uncommon.

However there may after all be a genuine link between mood disorders and irritable bowel syndrome, that is a disturbance in the “third arm” of the autonomic nervous system. The first arm is the sympathetic nervous system, the second the parasympathetic and the third is the enteric or gut nervous system that is closely linked with key regions of the brain.

Not long ago there was an interesting report of a woman who had multiple problems including environmental allergies, atypical bipolar disorder, irritable bowel syndrome and Raynaud’s phenomenon. Such odd constellations of problems are quite familiar to anyone working in the major referral centers around the world, and some can be exceedingly hard to treat. Tough cases like this often stimulate further research. I once tried and failed to treat a woman with a chronic illness. When she came back a year later to see if I had any new ideas, I told her that I now had a shelf of books and over a thousand reprint of papers about her condition: I don’t like failing someone. And I’m not unique in that.

A new study from the Karolinska Institute in Stockholm, has found that chronic widespread pain, which, as I explained recently, is the cardinal symptom of fibromyalgia, is prevalent and co-occurs with other symptom-based conditions such as chronic fatigue syndrome, joint pain, headache, irritable bowel syndrome, and psychiatric disorders.

There is more and more evidence of a link between fibromyalgia, irritable bowel syndrome and depression. It is not just that people are sick and get depressed: as we shall see in a moment, the link is more subtle than that. Another illness seemingly linked to these three is interstitial cystitis.

Now some colleagues at the National Institutes of Health have been looking at a serotonin transporter (SERT) that regulates the entire serotoninergic system and its receptors. This transporter is found throughout the animal kingdom, telling us that it must be important.

In humans the gene is located on chromosome 17, and disturbances in it have been found in people with autism, ADHD, Tourette’s syndrome and bipolar disorder. Experiments using genetic engineering suggest that SERT may be a candidate gene for several human disorders, from obesity to irritable bowel syndrome. People who have disturbances in SERT tend not to respond so well to the serotonin reuptake inhibitors (SSRI’s) antidepressant medicines.

SERT is not the whole story. Some geneticists from Los Angeles have found evidence linking irritable bowel syndrome, depression, migraine and inheritance of mitochondrial DNA.

Many approaches have been tried to help people with these groups of problems. I always find it remarkable that psychological treatments can be so effective in conditions with a genetic component, for this once again proves that biology is not destiny.

The best approaches to conditions like irritable bowel syndrome and coexisting mood disorders is to use medications and psychological approaches. Many of us have also found that the addition of nutritional, environmental and subtle energetic approaches have been of great help, together with some work to uncover the meaning and transpersonal value of a chronic illness. That last piece is not the first priority, which is to help the person gain control of his or her life. But if we don’t do something to work with the meaning and purpose of an illness, it will usually come back in some form or other. This comprehensive approach differentiates Integrated Medicine from many other types of therapy.

Black Cohosh and Liver Damage

After discovering that some of the Black Cohosh sold in the United States contains precious little of the active ingredient, we now learn that that may not have been such a bad thing.

In 2004, a Conference sponsored by National Center for Complementary and Alternative Medicine and Office of Dietary Supplements, National Institutes of Health indicated that Black Cohosh appeared to be safe. However, earlier this year, the regulatory authorities in Australia issued a policy statement about adding warnings about liver toxicity to all herbal products containing Black Cohosh. The European and British regulatory authorities followed suit.

This highlights a problem with which we’ve struggled before: are the reports of hepatotoxicity due to a “bad batch?” Adulterated perhaps, or collected incorrectly? Yet that highlights both the strength of natural remedies and also their Achilles’ heel. We have so little information about the purity of individual products.

The standardization of herbal medicines is difficult, particularly since herbals usually contain complex mixtures of constituents, some of which are active, and some not. We often do not know exactly which component of an herbal medicine is responsible for clinical effects. There are often also differences in the composition of herbal preparations among manufacturers and lots. There are also enormous variations in the identification of plants by the manufacturers, how they are handled and the presence of other chemicals. Just think of the variations in the taste of different types of coffee, and you will see the point.

This variation has important consequences in clinical trials, many of which have failed to address the question of whether the herbs that they were using were of high quality.

The information on the label does not always reflect the actual content of the preparation and it is difficult to give one standard dose for an herbal medicine.

I thought that I should give you the wording from The European Medicines Agency (EMEA) and the Committee on Herbal Medicinal Products (HMPC)”

“Following review of all available data, the HMPC considered that there is a potential connection between herbal medicinal products containing Cimicifugae racemosae rhizoma (Black Cohosh, root) and hepatotoxicity.

The EMEA therefore wishes to give the following advice to patients and healthcare professionals:

Advice to patients:

— Patients should stop taking Cimicifugae racemosae rhizoma (Black Cohosh, root) and consult their doctor immediately if they develop signs and symptoms suggestive of liver injury (tiredness, loss of appetite, yellowing of the skin and eyes or severe upper stomach pain with nausea and vomiting or dark urine).

— Patients using herbal medicinal products should tell their doctor about it

— Advice to healthcare professionals:

— Health care professionals are encouraged to ask patients about use of products containing Cimicifugae racemosae rhizoma (Black Cohosh, root).

— Suspected hepatic reactions should be reported to the national adverse reaction reporting schemes."

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