The Deceptive Income of Physicians

Tayson DeLengocky has an interesting post on what an internist really makes when you take into account the costs of medical school, the time it takes to train and what the taxman taketh. Would $34/hour surprise you?

Don't trust pollen levels from sites that use 'prediction' rather than measurement

They often don't provide valid results.

Neutrophils May Contribute to Anaphylaxis

...according to a report in JCI.

Tropomyosin not the only allergen in seafood hypersensitivity in mite sensitized individuals

The Annals has an article by Boquete et al arguing that tropomyosin does not appear to be the main allergen involved in patients who are sensitive to dust mite and experience allergy symptoms after eating seafood (esp shrimp). This is not an uncommon issue.

After learning about Jack Elias and Geoff Chupp's work on chitinases and asthma, I wonder whether chitin could be a player here, as well as with cockroach sensitivity. Just putting another marker out there.....

IgE Antibody Levels Double in Last 35 years

Not surprising....IgE antibody levels have doubled in patients over 50 years of age since the 1970s, and the rate of decline in IgE as we age is becoming slower than previous, this according to a NHANES study released at the recent ACAAI meeting in Phoenix. This is probably a result of the 'allergy epidemic,' although changes in assaying IgE may also account for some of the change.

Meet your new health care master

What could go wrong?

Is Allergy an Educational Disability?

That's what educational experts in the United Kingdom are asking. The journal Expert Review of Respiratory Medicine has an interesting article regarding whether allergic rhinitis (AR) could be considered a disabling disease, especially when it comes to test taking. The article cites a growing body of evidence that the high prevalence and disease burden of AR could be affecting performance on standardized testing in the United Kingdom. Such examinations are crucial in qualifying for university education in Britain and are routinely scheduled during the months of April and May, when grass pollens are at their highest. So if accommodations are made for other medical conditions (such as dyslexia), should test takers with allergic rhinitis be addressed? Solutions include moving test dates to different times of the year, identifying and treating allergy sufferers, etc. The treatment idea raises its own downsides with several allergy medications causing sedation and mental slowing as adverse effects.

Slightly Troubling News on the Use of Benadryl

A new article in Neurology claims that diphenhydramine (Benadryl) and other anticholinergic medications can have an affect on the cognitive function of ageing brains. This news is both interesting and slightly troubling. More analysis here. A bigger concern on my part would be the affect of anticholinergics on developing brains, since we use so much diphenhydramine in children.

The Vanishing Oath

I don't really know why, but I've never been impressed with the majority of blogging doctors. Whether it's the trivial complaints, the oversimplification that often comes with short blog entries or the misplaced idealism of physicians-authors, I generally avoid spending much time going through medblogs. However, DoctorWes is one writer that I follow religiously. His commentaries are enlightening and his cynical humor is funny without being derisive.

So it was with great interest that I followed his recent entries on a documentary film made last year called the Vanishing Oath. Wes had seen the film and become so compelled by its story that he hosted a local screening of it in a movie theater and actively brought physicians together to see and discuss it. Given Wes' interest, I bought myself a copy of the DVD and just finished watching it last week.

The film follows a relative young emergency room physician by the name of Ryan Flesher MD who finds that the practice of modern medicine to be lacking in terms of autonomy, benefits and lifestyle. Burnt out with fighting administrators and third party payers, Dr. Flesher takes a break to examine why he became a physician and whether the challenges of today's practice were worth the considerable investments made to get to his position in life. In his break, he travels the country to speak with former mentors, other physicians and even a medical malpractice lawyer. I will leave Dr. Flesher's conclusions to those who watch the film. But needless to say, we are left with the realization that medicine has changed, and those changes are driving away physicians from a profession that have given much of their lives to train for.

One of the most pressing scenes involved a discussion on malpractice with a primary care provider in Massachusetts. During the health care reform debate last year, I heard from so many colleagues that malpractice wasn't, in fact, a big deal.



How anyone can assert that medical malpractice doesn't lead to adverse effects on physicians or isn't a major driver of health care costs today is ignoring a very real problem. I recorded several other reactions that I had after watching the film.

1. This movie shows the double-edged sword that comes with third-party payers, whether private or public. When you don't work for the patient, the payer expects certain actions that are not always aligned with quality patient care or standard of practice.

2. Expanding the role of government in medical decision making will not make the fiduciary relationship between patients and physicians any more sound. The way I see it, such a camel in the tent will only make matters (and rationing) worse.

3. While there are many specialties where doctors have been squeezed too much, I am fortunate to be in one that is still, if only temporarily, relatively independent. However, the day after viewing this film, I received a notice from Cigna that I was not providing 'cost-effective' care. My crime, using CT scans to diagnose chronic sinusitis. The horror...the horror.

4. I tend to relate to the Italian-born physician rather than Dr. Flesher in that after studying the history of medicine I realize that for the vast majority of our profession, doctors have not been 'rich.' While that's not why I went into the profession, I did think that I would be able to at least guide my own life and my work with patients. Some of the lack of joy in medicine these days I blame on the constant second-guessing by non-medical people looking over your shoulder and trying to make decisions for you without proper training or an understanding of the patient's unique circumstances that present before you. While some of my colleagues are happy to be 'employees,' discharging medicine as to the edicts given to them by a hospital, government or insurer, I became a physician to be an advocate for my patient. And I don't appreciate people telling me what to do as long as I am not hurting or defrauding my patients.

5. While I didn't go into this profession to get rich, I can see how limiting opportunities in medicine through over-regulation will drive very talented people to choose other lines of work. With the government takeover of medicine likely on its way, I am not sure that I would recommend the medical profession to young people intersted in becoming physicians. That to me is the real tragedy represented in the film.

Please see this film.

Nutrition and Immunity

We have long known that one cause of secondary immunodeficiency is malnutrition. And we are constantly bombarded by claims that this or that supplement will "boost your immune system," whether they be online, on television or via naturopathic practioners. Many of these 'supplement' claims are overreaching if not downright false. And little scientific evidence seems to validate such assertions.

In contrast, a recent story in the Wall Street Journal has a nice (albeit brief) summary of what we know about nutrition & the immune system. I would always argue that the best way to obtain the proper amount of nutrients is not through a pill, but via a balanced diet.

Does your child have allergies?

Take the Childrens Allergy Quiz

Update: Sakina Bajowala. M.D. asked about the stress reduction therapy mentioned at the end of this posting. I assumed this was an advertisement for the author of the article. I believe that there are neuropsychoimmunologic connections that affect many chronic diseases, including allergies. However, I do not endorse any specific technique unless it's shown to provide efficacy in peer-reviewed, reputable journals. Thanks for the question Sakina.

The Lung Flute

Popular Science has a nice artile on an innovator who created a device that helps those with chronic lungs issues (emphysema, asthma, cystic fibrosis, etc) mobilize their mucus.

Happy Thanksgiving

"A Prosperous Wind" by Mike Haywood.
I am thankful for so much this year. First and foremost for my new wife, who has traveled across country and agreed to a new life far from our native home. Second, for my new position and colleages, who are supportive and highly capable. For my family and our continued good health. And I am appreciative of the sacrifices made by my ancestors, going all the way back to the brave souls who sailed the North Atlantic in the winter of 1620 to find a better life; John Howland, Elizabeth Tilley Howland, John Tilley, Joan Hurst Rogers Tilley, John Alden, Priscilla Mullins, John Mullins and Alice Mullins.

Inspiring quotes from my VA patients, Part XI

Heard during a family meeting discussing palliative care options for a WWII veteran with end-stage pulmonary fibrosis:

"Don't feel bad for me...Every day since '45 has been gravy."

Is it a food allergy or food intolerance?

MSNBC takes this question on

Singulair (Montelukast) & Suicidality

Singulair (montelukast) is a leukotriene receptor antagonist used for control of asthma and allergies. In March 2008, the FDA started a review to investigate numerous postmarket reports of suicidality related to the use of Singulair. Results of those reviews were recently published in the October 2009 issue of the Journal of Allergy & Clinical Immunology.

Each review went back through research data acquired during drug development to look for patterns that may have represented suicidality or "possible suicidality-related adverse events (PSRAEs)." These reviews were ordered by the FDA and completed by employees of the drug's manufacturer Merck.

There were no suicides reported during the clinical trials for Singulair. There was one case of suicidal ideation in almost 10,000 patients taking montelukast and none in over 11,000 control subjects (placebo and active control). The conclusion drawn was that PSRAEs were rare and similar to the control groups.

A related article in the same issue looked at behavioral-related adverse events (BRAEs) during Singulair clinical trials. The frequency of patients with 1 or more BRAEs was 2.73% and 2.27% in the montelukast and placebo groups, respectively. The frequency with a severe BRAE was 0.03% in both montelukast and placebo groups, suggesting no difference. And the frequency of patients being taken off of montelukast because of a BRAE was 0.07% while 0.11% of placebo patients were discontinued from the study for a BRAE.

Potential limitations of these reviews include the fact that they were completed by employees of Merck, and that they only included data collected during drug development, where suicidality would lead to exclusion from the study.

The latter issue is important because severe asthma and allergies have been associated with depression and anxiety and thus, such patients may be more prone to suicidality. Using Singulair in such patients requires proper counseling and close follow-up.

Anecdotally, I have seen patients (especially children) who do experience mood changes on Singulair. We stop the medication and provide other controllers of their symptoms, and there has never been complicating issues. For what it’s worth, I have also seen similar behavioral changes on antihistamines and even certain inhaled corticosteroids. And we commonly screen for depression/anxiety in our patients.

Practioners and patients should discuss the risks of behavioral changes with the use of Singulair before prescribing this medication.

What does your doctor really think about you?

UK Dr Phil Hammond spills the beans.

Images from Clinical Allergy

Percutaneous skin testing to aeroallergens with almost identical sensitivities in identical twins. This is actually not as common as you might expect.

IL-33 is a marker of severe asthma

A nice summary via Allergy Notes

Is there a genetic basis for 'bad driving?"

UC Irvine neurologists seem to think so...