My article Tolvaptan - New drug for low sodium in blood” has been recently quoted in an article titled “Content of weblogs written by health professionals” (pdf link) published in the Journal of General Internal Medicine by implying that the post is a product endorsement. The actual quote is:

“Up until now the treatment of this condition involved free water restriction and removal of inciting factors. Now a new drug - Tolvaptan promises to change it all.”

However, the article missed out the remaining post which in the end had my take on Tolvaptan -

“The main problem with the drug is that once approved, most clinicians will prescribe it for for a very long time especially in patients prone to developing and remaining hyponatremic. Since the study duration was only for 30 days, many new side effects may appear when the drug is finally marketed.”

Also my blog post was written in context of describing an article published in New England Journal of medicine and not for drug promotion which the article failed to mention. I should also add that I have no relationship with any pharmaceutical company as the article later implies (although not directly to this website) by writing:

“A recent survey reveals that 29% of blog authors have been approached by public relations professionals to endorse specific products, and 52% of them have written one post endorsing such products in their blog content. These endorsements are not advertisements that appear on the website; they are written into the blog narrative, often without any acknowledgement that they are paid promotions. Although we did find blogs that promoted health care products within their entries, we were unable to determine whether these were paid endorsements, because we found no disclosures indicating authors’ conflicts of interest.”

To all this I should also add that I pursue blogging because I have a passion for computers and technology and believe that we can help ourselves (physicians) as well as our patients by empowering them with the latest information in medicine that they can discuss with their physicians.

This case has been on my mind for some time and I thought that I would share it with the world and get some opinions.

A very elderly lady, Mrs. Y presented to the ER for worsening congestive heart failure (CHF). She was diagnosed with CHF about 2 years ago. She had decompensated in the past 4-5 months and had been in and out of the hospital and rehab facility for CHF exacerbations. In the ER, she said that she does not want any treatment and wants to die since she cannot live with her family and is tired of being sick. Therefore in consultation with the family (who were present in the ER) she was changed to comfort measures and admitted to the medical floor.

When I saw the patient, I thought she was depressed and most likely did not have the capacity to take her own decisions. The family supported the patients decision for comfort measures although they admitted that they would like the patient to be treated for CHF.

It was a difficult situation for me, as I clearly knew that the patient’s CHF was easily reversible and the patient was depressed and most likely unable to take decisions. Also I was unable to reverse the patients code status.

I decided to take the midline approach i.e. treat the patient for CHF with high dose diuretics and give her morphine for difficulty in breathing (which is also a treatment for pulmonary edema and CHF) along with an antidepressant. I hoped that if she responds to the diuretics (and morphine) her breathing would get better and by 2-4 weeks her depression would be under control by the anti-depressants. On the other hand if she does not improve or deteriorates, she would be on morphine which would keep her comfortable and thus honor her desire to be on comfort measures.

What would you do?

I recently saw a patient who came in for follow up after being treated for sexually transmitted disease. He wanted copies of his medical records - more importantly he wanted a copy of his HIV status!!

This guy who I will call Mr. X had had multiple sexual partners in the past few months and wanted the HIV medical report because he was HIV negative. On inquiring, Mr. X revealed that he wanted to “prove” to his girl friends that he was HIV negative so that he could have unprotected intercourse. I spent about 1 hour explaining to him the limitations of the HIV test and his chances of re-infection after unprotected sex. I hope he understood.

This encounter set me thinking. How many people are there in the world who use the “No HIV certificate” as proof of not having AIDS and thus running the risk of infecting themselves and others after having unprotected sex.

It is even more concerning in countries where most of the people are illiterate and have only heard that AIDS is a deadly disease. These people do not understand the significance of the test and most doctors do not take the trouble of explaining the test results and its limitations.

So I decided to write up the limitations of this HIV test and the risks of this “No HIV certificate.” And they are:-

1. ELISA test for HIV is not 100% sensitive. This means that even if the test is negative you still have the chance of having the infection.

2. Western Blot test is used to confirm HIV status after ELISA is positive.

3. After a patient is infected with HIV there is a window period of about 3 months when both the ELISA and western blot will be negative (this happens because the body has not made any antibodies against the virus and both the ELISA and western blot are unable to detect these antibodies)

4. You could become infected the next day after having an HIV negative test if you have unprotected intercourse (a factor to consider if someone shows you the “No HIV certificate”)

The most important take home message is that a negative HIV test indicates that probably you were not infected with the virus at that point in time. It does not say anything about your current HIV status.

Going back to our physician community - how many of us actually explain the limitations of the HIV test to our patients especially those who test negative.

Technorati Tags: AIDS, Certificate, ELISA, HIV, Western Blot

There is an excellent article written by Charles Wheelan on “The top ten reasons for soaring health care costs.” Charles is the author of “The Naked Economist” column on Yahoo finance.

Here is a summary of the more important ones:-

1. Nobody shops for value

You don’t ask how much a doctor is charging when you are dying of chest pain.

2. Medical innovations are more expensive, not less

Economic progress tends to come in two forms: Learning to do old things better and cheaper, or learning to do new things. Medical progress tends to involve the latter.

3. Health care is a “luxury good”

As people get richer they want treatment for conditions that earlier generations would have tolerated. Eg. Getting a knee replacement for osteoarthritis.

4. We don’t pay for what we consume

Health care is unique in that neither the service provider nor the patient gets the bill. For most people, the tab gets sent somewhere else. So nobody directly involved in the transaction has any incentive to control costs.

5. A surgeon can perform 1 operation at a time and his salary needs to keep pace with rest of the world (c.f. a farmer can grow 20 times more corn due to technological advances and therefore become 20 times richer)

To this list I would like to add another:-

6. Decreased earning lifespan of doctors

There are 2 big problems with medical education. Firstly it is very expensive and secondly it takes to long to complete thereby decreasing the “earning life span” of doctors.

Consider someone who has done an MBA or engineering, they typically start earning a decent sum in their early to mid 20’s. On the other hand doctors start earning in their late 20’s or early 30’s with not so great a paycheck (in residency) and with 2-3 times an education loan.

What choices do we have????

“Naked Economics: Undressing the Dismal Science” (Charles Wheelan)

Technorati Tags: Doctor, Health, Health costs, Medical education, Finance

The July 27th issue of New England Journal of Medicine has an interesting article titled “The Silent Epidemic — The Health Effects of Illiteracy.”

While dealing with patients we assume that they are educated and thus will be able to comprehend their medical situation and follow the advice of their doctor.

Consider this from the NEJM article:

The exact relation between literacy and health is still unclear, but people with low literacy are more likely to report having poor health, and are more likely to have diabetes and heart failure, than those with adequate literacy.3,4 Some studies have found correlations between literacy and measures of disease such as glycated hemoglobin levels in people with diabetes.

The National Assessment of Adult Literacy (NAAL), a large survey conducted by the National Center for Education Statistics, recently estimated that 14 percent of adults in the United States have a “below basic” level of “prose literacy” — defined as the ability to use “printed and written information to function in society, to achieve one’s goals, and to develop one’s knowledge and potential.”

Having practiced medicine for some time in India, I had to deal with such patients on a day to day basis (Infact most of my patients there were illiterate). It was a challenge to “educate” them about their medical condition and the proper use of medications. Some of the more common problems we faced there were:-

1. Most illiterate people are unable to comprehend the fact that they need to take drugs inspite of not having any symptoms such as in diabetes, hypertension or to complete an antibiotic course for pneumonia.

2. To explain the frequency of dosing we made the use of symbols. We commonly used a circle denoting a pill and marked the “jacket” containing the pills.

3. Such patients are infrequent and irregular in follow up and even when they do, it becomes difficult to ascertain if they have taken their medications properly.

Technorati Tags: Health, Illiteracy, Illiterate, Medicine, Patients, NEJM