Odysseys of George

A moving talk – something for patients and doctors alike…..something we doctors have forgotten .. the human touch.

As written on the TED, “Modern medicine is in danger of losing a powerful, old-fashioned tool: human touch. Physician and writer Abraham Verghese describes our strange new world where patients are merely data points, and calls for a return to the traditional one-on-one physical exam.”

There was an editorial written in Surgery News by the esteemed lead editor, Lazar J. Greenfield, M.D. who is a Professor Emeritus of Surgery, University Michigan and also the president-elect of the American College of Surgeons. The editorial brought about complaints and eventually, the inventor of the Greenfield filter — a device placed in the IVC (inferior vena cava), used to prevent blood clots migrating to the lung, resigned as the editor -in-chief and the editorial was retracted. However, the editorial was printed on a blog.

As I read the editorial, I personally find no fault with it. However, many women found it demeaning and offensive especially the last sentence. I would like to know what readers feel of this editorial thus I will paste the editorial here. For the comments and what was the issues leading to the resignation of a surgeon of such caliber and a retraction of the editorial seem to me just a little bit over-kill and very political in nature! I guess it is one of those instances where people were just waiting to kick his butt probably for some other reasons which have been accumulating over time – being a surgeon, I foresee a possible character issue with being blunt, sarcastic and occasionally rude.

** taken from Retraction Watch
Now back to the offending editorial, which we’ll bring you in its entirety since 1) we think given the events that you should read the whole thing, and 2) because the ACS has taken the entire February issue off its website we can’t link to it even if we wanted to (more on that later). Under the heading “Gut Feelings,” Greenfield wrote (we added links):

One of the legends of St. Valentine says that he was a priest arrested by Roman Emperor Claudius II for secretly performing marriages. Claudius wanted to enlarge his army and believed that married men did not make good soldiers, rather like Halsted’s feelings about surgical residents. But Valentine’s Day is about love, and if you remember a romantic gut feeling when you met your significant other, it might have a physiological basis.

It has long been known that Drosophila raised on starch media are more likely to mate with other starch-raised flies, whereas those fed maltose have similar preferences. In a study published online in the November issue of the Proceedings of the National Academy of Sciences, investigators explored the mechanism for this preference by treating flies with antibiotics to sterilize the gut and saw the preferences disappear (Proc. Nad. Acad. Sci. U.S.A. 2010 Nov. 1).

In cultures of untreated flies, the bacterium L. plantarum was more common in those on starch, and sure enough, when L. plantarum was returned to the sterile groups, the mating preference returned. The best explanation for this is revealed in the significant differences in their sex pheromones. These experiments also support the hologenome theory of evolution wherein the unit of natural selection is the “holobiont,” or combination of organism and its microorganisms, that determines mating preferences.

Mating gets more interesting when you have an organism that can choose between sexual and asexual reproduction, like the rotifer. Biologists say that it’s more advantageous for a rotifer to remain asexual and pass 100% of its genetic information to the next generation. But if the environment changes, rotifers must adapt quickly in order to survive and reproduce with new gene combinations that have an advantage over existing genotypes. So in this new situation, the stressed rotifers, all of which are female, begin sending messages to each other to produce males for the switch to sexual reproduction (Nature 2010 Oct. 13). You can draw your own inference about males not being needed until there’s trouble in the environment.

As far as humans are concerned, you may think you know all about sexual signals, but you’d be surprised by new findings. It’s been known since the 1990s that heterosexual women living together synchronize their menstrual cycles because of pheromones, but when a study of lesbians showed that they do not synchronize, the researchers suspected that semen played a role. In fact, they found ingredients in semen that include mood enhancers like estrone, cortisol, prolactin, oxytocin, and serotonin; a sleep enhancer, melatonin; and of course, sperm, which makes up only 1%-5%. Delivering these compounds into the richly vascularized vagina also turns out to have major salutary effects for the recipient. Female college students having unprotected sex were significantly less depressed than were those whose partners used condoms (Arch. Sex. Behav. 2002;31:289-93). Their better moods were not just a feature of promiscuity, because women using condoms were just as depressed as those practicing total abstinence. The benefits of semen contact also were seen in fewer suicide attempts and better performance on cognition tests.

So there’s a deeper bond between men and women than St. Valentine would have suspected, and now we know there’s a better gift for that day than chocolates.

Sad to say that such an editorial can bring down an eminent man to his knees. Any hopes to go further in the surgical fraternity is next to impossible. The question is where does this lead too – are we all going to have to write political correct articles and that being sarcastic or blunt is totally disallowed? I read that editorial over and over again and am still not able to find it offending or demeaning rather find it a little amusing. Are we getting too uptight?

An elderly gentleman who saw me in the clinic a few days ago mentioned that many doctors don’t listen much to their patients and tend to utilize the many investigative instruments they have too easily that sometimes it is more a knee jerk reflex action. I have to agree as I myself have seen more and more doctors becoming swamped into this peculiar rat race where one listens less, investigates more and treats excessively. Having had teachers and consultants from an era where clinical skills and assessment was priority, I have no one to blame but the education system where teachers and consultants as those I had had been quickly replaced by the younger and green doctors and the syllabus made easier to enable more passes than failures. With this, we become more a businessman than a doctor for we have over time lost that human touch. This article which I read from New York Times written by Professor Abraham Verghese, concurs with my feelings and also the feelings of that elderly gentleman. A particular statement made in that article which I wish to highlight would be,” The consequence of losing both faith and skill in examining the body is that we miss simple things, and we order more tests and subject people to the dangers of …….. unnecessarily.”

Treat the Patient, Not the CT Scan
Abraham Verghese
continue reading…

48 year old lady presented with bilateral breast lump. On examination, vague breast lump at upper outer quadrant of both breast. Negative risk for malignancy. Had a procedure done in a beauty parlour 25 years ago.

Any guesses?

The elderly lady above demonstrates a case I saw in my clinic recently, but my patient was way younger in her early 30s. She developed this weakness over the left side of the face which was rather sudden in onset 3 days prior. She was otherwise very well and there was no history of trauma, infection or ear symptoms. There was neither any headaches nor any weakness associated to the upper limbs and lower limbs. She was otherwise well.

She had all the findings as the picture above, actually exactly like the elderly lady above. So what was wrong?

Well, this condition occurs when the nerve which is responsible for the control of facial muscles becomes swollen or inflammed causing the muscles to paralyse or weaken. It is usually abrupt with no apparent cause. This syndrome was first described in 1821, by the Scottish anatomist and surgeon Sir Charles Bell. From then, this condition was called Bell’s palsy. It is an interesting disease but a scary phenomenon for patients.

The nerve involved is called the facial nerve. The path of the facial nerve is complex; this may be the reason the nerve is vulnerable to injury. Two portions of the facial nerve leave the brain at the cerebellopontine angle, traverse the posterior cranial fossa, dive into the internal acoustic meatus, pass through the facial canal in the temporal bone, then angle sharply backwards, where they pass behind the middle ear and exit the cranium at the stylomastoid foramen. From here, the facial nerve bisects the parotid gland, and then terminal branches extend from the parotid plexus to innervate the muscles of facial expression.

Though the cause is still yet unknown, many believe that majority of them are due to viruses. The most common being the herpes simplex virus, which also causes cold sores and genital herpes. Other viruses that have been linked to Bell’s palsy include the herpes zoster (chickenpox and shingles) and Epstein Barr (infectious mononucleosis).

Bell’s palsy occurs more often in people who:

* Are pregnant, especially during the third trimester, or who are in the first week after giving birth
* Have diabetes
* Have an upper respiratory infection, such as the flu or a cold

Like my patient, there is also a genetic predisposition where most of them have recurrent attacks of Bell’s palsy but this is rare.

For most people, Bell’s palsy symptoms improve within a few weeks, with complete recovery in three to six months. About 10 percent will experience a recurrence of Bell’s palsy, sometimes on the other side of the face. A small number of people continue to have some Bell’s palsy signs and symptoms for life.

Eye care, steroids, pain control and reassurance are the main essence in the treatment of Bell’s palsy.

Well it has been some time since I have written anything medical based. So, I was thinking and realized that for something so common this particular problem is so little discussed with public. Then again, I guess the reason being that despite knowing much about it, we still find this a difficult issue to treat.

So what is Dyspepsia? continue reading…