The Gift of Music for Christmas

I searched the internet to see when he had died.  He had been a regular performer on the Magnavox record player my Mom played when she was busy in the house.  He shared time with Floyd Cramer, Al Hirt, Roy Clark, Van Cliburn, The Chipmunks (at Christmas) and some guy named Liberace.  

As it turned out, he was still living.  Amazing.  The great pianist Roger Williams was still playing concerts.  He had five concerts that year - two in New York, two in Las Vegas and one in Bristol, Tennessee.  Bristol, Tennessee? And it was in two days.  

It was April 2006 and I went from wondering when a greatly admired pianist died to scrambling for a ticket to hear this eighty-two year old man ninety miles from home.  My wife and son couldn’t go, so it was a solo trip. The restored Paramount Theater in downtown Bristol, Tennessee (I parked in Virginia) was the venue.

The event was a massive new piano donated to the Paramount.  Roger Williams played Steinways most of his life, including his annual 12 hour marathon at Steinway in New York on his birthday.  He graciously agreed to play the new Baldwin, and no one there will forget it.  

He literally shuffled onto the stage appearing like a man who had a stroke.  His piano bench was a plastic office chair.  His hand nearly cupped under the front of a piano in a manner that would earn a first year piano student a stern correction.  He had been playing since 1927 and earned the only No. #1 piano instrumental on Billboard’s Chart in 1955 with “Autumn Leaves.” He made over 75 albums. 

His seat and his posture didn’t matter.  He played like no other pianist I have ever seen. 

He played his own arrangements of well known songs of his generation including movie themes.  He talked extensively about playing for every President from Harry Truman to George W. Bush.  He spoke very candidly of his admiration for Ronald Reagan.  He shared that JFK was listening to his record “Yellow Bird” while dressing on the fateful morning of November 22, 1963.  

He took twenty-three requests from the audience and played a medley of songs to the delight of the crowd and then ended it with his signature “Autumn Leaves”.  I watched his hands.  I know the song.  He was eighty-two.  I still can’t play it the way he did.  

He was diagnosed five years later with pancreatic cancer.  He played one more concert, and went home to die. 

His music still lives.  His gift of music, shared with countless others, still lives, also.  

As does Floyd Cramer’s.  And Liberace’s.  And John Lennon’s.  And now, Joe Cocker’s.  Their music, some original, some their interpretation (“cover”) lives on. 

Music defines, decorates, delivers, drives, and dominates the events of our lives.  Christmas music even more so.  Do couples remember what the minister said at their wedding or what was sung? Do families remember eulogies or the music of the funeral? What do we reach for when we are down or depressed?  Or when we are excited by an event? Or want to focus for sporting event? (“We’re Not Going to Take It, Anymore” was my football team’s theme).

Why do we listen to the same song performed by different artists during the Christmas season?  Because it tells us something about the artist - who they are, what their feelings and emotions are, what the song says to them, and how they reflect on the meaning of the season.  Do they have joy? Hope? Despair? Conflict? Loneliness? The song may reveal that, and we listen to catch a candid glimpse. 

As water is to the body, so music is to the soul.  Too much of either, and one will drown in an ungrounded excess.  Too little of either, and a dry life will not function as it could. 

Yet, as water needs electrolytes and proteins to enable the body to live, music needs the perspective of life to have meaning.  An artist grows up with the music, or with the instrument, and it becomes who they are, not just what they do. The artist can hear, mold, then own the music. 

Each of the artists I mentioned, had someone, somewhere, invest in their introduction to music.  An instrument.  Countless lessons.  The time of sitting and listening.  Persistent encouragement. Somewhere, an adult gave to a child or teenager.  

During the Christmas season there are many ways to invest in music for children and young adults.  Maybe attending a concert or play, or donating to a choir or band, or an event at church where timid children learn they can express who they are in song.  

Or maybe it is time to purchase an instrument and lessons for a young person.  Long after the knees, shoulders and hips have informed the mind that the athletic days are over, the mind, hands, fingers and muscles can coax a masterpiece of simplicity with an instrument.  

Or maybe later as an adult, a song performed in solitude in a empty house will be just the friend needed on a desperate, lonely night. No medicine can approach that. 

That is the power of music.  It is a friend always there.  It is a reminder of hope, of pain, and of comfort.  It is THE something that every child should have the opportunity to discover, even if some will not pursue.  No matter what career they choose, it can help them understand who they are, no matter where they are, and no matter how the world may see them.  

It could be an invaluable gift for a child this Christmas.  Imagine where this county, or country, would be if someone had not encouraged and given to Dolly Parton.  

Eric J. Littleton, M.D. (@DrEricLittleton) is a Family Physician in Sevierville, TN.  Send questions to askdrlittleton@gmail.com

Why People Stop, and Don't Stop, Smoking

A patient recently asked if the new electronic cigarettes (e-cigarette) really work and are safe.  Curiously, the question came from a patient who had broken his habit years ago with a simple decision to quit. 

The recent research on e-cigarettes is far from over with some studies suggesting they are safer due to the reduction in smoke inhalation of the chemicals added to traditional cigarettes while other studies have shown there is still a great risk with any intake of nicotine at all.  

A casual review of stories on e-cigarettes clearly shows the FDA is going to weigh in heavily on the regulation and taxation in a very short time.  A few of my patients enjoy a fiendish glee of lighting up in a restaurant (or my waiting room) and puffing a water vapor cloud while the non-smoking patrons look on in stunned disbelief and horror.  It will soon become a much more expensive practical joke. 

The latest research suggests that the e-cigarettes have nearly a 20% success rate, meaning, at one year, 2 out of 10 people will no longer smoke either cigarettes or e-cigarettes.  The 20% number is coincidently the same percentage of smokers who will succeed going "cold-turkey" at one year. 

The 20% success at one year is also the same as a recent heavily promoted pill for smoking cessation.  You might remember it from the television commercials which seemingly went on for minutes talking about the side effects of suicidal and homicidal thoughts while taking the drug.  Those side effects are very real.  I had one patient tell me he was sitting on top of his barn with a rifle ready to shoot up the neighborhood when he decided it was best to stop the pill and go back to smoking.  I refuse to prescribe it anymore.

Isn't there a pattern here?  Twenty percent success with e-cigarettes?  The same with cold-turkey? With the pill? 

I believe there is.  It has been my clinical experience that when a person is ready to stop smoking, they will.  Period. It is also my clinical experience that when a person is not wanting to stop they will find one excuse after another. And another.  And another.

The biggest excuse is anxiety.  However, the British Medical Journal recently published a report showing "smoking cessation is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke." Somewhere someone is yelling at the paper right now "Have YOU ever tried to quit?!". 

From what I have observed over the past twenty years, there are three basic reasons most people will stop tobacco products (dipping and smoking):  Love, Hate and Fear.  

Fear, of course, is a well known thing. Fear of cancer seems to trump fear of COPD probably because the commercials tout the wonders of inhalers for COPD.  When the fear of cancer moves from concept to reality, many find strength they never knew before.  That lump on the neck.  The blood while coughing.  The CT scan. The horror of seeing a loved one die with lung cancer.  I saw a man go from three packs of cigarettes a day to none when he was scared. He then jumped all over his smoking grandsons.  They didn't listen. 

Hate is a common one for younger adults.  The hatred of what it is costing financially is a daily reality.  I will ask a smoker in his twenties how long he wants to live ("Uh, I dunno, maybe 50 years...") then multiply his yearly tobacco cost (usually $1,500) by that.  I ask him what he would do with $75,000 if someone gave it to him.  I then suggest he write himself a check for $75,000 and put it on his refrigerator so everyday it will stare him in the face with how much it costs.  The hatred builds, and, especially on payday, it gets very real to him. 

And, of course, Love.  The essence of true love is denying one's own desires for another. It is difficult to recall how many times I have heard an older adult say they gave up smoking when a grandchild crawled up in their lap and either asked them to stop smoking, told them they stink and they don't want to be around them, or a combination of both.  But it works.  Strangely, this only works with grandchildren and not children. It is one of the most successful methods I know. 

There really is no more successful method for stopping smoking than simply making the decision to change.  But, that is true for anything in life - diet, exercise, attitude, prayer, or a host of other things that aren't as they should be and nag at us to be changed.  The power of a decided mind is incredible. 

Eric J. Littleton, M.D. (@DrEricLittleton) is a Family Physician in Sevierville, TN.  His office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com.  

 

The Love Drug

A ninety-one year old patient of mine recently received a very powerful drug. The effect was remarkable.  He looks and feels almost twenty years younger. 

This is the same patient I admitted as the very first admission to the new hospital in Sevierville on Sunday, February 14, 2010.  There was an unspoken competition to see who would be the first physician to admit a patient to the hospital.  It was a completely random process and I remember it as my pager went off while I was playing the piano in church.  I missed a chord, but silenced the pager, finished the music, and drove over to admit him.  He didn't look well at all. 

His heart was failing leading to fluid in the lungs and lower extremities.  The cough and shortness of breath had worn him down and a mild lung infection wasn't helping much, either. He had been faithfully caring for his wife of nearly sixty years who had dementia.  The loneliness and strain of caring for a spouse who was dearly loved, but unable to be the companion she had been before, was enormous.  His body and mind was showing the result. 

He needed rest.  His devout faith yearned for a greater rest. 

His recovery in the hospital was from medicine and grit.  He willed himself out of the hospital in order to care for his wife until she died a short time later. 

He was then alone.  His son provided support and his church loved him as a church should love a lifelong member. He was content to live the days he was given simply and with few desires.  

Then he met someone, again. 

They had dated as teenagers and were rudely interrupted by World War II.  He left to serve in the military, and as happens, she married another.  When he returned he fell in love with his future wife and was married.  

Sixty-plus years passed and they never saw each other.  Both faithfully loved their spouses until they died, remarkably in the same year.  

 

As I entered the room on his recent visit I clearly noticed a twinkle in his eye and a broader than normal smile on his face.  His cane was merely there for decoration because his gait was strong.  His swelling was better.  His shortness of breath was hardly there.  Arthritis? Not as severe.  Voice? Why yes, very strong.  Strong enough to sing a solo in church the day before.  

She was there in church, too, "to hear his solo," he said with a smile. This is the same church they attended as teens. 

Can being with someone, or accepted by someone, really make that much difference? 

A study reported by Dr. Aino Lammintausta (Turku University Hospital, Finland) and associates  in the European Journal of Preventive Cardiology, studied 15,330 cases of "acute coronary syndrome" (heart attack) from 1993 to 2012.  In essence, they found that unmarried men and women have nearly 60-65% greater chance of a heart attack and complications within one month.  

The scientists will studiously tell us the the serotonin, norepinephrine, and dopamine in the brain produce a feeling of love and fulfillment.  What they can't explain is how the thoughts of love, or the presence of one unique individual, can cause those chemicals to be released.  

The same week I saw two more patients who had begun a relationship after some time had passed from the death of their long time spouse.  Their entire demeanor, outlook and numbers on lab work reflected a person who is in a healthier, happier place in life than when they were alone.

The power of love, and being loved, is remarkable.  It truly has done more for this patient than any drug he has ever been given.  And yet it is all just thoughts - thoughts of another person who has their own problems and faults, and yet still is loved and accepted.  

Nevertheless, our world is full of people who don't know that "drug" - love.  We are seeing a level of hatred and death in this world that is incomprehensible, yet our video screens not only can comprehend it, they can place it in our hands to watch at any moment of the day. 

Even in our own world people will look happy in their family portraits, neatly manicured yards and perfectly kept houses, but they don't know love.  They know routines, obligations, duty, promises, appearances and, quietly hidden in the heart, emptiness of the soul.  Rarely a day passes that I am not reminded of this. 

My patient knows true love - love of his Almighty God first and foremost, and now, again, the love of another whom he first knew as a teenager.  He is accepted by her for who he is rather than for what he can do. 

If only a mere prescription could fill that for others.  

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com.

Prostate Cancer Screening

My patient was told in 1984 that he had prostate cancer and it would likely kill him within 5 years.  I wasn't the one who told him.  I was playing football as a senior in high school and more interested in putting people on their hind-quarters than examining them. I still had no clue I would even be a physician at that point.  But our eventual crossing of paths was set. 

In 1984 a diagnosis of prostate cancer usually meant only a 4% chance of cure. Currently, rates of 80-90% are common to cure prostate cancer.  The difference is a screening test called the Prostatic Specific Antigen, or PSA, which was developed by T. Ming Chu, PhD, DSc and his team in the 1970's at Roswell Park Cancer Institute in Buffalo, New York.  It was their specific goal to isolate a blood test for screening. They did exactly that. 

The PSA was released to monitor prostate cancer treatment effectiveness in 1986 and in 1994 it was approved as a screening test. There are many opinions on when, or even if, the test should be done from many different medical groups.   

My patient, and I'll call him Gary, was a stubborn sort of man and in 1984 he was 75 years old and not ready to die.  He actually vowed to his doctor that he would see his 95th birthday.  His doctor didn't really see it as realistic.  

When I met him in 2000 he was weaker, thin, had a lot of pain, and a lot of urinary infections from the cancer metastasis.  He still had steely, blue eyes and told me he would see his 95th birthday.  I admitted him to the hospital one night in 2002 just sure that his infection which was throughout his unconscious body would take him during the night.  I walked in the next morning to see him sitting up, eating eggs, and with a smile said, "Hey, Doc!"

Knowing the vastness of the tumors in his body it was unbelievable to see how he fought.  His mind was sharp, even sending me an article from Scientific American on the forefront of cancer treatment one month before he died.  He wanted to know if it could be developed in time for him.  

He passed three months after his 95th birthday, in his hospital bed in the home he built by hand on top of his mountain looking out the window at Mt. LeConte. I am certain he lived at least ten years on his will alone.  That's the power of the mind in the face of adversity.

Which is why I completely disagreed with the U.S. Preventive Services Task Force (USPSTF) recommendation on PSA screening that came out recently.  The USPSTF states “that there is moderate to high certainty that PSA testing has no net benefit or that harms outweigh benefits.”

Briefly, their reasoning is the too many false positive tests are causing too many biopsies and that the screening really doesn't extend life for those with diagnosed prostate cancer. 

Really? I truly believe this panel of experts (which did not include any primary care physicians) has "over-thunk" the problem.  The improvement in the cure rate alone should be enough of a counter-argument. 

The one thing that this talented, educated, number crunching, data extracting committee cannot measure is the power of knowing and the fear and anxiety of not knowing.  How does a data based decision weigh the emotions of a human mind? Medicine deals with people who have emotions, not an industrial process where a designed metal stamp produces one size fits all.  

I advise my male patients by age 50 to be screened for prostate cancer including the blood test and digital rectal exam (which usually should take less than 15 seconds) if they want it.  Some men decline.  Some don't.  All of their wives insist on it if for no other reason but to get even for the PAP tests they have had to endure. 

Family history, symptoms and race can prompt earlier screenings, but in my opinion, knowing what one is dealing with is better than not knowing anything at all.  That is the power of the mind and will meeting the options and methods of treatment.  Give the patient the chance to make the decision - and the consequences. 

It is another example of how computers, computing, and healthcare by a committee may have a role in our data driven society, but cannot, and never should, replace the patient-physician conversation, decision and treatment.  

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com.

Testing for the High in Tennessee High Schools

One of my very first vivid memories of high school football was sitting in a small wooden desk in Miss Poole’s first grade classroom.  She started that Friday morning introducing our guests who were stopping by.  

Two of the guests were Harriman High School Senior Cheerleaders in uniform accompanied by two huge, smiling, football players wearing their actual game jerseys with jeans.  They were selling tickets to the ballgame that night and did we want to buy any? We, mere little first graders, were too awestruck to even say a word as they smiled, thanked us, and left.

They were bigger than movie stars in our eyes and they actually came to see us.  We had the money the next week and actually got to stand close to the cheerleaders and catch a whiff of their perfume as they gave us our tickets. They were true celebrities.  We wanted to be just like them. 

It is still that way.  Elementary and intermediate school children still look up to the high school athletes, cheerleaders and band members with a sense of wonder.  You can see it as the players take the field on Friday nights when little boys stand in a line just to ‘give five’ to the players and get really excited if a player says anything to them.  You can see it in the little girls who wear uniforms and stand with the high school cheerleaders as they cheer.  You can see it in the kids who sit close to the band and watch as they play during the game.  

I remember lying on the grass at a home football game as a senior stretching before the game quietly thinking and enjoying the aromas of fresh cut grass, hot chocolate, popcorn, and fall leaves.  I looked over to see a little boy standing with his dad at the fence watching the big high school players who were going to battle for his city that night.  The memories of being in first grade came storming back as I remembered how I looked at them.  It made me want to play better. We sent Midway home very unhappy that night. 

It makes a lasting impact how the high school players behave, smile, work, play, and represent their school and community - not just on the children watching, but most of all, the athlete. 

The TSSAA governs high school athletics in Tennessee.  When I played there was not much intervention unless you really did something stupid. We got a letter for our fight after the game with Sweetwater (lost the game, won the fight). 

Now the TSSAA has taken a much larger role in managing the games and especially the safety of the athletes.  Coaches must strictly adhere to temperature and humidity readings kept during practice instead of judging the temperature by how many players passed out that day.  Concussion management has also become a large topic of concern for the safety of the athletes, both in the short term and long term consequences.  

Concussions have been linked to unusual behaviour, poor judgement, impaired performance in class, memory loss, emotional outburst and depression as well as long term concerns for poor mental function.   

But so does drug usage. 

A six year study released in 2013 from The Partnership for Drug Free New Jersey showed “when a student was randomly drug tested, those students were much less likely to abuse and to experiment with drugs throughout their highs school careers,” according to  Angelo Valente, executive director of the partnership.

New Jersey has had many districts implement drug screening as part of granting the privilege to participate in extracurricular activities such as sports, dances, and even being allowed to park on campus. It has proven to be a deterrent.  It is a policy supported by the Supreme Court in Board of Education v. Earls in 2002.  

It is time for random drug screening at least once per season for every athlete under the TSSAA’s authority.  For football, a ten game season means ten percent of the players are randomly tested per week and the results turned in to the officials on Friday night.   The athletic directors and officials already meet prior to each game to discuss sportsmanship.  Why not add drug-free compliance? 

A search of the TSSAA website for “drug screening” yields “Sorry, nothing found. Please try again with a different keyword.” The TSSAA sponsors are clearly seen, including Blue Cross/Blue Shield of Tennessee who posted record profits in 2013.  Blue Cross/Blue Shield and another sponsor, Farmer’s Insurance, might actually find it a worthy investment to financially support drug random drug screening for TSSAA athletes in order to deter potential costs from poor choices while under the influence. 

Positive tests would involve a meeting and counseling with parents and a reduction in privileges.  Further positive tests would significantly reduce privileges.  The athletes would then have a reason, or out, to push back against peer pressure.  Or a reason to avoid a party with drugs.  Or a reason to focus on the rare opportunity to compete and excel athletically and to make better choices. 

Drug usage went on when I was in high school.  I remember the players who were talented but when the pressure was on to lead and perform, they couldn't handle it and hid under the apron strings of drugs.  A safety on an opposing team was much larger and stronger than me but his eyes gave him away.  His helmet was on, but no one was home.  I wore him out that night when he could have dominated me. He never got his scholarship.  No college wanted to put up with him. 

Drug usage goes on in every high school and the ones close to any team know about it.  No school wants to move on this issue alone, so then they should all move as one. The coaches I have talked to across the state quietly support the idea, but they believe it should be all teams, not just a few. 

The athlete’s future may depend on it.  

And the children, who look up to them, are watching. 

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com.

Nice Knowing You, Niacin

There are many encounters with my attending professors, from renowned internationally recognized researchers to an aging kindly small town doctor, that easily come to mind as medicine adds gray to my own hair.  Dr. George Bosworth, a pediatrician in Rome, Georgia holds more than a few memories. 

He was a skilled B-52 bomber pilot in Vietnam who left the war to pursue a career in medicine, specifically pediatrics, possibly to quiet the memories of dropping bombs and death on people he never knew.  Later on he began teaching residents in training. Once he pummeled me with one of the worst professional chewing-outs I have ever had (well deserved as my talented colleague Paul Schriever and I were a bit unprepared for morning report) and then paid me one of the greatest compliments of my medical career less than a week later.  He was an attending physician I always wanted to have the correct answer for. 

He stormed into the Kid's Care Clinic we had one afternoon where I was working with a loud flourish, looking angrier and redder in the face than I could ever remember. We all knew he had heart disease and a temper, and that when he was really angry the one hair on top of his balding head would curl to the right.  

He looked at me and said, "Why am I red?.......What PILL did I just take, Littleton?" and from the depths of a distant memory I answered "Niacin".  

"Right," he said.  "How'd you know that? I hate this drug, but I'm supposed to take it to increase my HDL."

That was nearly twenty years ago and I remember it every time I discuss or prescribe niacin, or the long acting Niaspan, for a patient.  It is a ruggedly tough drug to take because of the side effects of "flushing", not to mention the long known concerns for the liver.  I have told my male patients it is as close to menopause as they will ever get. 

Well, I won't have to worry about that anymore. 

Niacin, a vitamin, was given its pharmaceutical eulogy in the New England Journal of Medicine last week after showing no ability to reduce cardiovascular events (heart attacks), causing "toxicity" (their word, not mine) and the unfortunate ability to increase the risk of diabetes. 

Niacin generated over one billion dollars in sales in 2013. 

And, ironically, niacin did exactly what it was supposed to do:  Increase the "good" cholesterol (HDL). 

Increasing the HDL, without the nasty side effects of niacin, has been a long sought after goal of the pharmaceutical industry.  From over 50 years of research in Framingham, Massachusetts,  we have learned that people with high HDL levels have much less risk of heart attacks and strokes.  So, the reasoning went, if niacin is known to increase HDLs, then we must use it to reduce cardiovascular disease.  

The two studies cited in the New England Journal noted that niacin increased HDL levels, but made no significant reduction in cardiovascular events of stroke and heart attack.  

It is sort of like seeing an NBA team with a lot of well paid, high scoring, big play stars and yet they can't win anymore games than a mediocre team.  

It is rare to see a drug given such a stunning blow from a leading medical journal.  Yet, even as we in the medical community focussed on treating the lab (the HDL), we failed to make a difference in the life.  The commentaries have discussed this at length, mostly settling on one uniform point:  emphasize a healthy lifestyle. 

Treating a lab has a value in many instances, but so does controlling the treats.  Wanting a lab number goal may be good, but so can setting a goal of numbers - numbers of minutes walking, exercising, or numbers of calories limited in the diet.  

One remaining use of niacin may continue in New Orleans, though.  Shared with me by someone who knows, a resident was utterly frustrated with a patient in the city hospital in New Orleans who was utterly convinced she was possessed by a demon (apparently this is a very common belief by some there) and said so on every office visit.  The resident (name withheld) had the idea to give her a 500 mg tablet of niacin and told her to take it when she got home.  He told her she would feel the demons coming out of her within two hours.  It worked, and she remained a loyal patient convinced the demons had left her for good thereafter.  

Niacin will rapidly fall from its pinnacle of notoriety as a prescribed medicine, or vitamin, recommended to reduce heart attacks, but its lessons will remain.  There is something more to treating a patient that just treating a number on a lab.   That all be a tough pill for some academics to swallow. 

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His new office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com.

Too Much Calcium?

Doc:  How much calcium should I take to protect my bones? 

A:  The amount recommended for daily calcium supplementation seems to have just become a little more confusing. 

Or maybe I should say as "clear as milk". 

The National Institutes of Health (NIH) states that women over 40 lose 0.5% to 1.0% of bone density per year.  Calcium and vitamin D3 supplementation are given to many postmenopausal women to reduce the risk of osteoporosis (bone thinning) in an effort to reduce the risk of bone fracture in later years.

The NIH recommended dietary allowance for vitamin D3 is 600 to 800 IU/day, and the recommended dietary allowance for calcium is 1200 mg/day.  

The question has been raised, though, whether this is too much daily intake.  Is there a risk taking this much calcium beyond the common side effect of constipation? 

There has been a concern that too much calcium supplementation causes hypercalcemia (too much calcium in the blood) and hypercalciuria (too much calcium in the urine). Too much calcium in the urine has been shown to increase the risk of nephrolithiasis, or kidney stones, as most people call them.  

(This is the point where every reader who has ever had a kidney stone pauses, reflects on the agonizing pain kidney stones inflict, and does a personal assessment of "what am I doing today to avoid ever having that unbelievable agony again?")

Without exception, every female patient I have known who has had a kidney stone and also childbirth states that kidney stone pain is much worse.  No exception. 

There is a strong suggestion that current recommendation might be too much according to a recent study released on June 16 by John Christopher Gallagher, MD, from the Bone Metabolism Unit, Creighton University, Omaha, Nebraska, in the medical journal 'Menopause' (my 'Sports Illustrated' was mainly covering World Cup Soccer and 'Menopause' was far more interesting). 

In a well controlled study of 163 white women aged 57 to 90 confirmed to be deficit in vitamin D, different levels of vitamin D were given to the women according to their group and a controlled amount of calcium citrate, adjusted for diet, between 1200 and 1400 mg/day was also given.  

Some women were given a placebo instead of vitamin D.  All of them received calcium.   

Every 3 months these ladies had their blood levels checked, and, amazingly, collected a 24 hour urine sample.  For anyone who has done a 24 hour urine sample, it isn't easy, and, obviously, especially for women. 

The researchers found that 8.8% experienced elevated calcium in the blood, and 31% experienced elevated calcium in the urine.  Most interestingly, they found no relationship between hypercalcemia or hypercalciuria and vitamin D dose, and hypercalciuria was equally frequent in the placebo group.

Essentially, 31% of women had a noticeably elevated presence of calcium in the urine regardless of vitamin D intake.  Further analysis noted some women had up to 20 times greater risk of calcium in the urine.  

That is a significantly increased risk of kidney stones, and to this point, is something that has not routinely been measured in modern medicine. 

So what is a patient to do who is concerned about their calcium intake? The researchers stated that even 500 mg/day might be too much for some women and they "recommend measuring blood and urine calcium levels before beginning calcium and vitamin D supplementation and repeating the measurements within 3 months."

Every 3 months a blood test and a 24 hour urine collection for every woman taking calcium and vitamin D supplementation?  Right. The researchers did not comment on how the women felt about collecting a 24 hour urine every three months but I believe I could guess how that conversation went.  And then recommend it be done indefinitely? They provided no clarity on this point. 

Clearly there is a concern here for too much calcium and it was also suggested that women carefully evaluate their diets for how much calcium they intake and to not go over the NIH recommended amount.  One study of 163 patients will not be enough to convince NIH to change its policy, however, it is worth paying attention to in future research. 

I am not a researcher, but my real world clinical experience tells me a 24 hour urine collection for every woman on calcium supplementation would be a challenge in the world of real medicine. 

There are risks and benefits with anything in life, including medicine and supplements.  The risk of bone fractures weighed against the risk of kidney stones and elevated calcium in the blood is another example of this fact.  Reading new research is only one part of maintaining a healthy lifestyle and should include a conversation with a physician prior to making a change in medicine. 

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His new office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com.

VAtergate

A very recent conversation with a veteran about his major cardiovascular surgery at a Veteran's Hospital here in Tennessee was enlightening, and not a surprise.  

"It was great.  They treated me very well and I feel better now than I have in years." 

That is consistent with many of the experiences shared with me from veterans I have known and also from my experience in training in the VA system.  There is a lot of good care that is provided the majority of the time. 

But, of course, not all of the time.  

The recent whistle blower case in Phoenix has brought a lot of attention to the failures of the VA medical system, especially the outpatient services.  Some have suggested that this is a failure of the current administration and there may be some blame to be shouldered there, but the inherent weakness here is one that any large government entity or corporation knows all too well. 

To quote a line from one of my favorite movies, "What we have here, is failure -  to communicate." 

Every veteran listened to the recruiter, or draft board, when they had their first encounter with the military.  They then listened, or they better have, to the sergeant in basic training.  Then they had to listen to the officer who gave the orders of where to move to and what to do there.  Listen, listen, listen, then do what you are told.  That's what the military does.

But when the veteran is discharged, it becomes the government's turn to listen. 

And that is where the problem begins.  

Failure of communication in listening to the projections of the number of service men and women who would need medical care as a result of military duty.  Failure to listen to the service men and women who complained about wait times.  Failure of the government as a whole to anticipate the number of physicians needed in order to provide basic access to medical care in both the Veterans Administration and the public as a whole.  

My training at the Memphis Veteran's Hospital was an experience not easily forgotten.  One of the things that really stood out to me was the patience of the veterans as they knew they were helping medical students learn and how willing they were to be a part of that process.  Our team consisted of an attending physician who had few words but a lot of intimidation, a fourth or fifth year resident, a second year resident, and intern who did all the work, and two or three medical students.  

As medical students we were viewed much like the kids at the card table at Thanksgiving: give them something to do to learn where they won't get in trouble.  The basics of taking a history and physical was the main emphasis and if you didn't spend two or three hours sitting with a patient as a medical student, you were sent back in.  

The vast majority of the vets enjoyed it, and actually were more that patient with the fumblings of a third year medical student learning his craft.  I will not forget the WWI vet I took care of, or the one who was in charge of giving lie detectors for the military - he had a way of looking through your skull as you talked to him. All of them had a story. All of them understood things didn't move quickly, but all of them wanted to be heard and cared for.  

There were extraordinarily dedicated physicians and nurses in the Memphis facility.  Yet they worked in an institution known for inefficiencies.  It was a given that if you wanted a chest x-ray on a patient, not only did you order it, but you found the wheelchair, loaded up the patient, carried him to radiology, waited on the films, and returned to the floor with the vet, wheelchair, chest x-ray and you better not make the attending wait, either. 

That will be the challenge for the Veteran's Administration: listen to the needs of the veterans and find a way to efficiently provide them.  It is a lessen for anyone who thinks that big government is the best source of medical care. 

It will take an massive effort of leadership to improve the communication, streamline the coordination, and utilize creative thinking to tackle this enormous problem.  

I would watch the simultaneous launch of two FedEx jets every minute, on the minute, beginning at 4 AM every morning as I jogged on the track at UT Memphis. It is an amazing thing to watch. It struck me as very ironic that in the same city where a transporter for a patient cannot be found in a government hospital, a major international company could deliver a package anywhere in the world with mind boggling efficiency. 

It can be done. 

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His new office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com.

Preventable Causes of Alzheimer's Disease

Doc: I fear losing my memory more than anything else.  What can I do to not get Alzheimer's?

A:  It is a fear a lot of people have and I hear it almost everyday.  A recent expert in the field actually addressed this very question.  

Dr. Kristine Yaffe, professor of psychiatry, neurology and epidemiology at the University of California, San Francisco gave the 2014 AAGP Distinguished Scientist Award Lecture in Orlando recently.  

The AAGP is the American Association for Geriatric Psychiatry - a group that is keenly interested in the "epidemic in dementia", its causes, and its treatments.  Part of the reason we are seeing such an increase is that people are living longer into their 80's and 90's.  She also addressed other contributing causes.

According to Dr. Kaffe, up to half, not all, of all the cases of Alzheimer's disease are attributable to seven modifiable risk factors.  

The list includes depression, diabetes, smoking, midlife obesity, midlife hypertension (high blood pressure), low educational attainment and physical inactivity.  It doesn't take long to see a lot of people are at risk.  

Three things really caught my attention from Dr. Yaffe that weren't actually included in the seven risk factors that she mentioned. She did not mention post-traumatic stress disorder and traumatic brain injury as risk factors, even though she has been a leader in identifying these as risks.  The third point is - what about the other fifty percent of Alzheimer's cases? Is there any hint of a clue?

It has been well documented that some people with normal memories have had changes noted on autopsy that would be consistent with Alzheimer's disease.  Therefore, the presence of the physical changes in the brain is not always consistent with memory changes.  

Also, many of us can easily think of someone we know who was highly intellectual, extremely active, non-smoker, lean and not diabetic who succumbed to Alzheimer's disease.  My grandmother comes to mind for me, along with several patients I have known over the years.

My grandmother on my mother's side of the family could work circles around most anyone well into her 80's.  She would sit at the dinner table hardly eating looking around the table for something someone needed, or might need, or something my grandfather would soon command she immediately jump from the table and do.

(I still remember how he would never ask her to refill his tea glass.  He wouldn't ask because all he did was tap one finger on the rim of his tea glass at the table and she would jump up to refill it in a swift blur.  I tried that once with my wife shortly after we were married. Once. Not twice.)

Her diet was lean, and mostly grown on the farm.  She never smoked, read whenever she sat down at night, and never complained.  She was the kind of person who never saw herself when she looked in the mirror.  She only saw what could be done for someone else.  

But living with my grandfather was a challenge.  When he died she opened up to caring for others in the community and quilting - until her own memory began failing.  Her body was so healthy that she lived many years in the prison of dementia.  Even then, the nursing home staff could put towels next to her and she would fold them happily for hours.

It is the unknown that is so frightening.  Was it her hearing loss (a known contributor)? The chronic stress of living with a challenging spouse? Or was is something common in the world we live in that we don't even recognize?

The longer I practice medicine, the more I believe chronic stress, but especially traumatic events during the older years, contributes significantly to memory decline.  It is almost as if the mind builds a wall to protect itself from further pain.  Unfortunately, stress, and how a person responds to it, is difficult to measure and even more difficult to treat.

Nevertheless, the fear of the unknown causes should not keep us from changing the known causes.  If a person is sitting in their worn out recliner with cigarette burns in the upholstery , hasn’t read a book in years, and is resting their bowl of ice cream on the top of their insulin injected belly, well, there are some steps that can be taken to reduce the risk of Alzheimer's disease.  

But there are steps we all can take, too. We can't let the fear of the unknown causes deter us from facing the known causes and making an effort to reduce them. It is a habit we should remember to do every day.

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His new office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com.

Pandora's Pill Box

Doc:  So how private are my medical records on computers?

Answer:  How safe are our national secrets over the past two years?

In late April 2014 the FBI released information stating a stolen credit card's information is worth one dollar on the black market of the internet.  

They also stated a (one) stolen computerized medical record is worth twenty dollars.

Twenty to one.  Think about that.

As a physician, my training from day one of medical school was to learn how to collect first what the patient says, then what is learned through physical exam and testing, assimilate it into an assessment list, and then make a plan based on reasoning, experience, deduction and medical science.  

It is called a SOAP note: S for subjective (what the patient says), O for Objective (what I find), A for Assessment (a list of diagnoses) and P for Plan.  The basic SOAP note has been expanded, stretched, and complicated by computers much like the basic Ivory Soap has been overshadowed by the current glitzy soap aisles in the store.  

One thing that has not changed in training is this: as a physician, you guard your patient's privacy. It is a unique an intensely personal relationship where patients share things they do not share with anyone else.  Maybe it is just a sore throat, or maybe it is from screaming because a marriage is collapsing.  Maybe it is a chronic headache, or maybe this woman who seems to have it all together is being beaten by her husband every night.

As a financial incentive (and threat of non-payment) from the Affordable Care Act in 2008, a larger percentage of this information is now floating around in computer systems along with personal demographic information such as financial identification numbers, Medicare numbers and insurance information.

These records have now become targets by computer hackers (think of them as modern day safe-crackers who never leave home) and they are finding the protection of this information is widely variable and significantly less secure than financial and retail systems.

In the recent Private Industry Notification (PIN) from the FBI to healthcare providers, it stated:  "Health data is far more valuable to hackers on the black market than credit card numbers because it tends to contain details that can be used to access bank accounts or obtain prescriptions for controlled substances."

The FBI seems to be quietly trying to nudge healthcare corporations and physician groups to re-examine their security systems.  

The larger corporations have some of the most elaborate protections on computer access implemented by people who stay up late at night worrying about the endless possibilities of hazards connecting an information system to the internet.  In order to exist in the current world of Medicare and insurance, this access is required to transmit billing data, and more recently, compliance data including lab results, medications, and preventive health measures.  The biggest problems with security seem to be the smaller corporations and physician offices which have less financial resources to pay for security.  

I have seen medicine grow from paper to pixels, documents to digital, charts to computers and facing-the-patient to staring-at-the-screen. The idea of connecting a computer with personal physician-patient information on it has been uncomfortable to many physicians, some because of privacy, and others because of belligerence.

Even the wealthy, internet-everything Google, which championed "Google Health" as an internet center for people to store their medical information and share with their healthcare providers, abandoned it in 2013 because they couldn't get enough people interested in placing their information on the internet.  (I signed my yellow lab up for an account - "Hobbes Littleton, do you know your cholesterol?" - my 125 pound bacon-eating dog didn't care).

At twenty dollars a chart, medical records are going to be targeted. Count on it. The FBI has warned the industry, and when a breach occurs, they will no doubt remind us they told us so.

Someone, somewhere will hack into a system, or steal the information with a jump drive, and sell it an make an illicit bounty on the internet.  But in a malicious side-thought, they will release the pharmacy records of all the men who obtained prescriptions for those, well, THOSE, pills - you know, "The Blue and The Bathtub Pills."

It will be Pandora's Pill Box.

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His new office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com.

Where's My Doctor?

Doc: Why doesn't my physician see me anymore when I'm in the hospital? 

A: It usually isn't because your physician doesn't want to, rather, it has more to do with the mechanisms of actually caring for a patient in a hospital becoming so complex.  

A trend in medicine began in the mid 1990's for some physicians to only work in a hospital, caring for patients admitted for treatment, whether it be a regular floor room or ICU, and then discharging the patient home to see their family physician for follow up.  It began as a service for physicians in large groups who would have to drive long distances to a hospital, often spending more time on the road than actually seeing patients. 

The New England Journal of Medicine then coined the word "Hospitalist" in 1996.  It has become a commonly used phrase now for the physicians who only work in a hospital caring for admitted patients. These are usually highly skilled physicians for whom the sickest and most critical patients are as routine as the sun coming up in the morning. The studies have shown they provide excellent care in most cases. 

The trend has rapidly increased with momentum as there are now residencies (the three to six years of training a physician undergo after medical school) which focus on training physicians for this roll and groups of physicians who work to staff several hospitals in a region as their sole focus. 

At first glance, quite a few patients may think that their physician is simply now taking the easy road and trying to coast along toward retirement not wanting to be with their patients in a hospital when they are the sickest.  Nothing could be further from the truth.  The fact is it takes nearly three times as long to deal with the process of managing a patient's care than it does for actually diagnosing and deciding what to do for that patient.  

This is true of all hospitals, not just a select few, because of the government, credentialing, and insurance regulations and requirements. 

All admissions to a hospital are reviewed for appropriateness simply because an unnecessary admission, in the eyes of the payer, will not be reimbursed.  This means it is critical for the nurses, pharmacists, physical therapists, social workers, discharge coordinators, dietitians and physicians to document, document, document.  Document everything because someone, sitting hundreds of miles away, will review the admission and one simple thing can cause the entire admission to be denied meaning no payment for the hospital or physician. This is the primary reason a discharge takes over 4 hours in most cases. 

I clearly remember sitting next to a talented hospitalist in the doctor's dictation room as she was on the phone to "case review" physician in Minneapolis trying to convince him the patient actually needed to be in the hospital.  She had been on the phone for nearly forty minutes to no avail and he was going to deny the admission in spite of the fact that she,  skilled physician looking at the patient, was adamant the patient was sick. 

At that moment, the nurse ran in the room informing the hospitalist that the patient was "coding", meaning had gone into cardiac arrest. She slammed the phone down and ran to care for the patient. 

If the hospitalist had been with the patient, instead of trying to convince a physician hundreds of miles away that the patient was sick, it is arguable that the patient would not have coded.    

The requirement of electronic medical records is a reason some physicians have left hospitals, and even more are leaving the profession altogether.  Anyone who has ever purchased a new computer, or upgraded, or obtained a new word processing software, knows how frustrating it can be to learn.  Imagine being responsible for a very sick patient and the only way to enter orders is through a program which may, or may not, have been well designed by people who actually use it. 

Case review is also time consuming.  Even months after an admission has been completed a physician may have to spend time clarifying details of an admission to satisfy regulations and requirements in place by the payers of healthcare. It can be extraordinarily difficult figuring out why a person behind a desk in another state is picking apart an admission for denial of payment. 

Many physicians will still make "social" rounds to see their patients because of the bond they feel with those they see in the office. 

The realities of time and complexities of satisfying regulations have created this hospitalist trend.  It is the further "industrialization of medicine" and in the hearts of many physicians, including my own, who try to be old-school - it is a sad, but understandable, reality.   

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  

The Medicine of Marriage

Q:  Doc, my wife made this appointment because she's worried about me.  I think I'm okay.  

A:  Well, it's nice to see she still loves you in spite of how stubborn you are.  Medical research now says you might live longer because of your marriage. 

I was told once by a patient who had known both good and bad marriages that a good marriage was like living on a mountain of joy and happiness and a bad marriage was like living in the valley of hell-fire on a daily basis.  He spoke with authority. 

Modern research is (again) noticing the advantages of marriage as a study was released this past weekend at the American College of Cardiology 2014 Scientific Session.  The results of studying 3.5 million people across the United States showed a 5% reduction in cardiovascular (CV) disease for married couples over single, divorced and widowed individuals. 

The married individuals were noted as having less cerebrovascular disease (stroke), coronary artery disease (heart attacks), abdominal aortic aneurysms, and peripheral vascular disease.  

Curiously, being divorced or widowed was associated with an increased risk of all vascular disease compared to people who have had never been married. Maybe it isn't better to have loved and lost than to never have loved at all. I doubt it. 

One of the commenters on the study, Dr Vera Bittner (University of Alabama, Birmingham) made this interesting quote:  "This . . . drives home the point that we cannot estimate CV risk purely on metabolic abnormalities that we can measure; psychosocial variables can also be very important. [This] adds to the literature on domains such as depression, hostility, stress without control, and social support and in general deserves further exploration."

In short, personal and mental stress causes heart attacks, strokes, etc. and a loving spouse may likely reduce the risk of this. On the other hand, a nasty divorce with a bitter ex- might lead to it. And yet, the loss of a long time beloved spouse may also be a significant contributor to cardiovascular disease. 

We discuss diets and exercise, measure our blood pressure and cholesterol, think about our medicines and whether or not they are helping, and worry over commercials that blare from the television.  Now science is warming to the idea that the worry, or "depression, hostility, stress without control" might be leading to cardiovascular disease.  

Nice to see science catching up with common sense.  

I can't count the number of times I've been asked "does stress lead to heart attacks?" usually from a person who is under a tremendous burden. 

But personal stress, the kind that hits to the core of us, who we are behind closed doors, from the person who knows the most about us, seems to have a real, physical impact on the level of the arteries.  The opposite, close loving support and a positive relationship, seems to provide some protection.  

It is remarkable to see a spouse who has lost their partner of over fifty years grieve with tears on every breath.  Teenagers and young adults seem to feel they have a corner on passionate and deep love, but my experience tells me otherwise. It is a lie to believe that all marriages are most loving at their inception and less so as the years go by.  There's no other way to put it.  Some marriages in their fifty plus years humble me in how they care for each other, with an occasional grumble, but a quick smile or touch of the hand and all is well.  There is powerful medicine in that kind of love, harmony, acceptance-with-all-faults-known, and forgiving kindness.  

The opposite is unfortunately true, too.  I've seen spouses released from a bondage of trapped torment when their marriage is over, either by death or divorce.  It is like watching someone walk out of prison to enjoy a new life of the things they missed out on.  These are the couples who look nice and happy in public and church, but behind closed door live a life of harsh words, separate beds, lots of alcohol (in spite of a public teetotaling perception) and hours on the computer or TV to take their minds off their personal life. Their health clearly takes a toll from the negativity of a difficult relationship, as we can lie to the world forever, but we can't lie to ourselves for long. 

There is a practical component to the positive effects of a good marriage.  I recently saw a man in the office who was convinced for four days his chest pain was reflux.  If his loving wife had not persisted, he would be in a grave right now.  His scar from his bypass surgery is healing nicely. She also is making sure he takes his medicine and makes his follow up appointments.  

The research, no doubt, will continue into the impact of the mind and emotions on our physical body.  

To anyone who has been in a stressful, anxious and hostile relationship and then lived in a loving, accepting relationship, there isn't much about its impact on the physical body they don't know.  I've seen everything from rashes to heart attacks caused by stress.

A wise older man who's been married to a 'determined' (I was told not to use the phrase 'high maintenance') woman for over sixty years told me this, "You fall in and out of love many times over the years.  You just keep trying and make it work.  And it does."

Hopefully, the vast majority of us will know that kind of love.  It's good medicine. 

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His new office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com. 

Nothing Works for Concussions

Q:  I've heard a lot about concussions recently. What is the best way to treat them? 

A:  Do nothing.  Absolutely nothing.  And it seems to work well.  

Concussions have been a significant focus of attention in medicine and media in recent years because of the feared consequenses of multiple concussions contributing to impaired thinking, memory loss, depression, and irratic behaviour later in life.  A lawsuit by former NFL players has brought this issue to the forefront in the news from a medical and financial standpoint. 

There are more questions than answers, but progress is being made.  Coaches, trainers and officials are much more aware of an athletes behaviour during a ballgame and will bench a player if suspected of having a concussion.  Sideline screening tests are more reliable and testing performed before the season can be used to assess a players level of concussion in the days between games.  

But what is the best treatment for a concussion? It is difficult to evaluate because concussions are not easy to measure.  There is no scan or blood test that will give an indication of injury, outside a rare, severe life threatening bleed on the brain which can also occur in sports. 

A recent study in the Journal Pediatrics shed some interesting light on a trend we may see in concussion treatment.  

It foung that 'nothing' works for concussion.  

No, really, nothing.  As in no reading, no school attendance, no school work, no school tests, no athletic practice and no strenuous activity.  

This is the point that teenage athletes are saying "Yes!". 

But the study went on to say no texting, no video games, no loud music, minimal TV and minimal thinking or conversations. Simply, lie in bed quietly with no interactions at all. 

Teenage athletes: "Huh?!"

Minimal thinking might be easily embraced by teenagers, but no texting, video games, loud music or TV? For at least five days? Or until they start improving? Good luck with that one. 

The teenage athlete might not be very excited with this new suggested remedy. 

The study showed in a group of about 350 athletes with concussions, those who stuck with the Nothing Therapy were usually symptom free after 40 days.  The athletes who were allowed to continue texting, school work, video games and all the other common mental activities of teenagers while they recovered, had symptoms last until nearly 100 days.  

That is a significant difference. 

The current theory is that a storm of chemicals are released in the brain after blunt trauma affecting the membranes of the cells of the brain.  The absense of mental activity supposedly allows the brain to "heal" itself, restoring normal chemical levels and repairing the walls of the cells membranes. 

It makes sense, actually, in a common sense kind of way.  Athletes with concussions often don't want to hear a lot of noise, have trouble focussing on school work, and try to avoid bright lights.  The brain simply is telling the body what is needs to heal.  

But it makes me wonder about this form of therapy and whether there is a bigger lesson here for all of us.  

Could it be that time away from the daily digital display, data and information flood, audio avalanche (even from the shelves in stores as we shop) takes a toll if we don't take time away from it all and enjoy nothing?  Literally, nothing? 

Maybe this is part of the reason a hike in the mountain seems to provide such mental clarity.  Or maybe sitting on a beach enjoying nothing but sunshine and the sounds of the waves coming ashore.  

Maybe that vacation needs to have less details and more sitting tails. 

Maybe we need to consider the value of finding time, say, oh, weekly, to rest, with minimal input or activity from the outside world and allow our minds to rest and recover from the constant input we receive during the week.  Or else, we too, might be prone to depression, anxiety, difficulty with remembering things and other such conditions.  It would be interesting to research.  

Maybe science of concussion research will lead to the suggestoin we take one day a week, or a portion of one day, to completely rest our brains. To allow healing.  To allow the "chemicals" to come back into a balance. 

Fascinating.  Seems like I've read about the idea of taking one day a week to rest before. 

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His new office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com. 

The Posicor Rule

Doc:  I heard of this new drug, Dangitol, that treats anxiety. Will you prescribe it? (Okay, I stretched that a bit.)

Answer:  Nope. Don’t drive a car that is in its first year of production and don’t be the first to try a new drug. 

I call this my “Posicor Rule” as I learned a tough lesson with the drug Posicor in 1998.  Roche Laboratories launched a new blood pressure pill names “Posicor” in 1997 with a lot of promotion and a lot of hype.  It was a new branch in an old class of medicines, appeared safe, and really worked well.  

Until it seemingly started killing people.  

Unfortunately the studies had not thoroughly covered all of the drug interactions that could occur and a commonly used cholesterol medicine apparently didn’t get along with Posicor too well.  The liver was the battle ground, and reportedly several patients died.  

Roche, a responsible company, immediately pulled the drug from the market and braced for the lawyer commercials. Nevertheless, I was stuck with several patients I had placed on the medicine and didn’t have any way to know which ones to call. (This is a quickly resolved problem now with electronic medical records.)

So I waited.  Waited for the refill requests to come from the pharmacy in order to know who to change medicines for, or for the patient to call in.  Many people weren’t on the internet in 1998 so the information did not quickly spread. While I waited, I decided I would never write a drug that has not been on the market for at least eighteen months. 

That was a good decision, too. 

The FDA has a very thorough process for evaluating drugs prior to release. Seeing the drug used for years in Europe and Asia usually helps approval, but not always.  Some companies spend hundreds of millions of dollars on a drug and then have to abandon the research.  That is why when one is released to the market, it now gets a lot of publicity. 

One drug, which we will call “Poopease” for sake of discussion, came on the market in 1998 to help women, only women, with abdominal pain and constipation.  I thought it was odd that a drug knew if it was in a male or female’s gut, but the drug rep persisted.  She was plucked from some modeling agency or dance team, given some basic education of the drug, and sent out with her Brooklyn accent and attitude to promote this new drug to doctors in Georgia (where I lived at the time). 

She was pushy.  Lots of perfume.  Even more smiles.  The ladies in my office didn’t like her or what she wore.  Or at least tried to wear. Her third time back she said ‘Dr. Littleton, don’t you WANT to help you women patients with abdominal pain?” and that was when I asked her to not come back, partly for the Posicor Rule, and simply because she wasn’t professional.  

She didn’t come back when the drug was recalled, either. 

Or the diabetic drug when it was subtly implied I wasn’t on the cutting edge of caring for my patients if I didn’t write it.  It killed patients with pancreatitis, an incredibly painful way to die. It, too, was pulled from the market. Posicor Rule, again. 

Bextra and Vioxx, however, were a little different. Both were on the market for years and I found they were very successful in treating arthritis and inflammation.  The FDA determined the risk for cardiac complications (heart attack and congestive heart failure) were too great and both were pulled from the market.  I literally had patients in tears when they learned they had to give up these meds as they truly worked well.  A few offered to sign waivers hoping the company would supply them with the meds for their pain. 

So when you see an ad on TV, during the news, showing happy people smiling and enjoying life while a soap opera voice talks about side effects that are worse than the disease, keep in mind those are usually newer medicines with potential unknown secrets.  Maybe it is a great drug that will extend life, reduce hospitalizations, and keep a person functional.  Or maybe it will be appearing in a lawyer commercial next year.  (I’ve often thought they should show  people at the pharmacy when they see the price of the new drug instead of sitting in bathtubs).

The Posicor Rule isn’t perfect, but it has served well.  No rule is perfect, but neither is the hype that often accompanies the launch of a new drug.  

Medicine as a Profession

Q:  Do the physicians you know still enjoy being in medicine with all of the changes that are occurring? 

A:  That is a tough question to answer, because physicians are trained to analyze a situation and focus on what is wrong in order to remedy it.  It seems as if our current medical climate breeds negativity from the television commentators to the physician lounge.  

Recent surveys also note that the majority of physicians no longer encourage their children to become physicians out of their own frustration.  That is truly sad, because families that seem to grow generations of physicians seemingly have more brilliant physicians with each generation. 

One of the beautiful things about this profession, though, will never be taken away by laws, computers, prior authorizations, co-pays, financial goals, meaningful use guidelines, and government oversight:  the relationships with fellow physicians and patients.  

I have known some brilliant physicians in my years of training and private practice and learned from them things that cannot be written in books or programmed into a computer. Mostly it is the bulldoggedness to try to figure out what is going on with a patient, keeping up with the latest in medicine, and the perspective that healed doesn't mean cured, and cured doesn't mean healed. 

I've also learned that the best physicians recognize their own personal weaknesses and demons and find a way to to overcome themselves in order to serve their patients.  It is a sort of peace that we all live and die, we should make every effort to try to live healthier. But, again, we all live and die. 

I remember the older, gray-haired, retired physician in Memphis who thought it would be fun to go back to medical school after retiring from 40 years of medicine to "see what they are teaching." He hung in there but had the same appearance of a weather reporter standing out in a hurricane.  The massive amount of information taught was the thing that overwhelmed him.  And the absence of the teaching of the art of medicine is what saddened him.  His report to the Dean changed the curriculum in the medical school for the better. 

Another older attending physician in Memphis clearly stands out.  After his group of green medical students visited thirty patients in the nursing home, read the foot thick charts, and presented the patients (whom he knew like the back of his hand), one turned to him and asked, "why are they all worried about their bowels?".  His response was a lesson I've never forgotten.  "Lads," he said, "when you are young you worry about sex and when you are old you worry about bowels.  Middle age is when you worry about both." 

The older physicians I have learned from have taught me a lot and those relationships I have cherished and will never forget. 

Dr. Randy Robinson was one of my attendings in residency who had been a 24/7, baby delivering, treat-it-all doc in the mountains of North Carolina prior to his roll as a teacher of snotty nose overconfident residents.  He could cut the cockiness out of a resident or medical student with one question sending them on an hours journey of reading to learn.  One afternoon he helped me shovel dirt at my house, pitched our resident softball game later that night and hammered me on an EKG the next morning at morning report. I never wanted to be unprepared when presenting a patient to him.  I vividly remember the ones where I wasn't. 

Dr. Joel Todino was another who could with grace and a smile lead a struggling nervous medical student through the basics of patient presentation which is the backbone of all physician communication.  He had seen it all, read the first EKG ever printed in Rome, Georgia, and had a collection of classic music that would rival the Smithsonian. He could reason through a jungle of medical facts and enjoy Beethoven that night while eating a salad grown in his garden.  He was not only a Renaissance man, he taught it.  

The late Dr Ed Wear of Sevierville will always be one of my favorites.  I had to be informally interviewed by him to be approved to move to Sevierville, and that is where my learning started from him.  I could never stump him.  If I had a puzzling medical case, a quick phone call to Dr. Wear, two minutes on the phone, and a quick change of plan or specialist seemingly resolved my problem.  But he taught me more than medical facts.  I learned from him that everyone, physicians included, have personal obstacles, and even demons, we battle everyday and that is AS real a condition as blood pressure.   Sometimes we can make a difference, and sometimes we can't.  He taught me to keep learning both the science and the art of medicine, and how to make things uncomfortable for the pencil pushers of medicine when necessary. I still miss him.  

There are several other physicians in this region whom I still trust and enjoy learning from - both medicine and life.  Along with the lessons I've learned from thousands of patients, the wisdom of fellow physicians makes this a rewarding career.  Even with the red-tape. 

I do not encourage young adults to go into medicine.  I don't discourage it, either.  That's a very personal choice that should come from the core of a person's being.  Nevertheless, the relationships with patients and discussions with my fellow physicians on subjects that only physicians share about life, death, and our personal lives, still make it a wonderful profession. 

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His new office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com. 

This is Your TV On Drugs

Doc:  Does anyone ever ask for one of those advertised drugs after hearing all of the possible side effects the drugs can cause? 

A:  Yes.  And if they go to the pharmacy to get the medication, they call back asking why the drug cost so much or their insurance won't cover it.  

The pharmaceutical industry spent $27 billion in America in 2012 on marketing medications to doctors and “direct to consumer” advertising.  “Direct to consumer” advertising is best known for the television commercials that interrupt dinner or a football game with words that are rarely used around the dinner table or in mixed company.  It also includes print media such as newspaper and magazines. 

According to a Pew Charitable Trust report, $3 billion of the $27 billion was spent on advertising to consumers in 2012.  It is a tightly regulated process with the FDA serving as the overseer.  

The television commercials for directly marketing to consumers began in 1997 when the FDA eased regulations on the industry.  Only two countries allow this type of advertising: the United States and New Zealand. The words used are carefully chosen and each ad must included potential reactions and side effects.  

It works, too.  Research has shown that consumers believe only “safe” drugs are advertised and that one in three will actually ask their physician about an ad.  Physicians find themselves either defending why it isn’t appropriate, or when it would be, or that there is a suitable generic alternative that is reasonably acceptable for the same condition. 

The description of the side effects and reactions that we have all learned to tune out after the nausea from the ad sets in, are common ones seen in research and required by the FDA to dispel the myth that any drug is completely safe.  

Think about it, though.  What if bottled water was advertised in the same way? 

“Big Pharma’s new drink, Aichtoome, the generic name ‘waterterizam’, has been shown to cause frequent urination, abdominal bloating, a sense of coldness, frequent diarrhea, and strange taste in the mouth.  Some reports of coughing or even choking have occurred with Aichtoome.  Others have experienced Aichtoome reflux with a cold sensation in the chest area.  A rare occurance of Aichtoome flying out of the nose has occurred if laughing while consuming Aichtoome….” 

The point is that any product can have side effects and drugs clearly can have some life-threatening complications from being used simply as they are intended.  That is why a conversation about the risks and benefits of using a drug should occur and the information printed for patients should be read.  Some patients choose to proceed, others decide to wait it out.  

An informed patient is a good thing.  A paranoid patient who is afraid of every side effect they hear or read should have a long conversation with their physician before ever taking the medication in question. 

As a physician, I believe the advertisements are good for discussion, with one glaring, unexcusable, unnecessary, and uncalled-for exception.  

It is the ED ads.  And I don’t mean the “emergency department,” either. 

I would defy anyone to find any man over the age of twenty-one who is not aware of the three prescription products available to turn back time in the privacy of their bedroom most likely with a spouse who would just as soon spend the $25 dollars each pill costs on a nice dinner. 

Nevertheless, the ads continue with bluer colors, catchy little jingles, catchier phrases (poor choice of words, I know) and strange scenes with two bathtubs.  I always wondered why two bathtubs and not one.  

The problem, and I must emphasize, MAJOR problem I have with these ads is the precautionary verbage at the end of the ad.  You might recall them as the ones when most men giggle and joke about calling their friends.  

What would happen if a man sat next to a child in a city park and said the very same phrases?  And yet, it is perfectly okay for the very same words to blare from the television in the middle of a Saturday afternoon SEC football game?  While the kids are watching with the family?  

And then the child says, “Mommy what does……..mean?”

It is time for the pharmaceutical industry and television broadcasters to reconsider this specific area of advertising.  The children don’t need to hear it, and the spouse wants to save some money for that nice dinner. 

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His new office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com.