What are processed foods, and are they bad for us?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Are Processed Foods Bad for Us?

We hear a lot about eating “real” foods and avoiding overly processed foods. Food writer Michael Pollan famously said his rules for the ideal diet were to 1) eat food, 2) not too much, and 3) mostly plants. He went so far as to say that any food with more than five ingredients, or an ingredient you can’t pronounce, is probably bad for you. But what’s the evidence that this is right?

Thanks to the work of investigators at the NIH, we have new evidence that processed foods should not make up the bulk of our diets. Researchers paid twenty volunteers to live in a research hospital for a month. Ten of them were men, and ten were women. The volunteers were randomly assigned to eat either an “ultra-processed” diet or an unprocessed diet for two weeks. The diets were identical in the number of calories and amount of nutrients like fat, sugar, protein, and fiber. The volunteers were observed closely for food intake, and frequent testing was done to determine how many calories they were burning.

An example “ultra-processed” meal was:

  • steak (Tyson)

  • gravy (McCormick)

  • mashed potatoes (Basic American Foods)

  • margarine (Glenview Farms)

  • corn (canned, Giant)

  • diet lemonade (Crystal Light) with NutriSource fiber (researchers had to add fiber to the drinks in the processed diet to match the fiber of the unprocessed diet)

  • low fat chocolate milk (Nesquik) with NutriSource fiber.

In contrast, the unprocessed meal on the same day was:

  • beef tender roast (Tyson)

  • rice pilaf (basmati rice (Roland) with garlic, onions, sweet peppers and olive oil)

  • steamed broccoli

  • side salad (green leaf lettuce, tomatoes, cucumbers) with balsamic vinaigrette (balsamic vinegar (Nature’s Promise)

  • orange slices

  • pecans (Monarch)

  • salt and pepper (Monarch)

In spite of having equal numbers of calories available to them at every meal and snack, the people eating the processed diet ate about 500 calories per day more than the people eating the unprocessed diet.

After two weeks each person in the study was “crossed over” to the opposite diet from what they’d started on. That is, the processed diet folks started eating the unprocessed diet, and vice-versa.

What the investigators found was dramatic. In spite of having equal numbers of calories available to them at every meal and snack, the people eating the processed diet ate about 500 calories per day more than the people eating the unprocessed diet. This showed up in their weight: the processed dieters weighed, on average, 2 pounds more at the end of two weeks than they did at the start of the diet. All their extra weight was in the form of fat.

This finding could have a real impact on your employees’ health. When you are thinking of food for a large function, or thinking of how to contract food in an on-site cafeteria, it may be worth looking at the NOVA food classification system and working to increase the availability of Group 1 foods, those that are “unaltered following their removal from nature.”

Examples of these would be:

  • vegetables

  • fruits

  • potatoes (fresh, packaged, cut, chilled, or frozen)

  • whole-grain wheat, oats and other cereals

  • eggs

  • fresh, chilled or frozen meat, poultry, fish and seafood

  • pasta, couscous, and polenta

  • milk or yogurt without added sugar

Bon appetit.

Fiction: The Dispensation of Hugs

To better understand Dr. Philip Cox’s sudden activism, it’s worth putting yourself in his shoes. After yet another strained call with a clinic administrator who insists that you need to see more patients, to increase your “productivity,” you knock twice on an exam room door. You enter to the smell of mint and ashtrays, and you greet a rail-thin woman who appears at least ten years older than her stated age. She has scheduled this appointment because she is in desperate need of a prescription for medical marijuana. Through the standard give-and-take of the usual rushed interview and examination, she describes hours upon hours of physical therapy daily for her chronic back pain, so much therapy, in fact, that it leaves little time to do anything else with her day (you know, she says, because she’s too busy with the therapy and whatnot. And besides, she thinks she might have the glaucoma. And she’s been a little nauseous.).

You do your best to let her down easy. You explain that her other medical conditions--to say nothing of the drug enforcement laws in your state--collectively constitute a set of strict contraindications for the prescribing of medical cannabis. And maybe since you’ve made the decision not to mention her history of repeatedly positive drug screens (positive, that is, for a number of synthetic and naturally occurring substances that neither mainstream nor holistic medicine have found to be of therapeutic value), she becomes tearful and thanks you for the seven minutes that the modern medical-industrial complex allows for such interactions.

She stands and strategically positions herself between you and the exam room door. You extend your hand and offer a final “Try these suggestions and we’ll see where you stand in three months.” But so thankful is she for your time and attention, you think, that she grasps your extended hand and pulls your body toward hers. There’s some initial confusion in regards to which arm goes over and which goes under, and maybe this results in some unintentional contact with her hips or flank. You worry about what the risk management department would have to say about such intimacy. Then you wonder: What does she want?

Suddenly (though time compresses a little here) your necks are in contact. There’s the blanch of a tear between your skin and hers, and her makeup stains your collar. Her hair crunches against your temple. Her breath warms your neck. You awkwardly place your hands over her shoulders and feel the crease of her bra strap over a shoulder blade. After three or four seconds of embrace, heavy sighs, the styptic smell of burnt tobacco, the sweet top notes of cheap perfume, and the casual exchange of bodily fluids, the patient takes a deep, premeditated breath.

“You know what? I lost that last prescription for my pain pills. Would you mind giving me a new ‘script now?” As you release and back away, she unleashes a hollow, rattling, expectorating cough into an unwashed hand, and you feel the mist on your face. You don’t have the heart to show her the pharmacy’s record of the last narcotic prescription having been filled or the missed appointment slips from the physical therapist’s office. Here is a patient who wanted a hug.

So enough with hugging, Phil had decided. There would be exceptions: he felt a sincere, oxytocin-tinged pleasure at the contact of his wife’s body against his. And he felt nothing uncomfortable about hugging his children, not even his awkward, blossoming tween daughter. But the rest of the world was, he had decided, going to have a hard time meeting the Phil Cox threshold for hugworthiness.

...

As Phil pedaled home from that day’s clinic he rode a steady, floating wave of euphoria. He parked his bike in the garage and almost skipped to the door. He approached his wife in the kitchen embracing their tearful eleven-year old daughter.

“I’ve made a decision,” he said. He was pleased with the Churchillian commitment of his voice in his head.

His wife looked up from the soft receding sobs of their daughter. “I can’t wait to hear all about it,” she said. Phil couldn’t quite interpret the look on her face.

“No more hugs,” he said. He couldn’t help but smile as he said it. “I’m on the first train out of huggy-town.”

“What are you talking about?” she asked. She let go of their daughter, who heel-toed down the hall toward her room, crying as she went. Phil’s wife began assembling grilled-cheese sandwiches.

“All the hugs. I’m done with them. I’m the newly elected Mayor of Mind Your own Business City.” His wife looked past him down the hall.

“You mean the kids? She was just upset about an audition. Wizard of Oz. Dorothy.”

“No, no, not the kids,” he replied. “All the other people that are always trying to hug me. Do you know that of the twenty people I saw today, fourteen tried to hug me on the way out? Men, women, everybody.”

“It just means they like you,” she replied.

“That’s just the thing. It has nothing to do with liking me. I’m the messenger of doom in there. I spend all day telling people what I won’t or can’t do for them. They have no reason to like me at all. They hug because they’ve somehow been programmed to hug. It’s the new handshake. And let me tell you: I for one do not want our kids growing up in a world where hugs replace handshakes.” He was happy with this little piece of improv. He’d managed to bring the kids’ welfare into the argument. He went on: “The entire patient interaction is driven by me right up until the end. The patients hardly talk. I keep doing what I’m doing, and people seem pretty happy, and then…” he paused. “They all of a sudden try to hug something out of me.”

“That seems a little dramatic. I hardly get hugged at all,” she said.

“But you’re a gynecologist.” Phil made a pointing gesture with the first two fingers of his right hand. “Half your patients feel traumatized by you by the end of the visit, what with the specula and the probing and whatnot.” His wife tilted her head. He could feel his  argument getting away from him. “I’m just saying, my patients and I have an implicit understanding that most of my job is to protect them from themselves: don’t smoke, don’t drink, take your medicines, but don’t take drugs.” He framed “medicines” and “drugs” with air quotes. “You, on the other hand, are coming at half-naked people with medieval torture instruments. Is a patient in a paper gown, open in the front,” he drew his hands across his chest and posed Mick Jagger-style to insinuate breasts exposed by the flimsy gown, “going to de-stirrup, jump off the table and give you a good, old-fashioned bear hug? No, of course not. So you’re protected, at least at work.”

“Well, I don’t get hugged that much outside of work, either,” she said as she reached for the bread.

“Um, your brother-in-law? I wouldn’t be surprised if that guy hugs the drive-through cashier. I’m always fighting him off, and I’m not an attractive…” he started to say ‘middle-aged woman,’ but stopped himself. “...hot little thing like you.”

She furrowed her brow and shook her head. “You know Dwayne comes from a tough background. He’s just happy to be in a family now where he’s loved. He asked if you were coming to the wedding next weekend. Are we still in for the $500 for a gift?”

“I suspect that decision’s not up to me. But if I go, I could stand a little less of the physical act of love from him. When two men hug, it’s like 75, 80 percent erection.”

“Dwayne gets you going, huh?” She aggressively flipped a grilled-cheese.

“No, God, no. Not even if I was gay.” Phil pantomimed a dry-heave. “Goatee and belt buckles? But you know what I mean. Or maybe you don’t. As a male, you spend most of your life trying to avoid public erections. It’s just the facts of life. One day you’re hugging your aunt and you feel this little acorn in your pants, and then...well, men just don’t like having their stuff touch. The other day I was at QuickTrip using the urinal. I heard this guttural noise--’gllrrgh’--behind me. I had no idea. I shook it off, zipped, and turned around, and there’s this smiling guy, Down’s Syndrome, maybe? He smiles really wide and makes eye contact with me. His pants were around his knees. He didn’t wait for me to get out of the narrow little stall thing, and as I tried to wriggle out, his penis brushed against my thigh. I thought I might die.”

    “For God’s sake, Phil. You’re a doctor. Get a grip. And what on earth does some poor mentally handicapped guy accidentally touching you with the distal point-oh-one percent of his penis have to do with hugging?”

    “Maybe it’s not a perfect illustration. I got distracted by all the Dwayne talk. But what about the overweight middle-aged guy the other night in the ‘Free Hugs’ tee-shirt?”

“You mean the school custodian? He moonlights at Red Robin as a balloon artist, and he offered to cover the school carnival. All he got out of it was a meal.”

“Yeah, well you know what exchanging physical intimacy for money is called?” Phil asked. “Prostitution. So thank goodness Pervy Custodian Balloon Man was giving the hugs away.”

“Would you calm down?” his wife said. “You’re overthinking this.”

“Did you notice what happened whenever he tried to hug a kid? Who had the power in that situation? Was the kid going to fight him off? No! That hug might have been the cost of doing business to get a balloon giraffe; total power play. The kids were just relieved when it was over. Look, I know ‘hugging’ sounds all nice and innocent, like Dwayne with his ‘Get over here, you,’” here Phil gave a small Nixonian jowl-shake. “But there’s no such thing as a free hug, trust me.”

She sighed. “Oh, I trust you, alright. Is this another phone thing?”

Phil knew what she meant. Last year, in an attempt to meet his corporate overlords’ demands for productivity, he'd decided that he could save a few minutes a day by discontinuing the use of a parting word on the phone. No more goodbyes. It hadn't been a disaster, and he liked the old-timey detective vibe it gave off when he simply ended the conversation and hung up, but Phil had needed to resort back to traditional sign-offs when patients started calling back the office thinking they'd been cut off, thinking that they'd missed out on some little nugget of information that would make their sex life better or get them out of an upcoming CT scan. And one of the office staff had misinterpreted his brusque phone manners as a sure sign she was going to be fired.

“Not even close. I’m taking a stand against the transactional embrace. No emotion, no purpose other than to make people uncomfortable. If you commit and really try to show some sincere affection for the other person, you’re a creep. If you try to abort the hug, you’re an asshole.”

Phil’s wife did not seem impressed.

“Look: I’m trying to get things done in clinic. Real work. And all this hugging gets in the way. And outside of work, well, we’re suffering a crisis of personal space.” He pointed his index fingers toward the floor and drew a circle around himself the diameter of his outstretched arms. “And I’m taking mine back.”

...

Phil’s wife’s niece’s wedding would be a test. He knew what he’d see: the drunken tandem bump-and-grind on the dance floor, the same-side arm neck-crane air-kiss, the shoulders-only three-pat fake embrace, the one-armed “take our picture” and its trashy cousin the “let me feel the outline of your underwear through your satin dress.” Maybe a few bro hugs. The awkward mixing of friends, extended family members, dates trying to fit in, the receiving line: weddings were to hugging what the Javari Valley was to uncontacted tribes. Except that the Javari Valley didn’t have Dwayne Moberly. To Phil, Dwayne was the lost, untamed frontier: a man that came from nowhere and is going nowhere, but is doing it as loudly, and while taking up as much space, as he can. To spend any time with Dwayne was to experience a full-on frontal assault to the senses.

It is worth considering an altogether unremarkable encounter with Phil’s brother-in-law. Maybe you’re at a relative’s house for Thanksgiving. You’re passively learning about the wonders of the Turducken when you’re suddenly thrown off center by a hard slap to the shoulder. Your first instinct is to turn against the perpetrator, but before you can even turn your head you fall prey to the sonic disorientation of Dwayne’s voice in your ear.

“Sonofabitch, great to see you! I wasn’t sure you’d be able to get away. I know you’re busy. Leaving the office costs you guys a lot of money.”

“Uh, good to see you, Dwayne. How about those Sooners, huh? You guys might have a chance this year.”

“Need a running game,” he says matter-of-factly. Then he grasps you by the left shoulder and squares you toward him. Tiny droplets of sweat on his forehead and nose wink in the light. He has tears in his eyes. He initiates intense, uninterrupted eye contact and lowers his voice. His breath reeks of Wild Turkey.

“You don’t know how much it means to me to have you guys as family,” he says, all Hee-Haw and Toby Keith in whispered basso profundo. He puts his left arm over your right shoulder and hooks your left shoulder with his right elbow, wrapping his right arm around your neck. You smell the leather of his Marshall Dillon vest and feel the humidity of his skin through the cotton of his Harley-Davidson shirt. He spills a little of his cocktail on your back, and you, possessing neither the protection of a leather cowboy vest nor the confidence to wear one in public, feel the cold droplets trace a path down your back. Dwayne doesn’t notice. Then he squeezes you. Tight.

“Great to see your wife and kids here. Everybody ok?” you say as you struggle for breath. “How’s the satellite dish business?” The stubble of his beard scratches your cheek and the bristle of his handlebar moustache tickles your ear. The buttons of his vest dig into your chest. His protuberant abdomen juts out over a turquoise belt buckle and presses against yours.

“New belt buckle, Dwayne?” He exhales heavily and steps on your toe. The embrace lasts two seconds too long, and just before you’re released from the maw, he gently sways you to the left, then to the right.

“Grrr,” he says as he shakes, then releases. Axe body spray sticks to you like tar. Here is a greeting from Dwayne Moberly.

...

Nine times out of ten, Phil would go through the receiving line of a wedding reception without complaint. Back-pat hugs would be transacted with unknown relatives from the other side of the wedding aisle, and faux debutante thanks would be sniffled from the bride.

But tonight was not nine times out of ten. Tonight was the debut of Phil 2.0, upgraded to a faster, more efficient operating system that effortlessly deflected intrusions from outsiders into its personal space. He touched the cold, moist corsage pinned to his chest and whispered to himself, good, good. He knew people would want to avoid crushing it. Furthermore, he’d not only steeled himself against unwanted intrusions, practicing eye contact and a firm, extended-arm handshake in the mirror in the days leading up to the event, he’d made the decision to temporarily suspend oral hygiene. Granted, it wasn’t a strategy that had perfect long-term consequences. He couldn’t skip brushing his teeth forever. But he figured that it could be a reasonable strategy to employ for special occasions, like a relief pitcher who is employed only to face left-handed pull-hitters in late innings. His halitosis hadn’t yet been noticed by his wife or kids, and he had a twinge of disappointment that the buffet wasn’t Mediterranean, Italian, or some other cuisine with the punch of onion and garlic behind it. But he could taste three cups of coffee in a battle royale with a bourbon neat and a caesar salad, and his tongue was the battlefield. Morning breath in the afternoon, he thought. He ran his tongue over his teeth and felt an uneven sheen of plaque. He was ready. He took his weaponized halitosis toward the receiving line.

“Hi Dwayne,” Phil said, emphasizing the “H” from the back of his throat. He crossed his arms and kept his mouth open, directed toward its target. “L’chaim! Hhow’s it hhanging hhombre?” He uncrossed and took Dwayne’s right hand in his and held it firm. He figured if he couldn’t fight off a hug from his brother-in-law entirely he could at least limit the damage to a homie hug. He immediately regretted not having called Dwayne “Homie.”

“G-good, Phil,” Dwayne said. He squinted his eyes and flared his nostrils slightly. He turned his head slightly to the right, then looked again at Phil. “The kids sure appreciate you being here, I can tell you that.” Dwayne seemed to recover slightly from the initial onslaught of Phil’s breath and started to bring his chest toward Phil’s.

“Hhell, Dwayne, hhowever we can hhelp we’re hhappy to.” Phil gave Dwayne’s hand one last shake, let go, and moved on to Dwayne’s wife. He grabbed her by both shoulders, kept her at just under arm’s length, and said,”Hhappy wedding. Hhow’s it been, hhot stuff?” He saw a fine mist of saliva enter the air between them as he finished off “stuff.” It had been unintentional, but he wasn’t displeased with it. She flinched, then recovered and responded that she was tired but happy, and that it had been a great day, and it was going to be a great night, and she was so happy to have another person in the family, and she was so happy that Phil had been able to make it.

“Hhallelujah,” Phil responded as he gave her a little stiff-arm shiver, and he moved on to the bride and groom. He was pleased with his ability to keep both of them at arm’s length, so he then briefly hit the bar before the dollar dance.

Phil was at ease with the extravagance of his family’s gift for the bride and groom. Part of it was good old-fashioned pragmatism: young people needed money more than they needed another place-setting, and maybe Dwayne would see it as a peace offering. But a bigger part of his tranquility was the idea that he could exchange the money at the dollar dance and, in the process, disrupt what he saw as a time-honored paean to wasted false intimacy. High on his newfound dominion over his personal space, and through the magic of a twenty dollar tip to the deejay, Phil had conspired to replace the usual swaying, hands-on-hips ceremony of false affection with an opportunity for an improvised pop-and-lock routine. No way his money to the bride could be seen as being in exchange for anything.

Phil approached the bride in line and nodded to the deejay, and the DJ transitioned abruptly from power ballad to the steady, four-on-the-floor thump of a rap song. Phil initiated his dance. Then, as Phil looked up from his robotic march across the dance floor, he saw his niece looking toward Dwayne. He turned toward Dwayne, raised a finger, smiled, and turned on a heel toward the bride. He had something in mind that was going to make Dwayne very happy. He Dougied toward her, pulled a neat roll of $100 bills out of his breast pocket, and held it between his fingers at arm’s length. She reached for the bills, and Phil stylishly dropped the wad into her hand. She stared at it and held her arms out to him. He reached out with the index finger of his left hand, gently placed it on her chin, and pushed her away as he playfully shook his head. He turned back toward Dwayne and couldn’t quite place the look he got. Phil finished his last, choreographed ten seconds of walking it out to the edge of the dance floor.

As Dwayne walked toward him, Phil turned toward the bride and saw the curl of her lip and a first glistening tear. Dwayne cornered Phil near the deejay booth.

“Phil, we got a problem here?”

“Not unless the happy couple has a problem figuring out how to spend five hundred big ones,” Phil said.

“Well, she don’t look none to happy to me, Phil,” Dwayne said as he tilted his head at his daughter, now soldiering on with a wheelchair-bound great-uncle. “Seems like a girl ought to get a little more attention on a day she’s planned for a year.”

“Dwayne, I think the kind of attention you’re talking about oughtta be reserved for the hotel room.” Phil smiled. Dwayne lurched forward and put his face directly in Phil’s.

“I think you’re treading on mighty thin ice, doc. You might wanna think about the next thing that comes out of that mouth.” Phil suddenly felt a strange sense of respect for Dwayne; this was a side of his brother-in-law he’d never seen.

“I...I just wanted her to know that we love her, no strings attached,” said Phil as he looked over Dwayne’s shoulder toward the dance floor. Dwayne’s daughter was back to slow-dancing with a boy of about fourteen. The boy had a noticeable bulge in his slacks.

Phil looked directly at Dwayne: “I think everybody’s having a good time, Dwayne. Great wedding, really. You nailed it. I’m gonna hit the head.” He patted Dwayne on the shoulder, gave an appreciative point to the deejay, and steered toward the bathroom.

Phil’s wife followed him. “Whatever that little ceremony was, knock it off,” she whisper-yelled to Phil through her teeth, her voice echoing off the tile and painted cinderblock of the back hallway.

“Just giving the bride her money for the dollar dance,” Phil said.

“I saw her try to hug you. You had to be cute, didn’t you?”

“Why do you like hugging so much?” Phil said. “You hate smells. Do you like somebody putting their body against yours so you smell like them the rest of the day? Aunt Sallie smells like cigarettes and onions. They aren’t even serving onions here! You hate onions! Why couldn’t you have given her the money?”

“Certain things like hugging or giving the bride money at her dollar dance are just part of the modern social contract,” she said. “The cost of doing business. Like the ‘Would you like to donate a dollar for starving orphans?’ button at the grocery store checkout. Sometimes if the cashier’s looking at you, you just gotta push that button, Phil. It doesn’t matter if you’ve already given a million dollars to charity. Doesn’t matter if you like it. You gotta push it.”

“Well, maybe my job is to shape, not follow, social norms. Maybe that’s my gift to the world.” Phil straightened and puffed his chest a little.

Phil’s wife’s shoulders slumped a little. “Your ‘gift to the world?’ Thanks a lot, Bill Gates. Dwayne asked me if you were okay. What am I supposed to say? That you’ve had a head injury or something? His feelings are hurt. Here he is, biggest night of his life, and he’s the unwitting subject of your little experiment.” Her voice softened a little here. “And Jesus, Phil, chew some gum or something. Your breath smells like the dog’s.”

...

As Phil brushed his teeth in the cold, blue light of a hangover the next morning, he conceded the bad-breath trick had probably been a step too far. And the cell-phone footage of his dollar dance routine was a little incriminating; he seemed to be a minor local YouTube sensation. Hurt feelings had not been his intention. He’d given his wife’s comments some thought. The social contract, she’d said in regards to hugs. But what about the rest of his contracts? Phil wasn’t paid for hugs in his professional life, after all. He did the math quickly: twenty patients per day at twenty seconds per hug equalled at least another patient interaction. Another interaction whose care could be quantified, whose outcome could be neatly defined, and whose data could be shoved back at his masters and their push for efficiency. Last night had been a minor setback. He felt he was ready to move forward, and he was ahead of schedule, to boot.

Phil’s wife had scored tickets to see a stand-up comedian, “Mickey Mac.” Mickey was known for his interaction with the crowd. This led to each show having its own signature moment, many of which were catalogued on Mickey’s website. Phil found seats near the front, stage right. To their left sat a couple with an impressive number of drinks already on their table by the time the opening act wrapped up: two empty beer bottles and two cocktails in varying stages of consumption, along with the drinks the couple were working on now. The couple had mostly ignored the first act, a red-haired prop comic that Phil agreed had leaned a little too hard on the bagpipe/Scottish jokes. But when Mickey Mac took the stage, the couple cheered so loudly that Phil wondered if they were aiming to be part of Mickey’s signature moment that night.

“Mickey! Hey Mickey! Let me take your picture!” the man yelled as the woman leaned over the tiny pedestal table, nearly knocking all the dead soldiers off as she tried to get her face between the camera and the comedian. “Let me take your picture!”

Phil’s face got hot. This was not what he’d paid for. Why were they hijacking the show like this?

“We gotta tell them to shut up,” he whispered to his wife. She shook her head and squeezed his hand. Phil craned his neck and looked for the bouncer. This was exactly what happens to me at work, Phil thought. I know exactly how Mickey feels right now.

Mickey marched on into his set and was well into the setup of his first series of jokes, a series of observations about how men could always tell if they were touching boobs, even through a raincoat, down sweater, and sports bra. You can’t fool a man with shoulder or hip-he knows if that’s tit he’s touching, Mickey said. And after the third or fourth “...take your picture!” Phil couldn’t take anymore. He squirmed in his seat.

“Let him do his job!” Phil yelled. He slapped the table and his drink spilled  onto the floor. The crowd, for the first time all night, fell silent.

Mickey turned to Phil and said, “You mean my man Gordon Parks here?” He pointed at the couple. “Let’s all thank him, everybody, for taking time out of the principal photography for ‘Shaft 2’ to come to the show.” Mickey put the mic on the stand and clapped. The audience hooted and clapped along. Then Mickey squinted at the woman and put his hand over his eyes to block the stage lights.

“And is that Twiggy?” he said. “You’re holding up alright, sister. You be good to my boy Gordon there.”

And that was it. Phil felt a soft rush of relief. The couple hadn’t suffered harm. Mickey had gone on autopilot, had recruited the rest of the crowd to his side, and had made the intruders  melt away. They hadn’t been kicked out of the show. They hadn’t even been treated particularly poorly. Mickey had simply redirected his show by a few degrees to take them on and, in turn, had actually made his show a little better. By the end of the show, Phil wasn’t sure he’d even remember the intruders had been there. And it had happened in no time! Phil figured the whole interaction, the whole process of getting the couple to sit and watch the show like everyone else, had taken less than two minutes.

Phil couldn’t help but compare this to his experiences with patients, whose insincere attempts at goodbye-hugs seemed to drag on forever. And after all, what real value, what therapeutic code, was there to apply to uncomfortable forced embraces? His mind wandered to a gray office cubicle where a mid-level administrator was assigned to the procedure: “CPT Code: 847xx – Embrace, therapeutic; Procedure includes: Qualitative report as positive or negative.” As Phil thought of this, and as Mickey stabbed ahead with his next setup for a series of jokes about how octopuses must have sex, Phil laughed as hard as he’d laughed all night.

...

The next day of clinic proceeded mostly without incident. Phil noticed the first patient of the day seemed a little confused by the abruptness of his goodbye, so he decided to spend just a few seconds longer with each patient as they left the room. He had refined his technique into what he called “The Presidential,” a handshake that involved the placing of his left hand on the patient’s right shoulder for depth control as he shook hands with his right. Then he would move his left hand from the shoulder to the patient’s right hand, clasping and cupping her hand with both of his. Two beats of solid eye contact from a comfortable distance, then break. Politicians used it all the time, and people seemed to love it. His life would no longer resemble an infinite junior high dance. He was a solid, reliable component of the medical machine: all business. He thought of changing his practice to an all-telemedicine venture, felt a blush of excitement, and sent a text message concluding with an emoji (of a woman with her arms crossed in front of her) to his wife. She did not respond.

Not even the prospect of Dwayne on the schedule could dampen his spirits. Dwayne was a bit of a handful to take care of, but not because of the usual reasons. He wasn’t addicted to prescription narcotics, which Phil granted might as well qualify him for sainthood in their city. He wasn’t particularly pushy, nor did he have unrealistic expectations of modern medicine. Phil figured this was because while most fifty-year-olds were watching new episodes of House or marveling at the unrealistic speed and tidiness of forensic medicine crime procedurals, Dwayne was watching reruns of John Wayne epics and Elvis teen beach movies. But still, conversations about erectile dysfunction had their place, and that place was not with your wife’s sister’s redneck husband. And, of course, Dwayne had a particular penchant for the visit-ending hug, a tradition by which Phil 2.0 would not abide. Dwayne was always scheduled for the last visit of the day. Unsurprisingly, he never complained about waiting; he seemed to draw his very life force from conversations with random strangers in the waiting room. Phil was consistently amazed at the depth of knowledge Dwayne had in regards to his patients’ private lives.

By the time he got to Mrs. Beekhuizen, the patient a slot or two ahead of Dwayne, Phil really felt like he was getting somewhere. “Look at me,” he triumphed to his nurse as he curtsied a little. “My shirt collar: unstained. My tie: unwrinkled.” He swept his hands from his chest down past his flanks. “My sense of sovereignty over my personhood untrampled upon. And oooooooon schedule!” He smiled a wide, almost surprised smile, walked to the room, knocked twice, and entered.

Mrs. Beekhuizen’s visit promised nothing out of the ordinary: she was an unlucky sixty-something lady with a smoldering case of terminal breast cancer who’d called wanting to be seen for “sadness.” In the gears of the modern medical machine, this generally meant a diagnosis of depression quickly followed by a prescription for one of several interchangeable, mostly benign drugs.

“Since my husband died, I’ve just been so irritable,” said Mrs. Beekhuizen. “I called the girl who bumped into me in the grocery line a ‘little bitch’ yesterday. Who would do that?” Phil turned to the tablet computer he used for charting and made a couple of jabs and drags with his index finger.

“Hmmm. What else?”

“I don’t sleep at night. I’ve been up since two this morning,” she said. Phil noticed his fingernails needed trimming. His right foot was asleep, so he straightened his leg. He pulled the lever to raise his stool a little.

She sighed. “I’m probably making too much of it all. I just feel so emotional; I cry at nothing.”

She kept talking. Phil looked back up at her. He thought about her mastectomy. Had it made her self-conscious? If he didn’t know about her history, he would not be able to tell she’d had the procedure. He thought about intimacy with such a person. Would it feel lopsided? He stole a glance at the clock. During the final years of hers and her husband’s intimate life, had she taken off her shirt during sex?

“Maybe we’d have both been better off if we’d just died together,” she said.

Phil stood up. “I think you’ll feel better soon,” he said. “I just sent in a script for Zoloft. One a day for three weeks and call me back. Don’t give up on it before then. It takes a while for it to get into your system.”

“Is that all, Dr. Cox?” Mrs. Beekhuizen stood and faced him, smiled softly, and nodded. She started to lean in, but when Phil deployed The Presidential, she startled slightly and looked down. Phil released his two-handed grip and waited for the turn toward the door. He saw the glisten of tears in her eyes, then the slow rise and fall of a first sob. She turned toward the door, whispered,”I’m a monster,” and since it took Phil a half-second longer than normal to interpret the language through the crying, her hand beat his to the doorknob.

“What do you mean, Mrs. Beekhuizen?” he asked, but she was on her way out, her back to him, headed toward the nurse’s station.

“I’m a monster and an amputee,” he heard her say to his nurse as she past.

“You’re all woman,” Phil said in response, then cringed as the words left his mouth. You’re all woman? What is wrong with me?

“She’s all woman?” his nurse whispered to him as she gave him a baffled look, then she and Phil watched Mrs. Beekhuizen take her appointment card and open the door to the clinic lobby.

“Words are hard to choose,” Phil said.

...

It is worth relating the experience of confronting death with a person with whose care you have been charged. You meet, usually in the clinic or in the hospital, but always in a setting in which you as the physician have the power. Your view of the person is focused by the lens of statistics: no advice, no drug, no intervention at all is going to change the cold, hard numbers undergirding her prognosis. She looks at you. Maybe you look over her shoulder and try to feign eye contact. Her eyes find yours again. What is she looking for? What does she think she’ll find in there? Her face slowly transforms from bravery to panic, then maybe to a steady state of fear. You wonder if the loneliness of losing her husband is speeding her death. You move closer to her to show that you’re not afraid of her. You let the catheters and the asymmetry of her body and the smell of iodine and the crust of sanitary dressings touch you. You hear the friction of your hands against the tasteful blouse she’s wearing to cover up the signs of her illness. You don’t move them away. You feel a strange comfort in knowing that vanity persists even to death.

You wonder what else she cares about. Not work, taxes, corporate outsourcing, ISIS, retirement, or an open internet, you think. Her grandchildren? Her cats? The Sunday paper? Good coffee? God? Maybe how many good days she has left? Whatever you feel, whatever oily taste or lump in your throat you swallow, whatever thoughts you have about her or your kids’ school or your wife’s discontentment with your marriage or your own mortality stay a secret.

Your job is to reassure her by your touch that you sense her dignity and her purpose. Your job is to reassure her that she is loved and that people will forgive her for whatever she thinks she’s done wrong. Your job is to ignore the number of beats of the embrace and let her release first, so that by the time you part, by the time she lets go, maybe the tears have started to dry. Your job is not the completion of a simple transaction; it is not the negotiation of some big, sloppy, forced, insincere act. Your job is the dispensing of a therapeutic dose of a medicine that is complex, relational, intense and personal, and it is as carefully dosed as the chemotherapy for which the patient is no longer a candidate. When you release, it is not the patient’s odor or desperation that sticks to you. If dosed carefully, it is some piece of you that departs with the patient. Here is a person who needs a hug.

Phil strode past his nurse without noticing the fleeting brush of her hand against his moist underarm. He pulled open the lobby door, and its moan swiveled the heads of the stragglers in the waiting room.

He started to say,”Mrs. Beek-,” but then he saw Dwayne. Dwayne Moberly, early as usual, in a standing bear hug with a depressed, self-loathing terminal cancer patient, rocking slowly side to side.

“I tell you what, Audrey, Dr. Cox has some unusual methods sometimes, but I tell you, I wouldn’t trust my care to anyone else,” Dwayne said. Mrs. Beekhuizen said something back, but Phil couldn’t hear it. Her voice was muffled by Dwayne’s neck against her face.

Are friends for hire a solution to loneliness?

Just out of college, one of my friends quit his good-paying, stable job at a big midwestern company to start a "jack of all trades" handyman business. He and another of our college friends mowed lawns, rebuilt decks damaged by tornadoes, repaired drywall, fixed sprinkler systems, and did other odd jobs. General handyman stuff. 

One day he was called to a house to change light bulbs. This was a common call; it was easier for people to call him than to get their own ladder and defy death above a stairwell. When he finished, the elderly lady who'd called him offered him a glass of water and a seat while she paid the bill. 

"How much would it cost to have you here weekly?" she asked. Again, this wasn't an uncommon request. Many people kept him on retainer and had him come by periodically to do little jobs. My friend eased into his spiel about the packages he had available, and what services were available at each price point. 

"No, no," she said. "How much would you charge just to come by and talk?"

I don't know what happened after this. Every time I heard him tell the story it ended there with all of us groaning about how sad it all was. How sad that an old lady was so lonely that she was willing to give money for company. The reason I bring the story up at all now is that I just read "How to Hire Fake Friends and Family" by Roc Morin in The Atlantic. 

"[Ishii Yuichi]'s 8-year-old company, Family Romance, provides professional actors to fill any role in the personal lives of clients. With a burgeoning staff of 800 or so actors, ranging from infants to the elderly, the organization prides itself on being able to provide a surrogate for almost any conceivable situation."

Some details are heart-wrenching: single moms hiring men to pose as Dad so they aren't discriminated against. Some of them are creepy: one of those single moms has never broken it to her daughter that Yuichi isn't her real dad after eight years. Some of them are downright strange, like this example of surrogacy that seems right out of an Uday and Qusay tale:

"Usually, I accompany a salaryman who made a mistake. I take the identity of the salaryman myself, then I apologize profusely for his mistake. Have you seen the way we say sorry? You go have to down on your hands and knees on the floor. Your hands have to tremble. So, my client is there standing off to the side—the one who actually made the mistake—and I’m prostrate on the floor writhing around, and the boss is there red-faced as he hurls down abuse from above."

Because of the "Romance" in the company name, I suppose, and to head off the inevitable comparison to prostitution, no, Yuichi and his workers do not provide sex. He claims that they aren't even allowed any physical contact besides hand-holding.

I've written several times in the short life of this blog about the dangers of loneliness. I've spoken about it even more. So this post isn't meant to poke fun at the sometimes bizarre social norms like this that crop up in Japan. They may only be bizarre to my western eye. After all, much of what we do in medicine, particularly in palliation, boils down to the act of being present for a person. And sometimes that's the hardest thing of all. My friend didn't take the lady's money for his company. But even if he had, I think we could argue he'd earned it. 

In the words of Yuichi himself, "It feels like work to care for a real person."

Links for Tuesday, November 21, 2017: more on the new HTN guideline, Gymnastics coaches throwing robot shade, the last iron lungs, Germany bans smartwatches, and Raymond Chandler hated US healthcare

Thoughtful post on the new HTN guideline by Dr. Allen Brett

Representative quote: "Consider, for example, a healthy white 65-year-old male nonsmoker with a BP of 130/80 mm Hg, total cholesterol level of 160 mg/dL, HDL cholesterol of 60 mg/dL, LDL cholesterol of 80 mg/dL, and fasting blood glucose of 80 mg/dL — all favorable numbers. The calculator estimates his 10-year CV risk to be 10.1%, making him eligible for BP-lowering medication under the new guideline. To my knowledge, no compelling evidence exists to support drug therapy for this person."

A gymnastics coach says the Boston Dynamics robot flip was a 3.5/5.0

'In a back salto, says Mazloum, “you want to be able to go as high as you can, and you want to be able to land as close to where you take off as possible.” To do that, the gymnast has to squat, throw her arms up by her ears so her body is a straight line (in gymnast-speak, opening the shoulder angle and the hip), then contract into a “closed” position again. By these standards, Atlas’ trick is “not the cleanest flip,” explains Mazloum.

Here’s Mazloum’s critique: Atlas didn’t quite get to that open position, “so it didn’t really get the full vertical that we look for. That’s why it went backwards a little bit.”'

The last of the iron lungs

Get your kids vaccinated for polio, folks.

Germany has banned smartwatches for kids

If I understand this correctly, it is not because smartwatches cause kids to be distracted monsters (although I don't doubt that that statement is at least a little bit true). The decision stems from the capability of bad guys to hack in and monitor the location of little Dick and Jane:

You have to wonder who thought attaching a low-cost, internet-enabled microphone and a GPS tracker to a kid would be a good idea in the first place. Almost none of the companies offering these “toys” implement reasonable security standards, nor do they typically promise that the data they collect—from your children—won’t be used be used for marketing purposes. If there ever was a time to actually sit down and read the terms and conditions, this was it.
Get your shit together, parents.

Asking parents to destroy them might be a bit of an overreaction, though.

Raymond Chandler paints a dark picture of American healthcare in a newly-discovered story

The title, "It’s All Right – He Only Died," sounds like the title of a video residencies would show interns to convince them that quality improvement and patient safety are part of their job.

The doctor who turned away the patient, Chandler writes, had “disgrace[d] himself as a person, as a healer, as a saviour of life, as a man required by his profession never to turn aside from anyone his long-acquired skill might help or save”.

 

Should young, healthy people with type 1 diabetes take statins?

I encountered this question a couple months ago in a consult and intended to blog about it then, but relatively little trial data was available. I would have essentially been giving my own off-the-cuff opinion. That's very unsatisfying to me, and probably to the reader.

As background: we tend to think of type 1 diabetes as more a need for hormone replacement (insulin) than as a disease state requiring the complex management that type 2 diabetes requires. That is to say that type 1 diabetes, for all the unpleasantness it causes for people, is easier on the blood vessels as a general rule than type 2 diabetes. The ADA has a statement in its guideline that "For patients with diabetes aged <40 years with additional atherosclerotic cardiovascular disease risk factors, consider using moderate-intensity or high-intensity statin and lifestyle therapy." It's a category C recommendation, meaning it's mostly opinion and has a less-than-spectacular evidence base. It also doesn't differentiate between type 1 and type 2 diabetes. Similarly, a joint statement by the ADA and the AHA states that "Adults with T1DM who have abnormal lipids and additional risk factors for CVD (eg, hypertension, obesity, or smoking) who have not developed CVD should be treated with statins." Both statements argue against the routine use of statins in young healthy type 1 diabetics.

But a recent study from the New England Journal helps us with the question of statins in kids, and throws in ACE inhibitors for good measure. Investigators led by M. Loredana Marcovecchio and Scott T. Chiesa randomized 443 kids between 10 and 16 years with type 1 diabetes and urine albumin-to-creatinine ratios in the upper third of "normal" to some combination of ACE inhibitor, statin, and placebo. Creatinine is a consistently excreted product of muscle metabolism that serves as a nice comparator for other things the kidney excretes. So even if you drink a lot of water and dilute the amount of albumin in your urine, we can look at it compared to the similarly diluted creatinine and see if you're excreting too much.

Anyway: the investigators used a 2 x 2 trial design, meaning that there were ultimately four groups: placebo-placebo, placebo-ACEi, placebo-statin, and ACEi-statin. The statin was atorvastatin 10 mg daily, and the ACEi was quinapril 10 mg daily (after titration). They were most interested in the change in albumin excretion (that is, how much protein spilled through the kidneys into the urine). They assessed this according to that same measure, the albumin-to-creatinine ratio in the urine, from three early-morning urine samples obtained every 6 months over about two and a half years. They also looked at secondary outcomes like the new development of microalbuminuria (that is, the new appearance of protein in the urine), worsening of eye disease, changes in kidney function, blood lipid levels, and measures of cardiovascular risk. For the cardiovascular risk, they did ultrasounds of the carotids to measure the thickness of the vessels (carotid intima–media thickness) and measured levels of high-sensitivity C-reactive protein and asymmetric dimethylarginine in the blood. Both of these are generic markers of vascular risk.

After an average of 2.6 years, no benefits were found within the ACEi group, the statin group, or the ACEi+statin group compared to placebo. Unsurprisingly, the ACEi group had a much lower incidence of new microalbuminuria, but "in the context of negative findings for the primary outcome and statistical analysis plan, this lower incidence was not considered significant (hazard ratio, 0.57; 95% confidence interval, 0.35 to 0.94)." Also unsurprisingly, the use of statins resulted in lower cholesterol levels (including, unfortunately, HDL). But neither drug had significant effects on carotid intima–media thickness, C-reactive protein, kidney function, or progression of eye disease.

So we can take away from this small-ish study that, at least in a short amount of time in pretty healthy twelve-year-olds (the subjects were excluded if they had genetically bad lipid levels; the participants' average A1c was ~8.3% and their average blood pressure was 116/65 mmHg), there was no benefit to statins or ace inhibitors. This study will influence my recommendations to patients and other docs in the future. The kicker, naturally, is that many young people with type 1 diabetes have imperfect blood sugar control. What about those who can't get their diabetes controlled? It's a tougher call in that case, and this study didn't address it. 

The Gingerbread Man: an iStory

“You should go as the Gingerbread Man,” she said. “I'll be the fox!”

“It's kind of played out, isn't it? Women as foxes?” I replied.

She glanced at my leg. “Well, I could go as the old lady or the farmer. But you have to be the Gingerbread Man.”

“You could be Little Red Riding Hood and I could be the Big Bad Wolf,” I offered.

“Meh. It just wouldn't be the same. Don't you think this would be fun? You never want to have any fun with this. Shouldn't we take advantage?” She looked down at me again.

I didn't bother to offer Hansel and Gretel.

On Halloween I wore a brown shirt and pinned up the right leg of my brown pants. I left my prosthetic leg at home. I left my crutches home, too, so I leaned on her all night. When we got home, I was just under a quarter gone.

What do we do with a free testosterone?

Put another way: what's the free testosterone cutoff we should use for initiating treatment in potentially hypogonadal men?

Spoiler alert: maybe 70 pg/mL?

Background: a new paper from Anna Goldman, Shalender Bhasin, Frederick Wu, Meenakshi Krishna, Alvin M Matsumoto, and Ravi Jasuja lays out their thoughts on the state of the science in free testosterone measurement. This is important because we currently operate under a theory of "bioavailable testosterone." That is, we think that only testosterone that is unbound by proteins, the most important one called "Sex Hormone Binding Globulin," or SHBG, has any effect on the testosterone receptor. All the testosterone that's floating around attached to SHBG or other proteins is inert.

But like any other hormone, testosterone's binding to SHBG or other proteins is affected by myriad causes, like obesity, other hormonal disorders, and other conditions or medications. Even the temperature at which it's measured. So guidelines from the Endocrine Society suggest measuring free testosterone levels in men whose total testosterone concentrations are low-ish and in men with conditions or medications that make total testosterone measurements less reliable (like obesity). But those same guidelines rely almost entirely on the total testosterone to determine who needs testosterone therapy. From their 2010 guideline:

The panelists disagreed on serum testosterone levels below which testosterone therapy should be offered to older men with symptoms. Depending on the severity of clinical manifestations, some panelists favored treating symptomatic older men with a testosterone level below the lower limit of normal for healthy young men [280–300 ng/dl (9.7–10.4 nmol/liter)]; others favored a level less than 200 ng/dl (6.9 nmol/liter). The panelists who favored treating men who had values less than 300 ng/dl were more influenced by the observation that men who have values below that level often have symptoms that might be attributable to low testosterone. The panelists who favored not treating unless the serum testosterone was as low as 200 ng/dl were more influenced by the lack of testosterone treatment effects in randomized clinical trials when subjects had pretreatment values of 300 ng/dl but suggestions of beneficial effects when the pretreatment values were closer to 200 ng/dl. The lack of definitive studies precludes an unequivocal recommendation and emphasizes the need for additional research. [emphasis mine]

No mention of the free testosterone in there. More research needed, they say. Well, Goldman et al have delivered it, in a way. They didn't do any new investigation, so far as I can tell, but they did review the existing literature pretty thoroughly and come up with a series of conjectures. The most important of these clinically is this (my words, not theirs):

 

Without a harmonized, replicable normal range between laboratories and methods, we cannot set a clinical threshold for free testosterone levels at which we should initiate treatment.

 

The authors point out that in a study by Le et al, only about a quarter of labs performing free testosterone assays would even confirm that they had performed validation studies on their assay. But seeking a clinically relevant answer, they go on to point out that In the Framingham Heart Study, the lower limit of the normal range for the calculated free testosterone for men between 19 and 40 (defined as the 2.5th %ile) was 70 pg/mL (242.7 pmol/L). They do not endorse this as a threshold. But given the lack of other published thresholds, I think it is at least a start. 

One more point before I wrap up: whatever value you or your doctor use, whether it's free testosterone, bioavailable, or total, the number is only one piece of data. A free testosterone of 70 pg/mL in a young man with normal body hair, normal muscles, and a normal libido would not cause me to treat him. That same level in a man with a known pituitary issue, enlarging breasts, and fatigue would definitely cause me to treat him. And I tend not to recommend checks of testosterone in elderly men, even those with fatigue, unless they have other compelling evidence of hypogonadism. And my opinion is generally in line with that of the Endocrine Society:

We recommend against a general policy of offering testosterone therapy to all older men with low testosterone levels. (1|⊕○○○)

We suggest that clinicians consider offering testosterone therapy on an individualized basis to older men with low testosterone levels on more than one occasion and clinically significant symptoms of androgen deficiency, after explicit discussion of the uncertainty about the risks and benefits of testosterone therapy. (2|⊕○○○)

Why else do I hesitate to give testosterone? In a series of trials in JAMA and JAMA internal Medicine earlier this year, men aged 65 and older with a total testosterone level <275 ng/dL plus either sexual or physical dysfunction or reduced "vitality" were randomized to get either testosterone gel (lotion that absorbs through the skin) or placebo for 1 year. The men who got testosterone developed more coronary plaque than the men on placebo. (This may or may not mean anything; in other observational studies, the rate of heart problems was lower in men prescribed testosterone than in untreated men). 

Importantly for the men who tend to come to me with suspected androgen deficiency, though, the men in these studies had no improvement in memory or other measures of brain function.

Testosterone did slightly improve bone density and bone strength compared with placebo. And testosterone seems to have improved the hemoglobin level (the weight of the oxygen-carrying protein in our blood) in anemic men by 1 g/dl more often than placebo did.

If all that sounds confusing, it's because it is. When I was an endocrine fellow, one of my faculty told me that in almost every case, if you don't know what to do, the correct path is to do nothing. So that's the direction I lean in borderline androgen deficiency cases, whether determined by total or free testosterone levels. I lean toward withholding therapy. 

Are triathlons dangerous?

First things first: I've never done a triathlon. I swim like a St. Bernard. But I've done a lot of endurance bike racing, and I've been at more than one event with a death, the most recent the 2017 Dirty Kanza. So I was interested that in the latest Annals of Internal Medicine, investigators looked into a sudden death database to identify 135 race-related deaths and cardiac arrests in American triathlons between 1985 and 2016. Interestingly, right at two-thirds of deaths and arrests happened in the swim part of races, which usually comes first, before the bike and run. The editorialists spend a lot of energy trying to link swimming to some special form of stress from cold water or other factors that might be extra-dangerous. But to me, the swimming link seems consistent with the finding that in autopsies, about half of subjects had cardiovascular abnormalities, most often old-fashioned atherosclerotic disease. Swimming caught most of these people simply because it was the first event. Had running or cycling come first, I suspect one of them might have been the death leader. I'm not convinced by their observation that most marathoners die toward the end of races; anyone who's seen the scrum at the beginning of a triathlon knows that it's inherently different than the often walking pace seen at the start of a marathon: 

From http://www.zwemza.com/?p=5515, triathletes tempting fate.&nbsp;

From http://www.zwemza.com/?p=5515, triathletes tempting fate. 

85% of victims were male, but I'm not sure the significance of that number, since >60% of participants (at least in pro Ironman races) are male:

From https://www.outsideonline.com/1964906/fight-gender-equality-ironman

From https://www.outsideonline.com/1964906/fight-gender-equality-ironman

And if you look at total Ironman competitors, the distribution of sex comes much closer to the death/cardiac arrest statistics:

kona-gender-breakdown-chart.jpg

But sex aside, we're forced to see that cardiac arrest and death are not rare among triathletes. Between 2006 and 2016, their incidence was 1.74 per 100,000 participants in the study. The risk of death increased with increasing age, unsurprisingly. Don't let this dissuade you from being more active. The benefits of physical activity far, far outweigh the risks in almost everyone. If you're inactive now and thinking of becoming active, or if you're active now and thinking of doing really hard-core things like triathlon, consider taking the American College of Sports Medicine's new-ish algorithm to your doctor and talking it over before you hit it really hard:

Original.00005768-201511000-00028.FF2.jpeg

We don't know how really weird stuff like performance enhancing drugs effects this. My suspicion is that it's not good. 

Is it too early for a Halloween reading list?

I picked up a copy of We Have Always Lived in the Castle by Shirley Jackson last week at the library:

You'll be missed, Wichita Public Library. #brutalismforever

You'll be missed, Wichita Public Library. #brutalismforever

It is a Gothic masterwork, and the speculation it allows around the psychopathology of Merricat and the townsfolk who hate her and her sister and uncle is irresistible.

Even though I didn't choose it with the intention of kicking off any kind of Halloween-y creepy reading list, now that I've started The Handmaid's Tale by Margaret Atwood, it seems I've inadvertently waded into Gothic waters. Atwood is incredible, but I'm in the mood for something a little more straightforward. So I've made it official: my next book will be It by Stephen King. I was a voracious King reader as a high-schooler. And a copy of Salem's Lot I found in a call room nightstand once got me through a snowy, slow call night as a resident. I left the book there when I finished, and I have wondered many times since how many residents at Deaconess Medical Center have found that same book and killed a couple hours with it. I know, I know, that King is hardly literary. His is not necessarily the kind of reading that increases empathy, but since It is currently crushing it (see what I did there?) at the box office and in critical reviews, it's time.

Assuming I can get through It's 900+ pages in the next few weeks, what other creepy-crawly books should I attack before All Hallow's Eve?

Once more to the lake for Labor Day

When I read the words in EB White's Once More to the Lake, I ache. His description of the smell of wood, the feel of the water, and the schedule set by the sun gives me a completely unearned sense of nostalgia. Most of my summer (and adult) trips to the lake have been marked by the anodyne scent of an RV air conditioner and the coconut-tainted slip and slide of sunscreen. But I ache for microwaved biscuits and gravy and cheese sandwiches and kool-aid. I can smell the fishy water covering the sandstone shore of Wilson Reservoir. I can see the treeless lunar landscape. 

Wilson Lake Rocktown 2010 (500x375).jpg
Pics from http://www.wilsonks.com/

Pics from http://www.wilsonks.com/

So this is your permission from me--not that you were seeking it--to engage in a Great American Pastime and head to the lake for Labor Day. Do it before the McMansions obliterate any of the charm that EB White talked about:

From http://www.tcbusinessnews.com/millennials-and-mcmansions-are-they-compatible/ &nbsp;Answer? No, I hope.&nbsp;

From http://www.tcbusinessnews.com/millennials-and-mcmansions-are-they-compatible/  Answer? No, I hope. 

 

Do it even though, unlike him, you won't be able to spend a month there. Do it because someday you'll wonder what you've done with your life, and the answer of "I took my [kids/wife/husband/friends/enemies] to the lake once in a while, and we had fun and made memories" is better than "I got high and played a lot of video games."

Happy eclipse day!

Before you see the sun obscured by the moon for yourself, read Annie Dillard's Total Eclipse.

I saw, early in the morning, the sun diminish against a backdrop of sky. I saw a circular piece of that sky appear, suddenly detached, blackened, and backlighted; from nowhere it came and overlapped the sun. It did not look like the moon. It was enormous and black. If I had not read that it was the moon, I could have seen the sight a hundred times and never thought of the moon once.

Follow-up on medical school rank and narcotic prescriptions

I've had several conversations with fellow docs about the NBER paper from last week showing a relationship between medical school rank and narcotic prescriptions. Naturally, the responses I got were pretty skeptical. A recurrent theme I ran across was that the authors didn't pay enough attention to practice setting. 

1. Higher-ranked medical schools tend to produce more students who eventually land in academia, often at higher-ranked medical schools or residency programs.

2. Because of the culture of those high-performing places, characterized by greater access to subspecialists, a slower pace of practice, the presence of trainees to keep you honest and whatnot, you practice more conservatively and without fear of patients firing you for not giving them narcotic prescriptions.

 3. Perhaps people graduating from lesser-ranked schools end up in private practice, where there is more pressure to write a narcotic prescription to all those patients with back pain, just to keep them from 1) firing you, and 2) telling all their friends and family what a crappy, uncaring doctor you are.

4. So the speculated end result is that people graduating from higher-ranked medical schools end up writing fewer narcotic prescriptions than their peers from lower-ranked schools.

I pointed out to several people that the study took into account specialty and location; the relationship held for people in the same specialty and same county. The investigators pontificated on practice setting (noting that DO graduates often take care of a more rural, white population, for instance). But they didn't control for it. So I held my hands up ¯\_(ツ)_/¯ and moved on with my life.

But then I listened to a segment about it on the Weeds podcast today (start at 1:01:25):

UPDATE: I'm having some trouble embedding the audio, so if you can't get it to play, go here: http://bit.ly/2uLk2lY

Sarah, Ezra, and Matthew made note that the relationship held within the same clinic, so I re-visited the paper. I found this: 

Check the footnote. *slaps forehead*

Check the footnote. *slaps forehead*

So the investigators did account for practice setting, but since it was hidden in a footnote, I missed it. 

The take-home from this paper is still kind of hard to identify. I'm not in favor of necessarily checking the LinkedIn page of every doctor you see to check what med school she went to, but there is clearly some kind of relationship between the culture of medical schools and the prescribing behavior of graduates.

The lower-ranked your doctor's medical school, the more likely he'll write you a narcotic prescription

You read that headline right: investigators in an NBER paper found that docs who went to a lower US News-ranked school are more likely to write narcotic prescriptions, and the ones who write narcotic prescriptions are likely to write for more drugs, depending on the ranking of their school. And lordy, those osteopathic schools:

US News publishes several rankings, in topics from research to primary care to women's health. For this paper, the investigators used the "research" ranking, which is difficult to translate into medical student bedside education. After all, some of my best teachers in med school hadn't published a paper in a decade.

Several other take-home points from this. First, at first glance general practitioners write a ton of narcotic prescriptions; their rate on the y-axis is roughly double the overall physician population's. But when you consider that primary care docs perform well over half of all the visits delivered, that number of narc prescriptions looks less impressive.

Second, the effect size, if you're willing to take a leap and go straight to the idea that the quality of research at your medical school somehow has a causative effect on how many hydrocodone prescriptions you write, is huge. Using Harvard as the index school, the schools in the eighties and nineties have graduating docs writing three times as many prescriptions.

My first thought when I read this was that docs who went to lower-ranked schools may end up on places where they're more compelled to write narcotic prescriptions: places with high poverty, or a large blue-collar workforce, for instance. But the investigators accounted for that, and found that the relationship persisted even within the same county:

I can't help but try to apply this research to myself, even though I'm an endocrinologist and therefore mostly shielded from the narcotic game, and even though I see relatively few patients nowadays. But here we go. I attended the University of Kansas, which is comfortably ensconced in a tie at number 65 on the research list:

Oof. Medical school got a lot more expensive in the last couple decades.

Oof. Medical school got a lot more expensive in the last couple decades.

So where would I live in the narc prescribing graph?

Riiiiiiiiight about there. It's a wonder I'm not a bonafide narcotic prescribing machine.&nbsp;

Riiiiiiiiight about there. It's a wonder I'm not a bonafide narcotic prescribing machine. 

What's unsaid in this list is that KU has three campuses (two at the time of my training). And it further goes without saying that the training in Wichita, Salina, or Kansas City may have subtle differences that would lead to slightly different physician performance or behavior. Furthermore, it would be interesting to see the research repeated with residency or fellowship training as the independent variable, since those are the years when trainees really fall into a groove of prescribing habits. If I were held to the standard of my internship with a University of Washington program, I'd be compared to the folks at the skinny end of the graph:

Go dawgs.

Go dawgs.

But if my fellowship training at UNC-Chapel Hill were the standard, I'd be in a nice, comfortable happy medium between the narc-crazed sixties and the narc-stingy pre-teens:

The take-home from this isn't that we should all check our doctors' CVs before we go see them, in fear of them hooking us on oxycodone. It's just that schools who inhabit the lower tiers of medical research need to do a better job of teaching narcotic prescribing. 

And obviously, the take-home for patients is to be very, very careful about requesting narcotics for pain. They don't work as well as we think they do, and the potential for harm is huge. 

I found this link, fwiw, via marginalrevolution.com

Hormonal diseases in literature

I have three favorite pieces of endocrinology-themed fiction.

The short story "Baster" by Jeffrey Eugenides, was featured on this week's New Yorker Fiction podcast. It is in his collection of short stories Fresh Complaint, to be released this fall. "Baster" was adapted into the movie The Switch with Jason Bateman and Jennifer Aniston, but only the first half of the movie, where Wally obsesses over Kassie's impending insemination and eventually switches his own specimen for her better-looking donor's, is drawn from the story. The rest of the movie, dealing with Wally's growing affection for his neurotic son and his eventual confession, are new. 

My absolute favorite piece of endocrinology-related fiction is Middlesex, also by Jeffrey Eugenides.

It tells the story of consanguinous parents of a child born with 5-alpha reductase deficiency, a hormonal disorder in which male children do not make enough of the active male hormone dihydrotestosterone.

The red line is the enzyme defect we're talking about here. Image from Wikipedia.&nbsp;

The red line is the enzyme defect we're talking about here. Image from Wikipedia. 

This causes them to be very feminized at birth, with a micropenis and undescended testicles. They were often raised female before the disorder was well-known. But at the onset of puberty, people with the disorder suddenly and sometimes dramatically get male features. Callie (later Cal) is the narrator, and his gender identity evolves in parallel with the family's experience in immigrating from Asia Minor to Detroit, then to San Francisco. It's fantastic.

Finally, the novel The Amazing Adventures of Kavalier and Klay, by Michael Chabon, has a clever endocrinologic twist at the beginning. 

It starts off with one of the main protagonists, Josef Kavalier, escaping to New York from Prague, Czechoslovakia by being concealed inside the coffin of the Golem of Prague, a clay mannequin, by his magic teacher, Kornblum. The giant clay mannequin is clothed in the suit of a giant obtained from a deceased patient of Josef's endocrinologist father. It's the first of several escapes by Joe in the book (first from Nazi Europe, then from poverty, then from Antarctica, then from loneliness). The book concludes with (spoiler alert) Sammy, his best friend and cousin, escaping from life as a closeted homosexual. Haunting book.