Monday, March 23, 2009


At least one billion people worldwide are overweight (BMI ≥ 25 kg/m2) and at least 300 million are obese (BMI ≥ 30 kg/m2). Obesity is a plaque of developed countries, a direct consequence of increases in energy intake and decreases in energy output. Unfortunately obesity has great consequence to the health of a nation, being linked to numerous chronic diseases. In a study of the western hemisphere, especially Brazil, Mexico, Canada and the United States it was found that the United states had the highest rates of obesity, but the other countries were not far behind. Data also indicates that obesity is increasing every year as underdeveloped countries adopt Western lifestyle habits. As mentioned above the easiest explanation of the cause of obesity is an increased energy intake and decreased energy expenditure, there are however more causes. These stem from familial, social, societal, cultural, governmental, and environmental factors. Because the different causes vary from country to country, making a plan of action to reverse this epidemic can be problematic. A specialized plan should be tailored for each country. Obesity, being preventable in most cases, represents one of the most costly consequences of people’s neglect for preventative medicine. Guidelines for a healthy lifestyle used to promote exercise to be physically fit, a shift has occurred recently to do physical activity to become healthy. The weekly recommendation includes 30 minutes of moderate intensity physical activity 5 days a week or 25 minutes of vigorous physical activity 3 days a week. In addition to one of these options people should do strength training 2 days a week. Increasing physical activity has a greater impact on overall health than any other lifestyle change. All-cause mortality is decreased by increasing physical fitness. With all these things in mind, Americans need to get off their lazy butts and become physically active. Governments need to encourage this as well.

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Doctors' Right of Conscience

The Bush administration put forth a ‘right of conscience’ rule recently (end of 2008) permitting health care professionals to refuse in any procedure they find morally objectionable (this could include abortion, artificial insemination, birth control, etc.). Doctors already had the right to refuse to do abortions by federal laws which have existed for more than thirty years, so what was the objective of the ‘right of conscience’ rule (what does it change)? First of all it covers a broader spectrum of personnel, from the surgeons right on down to the people who clean the instruments. It also allows professionals to not only refuse to do the procedure, but also to refuse giving advice or information to someone wanting the procedure. It's language also suggests that it may cover more than abortion. "The real battle line is the morning-after pill," Dr. David Stevens president of the Christian Medical Association (CMA) said. "This prevents the embryo from implanting. This involves moral complicity. Doctors should not be required to dispense a medication they have a moral objection to." He also stated that “the rule is not limited to abortion, it will protect doctors who do not wish to prescribe birth control or to provide artificial insemination.” Critics of the rule say that it is an attack on patient’s rights to receive proper medical care. Should patients sacrifice their medical care for the religious beliefs of their providers? We have a right to freedom of religion after all, but how far do those boundaries reach? "Although respect for conscience is important, conscientious refusals should be limited if they constitute an imposition of religious or moral beliefs on patients [or] negatively affect a patient's health," American College of Obstetrics and Gynecology (ACOG)'s Committee on Ethics said. It also said physicians have a "duty to refer patients in a timely manner to other providers if they do not feel that they can in conscience provide the standard reproductive services that patients request." Obama has already taken steps toward overturning the bill.

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Saturday, March 21, 2009


Euthanasia is defined as the intentional termination of someone’s life by someone other than the person concerned, at the person’s request. Many people with in the advanced stages of illness will request a physician to help in a painless death. The difficulty in dealing with such requests is to ascertain what reason the request was made. Is it caused by psychological distress, or merely an insincere comment not meant to be interpreted literally as a death wish? Moral issues aside, let’s assume that euthanasia is legal, and the physician is required to respond to such death requests professionally. Discussing the topic of euthanasia with a patient is tricky, the consequences could be emotionally draining, unhelpful to hopefulness, or psychologically harmful to the patient. Another issue is the preparedness of doctors or nurses to respond to desire to die statements (DTDS). That preparedness could include legal and professional knowledge and understanding, saying the right thing at the right time, etc. These fears can lead professionals to ignore DTDSs hindering the patient’s ability to express any psychosocial concerns, thinking that the physician won’t be able to help, or is unconcerned with his/her personal well-being. Another issue regarding DTDSs is that these desires can fluctuate over time. How does a physician gauge the sincerity of such a request? Research suggests that interactions that convey empathy for the patient’s distress and active listening assist psychological adjustment, that information and comprehensive understanding about what to expect in the future promotes psychological well-being, and an opportunity to discuss feelings with a health professional reduces psychosocial distress. In light of these findings, it is important that health care professionals be adequately trained in handling DTDSs and respond to them appropriately. As I said before, I have ignored whether or not physician assisted suicide is morally right or not, my focus is to point out what difficulties arise in responding to a DTDS and what research shows can help a patient in a palliative care setting.

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Stem Cell Research

Stem cell research is a controversial issue. Even in countries that allow embryonic stem cell research, strict principles and procedures have been established. These include limiting the growth of the embryo to 14 days (enough time for the primitive streak to form), informed consent for the donor, patient confidentiality, noncommercialization (i.e. you can’t pay for embryos), avoidance of conflicts of interest, limitations to therapeutic purposes, ethics reviews, and traceability to cell lines with respect to their sources. A developing procedure is able to create stem cells using a woman’s oocyte and adult stem cells which are easily harvested. This is called somatic cell nuclear transfer (SCNT). One problem with this method is that women who donate their oocytes exclusively for research are taking an unnecessary health risk. Up to 10% of the women who undergo ovarian stimulation to procure oocytes experience severe ovarian hyper-stimulation syndrome, which can be painful, lead to renal failure, cause infertility, or even death. We could view these people as research subjects, who willingly submit to risky situations, except most research subjects gain some kind of benefit in return. Physician’s fiduciary obligations would prevent recommendation of such a course of action for no benefit. Altruistic donation seems reasonable when it goes to a family member (an organ transplant for example) but is it ethical to do such for a stranger? Who in their right mind would walk up to the hospital today and donate their kidney with no particular person in mind? Even if one would donate the organ since the benefits of organ transplants are so well established, who would act co altruistically for a procedure like SCNT which has no clearly established benefits? There is a wide gap between research and therapy. Stem cell research needs to be understood as research, not as a therapy that will se immediate results. “Stem cell therapy” is still years away, so donors will not be directly influencing themselves or their loved ones. Understanding of this is important for informed consent of any potential oocyte donors.

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Universal Health Care

This weekend I will be studying various health care issues and posting short blurbs about them. The first one should be very familiar: Universal Health Care. Here's some thoughts:

Is health care a necessity or a luxury? Right now many consider it a luxury, one that requires sacrifice to obtain. People fear that if a universal health care system is put in place it may ruin the quality health care service provided to those fortunate enough to have health care insurance. Sure Medicare provides care for those over 65, and Medicaid for those in poverty, but has this ensured health care is available to anyone who needs it? With increasing health care costs many employers are cutting those benefits leaving many uninsured. When I am a doctor will I have to turn away sick people because they are uninsured, or will I be forced to perform an operation which will replace injury with debt and bankruptcy? Another drawback of the current system is that PPO’s and HMO’s limit the person’s access to health care. It’s not just a matter of will you receive health care, it’s a matter of where can I receive health care. The US system favors specialty doctors (secondary care physicians). This is represented by the portion of doctors that go into primary care (only 13% in the US, compare that to 66% in England). With more and more people not seeing a primary care physician (PCP) preventative medicine gets neglected, replaced by reactionary medicine. In England, the National Health Service (NHS) requires everyone to be screened by a PCP and then referred to a specialist. With everyone required to have their own general practitioner, people are better educated in preventative medicine for chronic diseases (improving health and saving tons of money). There are plenty of drawbacks to the English health care system as well, the most notorious being the long waits to see a doctor (months if not years). Unfortunately there is no direct study comparing the two systems, and until there is a fair conclusion cannot be made judging which provides better quality care.

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Thursday, March 19, 2009

Jehovah Complex

It's strange how physician's are often infamously attributed with what many call a Jehovah complex. With this they don't listen very well to their patients, thinking they are the one's that went to medical school and they are the one's who know everything. Dr. House is the personification of this caricature. Now I chose long ago to pursue a career in medicine, resolving within myself to be open to others opinions and criticism. In learning the Hmong language I was forced to accept the fact that I needed to be teachable. Fluid minds are able to adapt better to new information, they are better apt to exceed in unfamiliar situations.

These observations made, I find myself slipping into a pseudo-Jehovah complex myself this semester. In all my classes I've become that kid who everyone rolls their eyes at because he raises his hand to answer every question in a smug manner (like hermione from the harry potter series). To my acknowledgment this is a new development in my personality, sure I've always considered myself bright, but never self-righteous. What catalyzed this change? I have decided my MCAT preparation is to blame. I have put more time into study this semester than ever before in my life (approx 70 hours a week). This extra mental practice has sharpened my cognitive ability, making me more alert to new material shared in class. Now don't get me wrong, I appreciate and am grateful for my new found cognitive endurance and aptitude. I am humbled at how amazing an instrument the nervous system can be, especially if one will spend the time nourishing it. However, it scares me that I could go down the path of anti-social behavior many doctors do.

I guess the purpose of this post is to remind myself, and others if they're interested, to always stay fluid. Avoid at all costs the Jehovah complex, because that mindset is potentially crippling.

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Tuesday, March 17, 2009

Attack on Doctors' Moral Rights

Obama's Attack on Medical Civil Liberties

Sunday, March 15, 2009 5:23 PM

By: Newt Gingrich and Rick Tyler

Candidate Barack Obama offered a compelling but formless message of hope and change. Many Americans desiring a new national direction filled his empty rhetorical vessels with their dreams and aspirations. It worked.

But now, obliged by his office, President Obama is giving those words definition and shape bewildering even some of his most ardent supporters.

While the media remain fixated on a slumping economy that gets sicker with each punishing presidential prescription, a different set of defining and similarly freedom-diminishing policy directives emerging from the White House goes dissimilarly unnoticed.

Earlier this month, the President took the first step in rescinding a Bush administration moral conscience regulation which enforces existing legal protections against discrimination and intimidation for doctors and other healthcare professionals who invoke conscience by refusing to participate in medical procedures they believe immoral.

The rule, which was finalized last year placed no restriction upon any legal medical procedure; it simply brought the executive branch into compliance with several existing laws including:

the 1973 "Church Amendments" which protect doctors and other healthcare professionals from discrimination due to religious belief or moral conviction;
the 1996 “Public Health Service Act Amendment” which prohibits government from discriminating against individual and institutional healthcare providers who choose not to provide abortion services or receive abortion training; and
the 2004 "Hyde-Weldon Amendment” which prohibits certain federal funds going to federal and state agencies and programs that discriminate against healthcare providers who decline to offer or refer abortion services.
Simply put, these three venerable laws passed by Congress and signed by former Presidents protect doctors and nurses from being professionally threatened because they allow their conscience to dictate their professional actions.

By eliminating the enforcement of these legal protections, the Obama Administration is signaling that it intends to ignore the law and refuse to protect the civil liberties of healthcare professionals based upon religious or moral conscience. Without enforcement, healthcare personnel will have scant legal recourse for intimidation and bigotry rendering the laws intended to protect them meaningless.

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