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Blood – The Doctor Giveth and the Doctor Taketh: Myths, Beliefs and Evidence

This Country Doctor learned something interesting at Grand Rounds the other day. One of the Cityside hematologists gave a talk about blood transfusions that made me think about how slow the medical profession is to change its beliefs and its practice, even when faced with overwhelming evidence that we are doing the wrong thing.

It turns out our profession has been wrong about the benefits of transfusing anemic patients, just like our predecessors were wrong in their belief that bloodletting was helpful.

For thousands of years medical practitioners used bloodletting, drawing off sometimes very large quantities of blood, as a treatment for various illnesses. After this treatment was proven useless and dangerous in 1628 by Harvey, the practice continued for more than 200 years. It is said to have brought on George Washington’s death in 1799 after 9 pints of his blood was withdrawn. Samuel Hahnemann, the physician who founded Homeopathy, looking for kinder, gentler treatments for his patients, wrote in 1809:

“The more refined humoralists, in addition to the impurities in the blood, alleged, besides, the existence of a pretended, almost universal, plethora, as an excuse for their frightful, merciless bloodlettings.”

Analyzing why it took so long to eliminate this type of treatment, Kerridge and Lowe wrote in 1995:

“That bloodletting survived for so long is not an intellectual anomaly—it resulted from the dynamic interaction of social, economic, and intellectual pressures, a process that continues to determine medical practice.”

Legend has it that early adopters of non-bloodletting didn’t dare to withhold this “treatment” for their sickest patients. They, like modern day physicians, were afraid of “doing nothing”.

Today, bloodletting is only used for a handful of conditions where the patient actually has too many red blood cells or too much iron in the blood. But we have gone too far in the opposite direction, thinking that most anemic patients could benefit from a couple of extra units of blood.

In 1999 The New England Journal of Medicine wrote authoritatively about several negative effects from transfusions. Since then the evidence has continued to mount against transfusion in medical patients with anemia. Bleeding surgical patients are in a different category.

But for many years we transfused our sickest patients in hope of helping them do better. When they didn’t, we usually didn’t blame the transfusion, but thought they were just too sick to fully benefit from transfusion. This is exactly what happened in the days of bloodletting.

The new findings about the negative effects of transfusion were ignored, perhaps even swept under the carpet. After all, giving blood seemed like such an obvious thing to do.

Even though we know that anemic patients are more likely to suffer for example heart attacks due to low oxygen delivery to their tissues, it turns out that blood transfusion to correct anemia actually further decreases oxygen delivery to heart muscle tissue. Transfused patients have a greater risk for illness and death than non-transfused patients, all the way down to degrees of anemia that usually raise the hair on every physician’s back. Even our own (autologous) blood donation has this effect due to changes in blood cells and plasma caused by handling and storage. Transfused blood cells have a tendency to be less flexible and slippery than normal blood cells and have been proven to block tiny blood vessels and thereby keeping patients’ own, healthy, blood cells from getting through.

A chilling fact is that even though blood between 30 and 42 days old carries a dramatically greater risk of negative effects than blood less than 30 days old, we still continue to offer it to patients without informing them of the additional risk we subject them to.

The increased risk for illness and death extends well beyond the immediate period after transfusion: We are now seeing an increased cancer risk in people who have received blood transfusions several years ago.

The International Consensus Conference on Transfusion and Outcomes issued this statement in 2009:

“There is little evidence to support a beneficial effect from the greatest number of transfusions currently being given to patients. The vast majority of studies show an association between red blood cell transfusions and higher rates of complications such as heart attack, stroke, lung injury, infection and kidney failure and death.”

At Cityside and many other hospitals, the threshold for transfusion in medical patients has been lowered, and surgical patients sometimes have their operations postponed in order to manage anemia with iron infusions and erythropoietin injections to allow the patient to build up their own blood supply before surgery. And if transfusions are given, they are kept to a minimum.

Such changes in practice are likely to happen in other areas of medicine if we are willing to really practice evidence based medicine and not just do what sounds like a good idea. Too many things have sounded good and turned out bad to make that a defensible strategy.

I can’t help thinking about how uncomfortable many doctors have been over the years when treating Jehovah’s Witnesses, whose religion forbids them to accept blood transfusions. That belief may actually have saved many lives.

Medicine is an ever-changing practice, and it is humbling to realize how doctors sometimes harm their patients by doing what seems to be the right thing to do.

Dr. Martin H. Fischer said it well:

”It is not hard to learn more. What is hard is to unlearn when you discover yourself wrong.”

Rural Medicine – Not Just Runny Noses

Published May 7, 2012 Reflections 4 Comments

A lot of people, many of them medical students, think that rural doctors don’t get to see many interesting cases.

The opposite is true; if you are the only doctor within a wide radius, people will come to you for help, rather than try to pick the appropriate out-of-town specialist to diagnose their problem. In this state with widespread physician shortages most specialists won’t even see self-referred patients.

Sir William Osler wrote:

“The environment of a large city is not essential to the growth of a good clinical physician. Even in small towns, a man can, if he has it in him, become well versed in methods of work, and with the occasional visit to some medical centre he can become an expert diagnostician and reach a position of dignity and worth in the community in which he lives.”

Today, with UpToDate and all the medical journals of the world instantly at our disposal through the Internet, rural physicians cannot blame the size of their patient panel or of their medical community for not keeping up with the essentials in their field. Rural primary care doctors are usually the first ones with an opportunity to evaluate and diagnose our community members’ medical problems, regardless of their complexity or severity.

In situations when I feel stumped with a difficult diagnosis, I sometimes end up explaining to patients that until I understand better what the nature of the problem is, I don’t even know which specialty is the right one to refer them to, since the delineation of specialties follows disease location or mechanism rather than presentation.

For example, a person with weight loss could have an endocrine problem, an intestinal problem, cancer or a psychiatric diagnosis. The family physician is usually in the best position of all specialists to sort out which is the underlying cause.

It is sometimes quite touching when, after I have diagnosed a patient with a rare disease that only a big city or university-based specialist can manage, patients say “ah, Doc, can’t you treat me instead – I’m comfortable with you, and you’re the one who figured out what was wrong with me”.

Rural medicine, in terms of the spectrum of disease we encounter, is the most challenging and most stimulating kind of primary care medical career available to doctors in this country.

The double-booked visit with the Chief Complaint “I think I have a sinus infection” could be a brain tumor. The woman with chest pain could have an esophageal diverticulum, and the man with heart palpitations could have hyperthyroidism, an arrhythmia, a drinking problem or an anxiety disorder – perhaps even a pheochromocytoma.

It is my job to do the right thing, not too little and not too much, for each one of these patients, who trusts me with their care.

It’s all in a day’s work in primary care.

And, oh, one man with a runny nose just didn’t act right. He seemed vague with some word-finding difficulties. I had never seen a brain abscess before, but that is what he had.

Journey’s End

Published April 30, 2012 My Father's Eyes 10 Comments

The long journey that began a year and a half ago ended suddenly this morning.

The Swedish ringtone sounded four times after I dialed the number I had dialed the same time every morning for several years as well as every weekend afternoon, the number I knew would suddenly become meaningless any time as my mother’s disease progressed.

A strange voice answered and in one instant I was orphaned at age fifty-eight, never having said a final good bye. My last words had been “get a good night’s sleep and I’ll call you when I wake up in the morning”.

Hers had been “I am content, take care of yourself”. She was ready, even if I was not.

I have lost count of how many deaths I have attended as a physician, but it is always with an eery swiftness that the moment passes, no matter how long the wait has been.

Instantly the moment is gone, the chance to say the words we wanted to have said. Instantly the feeling of loss overwhelms us as we are hurled from one way of existing to another, just like our loved one is whisked away from our presence.

Hearing a young Hospice nurse struggle to find the right words to tell me what must have happened before she arrived for her scheduled visit, I realized what had happened with the speed of my imagination as her words continued to form in slow motion. Through the receiver, across three thousand miles of frigid ocean and across a time difference of half a day I gathered up the pieces of my mother’s last hours on this earth.

Somehow, I knew it would end like this. I knew it the day my father died and I was the one who walked across my home town to tell her, confined to her hospital room across the river. I knew it every time I said good bye on the telephone, that one day the phone would ring and ring, she would not answer and the familiar number wouldn’t be hers anymore.

I just didn’t know it would be today.

QS, Ad Lib and PRN

Published April 30, 2012 Reflections 4 Comments
Tags: Prescription Latin

Our hospital has a list of approved abbreviations. It is shorter than the list I had to memorize during my training. The reason some long-established abbreviations have been banned is their similarity to other abbreviations with different meaning. Even when doctors type orders instead of writing them by hand, the concern is that nurses and pharmacists may mistake them for something other than what the doctor ordered.

For this reason both QID (quater in die; four times a day) and QD (quaque die; once daily) are off the list; a hurried nurse or pharmacists could inadvertently quadruple a patient’s daily dose by imagining an “I” that wasn’t there to begin with.

At the local pharmacy, thanks to e-prescribing, we are forced into a specificity we weren’t tied to before:

Gone is the universal “QS”, (quantum sufficat; sufficient quantity), which made it the pharmacist’s responsibility to figure out how many pills it takes to do a prednisone taper with 6 pills the first two days, 5 the next two, then 4 a day for two days etcetera until zero.

“QS” also got us doctors off the hook with liquid medicines for children; while the printed “Monthly Prescribing Reference” listed the size bottles all the common antibiotics come in, the new e-prescribing software doesn’t tell us that. Consequently we have to prescribe the exact volume needed for a full course, hoping there is a bottle of just that size or that the pharmacist will be allowed to pick the closest size up without having to call us back.

“Ad Lib” (ad libitum; “freely as wanted”) has fallen by the wayside in medicine, and now seems mostly a term used in theater, public speaking or music.

Curiously, a theatrical synonym for ad libitum, extempore, was often used in my native Sweden for a custom prescription, usually for a cream or ointment, less often a hand-made capsule or pastille. In the United States, this term is seldom used, although the concept of specially compounded medications is not uncommon.

“PRN” (Pro Re Nata; “as the circumstance arises”) seems to have survived the abbreviation cutbacks. It allows the patient or caregiver to use the medication as needed.

Prescriptions were historically a vehicle for doctor-to-pharmacist communication that was written specifically to exclude the patient. This is to some extent why so many abbreviations were used. Somewhere near the bottom of most prescriptions typically was the word Label with a check box in front of it. Only when checked did the patient get to see the name of the medication on the bottle. That was before the era of informed consent, but the word and the check box can occasionally still be found on prescriptions.

Abbreviations and secret symbols still find their way into modern medical jargon and documentation, even if they are not allowed on prescriptions or in hospital records, from the handwritten Ψ for psychiatry or psychiatric to classics like GOMER – Get Out of My Emergency Room, ETKTM – every test known to man, and FF – Frequent Flyer, to some newer ones like:

PJAR – Person Just Ain’t Right

SALT – Same As Last Time

TMB – Too Many Birthdays, and

GOK – God Only Knows

Every profession needs its abbreviations…

Art, Science and Charity in Medicine

Published April 29, 2012 Reflections 1 Comment

Sir William Osler spoke of the influence of these three forces on the life and conduct of a physician. He eloquently used temperature analogies to characterize the necessary qualities of a physician – burning hot or keeping cool, but never being lukewarm:

”….of Art, the highest development of which can only come with that sustaining love for ideals which burns bright…”;

“Science, the cold logic that keeps the mind independent and free from the toils of self-deception and half-knowledge”;

“of Charity, in which we of the medical profession, to walk worthily, must live and move and have our being.”

(Aequanimitas, 1904)

Today’s medicine tends to be more tepid, at least in my field, Primary Care. Others clamor to set our priorities, to the point that doctor and patient sometimes both feel marginalized. The personal doctor-patient relationship is sometimes replaced by a more generic consumer-provider exchange, where a patient may see the physician as just a necessary intermediary between their need and the solution they already know they want – as in the case of asking for a drug advertised on television.

We must start with what Osler calls “the cold logic of Science”. It is our role and our duty as physicians to view new claims of clinical benefit from tests, procedures or pharmaceuticals with a critical mind, applying our training and experience. Simply following guidelines is an abdication from our professional responsibility. You don’t need to go to medical school to follow guidelines – in fact, it may make it harder sometimes.

The burning flame behind our passion for the Art and compassion for our fellow human beings, what Osler calls Charity, must never be lukewarm.

We all have to work at the Art of medicine. It is easy to slip into routines of complacency; another case of this or that, giving it our usual “Spiel”. Seeing each patient and each clinical presentation as unique is necessary in order to connect with the other person in the exam room. Finding the right way to approach each one of many seemingly similar case histories is what makes a personal physician just that – each patient needs something slightly different from us. The better we understand those needs, the more effective we can be.

The Art of the medical practitioner lies in the balance between cold science and hot passion. This is where the chemistry between physician, patient and disease takes place.

Call it chemistry, even alchemy: As physicians, we are catalysts in each patient’s transformation. And just as any other catalyst, we cause a chemical reaction to take place without being consumed ourselves in the process.

Our true challenge as physicians in today’s health care climate is keeping the flame Osler spoke of. Without that flame we are at risk for straying from the ideals behind our profession.

Osler warned us never to feel lukewarm about being doctors:

“By far the most dangerous foe we have to fight is apathy – indifference from whatever cause, not from a lack of knowledge, but from carelessness, from absorption in other pursuits, from a contempt bred of self satisfaction.”

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