Supplements, Lifestyle Change Work as Well as Cholesterol-Lowering Medications in Small Study, Edited Michael W. Smith MD, by Kathleen Doheny — Supplements of fish oil and red yeast rice, coupled with lifestyle changes in diet and exercise habits, can reduce cholesterol as much as standard cholesterol-lowering medications known as statins, according to a new study.

But the study’s lead author, David J. Becker, MD, a cardiologist at Chestnut Hill Hospital and the University of Pennsylvania Health System, emphasizes that the alternative approach is not for everyone.

“Statins remain the primary and best treatment for people with high cholesterol, especially if you have known coronary disease,” Becker tells WebMD. The study evaluated only people with high cholesterol who did not yet have coronary disease.

“If you are someone dead set against taking a statin, this may be an attractive option, assuming you are willing to make the lifestyle changes,” Becker says.

“This is one of the first studies that has shown there is some promise here,” he says, referring to the alternative approach with supplements instead of statins.

Finding alternatives to medication for lowering cholesterol is important, he says, because studies show as many as 40% of people who get a statin prescription are believed to take it for less than a year.

Supplements vs. Statins: Study Details

Becker and his colleagues studied 74 people with high cholesterol. Half took the statin drug Zocor and the other half took fish oil and red yeast rice supplements. They were followed for 12 weeks.

Red yeast rice is the product of yeast grown on rice and includes several compounds that hinder production of cholesterol in the body. Fish oil has been shown to lower the blood fats known as triglycerides. The study was funded by the state of Pennsylvania and is published in Mayo Clinic Proceedings.

The medication group took 40 milligrams of Zocor daily and received traditional counseling in the form of handouts on diet and exercise.

The supplement group took three fish oil capsules twice daily. In addition, those with an LDL cholesterol higher than 160 mg/dL took 3.6 grams of red yeast rice daily, divided into two doses. If the initial LDL level was 160 or less, they took 2.4 grams of red yeast rice daily, divided into two doses.

The supplement group also attended weekly meetings and was taught about lifestyle changes by a cardiologist and a dietitian. The group was urged to follow a modified Mediterranean diet, limiting fat intake to less than 25% of daily total calories, and to exercise for 30 to 45 minutes five to six times a week.

“We followed them for a three-month period,” Becker says. At the study’s end, the levels of bad cholesterol had declined nearly the same amount in both groups. “The LDL declined 42% in the supplement group and 39% in the Zocor group,” Becker says.

The supplement group also lost an average of 10 pounds in 12 weeks, but there was no significant weight loss in the medication group. Triglyceride levels, while on average normal in both groups at the start, decreased by 29% in the supplement group but just 9.3% in the medication group — a significant difference, Becker says.

“This homeopathic, natural approach in a group of people who do not have known coronary disease and who can make these kinds of exacting lifestyle changes may be worth exploring in longer and better studies,” Becker tells WebMD.

Supplements vs. Statins: Second Opinion

The study results don’t surprise Robert Eckel, MD, former president of the American Heart Association and a professor of medicine at the University of Colorado at Denver. The red yeast rice, he tells WebMD, works in much the same way as a statin.

“Fish oils don’t affect LDL cholesterol,” he says, but only triglycerides. And the participants’ triglyceride levels, on average, were normal, he says, and did not need reduction.

If you are trying to lower cholesterol, he says, the first step is to see a doctor.

Supplements vs. Statins: Downsides & Caveats

Becker sees downsides to supplements over statins.

“The red yeast rice is an unregulated supplement,” Becker says. He cites a recent report in which researchers found significant differences in the amount of red yeast rice in different brands of supplements.

In August 2007, the FDA warned against buying or eating specific red yeast rice products (Red Yeast Rice/Policosonal Complex by Swanson Healthcare Products, Inc., and Cholestrix) because they ”may contain an unauthorized drug that could be harmful.” FDA testing had detected lovastatin, the active ingredient in Mevacor, a prescription drug for cholesterol lowering.

Red yeast rice sold in the U.S. typically comes in 600 milligram to 1,200 milligram doses, with recommendations of taking no more than 2,400 milligrams (2.4 grams) a day, the lower dose used in the study. Doses higher than this increase the risk of side effects similar to that of statin drugs, including muscle pain or tenderness, and possibly liver damage. Red yeast rice and statins work similarly in the body, so they should not be taken together, as this increases the chance of side effects.

For anyone who wants to try the alternative approach, Becker recommends talking with their doctor, having all recommended blood tests to make sure the approach is working, and checking for potential side effects.

By Ezekiel Emanuel

In this installment of Health Care Watch, Stuart M. Butler and Ezekiel Emanuel talk about what President-elect Barack Obama should and shouldn’t do on health care reform. Go to Mr. Butler’s post.

Ezekiel Emanuel, an oncologist, is the chairman of the department of bioethics at the Clinical Center of the National Institutes of Health. He is the author of “Health Care, Guaranteed: A Simple, Secure Solution for America.

The New York Times, November 17, 2008 — The election of Barack Obama is a historical transformative event. As he and his new administration wrestle with health care reform here are five points to be kept in mind.

1) “Make no little plans. They have no magic to stir men’s blood and probably will not themselves be realized.” So said Daniel Burnham, the architect and urban planner (and fellow Chicagoan).

In health care, big plans are necessary not only to motivate people but as a matter of sound policy. The health care system is broken. It is not enough to just add more people to a broken system. Health care reform must reorganize the system to deliver higher quality care while keeping costs under control. Incremental change that just covers more people will not be sustainable. Reform must include changing the delivery system and how we pay for care. The health care system needs major surgery, not more Band-aids.

More important, as negotiation specialists note, you don’t begin with your compromise position. If we have to settle for incremental Band-aids, it should be only as a last resort.

2) Health care policy is fiscal policy.

Forget Social Security or defense, health care costs are the long-term driving force in federal and state budgets. To control the deficit and keep the country solvent, health care must be solved. Therefore, when the president-elect considers senior economic advisers, one test should be whether they really get health care policy.

Fortunately, Peter Orzag at the Congressional Budget Office does. So do some of the people rumored to be leading candidates for appointments — Larry Summers at the Treasury, Jim Cooper at the Office of Management and Budget and Jason Furman at the Domestic Policy Council. This is very encouraging.

3) Comprehensive health care reform is cheaper.

One of the secrets of health care reform that has not yet sunk in, is that bigger changes to the system actually cost less. Consider the Lewin Group’s analysis of the different health care from plans, which I wrote about in an earlier post.

4) No plan is perfect, institutionalize tinkering.

Health care reform will be incredibly complex. As improvements are made, problems will arise and unintended consequences will occur. There will need to be numerous mid-course corrections. Good reform will make addressing these issues easy by not requiring major legislation for each adjustment.

5) Everything is connected.

Health care reform cannot be considered in isolation. The new administration must remember that health care is so big — $1 out of every $6 in the economy, dwarfing automobiles and all other economic segments. Everything is affected by health policy, and every decision should be examined for its impact on health care reform.

Consequently, if the heart of Mr. Obama’s economic policy is job creation, then it is contradictory to have a health care reform built on an employer mandate or to fund reform with a payroll tax. Employer mandates and payroll taxes stymie job formation.

Similarly, every favor to a constituency should be linked to support for the health care reform agenda. If the automakers want a bail out, then they and their suppliers have to agree to support and lobby for the administration’s health care reform effort. This builds grass roots support.

Since 1913, the United States has been trying to achieve comprehensive health care reform. If the Obama administration finally does it, it will truly be history making. The challenge is huge, but the rewards — for the administration and every citizen — will be even “huger.”


Health Care Watch — Think Small

By Stuart M. Butler

In this installment of Health Care Watch, Stuart M. Butler and Ezekiel Emanuel talk about what President-elect Barack Obama should and shouldn’t do on health care reform. Go to Mr. Emanuel’s post.

Stuart M. Butler is the vice president for domestic policy at the Heritage Foundation, a research foundation.

The New York Times, November 17, 2008 — My fellow Campaign Stops contributor, Ezekiel Emanuel, is right that Barack Obama’s election could be transformative for health care as well as other areas of policy. Let’s hope Mr. Obama doesn’t blow it, as others have on health care — most notably Bill Clinton. Getting it done right will require Mr. Obama to keep four things strongly in mind or his honeymoon on health care will end soon.

First, he has to make a strong commitment to bipartisanship, which was distinctly lacking in President Clinton’s health strategy and helped assure its demise. Not often obvious during the heat of the election season, there has been a good, honest conversation about health reform across the reasonable political spectrum in recent years. We saw it in Massachusetts. We see it in the bipartisan proposal introduced by Senators Robert Bennett of Utah and Ron Wyden of Oregon. We see it, too, in Massachusetts’ senator Ted Kennedy’s wide outreach in the last several weeks, and in bipartisan conversations about health tax reform and health exchanges. Mr. Obama needs to tell the more triumphalist liberal supporters on Capitol Hill to chill, and that he’s looking for common ground.

Second, these very difficult economic and budget times underscore the need to find better ways to use the money we are currently spending on health rather than throwing tens of billions in new money at the health industry in an effort to expand coverage. That’s why reallocating the $200 billion tax expenditure on the tax exclusion is so critical. Ezekiel Emanuel and virtually every other health expert agrees with me on that. Mr. Obama must not adopt a “not invented here” attitude just because John McCain proposed reforming the exclusion. It’s a real opportunity for him to reach out to his former opponent and craft a workable bipartisan solution. Fortunately the Democratic chairman of the Senate Finance Committee, Senator Max Baucus of Montana, may have opened the door to that in his own just-released health plan by raising the idea of reforming the tax exclusion.

Third, and in the same vein, Mr. Obama should put meat on the bones of his campaign proposal to allow states flexibility to redesign existing health programs and use money more efficiently to reach the goal of maximizing affordable coverage. I wrote about this in my last post. Again, he can go bipartisan. Various bills in the Senate and the House have been introduced to enable states to receive waivers from existing federal programs and laws to try out bold ways to use funds to expand coverage. Mr. Obama should embrace these approaches. Allowing states to try out major changes first means skeptical Americans can see a model of reform before they are asked to accept it. That strategy was essential in building public support for major welfare reform, and it is needed even more for significant change in the especially sensitive area of health care.

And finally, he needs to remember that Americans are very conservative about their health care. Those with coverage are extremely nervous about changing what they already have. John McCain was hurt by claims that his approach to health care was too radical and might result in people losing their employer-based coverage. Mr. Obama’s plan actually masks what would be big changes. As I’ve pointed out, for instance, millions of workers will discover that they will be put into a public plan by their employers. Once workers with coverage know this, they are going to feel tricked and angry if he pushes ahead with changes that are more substantial than they thought they were voting for.

All the more reason, then, for President-elect Obama to tread carefully, to set up models at the state level so Americans can kick the tires of major reforms first, and to reach across the aisle to build trust and broad support for a workable way of reaching the goal we all share.

However, diabetic patients with established cardiovascular disease should still take aspirin for secondary prevention.

Antiplatelet drugs lower risk for adverse cardiovascular events in diabetic patients with established cardiovascular disease (CVD). However, whether antiplatelet drugs lower risk for adverse cardiovascular events in diabetic patients without symptomatic CVD is unclear. In this multicenter trial from Scotland, investigators randomized 1276 type 1 or 2 diabetic patients with asymptomatic peripheral vascular disease (ankle-brachial index, 0.99; age, 40) to aspirin (100 mg) plus antioxidant (containing vitamins B3, B6, C, and E, plus lecithin, selenium, and zinc), aspirin plus placebo, antioxidant plus placebo, or double placebo. Patients with symptomatic CVD were excluded.

The composite endpoint (death from coronary heart disease or stroke, nonfatal myocardial infarction or stroke, or above-ankle amputation for critical limb ischemia) occurred with similar frequency (about 18%) among aspirin recipients and nonrecipients. Also, 6.7% of patients who received aspirin and 5.5% of those who did not died from coronary heart disease or stroke — a nonsignificant difference. Notably, antioxidant had no effect on these outcomes, and no interaction was observed between aspirin and antioxidant.

Comment: American Diabetes Association guidelines recommend low-dose aspirin for primary prevention of adverse cardiovascular events in diabetic patients “at increased cardiovascular risk” (Diabetes Care 2008; 31:S12). However, these results and those of a prior study (Diabetes Care 2003; 26:3264) suggest that aspirin does not benefit such patients. In contrast, diabetic patients with symptomatic CVD still should take aspirin.

— Paul S. Mueller, MD, MPH, FACP

Published in Journal Watch General Medicine November 13, 2008

Stuart Bradford

The New York Times, by Tara Parker-Pope — In a set of recent focus groups, participants were asked to rank the severity of various health problems, including cancer, heart disease and diabetes.

On a scale of 1 to 10, cancer and heart disease consistently ranked as 9s and 10s. But diabetes scored only 4s and 5s.

“The general consensus seems to be, ‘There’s medication,’ ‘Look how good people look with diabetes’ or ‘I’ve never heard of anybody dying of diabetes,’ ” said Larry Hausner, chief executive of the American Diabetes Association, which held the focus groups. “There was so little understanding about everything that dealt with diabetes.”

But diabetes is anything but minor. It wreaks havoc on the entire body, affecting everything from hearing and vision to sexual function, mental health and sleep. It is the leading cause of blindness, amputations and kidney failure, and it can triple the risk for heart attack and stroke.

“It is a disease that does have the ability to eat you alive,” said Dr. John B. Buse, a professor at the University of North Carolina School of Medicine who is the diabetes association’s president for medicine and science. “It can be just awful — it’s almost unimaginable how bad it can be.”

Diabetes results when the body cannot use blood sugar as energy, either because it has too little insulin or because it cannot use insulin. Type 2 diabetes, which accounts for 90 to 95 percent of cases, typically develops later in life and is associated with obesity and lack of exercise. Type 1 diabetes, which is often diagnosed in children, occurs when the immune system mistakenly destroys cells that make the insulin.

The disconnect between perception and reality is particularly worrisome at a time when national diabetes rates are surging. Just last week, the Centers for Disease Control and Prevention announced that the number of Americans with diabetes had grown to about 24 million, or 8 percent of the population. Almost 25 percent of those aged 60 and older had diabetes in 2007. And the C.D.C. estimates that 57 million people have abnormal blood sugar levels that qualify as pre-diabetes.

To be sure, diabetes is treatable, and an array of new medications and monitoring tools have dramatically improved the quality of care. But keeping the illness in check requires constant vigilance and expensive care, along with lifestyle changes like losing weight, exercising regularly and watching your carbohydrates.

Dr. Buse says patients who are focused on their disease and who have access to regular medical care have a good chance of living out a normal life span without developing a diabetes-related disability.

But some patients say they are too busy to take better care of themselves, and many low-income patients can’t afford regular care. Even people with health insurance struggle to keep up with the co-payments for frequent doctor visits and multiple medications.

And to make matters worse, diabetes is associated with numerous other health problems. Last July 2008, for example, The Journal of the American Medical Association reported that people with depression were at higher risk for Type 2 diabetes, and vice versa.

That is not surprising: according to data published last year in the journal Diabetes Care, depression tends to interfere with a patient’s self-care, which requires glucose monitoring, medications, dietary changes and exercise.

Ultimately, diabetes can take a toll from head to toe. In the brain, it raises the risk not only for depression but also for sleep problems and stroke. It endangers vision and dental health. This month, The Annals of Internal Medicine is reporting that the disease more than doubles the risk of hearing loss.

Moving down the body, diabetes can lead to liver and kidney disease, along with serious gastrointestinal complications like paralysis of the stomach and loss of bowel control. Last year the journal Diabetes Care reported that in a sample of nearly 3,000 patients with diabetes, 70 percent had nonalcohol fatty liver disease.

Poor circulation and a loss of feeling in the extremities, called neuropathy, can lead to severe ulcers and infections; each year in the United States, there are about 86,000 diabetes-related amputations.

Diabetes can also take a toll on relationships. By some estimates, 50 percent to 80 percent of men with diabetes suffer from erectile dysfunction. Experts say women with diabetes often lose their libidos or suffer from vaginal dryness.

The challenge for doctors is to convince patients that diabetes is a major health threat. For years, the message from the American Diabetes Association has been one of reassurance that the disease is treatable. Now, beginning in 2009, the association plans to reframe its message to better communicate the seriousness of the disease.

“Our communication strategy is going to be that diabetes has deadly consequences, and that the A.D.A. is here to change the future of diabetes,” said Mr. Hausner, a former executive with the Leukemia and Lymphoma Society who came to the association 10 months ago. “It’s the word ‘deadly’ that was the potentially controversial word for the organization. In the past, people said, ‘We don’t want to get anybody scared.’ ”

The new strategy is not a scare tactic, he added. Prevention and hope will still be part of the message.

“It’s not that we don’t want people to have hope,” he said. “We want people to understand this is serious.”

Aaron Houston for The New York Times
Tia Harmon, a patient at Saint Barnabas Medical Center in Livingston, N.J., listens as Dr. Benjamin Kaplan reads from “Kitchen Table Wisdom: Stories That Heal,” by Dr. Rachel Naomi Remen.

The New York Times, by Pauline W. Chen MD — The white-coated crowd with stethoscopes slung casually around their necks would have looked familiar to anyone who has attended morning hospital rounds. Resident physicians and medical students milled about, chatting animatedly, and at the appointed hour, the attending physician signaled to begin.

But instead of filing toward a patient’s room, the group at Saint Barnabas Medical Center in Livingston, N.J., settled into a conference room at the end of the hall, not to recite details of patient cases but to read “Empty Pockets,” a personal essay by Dr. Kevan Pickrel from The Annals of Internal Medicine. In the piece, Dr. Pickrel describes being unable to save a 36-year-old woman, then going to the waiting room to inform the woman’s family of her death:

“The youngest daughter sat on Dad’s lap looking at pictures in an outdoors magazine. The older sat watching her hands rest in her lap. [The] husband’s eyes lifted to me and met mine. I didn’t, couldn’t, say a word…. He turned back toward his daughters, a single father, and they lifted their eyes to his. As he drew a breath to begin, his eldest daughter knew.”

After the reading, the attending physician, Dr. Sunil Sapru, looked up at the group assembled. “Do you identify with any of these situations?” he asked.

“Yes, it happens all the time,” a resident responded immediately. Others nodded in agreement, and one resident flicked a tear away.

The next morning, in a similar room at New York-Presbyterian Hospital in upper Manhattan, a group of obstetrics and gynecology residents gathered to read E.B. White’s short story “The Second Tree From the Corner.” Told from the perspective of an anxiety-ridden patient, the story ends with the main character finding meaning in his life and suddenly feeling liberated:

“He felt content to be sick, unembarrassed at being afraid; and in the jungle of his fear he glimpsed (as he had so often glimpsed them before) the flashy tail feathers of the bird courage.”

As the reading ended, one of the young doctors commented on how personally fulfilling it was to help her patients and how those feelings invigorated her, even after many hours of work. Other doctors in the room nodded in agreement.

While it has long been understood that clinical practice influenced the youthful writing of doctor-authors like Chekhov and William Carlos Williams, there is now emerging evidence that exposure to literature and writing during residency training can influence how young doctors approach their clinical work. By bringing short stories, poems and essays into hospital wards and medical schools, educators hope to encourage fresh thinking and help break down the wall between doctors and patients.

Aaron Houston for The New York Times
Dr. Richard S. Panush

“We’re teaching the humanities to our residents, and it’s making them better doctors,” said Dr. Richard Panush, a rheumatologist and chairman of the department of medicine at Saint Barnabas.

The idea of combining literature and medicine — or narrative medicine as it is sometimes called — has played a part in medical education for over 40 years. Studies have repeatedly shown that such literary training can strengthen and support the compassionate instincts of doctors.

Dr. Rita Charon and her colleagues at the program in narrative medicine at Columbia University’s College of Physicians and Surgeons found, for example, that narrative medicine training offered doctors opportunities to practice skills in empathy. Doctors exposed to literary works were more willing to adopt another person’s perspective, even after as few as three or four one-hour workshops.

“You want people to be able to leave their own individual place,” Dr. Charon said, “and ask what this might be like for the child dying of leukemia, the mother of that child, the family, the hospital roommate.”

Over the last 15 years, an ever-increasing number of medical schools have begun offering narrative medicine to medical students. These courses often involve writing, reading and discussing works by authors as diverse as Leo Tolstoy, Virginia Woolf, Lori Moore and various doctor-authors. Students then explore the relevance of these texts, and their own writing, to their clinical work.

But until recently, few educators have attempted to bring such literary training into residency programs.

Residency is the most intense period of a young doctor’s life. The years spent squirreled away in hospitals and clinics are rich in clinical learning, but the wealth of that experience comes at the cost of free time.

And with time at a premium, residency program directors and clinical educators have been hesitant to add narrative medicine to their curricula, particularly since it has never been clear that such an addition would have any effect other than further overworking the trainees.

That could be changing.

For over a year now, Dr. Panush, a tall, bespectacled, soft-spoken man with the lean physique of a runner, has been systematically incorporating literature into the daily rounds of every one of the internal medicine residents at Saint Barnabas Medical Center.

As part of the Accreditation Council for Graduate Medical Education’s Education Innovations Project, Dr. Panush and his faculty colleagues bring poetry, short stories and essays to rounds each day and discuss them in the context of the patients they see. These daily discussions, supplemented by offsite weekly conferences, form the core of the residents’ narrative medicine experience.

One year into the program, Dr. Panush and his colleagues looked at the effect of these daily discussions on the residents and their patients. What they found were significant improvements in patient evaluations of residents and patients’ health and quality of life, from hospital admission to discharge.

A handful of other residency programs across the country have taken steps toward establishing narrative medicine training for their residents, including Vanderbilt University’s Department of Surgery and New York/Presbyterian Hospital-Columbia’s Department of Obstetrics and Gynecology. As with the program at Saint Barnabas, it has been the doctors within these departments who have initiated the workshops, sessions and lectures.

“As we improve the technology of medicine, we also need to remember the patient’s story,” said Dr. A. Scott Pearson, an associate professor of surgery at Vanderbilt University Medical Center.

To that end, Dr. Pearson has completed a pilot study examining the feasibility of incorporating narrative medicine into Vanderbilt’s surgical residency and has plans to make such training available eventually to all surgical residents at his medical center. Dr. Pearson believes that narrative medicine will not only help residents reflect on what they are doing and how they might do better, but may also aid surgical educators in teaching professionalism and communication skills.

“Narrative medicine changed my entire approach to medicine,” said Dr. Abigail Ford, a senior resident in obstetrics and gynecology at New York-Presbyterian Hospital/Columbia who studied under Dr. Charon as a medical student. “As a doctor you are really a co-author of patients’ experiences and need to hear their story and take it on.”

With her former professor’s guidance, as well as the support of Dr. Rini Ratan, the residency program director, Dr. Ford has initiated a narrative medicine program for her fellow obstetrics and gynecology residents. While the program is still in its first year, “we’ve always run over,” said Dr. Ford. “People have to be dragged away.”

“Our hope is to look at it in terms of physician empathy,” added Dr. Ratan, “Does it add anything? Does it prevent natural jadedness over the course of the busy training process? Does it prevent burnout?”

In the near future, Dr. Ratan and Dr. Ford also hope to begin doing the kind of patient outcome evaluations that Dr. Panush and his colleagues have begun.

“To do what we’re doing is pretty simple,” said Dr. Panush. “But the measurement stuff is harder. The program needs to be supported institutionally and internally.”

Despite such challenges, the effects of these programs are striking. Dr. Benjamin Kaplan, a second-year resident at Saint Barnabas, remarked on the transformation he saw in fellow resident physicians during the first year of the humanities program.

“Their management of patients changed,” Dr. Kaplan said. “They remembered to do things that I don’t think they would have otherwise done, like always talking to the family, gently touching patients, and continually explaining the course of treatment and what the doctors are thinking so patients know.”

And the time commitment? “It does get pretty busy,” Dr. Kaplan conceded. “But if you want to make time for it, you can. Spending a half hour a day to remember that we are all human, not just doctors or pharmacists or nurses or patients, is important enough that I think you should do it.”

Although it is still too early to determine the long-term effects of narrative medicine on doctors in training, residents were quick to note that certain essays, short stories and poems they have read on rounds continue to influence their work.

Dr. Ramesh Guthikonda, a second-year resident at Saint Barnabas, spoke about a poem called “When You Come Into My Room,” by Stephen A. Schmidt. In the poem, published in The Journal of the American Medical Association, a man struggling with chronic illness lists all that he believes a doctor meeting him should know:

“When you come into my hospital room, you need to know the facts of my life

that there is information not contained in my hospital chart

that I am 40 years married, with four children and four grandchildren….

that I love earthy sensuous life, beauty, travel, eating, drinking J&B scotch, the theater, opera, the Chicago Symphony, movies, all kinds, water skiing, tennis, running, walking, camping…

that I am chronically ill, and am seeking healing, not cure.”

The poem so affected Dr. Guthikonda that he began regularly asking his patients about their hobbies and families, and he enrolled in a Spanish class so he could learn to better pronounce their names. “My rapport with patients, especially with my Hispanic patients, was not up to the mark,” he said. “I never asked about the patients’ lives, about who they are. I am much more sensitive to those issues now.”

Reflecting on the changes in Dr. Guthikonda, Dr. Panush said, “We changed the way he thinks and does medicine. You can’t put a p-value on that.”

Illustration by Nola Lopez, with Anatomical Images by Bryan Christie

The New York Times, by Tara Parker-Pope — Are patients swimming in a sea of health information? Or are they drowning in it?

The rise of the Internet, along with thousands of health-oriented Web sites, medical blogs and even doctor-based television and radio programs, means that today’s patients have more opportunities than ever to take charge of their medical care. Technological advances have vastly increased doctors’ diagnostic tools and treatments, and have exponentially expanded the amount of information on just about every known disease.

The daily bombardment of news reports and drug advertising offers little guidance on how to make sense of self-proclaimed medical breakthroughs and claims of worrisome risks. And doctors, the people best equipped to guide us through these murky waters, are finding themselves with less time to spend with their patients.

But patients have more than ever to gain by decoding the latest health news and researching their own medical care.

“I don’t think people have a choice — it’s mandatory,” said Dr. Marisa Weiss, a breast oncologist in Pennsylvania who founded the Web site “The time you have with your doctor is getting progressively shorter, yet there’s so much more to talk about. You have to prepare for this important meeting.”

Whether you are trying to make sense of the latest health news or you have a diagnosis of a serious illness, the basic rules of health research are the same. From interviews with doctors and patients, here are the most important steps to take in a search for medical answers.

Determine your information personality.

Information gives some people a sense of control. For others, it’s overwhelming. An acquaintance of this reporter, a New York father coping with his infant son’s heart problem, knew he would be paralyzed with indecision if his research led to too many choices. So he focused on finding the area’s best pediatric cardiologist and left the decisions to the experts.

Others, like Amy Haberland, 50, a breast cancer patient in Arlington, Mass., pore through medical journals, looking not just for answers but also for better questions to ask their doctors.

“Knowledge is power,” Ms. Haberland said. “I think knowing the reality of the risks of my cancer makes me more comfortable undergoing my treatment.”

Dr. Michael Fisch, interim chairman of general oncology for the University of Texas M. D. Anderson Cancer Center, says that before patients embark on a quest for information, they need to think about their goals and how they might react to information overload.

“Just like with medicine, you have to ask yourself what dose you can take,” he said. “For some people, more information makes them wackier, while others get more relaxed and feel more empowered.”

The goal is to find an M.D., not become one.

Often patients begin a medical search hoping to discover a breakthrough medical study or a cure buried on the Internet. But even the best medical searches don’t always give you the answers. Instead, they lead you to doctors who can provide you with even more information.

“It’s probably the most important thing in your cancer care that you believe someone has your best interests at heart,” said Dr. Anna Pavlick, director of the melanoma program at the New York University Cancer Institute. “In an area where there are no right answers, you’re going to get a different opinion with every doctor you see. You’ve got to find a doctor you feel most comfortable with, the one you most trust.”

Keep statistics in perspective.

Patients researching their health often come across frightening statistics. Statistics can give you a sense of overall risk, but they shouldn’t be the deciding factor in your care.

Jolanta Stettler, 39, of Denver, was told she had less than six months to live after getting a diagnosis of ocular melanoma, a rare cancer of the eye that had spread to her liver.

“I was told there is absolutely nothing they could help me with, no treatment,” said Ms. Stettler, a mother of three. “I was left on my own.”

Ms. Stettler and her husband, a truck driver, began searching the Internet. She found Dr. Charles Nutting, an interventional radiologist at Swedish Medical Center in Englewood, Colo., who was just beginning to study a treatment that involves injecting tiny beads that emit small amounts of radiation. That appeared to help for about 18 months.

When her disease progressed again, Ms. Stettler searched for clinical trials of treatments for advanced ocular melanoma, and found a National Institutes of Health study of “isolated hepatic perfusion,” which delivers concentrated chemotherapy to patients with liver metastases. After the first treatment, Ms. Stettler’s tumors had shrunk by half.

“I don’t like statistics,” she said. “If this study stops working for me, I’ll go find another study. Each type of treatment I have is stretching out my life. It gives me more time, and it gives more time to the people who are working really hard to come up with a treatment for this cancer.”

Don’t limit yourself to the Web.

There’s more to decoding your health than the Web. Along with your doctor, your family, other patients and support groups can be resources. So can the library. When she found out she had Type 2 diabetes in 2006, Barbara Johnson, 53, of Chanhassen, Minn., spent time on the Internet, but also took nutrition classes and read books to study up on the disease.

“I was blindsided — I didn’t know anybody who had it,” said Ms. Johnson, who told her story on the American Heart Association’s Web site, “But this is a disease you have to manage yourself.”

Tell your doctor about your research.

Often patients begin a health search because their own doctors don’t seem to have the right answers. All her life, Lynne Kaiser, 44, of Plano, Tex., suffered from leg pain and poor sleep; her gynecologist told her she had “extreme PMS.” But by searching the medical literature for “adult growing pains,” she learned about restless legs syndrome and a doctor who had studied it.

“I had gone to the doctors too many times and gotten no help and no results,” said Ms. Kaiser, who is now a volunteer patient advocate for the Web site The new doctor she found “really pushed me to educate myself further and pushed me to look for support.”

Although some doctors may discourage patients from doing their own research, many say they want to be included in the process.

Dr. Fisch of M. D. Anderson recalls a patient with advanced pancreatic cancer who decided against conventional chemotherapy, opting for clinical trials and alternative treatments. But instead of sending her away, Dr. Fisch said he kept her in the “loop of care.” He even had his colleagues use a mass spectroscopy machine to evaluate a blue scorpion venom treatment the patient had stumbled on. It turned out to be just blue water.

“We monitored no therapy like we would anything else, by watching her and staying open to her choices,” Dr. Fisch said. “She lived about a year from the time of diagnosis, and she had a high quality of life.”

Dr. Shalom Kalnicki, chairman of Radiation Oncology at the Montefiore-Einstein Cancer Center, says he tries to guide his patients, explaining the importance of peer-reviewed information to help them filter out less reliable advice. He also encourages them to call or e-mail him with questions as they “study their own case.”

“We need to help them sort through it, not discourage the use of information,” he said. “We have to acknowledge that patients do this research. It’s important that instead of fighting against it, that we join them and become their coaches in the process.”

David Sandlin

The New York Times, November 17, 2009, by Professor James E. McWilliams — China’s food supply appears to be awash in the industrial chemical melamine. Dangerous levels have been detected not only in milk and eggs, but also in chicken feed and wheat gluten, meaning that melamine is almost impossible to avoid in processed foods. Melamine in baby formula has killed at least four infants in China and sickened tens of thousands more.

In response, the United States has blasted lax Chinese regulations, while the Food and Drug Administration, in a rare move, announced last week that Chinese food products containing milk would be detained at the border until they were proved safe.

For all the outrage about Chinese melamine, what American consumers and government agencies have studiously failed to scrutinize is how much melamine has pervaded our own food system. In casting stones, we’ve forgotten that our own house has more than its share of exposed glass.

To be sure, in China some food manufacturers deliberately added melamine to products to increase profits. Makers of baby formula, for example, watered down their product, lowering the amount of protein and nutrients, then added melamine, which is cheap and fools tests measuring protein levels.

But melamine is also integral to the material life of any industrialized society. It’s a common ingredient in cleaning products, waterproof plywood, plastic compounds, cement, ink and fire-retardant paint. Chemical plants throughout the United States produce millions of pounds of melamine a year.

Given the pervasiveness of melamine, it’s always possible that trace elements will end up in food. The F.D.A. thus sets the legal limit for melamine in food at 2.5 parts per million. This amount is indeed minuscule, a couple of sand grains in an expanse of desert that pose no real threat to public health. Moreover, the 2.5 p.p.m. figure is calculated for a person weighing 132 pounds — a cautious benchmark given that the average adult weighs 150 to 180 pounds.

But these figures obscure more than they reveal. First, while adults eat about one-fortieth of their weight every day, toddlers consume closer to one-tenth. Although scientists haven’t measured the differential impact of melamine on infants versus adults, it’s likely that this intensified ratio would at least double (if not quadruple) the impact of legal levels of melamine on toddlers.

This doubled exposure might not land a child in the hospital, but it could certainly contribute to the long-term kidney and liver problems that we know are caused by chronic exposure to melamine.

On a more concrete note, melamine not only has widespread industrial applications, but is also used to buttress the foundation of American agriculture.

Fertilizer companies commonly add melamine to their products because it helps control the rate at which nitrogen seeps into soil, thereby allowing the farmer to get more nutrient bang for the fertilizer buck. But the government doesn’t regulate how much melamine is applied to the soil. This melamine accumulates as salt crystals in the ground, tainting the soil through which American food sucks up American nutrients.

A related area of agricultural concern is animal feed. Chinese eggs seized last month in Hong Kong, for instance, contained elevated levels of melamine because of the melamine-laden wheat gluten used in the feed for the chickens that produced the eggs.

To think American consumers are immune to this unscrupulous behavior is to ignore the Byzantine reality of the global gluten trade. Tracking the flow of wheat gluten around the world, much less evaluating its quality, is like trying to contain a drop of dye in a churning whirlpool.

More ominous, the United States imports most of its wheat gluten. Last year, for instance, the F.D.A. reported that millions of Americans had eaten chicken fattened on feed with melamine-tainted gluten imported from China. Around the same time, Tyson Foods slaughtered and processed hogs that had eaten melamine-contaminated feed. The government decided not to recall the meat.

Only a week earlier, however, the F.D.A. had announced that thousands of cats and dogs had died from melamine-laden pet food. This high-profile pet scandal did not prove to be a spur to reform so much as a red herring. Our attention was diverted to Fido and away from the animals we happen to kill and eat rather than spoil.

Frightening as this all sounds, the concerned consumer is not completely helpless. We can seek out organic foods, which are grown with fertilizer without melamine — unless that fertilizer was composted with manure from animals fed melamine-laden feed (always possible, as the Tyson example suggests).

We could further protect ourselves by choosing meat from grass-fed or truly free-range animals, assuming the grass was not fertilized with a conventional product (something that’s also very hard to know).

But as all the caveats above indicate, these precautions will only go so far. Melamine, after all, points to the much larger relationship between industrial waste and American food production. Regulations might be lax when it comes to animal feed and fertilizer in China, but take a closer look at similar regulations in the United States and it becomes clear that they’re vague enough to allow industries to “recycle” much of their waste into fertilizer and other products that form the basis of our domestic food supply.

As a result, toxic chemicals routinely enter our agricultural system through the back channels of this under-explored but insidious relationship.

So, sure, let’s keep the heat on China. And, yes, let’s take with a big dose of skepticism the Chinese government’s assurances that they’re improving the food supply.

At the same time, though, instead of delivering righteous condemnation, the United States should seize upon the melamine scandal as an opportunity to pass federal fertilizer standards backed by consistent testing for this compound, which could very well be hidden in plain sight.

James E. McWilliams, a history professor at Texas State University at San Marcos, is the author of “American Pests: The Losing War on Insects From Colonial Times to DDT.”

What’s the big secret? Take the GEN Microarray Challenge to find out and win $1,500


This isn’t just any picture of a microarray — it’s a cryptogram with a $1,500 message.

GEN along with partner, Scintellix, and sponsor, Agilent, bring you the Microarray Challenge. Crack the code, and you can win big.

Peter C. Johnson, M.D., president and CEO of Scintellix, created this painting called ‘MicroArray.’ He has embedded a cipher based on the dots in the pastel. Pit your skills against this cryptogram and decipher what’s turning on these ‘genes.’

The first to unravel the hidden message will win $1,500. The first 50 registrants will receive a MicroArray copy poster and a poster tube.

Every Monday, starting from November 17, a clue will be provided to put you on the right track. You can check this website for clues as they come in.

You have until December 31 to prove that you are a master code breaker. Feel free to give the Microarray Challenge a shot as many times as you like up to once a day. All entries will be considered.

For more rules and regulations as well as to register and play the Microarray Challenge, click the button below.

Take the Challenge


November 17, 2008 — If you thought the Da Vinci Code was exciting, try the GEN Microarray Challenge. Genetic Engineering & Biotechnology News (GEN) along with partner, Scintellix, and sponsor, Agilent, are proud to bring you the puzzle that’s sure to make you think.

The stimulating painting, called Microarray, which is featured on the contest site, was created by Peter C. Johnson, M.D., the president and CEO of Scintellix. The image requires not only skill and scientific experience to decode so as to determine its cryptic message, but also a strong appreciation for biological studies. “Anyone who performs biological research knows what an unending puzzle it is to decipher truth in the processes of life,” said Dr. Johnson. “In Microarray , I wanted to emphasize this by inserting man’s own puzzle-making capability [a cipher] into the art.”

The first contestant to solve the cryptic message will be featured in a February issue of GEN and receive $1,500. The first 50 registrants will receive a complimentary poster depicting Microarray, along with a poster tube.

The contest runs from November 13 to December 31. Although contestants can submit several entries within the specified dates, only one submission is allowed per day. All submissions must be received electronically by midnight on December 31. Clues will be provided every Monday, starting November 17 on the GEN Microarray Challenge website.

Dr. Johnson will be the judge, and a sealed solution will be held in escrow.

“GEN is absolutely delighted to work with Dr. Johnson and Agilent on this exciting project that promises to be a demanding and, even more importantly, fun experience for all who participate,” added Joan Boyce, group publisher of GEN.

About the Partnership

GEN and Scintellix have formed a partnership to explore the hidden meaning found in biological imagery. The Microarray Contest is the first installment of the partnership.

About GEN

Genetic Engineering & Biotechnology News is the most widely read publication in the biotechnology industry and the only high-frequency publication focused on international bioindustry news. Established in 1981, GEN has been the publication of record since its inception.

About Scintellix, LLC

Scintellix, LLC applies decision analysis methodologies to support the resolution of complex problems in personal and corporate development. The company is located in Raleigh, NC.

About Agilent

Agilent Technologies Inc. is the world’s premier measurement company and a technology leader in communications, electronics, life sciences, and chemical analysis. The company’s 20,000 employees serve customers in more than 110 countries. In fiscal 2007, Agilent had net revenues of $5.4 billion. Information about Agilent is available on the company’s website at

Contact: John Sterling, Editor in Chief, Genetic Engineering and Biotechnology News

(914) 740-2196,