The Pilot Investigation of Teachers’ Perceptions of Psychotropic Drug Use in Schools by Lien, Carlson, Hunter-Oehmke and Knapp presents a startling finding — “more than half the parents seeking medication treatment for their child’s externalizing behavior in one pediatric setting were doing so as the result of recommendations from school personnel.” Yet, the teachers in their study responded that they had “none or limited” (88.9% and 100% respectively) training on children’s mental health problems or the medications prescribed to treat them.

The teachers involved in the study’s answer to this dilemma? They want more training in the area of child psychopharmacology and more collaboration with parents and physicians who prescribe the medication, which at present is a near non-existent relationship. In short, they want to become an integral part of the child’s treatment plan.

Society at large however, begs to differ. Legislation is markedly on the rise to limit the role of educators of all stripes in student psychopharmacological treatment. In fact, while the American Psychiatric Association (APA) and others advocate in favor of certain psychotropics for youth, an increasing number of lawsuits are challenging the use of this medication altogether. The legal actions involve questions such as the validity of psychiatric tests, the need for side effect warnings, and studies indicating psychotropics like Ritalin can lead to substance abuse.

In the United Kingdom, the National Institute of Clinical Excellence (NICE), an organization that issues health guidelines, has questioned to the exorbitant uptake in young people on psychotropics, as well as studies indicating that some antidepressants may increase suicidal tendencies. NICE’s most current report flatly asserts that only in cases of “severe depression” should psychotropics be administered in combination with “talking therapies.”

While the two schools of thought slug it out, The No Child Left Behind Act of 2001 prohibits federal intervention in education issues, placing the ball in state and local courts. As it currently stands, legislation against school and child psychotropic liaisons is the trend du-jour. What do you think?

References

Wegner, L. (2005). Pediatricians and Antidepressant Medications: Black Box or Black Hole? PEDIATRICS, 116 (1), 233-235 DOI: 10.1542/peds.2005-0928

Lien, M., Carlson, J., Hunter-Oehmke, S., & Knapp, K. (2007). A Pilot Investigation of Teachers’ Perceptions of Psychotropic Drug Use in Schools Journal of Attention Disorders, 11 (2), 172-177 DOI: 10.1177/1087054707300992

Lakhan, S., & Hagger-Johnson, G. (2007). The impact of prescribed psychotropics on youth Clinical Practice and Epidemiology in Mental Health, 3 (1) DOI: 10.1186/1745-0179-3-21

Many studies have demonstrated a negative relationship between increased body mass index (BMI) and income. This relationship is most obvious in jobs that require interpersonal skills, often with a great deal of social interaction. The salary disparity between normal-BMI and high-BMI employees gets worse as the workers get older. Overall, being overweight or obese minimizes the chance of obtaining gainful employment. Health economists attribute this salary-weight association to consumers and employers disliking obese workers.

The wage-weight discussion expands not only to the actual salary workers bring home, but weight affects social success, too. Moving up or down the social hierarchy and accumulating social advantages is correlated to weight. A recent epidemiological study reported that downwardly mobile people were more likely to be overweight or obese than socially stable individuals of high socioeconomic status. The likelihood of being overweight or obese also increased with the accumulation of social disadvantages. This maintains the cycle of poor social status, increased weight, poor health, and decreased employment opportunities.

A recent health economics study calculates the overall economic burden attributable to overweight and obesity, if currently overweight adolescents become obese adults. The study examined the predicted population of working-age adults in the United States from 2020 to 2050. Based on current trends, that population will suffer from 161 million life-years complicated by obesity, diabetes, or heart disease. There will be 1.5 million life-years lost. These conditions will cost society $254 billion. Most of the expense is due to lost productivity either from early death or disease morbidity. Only $46 billion is related to direct medical expenses. Applying currently available treatments to obesity-related diseases would only decrease the life-years lost to 1.1 million, but would increase medical costs by $7 billion.

Most Americans spend most of their day at work. If society is losing money and resources because of overweight and obesity, it seems obvious that employers would want to address the issue and improve worker productivity. But, workplace interventions to promote proper nutrition and physical activity have little benefit in improving weight status. Most successful participants in workplace interventions already have a healthy or near-healthy BMI.

America is losing its reputation as a productive, prosperous country. If not to improve the physical health of the population, Americans should get fit and lose weight to improve the economic and fiscal health of this great nation.

References

Lemon SC, Zapka J, Li W, Estabrook B, Magner R, Rosal MC. Perceptions of worksite support and employee obesity, activity, and diet. American journal of health behavior 2009;33(3):299-308.

Anderson, L., Quinn, T., Glanz, K., Ramirez, G., Kahwati, L., Johnson, D., Buchanan, L., Archer, W., Chattopadhyay, S., & Kalra, G. (2009). The Effectiveness of Worksite Nutrition and Physical Activity Interventions for Controlling Employee Overweight and ObesityA Systematic Review American Journal of Preventive Medicine, 37 (4), 340-357 DOI: 10.1016/j.amepre.2009.07.003

Lightwood, J., Bibbins-Domingo, K., Coxson, P., Wang, Y., Williams, L., & Goldman, L. (2009). Forecasting the Future Economic Burden of Current Adolescent Overweight: An Estimate of the Coronary Heart Disease Policy Model American Journal of Public Health, 99 (12), 2230-2237 DOI: 10.2105/AJPH.2008.152595

Han, E., Norton, E., & Stearns, S. (2009). Weight and wages: fat versus lean paychecks Health Economics, 18 (5), 535-548 DOI: 10.1002/hec.1386

Clarke, P., O’Malley, P., Johnston, L., & Schulenberg, J. (2008). Social disparities in BMI trajectories across adulthood by gender, race/ethnicity and lifetime socio-economic position: 1986-2004 International Journal of Epidemiology, 38 (2), 499-509 DOI: 10.1093/ije/dyn214

Heraclides, A., & Brunner, E. (2009). Social mobility and social accumulation across the life-course in relation to adult overweight and obesity: The Whitehall II study Journal of Epidemiology & Community Health DOI: 10.1136/jech.2009.087692

Stories like this could be more likely if some cancer researchers have their way. An opinion piece in a recent issue of the Journal of the American Medical Association (JAMA) offers a new perspective on cancer screening. For decades, clinicians, researchers, advocacy groups, and public service announcements have touted the benefits of early cancer screening and insisted that women get routine screenings for breast and cervical cancer, and men get tested for prostate cancer, among other testing and prevention strategies. Still, while the nearly-30 years of research on early cancer screening and prevention has led to a vast body of scientific knowledge, it has not led to decreased deaths from cancer, calling in to question the effectiveness of cancer screening.

The authors of the JAMA article report that the incidence of breast and prostate cancers has increased since the initiation of aggressive screening and detection techniques. Also, the incidence of cancers early in life has increased. The authors contend that screening may increase the diagnosis of low-risk cancers, but still does not adequately diagnose aggressive cancers, explaining the lack of reduction in cancer mortality. The more aggressive the tumor, the less likely it is to be diagnosed in time to save the patient. Further, the authors believe that early screenings have led to over-diagnosis and over-treatment of cancers that would likely not harm an individual or shorten the lifespan.

Currently, nearly half of men at risk for prostate cancer receive routine PSA tests — the standard screening tool for prostate health, and 70 percent of women over 40 have had a mammogram recently. But, the increased prevalence of these screenings has doubled the likelihood that a man will be diagnosed with prostate cancer in his lifetime, and the chance that a woman will be diagnosed with breast cancer has risen from 1 in 12 to 1 in 8 in the last 30 years. Today, more than 800 women need to be screened in 6 years to prevent 1 breast cancer death.

Many studies support the conclusions in JAMA and report that early screening and cancer prevention practices have shown only modest improvements long-term survival over the last 30 years. Mostly, there is still a lot about cancer that remains a mystery. Tumors are all different and therapies are always evolving. Still, strides have been made — through drug therapy intervention, early detection tests, and healthy lifestyle education — in preventing or detecting early the 4 deadliest cancers in the United States (breast, prostate, lung, and colorectal cancer). Some clinicians support increased lifestyle and basic nutrition education instead of, or in addition to, traditional medical approaches for cancer screening and prevention. Still others support reforming the clinical trial system to allow earlier human trials and speed the development of new cancer treatments.

There are inherent limitations to screenings: Who should be a candidate? What should the patient do with the information? What is the success rate of the test? No one is advocating stopping the early detection and prevention strategies for cancer completely — they have saved countless lives. But, patients should be informed before undergoing the testing and the physicians should be able to separate the life-threatening cancers from the not-so-serious ones. Fine-tuning screening techniques and evaluating the patient’s stage in life and overall health are important before proceeding with mass cancer screenings for everyone. But, then again, if you or your family member were the 1 cancer death prevented by early detection, would you want everyone to be screened?

References

Esserman, L., Shieh, Y., & Thompson, I. (2009). Rethinking Screening for Breast Cancer and Prostate Cancer JAMA: The Journal of the American Medical Association, 302 (15), 1685-1692 DOI: 10.1001/jama.2009.1498

Greenwald P (2007). A favorable view: progress in cancer prevention and screening. Recent results in cancer research. Fortschritte der Krebsforschung. Progres dans les recherches sur le cancer, 174, 3-17 PMID: 17302181

GREENWALD, P. (2008). S1. Do we make optimal use of the potential of cancer prevention? European Journal of Cancer Supplements, 6 (3), 1-1 DOI: 10.1016/S1359-6349(08)70193-9

New research published in the medical journal The Lancet posits that most babies born since the year 2000 will live to be at least 100 years old. The authors studied the life expectancies of children born in several countries of Europe and North America, wealthy countries that already have long life expectancies. However, the trend of increasing life expectancy is similar throughout the world. We have known for decades that people are living longer, thanks to advances in medical treatment, better understanding of healthy lifestyle habits, and improvements in living and working conditions. The real question is: what is the quality of the extra years of life?

Will the someday-centenarians simply be alive longer, but be afflicted with the same maladies and disabilities seen in aging populations today? Or, will they maintain their strength and fitness longer into life? Thankfully, the authors of the current article believe that aging is a modifiable process, and that the aging populations of the future will be healthier than those today, making the extra years a blessing rather than a curse.

Much research has been conducted on the process of aging and a great deal of it focuses on calorie and nutrient intake. Reducing caloric intake in rats, mice, and primates extends their lifespan up to 40 percent, and is accompanied by health benefits. Caloric restriction protects against the damaging effects of aging by blocking certain proteins and activating signaling molecules, which lead to leaner body mass, stronger bones, protection against type 2 diabetes, improved immunity, and increased cognition and motor skills.

Drugs that might mimic caloric restriction and the function of proteins and signaling molecules are being investigated, including the well-known diabetes drug metformin and the immunosuppressant rapamycin. Clinical trials are already underway investigating the effects of highly concentrated antioxidants, such as those found in red wine, that have similar effects to reducing caloric intake.

Just adding more years to life may not be desirable, unless we can add life to the years. With an ever-aging population that will live longer than ever before, it is important to ensure that people live healthier lives. Healthy aging, no matter what the life expectancy, includes proper nutrition and physical activity, disease and disability prevention, and optimal social structure. By manipulating the process of aging, people no longer have to assume that poor health and disability are unavoidable, but can live long, healthy lives.

References

Um, S., D’Alessio, D., & Thomas, G. (2006). Nutrient overload, insulin resistance, and ribosomal protein S6 kinase 1, S6K1 Cell Metabolism, 3 (6), 393-402 DOI: 10.1016/j.cmet.2006.05.003

Christensen, K., Doblhammer, G., Rau, R., & Vaupel, J. (2009). Ageing populations: the challenges ahead The Lancet, 374 (9696), 1196-1208 DOI: 10.1016/S0140-6736(09)61460-4

Selman, C., Tullet, J., Wieser, D., Irvine, E., Lingard, S., Choudhury, A., Claret, M., Al-Qassab, H., Carmignac, D., Ramadani, F., Woods, A., Robinson, I., Schuster, E., Batterham, R., Kozma, S., Thomas, G., Carling, D., Okkenhaug, K., Thornton, J., Partridge, L., Gems, D., & Withers, D. (2009). Ribosomal Protein S6 Kinase 1 Signaling Regulates Mammalian Life Span Science, 326 (5949), 140-144 DOI: 10.1126/science.1177221

Sadovsky, R. (2009). Facilitating healthy aging among men: making some impact Journal of Men’s Health, 6 (2), 98-100 DOI: 10.1016/j.jomh.2009.02.002

Studies exploring the role of humor in pain perception involve showing participants funny videos prior to the “cold presser task,” in which participants submerge their hand into very cold water for as long as possible. Researchers measure the time it takes before the participants declare that the task is painful, indicating “pain threshold,” and the subsequent time that they can bear the pain, known as “pain tolerance.” One study found that when participants view a humorous video, compared to neutral and negative videos in similar length and interest level, they show increased levels of pain tolerance and duration. Intrigued as to which components of appreciating humor drive this effect, another set of researchers explored whether measuring participants’ cheerful mood invoked by humor, their extent of facial expressions of humor appreciation, or their focus on the humorous content of a short clip of “Mr. Bean” differentially effected pain perception. Interestingly, all three conditions yielded increased pain tolerance to the cold presser task.

The biological mechanisms that underlie humor’s effect on pain remain undetermined. However, some suggest that humor and/or laughter release endorphins, which are known to lend analgesic effects. However, this view remains purely speculative, as there is no causal scientific evidence to support the claim. Alternatively, two brain imaging studies offer other insights. That is, when participants view humorous cartoons, compared to non-humorous cartoons, certain brain regions are significantly more active. Among them is the anterior cingulate cortex, which has been shown to activate in response to the affective aspects of pain (i.e. the ‘feeling’ of pain). On the one hand, that the same area is active in response to both kinds of stimuli seems counter intuitive, but it may be that pain states and appreciation of humor rely on the anterior cingulate to detect ‘discrepancy’ in stimuli, and guide the emotional response to the discrepancy. In the case of pain, the discrepancy (i.e. I feel what I should not) is negatively appraised, while the discrepancy perceived in humor (i.e. this is not what I expected in this situation) is appraised positively. This interpretation is supported by the fact that viewing humorous compared to non-humorous cartoons also activates the human ‘reward system,’ brain areas that also light up when we eat chocolate.

While the biology of humor as an anodyne requires further research, medical practitioners, such as Dr. “Patch” Adams, have long noted its soothing effects on patients. As Freud once said,

Humor is a means of obtaining pleasure in spite of the distressing effects that interface with it.

References

Weisenberg M, Raz T, & Hener T (1998). The influence of film-induced mood on pain perception. Pain, 76 (3), 365-75 PMID: 9718255

Zweyer, K., Velker, B., & Ruch, W. (2004). Do cheerfulness, exhilaration, and humor production moderate pain tolerance? A FACS study Humor – International Journal of Humor Research, 17 (1-2), 85-119 DOI: 10.1515/humr.2004.009

Watson, K., Matthews, B., & Allman, J. (2006). Brain Activation during Sight Gags and Language-Dependent Humor Cerebral Cortex, 17 (2), 314-324 DOI: 10.1093/cercor/bhj149

Mobbs D, Greicius MD, Abdel-Azim E, Menon V, & Reiss AL (2003). Humor modulates the mesolimbic reward centers. Neuron, 40 (5), 1041-8 PMID: 14659102

The BMJ “fast track” study surveyed healthcare workers — physicians, nurses, and allied health professionals — in the first several months of 2009 to assess their willingness to receive a flu vaccine as part of pre-pandemic planning. When the WHO pandemic alert was phase 3, indicating limited human-to-human transmission, less than one-third (28.4%) of workers were willing to receive a vaccine. At phase 5 alert level, an indicator that a global pandemic is imminent, less than half (47.9%) were still willing to do so.

The most common reasons that healthcare workers who were willing to receive the vaccine included the desire to be protected against the virus, and compliance with the recommendations of healthcare authorities. Also, healthcare workers who received seasonal flu vaccines in the past, and those who perceived an increased risk of becoming infected, were more likely to be willing to receive the vaccine. Fear of possible side effects, as well as questions regarding the effectiveness of the vaccine, limited the willingness to receive the vaccine.

The results of this study are similar to those of a survey recently conducted by Nursing Times that reported only 37% of nurses with direct patient contact were planning to be vaccinated against H1N1 flu. Additionally, 33% were undecided, but 30% of nurses were not planning on being vaccinated. The same reasons reported in the BMJ study are cited as reasons in favor of or opposition to vaccine acceptance.

Overall rates of healthcare worker vaccination are low, with only 42% of healthcare workers typically receiving seasonal flu vaccines. In many hospital settings, this vaccine is recommended by the Centers for Disease Control and Prevention, as well as hospital administrators, but is not mandatory. In contrast, immunization requirements for healthcare workers have resulted in near-100% coverage against measles, mumps, rubella, and tuberculosis screening. A required flu vaccine — seasonal or H1N1 — could have the same outcome, according to the recent position paper by the Association of Professionals in Infection Control and Epidemiology.

With a flu pandemic almost certain according to most health organizations, hospitals will face many decisions regarding protective measures against the flu. Ordering extra surgical masks, providing family support for affected hospital staff, reinforcing infection control procedures, limiting unnecessary visitors to the hospital, and limiting procedures that may increase the spread of the flu virus are all potential strategies to keep healthcare workers and patients safe.

The acceptance of flu vaccines by healthcare workers limits the spread of the disease to vulnerable patients and keeps the healthcare system running at optimal levels. Moreover, healthcare workers also influence the vaccination of patients and people in the community at large. According to research among children and adults, healthcare providers are very influential in the decision to vaccinate or not. Most importantly, healthcare workers must be confident that flu vaccines are safe and effective, and be motivated to pass this information on to the community.

The media hype and conflicting information since the first cases of H1N1 flu appeared in the spring of 2009 has prevented many people — healthcare workers included — from fully understanding the risks of H1N1 flu or how to prevent it. Complete and accurate information needs to be provided to healthcare workers as hospitals make decisions about vaccine requirements and other flu prevention strategies.

References

Baeyens JP, Lang PO, Michel JP. Willingness to vaccinate and to be vaccinated in adults. Aging Clin Exp Res. Jun 2009;21(3):244-249.

Jordan, R., & Hayward, A. (2009). Should healthcare workers have the swine flu vaccine? BMJ, 339 (aug25 2) DOI: 10.1136/bmj.b3398

Jordan, R., & Hayward, A. (2009). Should healthcare workers have the swine flu vaccine? BMJ, 339 (aug25 2) DOI: 10.1136/bmj.b3398

Smith, P., Kennedy, A., Wooten, K., Gust, D., & Pickering, L. (2006). Association Between Health Care Providers’ Influence on Parents Who Have Concerns About Vaccine Safety and Vaccination Coverage PEDIATRICS, 118 (5) DOI: 10.1542/peds.2006-0923

Use of Influenza A (H1N1) 2009 Monovalent Vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR Recomm Rep. August 28, 2009 2009;58(RR10):1-8.

Zarocostas, J. (2009). Healthcare workers should get top priority for vaccination against A/H1N1 flu, WHO says BMJ, 339 (jul15 1) DOI: 10.1136/bmj.b2877

The secret to a happy life has eluded mankind for generations. Ancient philosophers, progressive thinkers, and contemporary educators have all offered theories and opinions on what makes us happy. But no one has collected more objective evidence on the subject than researchers from the Harvard Medical School. The Harvard Study of Adult Development began in 1937, examining more than 200 healthy, well-adjusted Harvard sophomores. The study has become the preeminent example of a longitudinal study, following its subjects for more than 70 years. The group of men is not at all representative of the population as a whole, consisting entirely of well-educated, socioeconomically-favored males, but the homogenous group of subjects has still uncovered some surprises in the quest for happiness.

Over the years of the study, researchers have collected extensive information on the men’s physical, mental, and emotional health, and compared this to their accomplishments in their occupations, marriages, and hobbies, as well as their self-perceived level of satisfaction with life. Researchers have found that cholesterol levels in middle age had no correlation to overall health in old age. They concluded that regular exercise in college was positively correlated with mental health later in life. They discovered that religious involvement, in contrast to many previously reported studies, was not associated with physical, mental, or social well-being.

Successful aging and happiness later in life, the researchers have concluded, is predicted by many difference variables — some of which can be controlled, and some of which cannot: parental social class, family cohesion, major depression, ancestral longevity, childhood temperament, physical health at age 50, alcohol abuse, smoking, marital stability, exercise, body mass index, coping mechanisms, and education. Ultimately, there is no one secret to a happy, successful life. Men who seemed to have every advantage in life failed to succeed in careers and family life, and many have died prematurely or unexpectedly. Men, on the other hand, who seemed doomed for failure due to their circumstances rose to the challenge and eventually led exceptional lives.

It turns out that success and happiness might not be determined by what you know, but by who you know. The closest thing that researchers have been able to identify as a single secret to happiness is successful relationships. High levels of intelligence, social aptitude, physical strength, or mental health mean very little in the pursuit of happiness. Positive relationships — with parents, siblings, spouses, children, friends, neighbors, and colleagues — as early as childhood are the most important predictors of happiness and success as we age. Largely, loving relationships and an appreciation for beauty positively predict life satisfaction.

Of course, happiness and life satisfaction are individually defined, depending on culture, society, and personality. Self-expression and individualism play an important role in happiness in many cultures, while simple survival constitutes a successful life in others. But, however we define happiness, positive emotions are linked to resilience and a satisfaction for life. As much as scientists are called to delineate objective measures of subjective experiences, maybe we should heed Albert Camus’s warning:

You will never be happy if you continue to search for what happiness consists of.

References

Cohn, M., Fredrickson, B., Brown, S., Mikels, J., & Conway, A. (2009). Happiness unpacked: Positive emotions increase life satisfaction by building resilience. Emotion, 9 (3), 361-368 DOI: 10.1037/a0015952

ISAACOWITZ, D., VAILLANT, G., & SELIGMAN, M. (2003). STRENGTHS AND SATISFACTION ACROSS THE ADULT LIFESPAN The International Journal of Aging and Human Development, 57 (2), 181-201 DOI: 10.2190/61EJ-LDYR-Q55N-UT6E
Kuppens P, Realo A, Diener E. The role of positive and negative emotions in life satisfaction judgment across nations. J Pers Soc Psychol. Jul 2008;95(1):66-75. doi:10.1037/0022-3514.95.1.66

VAILLANT, G., TEMPLETON, J., ARDELT, M., & MEYER, S. (2008). The natural history of male mental health: Health and religious involvement Social Science & Medicine, 66 (2), 221-231 DOI: 10.1016/j.socscimed.2007.09.011

Vaillant, G., DiRago, A., & Mukamal, K. (2006). Natural History of Male Psychological Health, XV: Retirement Satisfaction American Journal of Psychiatry, 163 (4), 682-688 DOI: 10.1176/appi.ajp.163.4.682

Vaillant, G. (2001). Successful Aging American Journal of Psychiatry, 158 (987), 839-847 DOI: 10.1176/appi.ajp.158.987.839
Waldinger RJ, Vaillant GE, Orav EJ. Childhood sibling relationships as a predictor of major depression in adulthood: a 30-year prospective study. Am J Psychiatry. Jun 2007;164(6):949-954. doi:10.1176/appi.ajp.164.6.949

Shenk JW. What Makes Us Happy? The Atlantic; 2009.

In the past few years, many health care agencies and organizations have promoted programs to reduce the use of unnecessary antibiotics. These programs have included everything from prescriber training to patient education to additional diagnostic testing, and only a few programs have seen moderate success in reducing the use of unnecessary antibiotics. A new study in the British Medical Journal (BMJ) evaluated yet another approach to promoting judicious antibiotic use and concluded that the most effective method of decreasing antibiotic use is a combination of diagnostic testing and enhanced physician-patient communication.

The BMJ study evaluated 413 patients with suspected LRTIs among 40 general practitioners in the Netherlands. Practitioners used a C-reactive protein (CRP) point of care test and enhanced communications techniques, alone and in combination. This assessment of a disease or diagnostic approach versus a patient-centered approach is similar to other studies conducted, and observed that antibiotics were prescribed significantly less often in the CRP test group versus the no test group (31% versus 53%). Similarly, antibiotics were prescribed significantly less often in the enhanced communication group (27%) compared with the group that practiced traditional communication techniques (54%). The practitioners who used a combination of CRP testing and enhanced communication skills prescribed antibiotics the least. These interventions did not affect patients’ recovery or satisfaction with care received.

The thoughtful and appropriate use of antibiotics is vital for reducing the global crisis of antibiotic resistance. Patient demands and lack of prescriber training and education contribute to the over-use and misuse of antibiotics for conditions for which they are ineffective. The current study is just one in a long line of similar appraisals that promote patient-centered approaches, including education and communication, as important factors in reducing unnecessary antibiotic use.

While nearly every health care professional acknowledges the general need to use antibiotics appropriately, most do not view it as a problem they can fix themselves and most have not altered their own prescribing habits, even in light of the increasing concern of antibiotic resistance. While the authors of the current study are doing their part to increase awareness of appropriate antibiotic use, it is a little disheartening that physicians need a randomized, controlled clinical trial and a peer-reviewed journal article to encourage them to communicate with their patients.

References

Briel M, Langewitz W, Tschudi P, Young J, Hugenschmidt C, Bucher HC. Communication training and antibiotic use in acute respiratory tract infections. A cluster randomised controlled trial in general practice. Swiss Med Wkly. Apr 15 2006;136(15-16):241-247.

Cals, J., Butler, C., Hopstaken, R., Hood, K., & Dinant, G. (2009). Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial BMJ, 338 (may05 1) DOI: 10.1136/bmj.b1374

Cals JW, Hopstaken RM, Butler CC, Hood K, Severens JL, Dinant GJ. Improving management of patients with acute cough by C-reactive protein point of care testing and communication training (IMPAC3T): study protocol of a cluster randomised controlled trial. BMC Fam Pract. 2007;8:15. DOI: 10.1186/1471-2296-8-15

Francis NA, Hood K, Simpson S, Wood F, Nuttall J, Butler CC. The effect of using an interactive booklet on childhood respiratory tract infections in consultations: study protocol for a cluster randomised controlled trial in primary care. BMC Fam Pract. 2008;9:23. DOI: 10.1186/1471-2296-9-23

Spurling GK, Del Mar CB, Dooley L, Foxlee R. Delayed antibiotics for respiratory infections. Cochrane Database Syst Rev. 2007(3):CD004417. DOI: 10.1002/14651858.CD004417.pub3

The BAIPA was initially understood to be antiabortion legislation, granting legal status to all live-born infants in the United States, regardless of whether birth was spontaneous, by Cesarean section, or induced by an elective abortion. Immediately after the passage of the BAIPA, the Neonatal Resuscitation Program Steering Committee issued an opinion that the law should not change neonatology practice with respect to the extremely premature infant. However, the DHS soon released enforcement guidelines that threatened investigations of violations of long-standing regulations — the Emergency Medical Treatment and Labor Act and the Child Abuse Prevention and Treatment Act — if any lay observer claimed that medical care was withheld from a newborn. The enforcement guidelines did not include a stipulation for a physician’s medical training and knowledge to prevail over the layperson’s observations. With the threat of hefty fines and litigation, many physicians and hospitals worry about the day when the BAIPA will actually be enforced.

The last several decades have seen vast improvements in technology and understanding of neonatal physiology, but surprisingly minor improvements in the actual survivability of extremely premature and low birth weight babies. Much debate still surrounds the gestational age and birth weight limits used to identify an infant’s ability to survive outside of the mother’s womb. In most cases, survival of infants born at less than 25 weeks gestation is unlikely. Most practitioners agree that aggressive measures of resuscitation for newborns born at less than 23 weeks gestation is futile and unwarranted. In such cases, neonatologists are more likely to provide comfort care to the infant and the family until the infant dies naturally.

The decision to resuscitate a newborn that is unlikely to survive is a complex one that should involve physicians, other health care professionals, and parents. However, these decisions must also be made quickly. In these cases, timely and appropriate decision-making can decide whether an infant dies, survives with impairment, or survives intact. The consequences of the decisions — positive or negative –- are almost immediate. Medical professionals bring their judgment and experience, as well as perceived obligations and legal mandates to the decision-making; parents bring cultural, personal, ideological, and religious beliefs to the decision-making. Who should be permitted to make the final judgment of what treatment is in the best interest of the child?

The American Academy of Pediatrics recommends that neonatologists perform complete prenatal consultations with parents in the likelihood of an extremely premature birth. Most physicians are comfortable discussing clinical issues with parents, but far fewer are comfortable discussing quality-of-life issues, expected long-term outcomes, or parental preferences. Physicians should provide parents with the medical information necessary for informed decision-making, and but should also foster parental involvement in the care of their child. A framework for newborn resuscitation may be necessary to clarify each practitioner’s role in the care of likely nonviable newborns, and to aid in decision-making, but the government should not be mandating medical procedures or making therapeutic decisions in a complex life or death decision of a child.

References

Campbell, D., & Fleischman, A. (2001). Limits of Viability: Dilemmas, Decisions, and Decision Makers American Journal of Perinatology, 18 (03), 117-128 DOI: 10.1055/s-2001-14530

HUSSAIN, N., & ROSENKRANTZ, T. (2003). Ethical considerations in the management of infants born at extremely low gestational age Seminars in Perinatology, 27 (6), 458-470 DOI: 10.1053/j.semperi.2003.10.005

Partridge, J., Sendowski, M., Drey, E., & Martinez, A. (2009). Resuscitation of Likely Nonviable Newborns: Would Neonatology Practices in California Change if the Born-Alive Infants Protection Act Were Enforced? PEDIATRICS, 123 (4), 1088-1094 DOI: 10.1542/peds.2008-0643

Sayeed, S. (2005). Baby Doe Redux? The Department of Health and Human Services and the Born-Alive Infants Protection Act of 2002: A Cautionary Note on Normative Neonatal Practice PEDIATRICS, 116 (4) DOI: 10.1542/peds.2005-1590

Lakshminrusimha S, Carrion V. Perinatal phsyiology and principles of neotal resuscitation. Clin Ped Emerg Med. 2008;9:131-139.

Bastek, T. (2005). Prenatal Consultation Practices at the Border of Viability: A Regional Survey PEDIATRICS, 116 (2), 407-413 DOI: 10.1542/peds.2004-1427

Partridge, J. (2005). International Comparison of Care for Very Low Birth Weight Infants: Parents’ Perceptions of Counseling and Decision-Making PEDIATRICS, 116 (2) DOI: 10.1542/peds.2004-2274

As the medical profession evolved into a scientific discipline, the white coat began to represent the physician as a scientist. It also epitomized a feeling of cleanliness, and served as a barrier between the physician and his patient. As time passed, the white coat became so symbolic of physicians that medical students began taking part in “white coat ceremonies” to signify the beginning of a professional journey and undertaking of considerable responsibility. Many medical students see the white coat ceremony as the transition from nonphysician to physician and donning the coat helps to symbolize the commission they are accepting.

Still, the white coat – in all cleanliness and purity — is losing favor among some circles. Remarkably, white coats were actually banned in England in September of 2007 by the United Kingdom Department of Health. Physicians are now required to adhere to a “bare below the elbows” dress code. That is, short sleeves and no watches or jewelry when engaging in clinical activity. (Neckties are also banned.) The reason? Infection control. It was believed that white coats worn in clinical environments, and laundered infrequently, contribute to the spread of hospital-associated infections. Also, the dress code is believed to promote effective hand washing. On a smaller scale, some infectious disease departments in the United States, as well as some hospitals, have implemented, or are considering implementing, a similar policy.

While the dress code is well intentioned, it is not based on many facts. Many studies have shown that health care workers’ uniforms, as well as hospital curtains and linens, can be contaminated with pathogens from the clinical environment, but there is a lack of evidence that the colonization actually leads to the spread of disease. A recent poster presented at the annual meeting of the Society for Healthcare Epidemiology of America reported that bacteria common in hospital-acquired infections (methicillin-resistant Staphylococcus aureus, Vancomycin-resistant Enterococcus, and pan-resistant Acinetobacter) could be isolated from lab coats, transferred to pig skin, and re-isolated from the skin. The isolates were obtained from the white coats at 1-minute, 5-minute, and 30-minutes intervals after contamination. While this investigation shows the biological plausibility of white coats transmitting infections, it is a long way from proving disease transmission.

So, should all physicians ditch the white coat? Not so fast, say the patients. In numerous studies, patients significantly favor physicians who dress professionally and wear white coats. Patients are also more likely to attribute competence to a physician who is professionally dressed. Many patients favor white coats owing to the ease of identification, as well as tradition. There are very few patients who believe white coats are an infection risk, though many do view them as intimidating.

Physicians who choose to wear white coats in daily practice do so for many reasons: tradition, peer pressure, identification, keeping underlying clothes clean, and pockets for carrying references and equipment. Also, many physicians still like the prestige that accompanies the white coat. However, with more and more health professionals working in clinical settings, everyone from pharmacists and nurse practitioners to phlebotomists and dietitians are dressing in white coats, making identification and stature harder to ascertain.

The English ban on white coats is not likely to cross its borders, so physicians in the United States can keep wearing the traditional cloak of hope and purity for now. Medical professionals would be better advised to focus on hand washing, high hospital bed occupancy, and the excessive use antibiotics to combat the spread of disease.

References

Douse, J. (2004). Should doctors wear white coats? Postgraduate Medical Journal, 80 (943), 284-286 DOI: 10.1136/pgmj.2003.017483

KAZORY, A. (2008). Physicians, Their Appearance, and the White Coat The American Journal of Medicine, 121 (9), 825-828 DOI: 10.1016/j.amjmed.2008.05.030

REHMAN, S., NIETERT, P., COPE, D., & KILPATRICK, A. (2005). What to wear today? Effect of doctor’s attire on the trust and confidence of patients The American Journal of Medicine, 118 (11), 1279-1286 DOI: 10.1016/j.amjmed.2005.04.026

Wilson, J., Loveday, H., Hoffman, P., & Pratt, R. (2007). Uniform: an evidence review of the microbiological significance of uniforms and uniform policy in the prevention and control of healthcare-associated infections. Report to the Department of Health (England) Journal of Hospital Infection, 66 (4), 301-307 DOI: 10.1016/j.jhin.2007.03.026

A new study published in the journal Pediatrics concluded that, among members of the American Academy of Pediatrics Section of Emergency Medicine who are attending emergency physicians, 85% had prescribed EC, and 71% had done so within the past year. Nearly three-quarters of physicians reported a concern about the lack of follow-up care as the primary barrier to providing EC. Other common barriers included time constraints (40%), lack of clinical resources (33%), concern about discouraging regular contraceptive use (29%), and concern about possible birth defects (27%). Only 14% of physicians reported ethical beliefs as a barrier to the provision of EC. In total, 39% of physicians reported 5 or more barriers to prescribing EC for their patients. Understandably, the more barriers reported, the less likely the physician was to have ever prescribed EC.

Interestingly, only 11% of the emergency department physicians in the recent survey cited lack of knowledge about EC as a barrier to providing EC to their patients. However, as part of the same survey, physicians answered knowledge-based questions about EC and only 57% were able to correctly answer more than half of the questions. For example, many physicians incorrectly answered that EC was effective within the first 24 hours after unprotected sexual intercourse; EC is actually effective within the first 72 hours after intercourse, with limited effectiveness up to five days after intercourse.

Several recent studies have examined barriers to effective provision of EC, in an effort to reduce the obstacles facing some women seeking EC. Not surprisingly, provision of EC by physicians depends on practice specialty, year of graduation, gender, religion, and location. As expected, physicians practicing in obstetrics and gynecology prescribe EC more than other practice specialties; women also prescribe EC more than male counterparts. Overall, however, a majority of physicians in many studies do not routinely prescribe EC, do not initiate conversations about EC with their patients, and do not offer advance prescriptions for EC.

Recently, EC was made available without a prescription for women over 18 years old. (Patients 17 years old and younger may obtain EC, but need a prescription to do so.) While this increased access may seemingly diminish some barriers to EC access, more barriers were discovered among pharmacists. Another recent survey in the journal Contraception reported that many pharmacists are providing inaccurate information about EC. Not all pharmacies maintain a supply of EC, and it is appropriate for these pharmacists to refer patients elsewhere. However, some pharmacies inappropriately reported that nothing could be done for patients requesting EC in these cases. Also, pharmacists often did not provide accurate and timely information to patients requesting EC, even if EC was available on the premises. These barriers from physicians and pharmacists all prevent many women from obtaining, or even understanding, EC.

Pharmacists reported other barriers to EC in yet another survey from early 2009 in the Journal of the American Pharmacists Association. In this survey, pharmacists reported a lack of time, lack of reimbursement, and resistance from physicians as barriers to efficient access to EC in the community pharmacy setting. This survey of more than 2700 pharmacists, in contrast to the Contraception study, reported a strong interest, comfort level, and knowledge base in increasing access to EC. Practice guidelines and up-to-date information would further increase pharmacist support for providing EC in the community setting.

Many healthcare providers report concerns about increasing sexually irresponsible behavior and decreasing use of regular contraceptive practices if access to EC is increased. To date, most studies have not supported this belief. Instead, education about the proper use of EC has not reduced the use of regular contraceptives or increased sexual behavior among groups at-risk for unintended pregnancies.

Even after 10 years, barriers exist in the appropriate provision of EC to patients in need. While some of the barriers are physician- or pharmacist-related, others are still patient-related. Unfortunately, socioeconomic status and geographic location are barriers to EC, as they are to the provision of other medical services. Patients in lower socioeconomic brackets are more likely to access EC if it is available in a community pharmacy without a prescription, but some rural pharmacies do not maintain a supply of EC.

Estimates suggest than more than half of the 3.5 million unintended pregnancies in the United States each year could be avoided with timely access to EC. Overall, however, there is still an under-utilization of EC, even with procedures in place to seemingly increase access to it. This under-utilization results from barriers from patients, as well as the health care community. While the moral and ethical debate concerning EC practices will continue, these barriers are not the most significant in most cases. By directing the appropriate time, clinical resources, and education to physicians and pharmacists, EC access could be increased to patients in a prudent and professional manner.

References

Chuang, C. (2004). Emergency contraception: prescribing practices of general internists compared with other primary care physicians Contraception, 69 (1), 43-45 DOI: 10.1016/j.contraception.2003.09.003

Costa NF, Ferraz EA, Souza CT, Silva CF, Almeida MG. [Access to emergency contraception: old barriers and new questions]. Rev Bras Ginecol Obstet. Feb 2008;30(2):55-60.

Goyal, M., Zhao, H., & Mollen, C. (2009). Exploring Emergency Contraception Knowledge, Prescription Practices, and Barriers to Prescription for Adolescents in the Emergency Department PEDIATRICS, 123 (3), 765-770 DOI: 10.1542/peds.2008-0193

Landau, S., Besinque, K., Chung, F., Dries-Daffner, I., Maderas, N., McGhee, B., & Foster, D. (2009). Pharmacist interest in and attitudes toward direct pharmacy access to hormonal contraception in the United States Journal of the American Pharmacists Association, 49 (1), 43-50 DOI: 10.1331/JAPhA.2009.07154

LANDAU, S., TAPIAS, M., & MCGHEE, B. (2006). Birth control within reach: a national survey on women’s attitudes toward and interest in pharmacy access to hormonal contraception? Contraception, 74 (6), 463-470 DOI: 10.1016/j.contraception.2006.07.006

NELSON, A., & JAIME, C. (2009). Accuracy of information given by Los Angeles County pharmacies about emergency contraceptives to sham patient in need??? Contraception, 79 (3), 206-210 DOI: 10.1016/j.contraception.2008.10.003

Raine, T. (2005). Direct Access to Emergency Contraception Through Pharmacies and Effect on Unintended Pregnancy and STIs: A Randomized Controlled Trial JAMA: The Journal of the American Medical Association, 293 (1), 54-62 DOI: 10.1001/jama.293.1.54

Sarkar, N. (2008). Barriers to emergency contraception (EC): does promoting EC increase risk for contacting sexually transmitted infections, HIV/AIDS? International Journal of Clinical Practice, 62 (11), 1769-1775 DOI: 10.1111/j.1742-1241.2008.01827.x

Xu, X., Vahratian, A., Patel, D., McRee, A., & Ransom, S. (2007). Emergency Contraception Provision: A Survey of Michigan Physicians from Five Medical Specialties Journal of Women’s Health, 16 (4), 489-498 DOI: 10.1089/jwh.2006.0196

Of the nearly 7 million people on the planet today, more than 1 billion are overweight, and 300 million are obese. Of course, overweight and obesity contribute to numerous health concerns, including type 2 diabetes, cardiovascular disease, and cancer. But, do overweight and obesity cause global warming as well? The authors of the article say “yes.” They compared 2 hypothetical populations: one consisting of a “normal” adult population and one consisting of an “overweight” adult population. The “normal” population of 1 billion people had a mean body mass index (BMI) of 24.5 kg/m2 and 3.5% of the population was obese, having a BMI of greater than or equal to 30 kg/m2. (A BMI between 18 and 24.9 kg/m^2 indicates a healthy weight, and a BMI of 25 to 29.9 kg/m^2 indicates overweight.) The “overweight” population had a mean BMI of 29.0 kg/m^2 and 40% of the population was obese.  The normal population demographics were based on census data from the United Kingdom in 1970, and the overweight population reflects the predicted UK population in 2010.

Food production is estimated to account for 20% of global greenhouse gas emissions, and transportation accounts for 14%. Since food consumption is strongly correlated to increased BMI, and increased BMI leads to increased transportation energy expenditures, the authors assumed that a population with a higher average BMI would be a significant contributor to global climate change. Based on statistical modeling, the authors concluded that the overweight population required 19% more food energy than the normal population, leading to an additional production of 0.54 gigatonnes of carbon dioxide equivalents. (In 2000, the total global production of carbon dioxide equivalents was approximately 42 gigatonnes.) Considering transportation and food production, the total increase in carbon dioxide equivalents is estimated to be up to 1.0 gigatonnes each year for the overweight population.

Industrialized nations produce most of the world’s greenhouse gas emissions owing to increased food production and transportation. Further, most of the world’s overweight and obese people live in industrialized nations. The potential of what we eat and how we travel could, therefore, have significant environmental consequences. The world is moving from a plant-based diet to an animal-based diet, contributing significantly to chronic disease and obesity, but also environmental deterioration. However, is blaming overweight and obese people the best solution to a global crisis? The current epidemiological evaluation makes very broad assumptions about hypothetical populations to draw its conclusions. Body mass index is not an entirely reliable indicator of body fat content, as it relies only on height and weight to calculate fat content. This estimation is particularly unreliable in elderly people who lose muscle mass due to age, or in athletes with a muscular build. Last, the authors make no assertions that the 1.0 extra gigatonnes of carbon dioxide equivalents would have a significant impact on the total production of carbon dioxide equivalents. While every little bit helps in solving the environmental problems that face our planet — think globally, act locally! — is focusing on body size the best way to minimize our carbon footprint?

References

AKHTAR, A., GREGER, M., FERDOWSIAN, H., & FRANK, E. (2009). Health Professionals’ Roles in Animal Agriculture, Climate Change, and Human Health American Journal of Preventive Medicine, 36 (2), 182-187 DOI: 10.1016/j.amepre.2008.09.043

Dummer TJ. Health geography: supporting public health policy and planning. CMAJ. Apr 22 2008;178(9):1177-1180.

Edwards, P., & Roberts, I. (2009). Population adiposity and climate change International Journal of Epidemiology DOI: 10.1093/ije/dyp172

Haines A, McMichael AJ, Epstein PR. Environment and health: 2. Global climate change and health. CMAJ. Sep 19 2000;163(6):729-734.

Currently, more than 40 states impose higher food taxes on sugary beverages and snacks, but larger taxes — a penny-per-ounce tax is discussed in the NEJM article — have recently been proposed. The taxes have the potential to generate large revenue for states, and most supporters hope that the tax would be earmarked for campaigns to fight overweight and obesity, particularly in children. The intake of sugar-sweetened beverages is associated with increased body weight, poor nutrition status, and the displacement of more healthy foods. This, in turn, leads to an increase in diabetes, stroke, heart disease, high blood pressure, asthma, pregnancy complications, depression, and countless other diet-related medical conditions.

In the past decade, the United States per capita intake of calories from sugary beverages has increased by 30%. Beverages now account for 10-15% of the total calories consumed by children and adolescents. One study reported that for each serving of a sugary drink consumed each day, the likelihood of a child becoming obese increases by 60%. One factor contributing to the dramatic increase in consumption is the affordability of so-called junk food. On average, high-calorie, high-fat convenience foods are less expensive than the lower-calorie, nutrient-rich fruits, vegetables, and lean proteins that are essential to a healthy, balanced diet. (Couple that with the nearly $2 billion that soft drink manufacturers spend on marketing and advertising –- a large majority of which is aimed at children under 12 years old –- and it is no wonder there is no shortage of buyers for soft drinks and related junk food.) A tax on foods of poor nutritional value aims to make healthier foods appear more affordable and reduce the consumption of the apparently more expensive junk food. The one-penny-per-ounce tax on sugar-sweetened beverages discussed by the authors of the current article claim it would reduce consumption by 13% (2 servings of sugary drinks per person per week), and raise more than $1.2 billion in revenue in New York State alone.

There are many shortcomings to an excise tax on junk food. Such a tax could unfairly burden the lower socioeconomic groups –- the largest consumers of unhealthy convenience foods, but also the group most largely affected by diet-related diseases. Intuitively, this group needs the most help and would derive the most help from a healthier diet –- even if the government forces their food choices. But, would people automatically stop drinking soft drinks and start drinking water or milk instead? Not likely, without proper education on nutrition, health, and fitness. Perhaps this tax would only lead to a change in the proportion of calories derived from drinks versus solid foods. Further, people that are already obese find food more rewarding and reinforcing than do thin people, so the obese would be more motivated to obtain their preferred food or drink, independent of price. Not the least of opponent’s concerns is the ever-present hand of Big Brother in our wallets, pantries, and grocery carts. The government already tells us how much fluoride needs to be in our drinking water, how many vaccinations our children need to receive, and how often we have to wear seatbelts; the government uses public funds to subsidize farms and agriculture and set standards for school lunches. Should they also tell us what food to buy and feed our families?

As far back as the founding of the United States, politicians have posited the idea of taxing non-essential food items. Adam Smith, often cited as the father of modern economics, proposed a tax on sugar, rum, and tobacco in 1776, since these were not necessary for life, but were universally consumed. In his words, these items were “extremely proper subjects of taxation.” Opponents then and now argue that, while tobacco and alcohol are not, in fact, essential for life, food is necessary for survival and should not be singled out for a specific tax. Still, overweight and obesity have consequences for those who do not consume them, as do tobacco and alcohol. Each year, the United States spends more than $79 billion treating overweight and obese patients, and Medicare and Medicaid (that is, taxpayers) incur more than half of the total cost. Additionally, complications of overweight and obesity lead to lost productivity, increased absenteeism from school and work, poor academic performance, and reduced overall fitness of children and young adults, including military recruits: problems that affect us all.

Price does influence food purchases. Several studies have shown that manipulating price in vending machines, cafeterias, and restaurants influences food choices, leading to less consumption of high-calorie, high-fat foods, and more consumption of nutrient-rich foods. Obesity is more than an economic issue and a single intervention, such as an excise tax on junk food, is unlikely to shrink the waistline of America, but it is one option in the fight against overweight and obesity that may have limited benefits. Would a new tax on food bring us closer to a nanny state, or help Americans live healthier, more productive lives?

References

Brownell, K., & Frieden, T. (2009). Ounces of Prevention — The Public Policy Case for Taxes on Sugared Beverages New England Journal of Medicine DOI: 10.1056/NEJMp0902392

Chriqui JF, Eidson SS, Bates H, Kowalczyk S, Chaloupka FJ. State sales tax rates for soft drinks and snacks sold through grocery stores and vending machines, 2007. J Public Health Policy. Jul 2008;29(2):226-249.

Drewnowski A, Darmon N. The economics of obesity: dietary energy density and energy cost. Am J Clin Nutr. Jul 2005;82(1 Suppl):265S-273S.

Epstein LH, Dearing KK, Paluch RA, Roemmich JN, Cho D. Price and maternal obesity influence purchasing of low- and high-energy-dense foods. Am J Clin Nutr. Oct 2007;86(4):914-922.

Powell LM, Chaloupka FJ. Food prices and obesity: evidence and policy implications for taxes and subsidies. Milbank Q. Mar 2009;87(1):229-257.

Schroeter C, Lusk J, Tyner W. Determining the impact of food price and income changes on body weight. J Health Econ. Jan 2008;27(1):45-68.

Rudd Center for Food Policy and Obesity. Soft drink taxes: Opportunities for public policy. New Haven, CT: Yale University; February 2009.

In the article, many of his fellow medical students expressed harsh criticism of the school for admitting this student, if not outrage. But one student openly wondered who had the right to say that this person may not turn out to be a great doctor, in spite of his past misdeeds.

Who, indeed? After all, there are reports that some congressmen have prior convictions. George W. Bush may have been the first U.S. president to enter office with a criminal record. Even Bill Gates has a rap sheet, and I think it’s fair to say he’s doing pretty well for himself. Moreover, our country is faced with an imminent shortage of physicians, and declining interest in primary care. In light of such shortages, should we keep people who are willing and able out of medical school due to past offenses? And if so, where do we draw the line? Murder seems to be a likely exclusion criterion. How about rape? Assault with a deadly weapon? DUIs? Parking tickets? Domestic abuse? Animal cruelty? Fraud?

As anyone schooled in behavioral interviewing can confirm, the best predictor of future behavior is past behavior. A 2008 article published in the Annals of Internal Medicine found that physicians who had poor professionalism behaviors during residency were much more likely to face disciplinary actions as practicing physicians. In addition, a 2005 article published in the New England Journal of Medicine found that disciplinary actions by state medical boards were strongly associated with prior unprofessional behavior in medical school.

So to the extent that having a criminal record can be considered “unprofessional,” it seems that a criminal record — any criminal record — would be sufficient reason to keep someone from becoming a doctor. And if the Swedes don’t want to look for a record of criminal activity prior to admitting people to medical school, they’re going to have to make sure their medical licensing boards, as well as their citizens, are ready to suffer the consequences.

References

Altman, Lawrence. A Quandary in Sweden: Criminals in Med School. The New York Times, March 23, 2009: D1.

Papadakis M, Arnold G et al. Performance during Internal Medicine Residency Training and Subsequent Disciplinary Action by State Licensing Boards. Annals of Internal Medicine, June 3 2008. Volume 148, Issue 11, pp 869-876.

Papadakis, M. (2005). Disciplinary Action by Medical Boards and Prior Behavior in Medical School New England Journal of Medicine, 353 (25), 2673-2682 DOI: 10.1056/NEJMsa052596

In spite of the disturbing mental image this conjures, it actually is possible for men to produce breast milk. As DeNiro’s character so comedically noted, men do indeed have nipples. They also have the rudimentary breast tissue and ductal structure that would make the production of milk, called lactation, possible. What they lack is the proper combination of hormones to plump up the breast tissue and stimulate the production of milk.

The formation and proliferation of breast tissue is dependent on the hormone estrogen. Though generally considered to be a “female” hormone, men do produce small amounts of estrogen, as well. In men, its effects are usually tempered by the large amount of testosterone that they produce. The actual production of milk by the breast tissue is dependent on the hormone prolactin, which is secreted by the pituitary gland in the brain. Following the birth of a child, the pituitary gland increases its secretion of prolactin, enabling the new mother to begin producing milk for her infant. Stimulation of the nipples by the nursing infant also causes a spike in prolactin production.

Most cases of male breast formation and lactation in humans are the result of disease or medication side effects and not the need to feed their offspring. The medical literature is replete with reports of men developing breast tissue due to medications or medical conditions. Fat cells are known to increase the production of estrogen, so it’s not uncommon for obese men to develop more prominent breast tissue, known as gynecomastia. In addition, steroid use, cirrhosis, certain medications and certain herbal formulations may cause gynecomastia. Reports of males producing milk are much less common, and are usually seen in infancy when the baby’s overall hormonal status is in quite a bit of flux. And although multiple causes of increased prolactin secretion exist, such as from a pituitary tumor or side effect of a medication, men rarely get galactorrhea as a result.

So while male lactation is possible, it’s very rare, and almost never physiologic. And for those of you who are fans of Meet the Parents, please don’t try this at home.

References

Devidayal (2005). A Male Infant with Gynecomastia-Galactorrhea The Journal of Pediatrics, 147 (5), 712-712 DOI: 10.1016/j.jpeds.2005.06.026

van der Steen M, Du Caju MV, Van Acker KJ. Gynecomastia in a male infant given domperidone. Lancet. 1982 Oct 16;2(8303):884-5.