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Thursday, January 3, 2019

Conflict of interest in medicine

Just the idea of packing a lunch elicits a stress response in so many of us. Maybe we’re packing lunch for our kids, maybe it’s for us, but the pressure is on to create a simple yet satisfying, healthy yet hearty, easily transportable meal. This seemingly impossible task is daunting to many people. So much easier to rely on the school cafeteria, lunch trucks, and takeout, right?

Wrong! Let us consider the short- and long-term effects of poor choices at lunchtime. Yes, the school cafeteria may offer some healthy-ish options. I can count on my kids not to choose any of them. Likewise our workplace food trucks and fast food/delivery services: it’s a dietetic disaster out there, folks, and not packing a lunch is akin to heading out to the battlefield in a bathing suit.

My kids would eat mostly carbs, fats, and sugars, if given the chance, and their trays would be piled with pizza, pasta, burgers, hot dogs and fries, chips, juice, and dessert. The downtown lunch scene features pretty much the same choices. Almost all options include refined grains and added sugars, foods with a high glycemic index and load. These will cause a spike in blood sugar, which triggers a surge in insulin. The insulin grabs all that sugar and brings it to the fat cells to be stored away, causing a nice late-afternoon blood sugar crash.

Studies show that people who eat meals prepared at home, including brown-bag lunches, tend to consume significantly more fruits and vegetables and have a lower body mass index than those who do not. If we pack a lunch, we can make better choices: a meal higher in fiber, protein, complex carbohydrates, and healthy fats has a lower glycemic index and load, and will keep our blood sugar steady — no crash! So in the short term, we can be productive through the afternoons. A little planning goes a long way: in the long term, studies show that a healthier diet is associated with improved cognition through the elder years.
How to build a healthy lunch

There’s a basic formula to follow: Primarily plants (actual fruits and vegetables) and protein (like legumes, lentils, tofu, seafood, chicken), with some complex carbohydrates (think: whole grains) and healthy fats (think: nuts and nut butters, seeds and seed butters, avocado, healthy oils).

If the bulk of the meal is plants, like actual fruits and vegetables, you’ll get plenty of fiber. Protein and healthy fats are satisfying. If you include whole grains, you’ll get complex carbohydrates. All of these are absorbed slowly, preventing that blood sugar spike and crash (and also inhibiting fat formation).

But what do these healthy options look like? Below are some simple lunches that follow the basic formula, and that our family actually eats.

Everyone loves dipping and stacking their food, not just kids — this is why those prepackaged boxes of processed food sell so well. So we make our own healthy versions of these with things that can be simply thrown into a “bento box”-style container, without requiring much prep. Here are a number of suggestions that are easy, inexpensive, require slicing at most, and travel well:

Build-Your-Own Gourmet Pizza: Sliced cherry tomatoes; mozzarella cheese; fresh basil; marinara sauce; mini whole-wheat pita breads or pizza dough rounds; orange sections.

Nacho Lunch Muncher: Strips of bell peppers; pinto beans; slices of cheddar cheese; whole-grain chips; low-sodium salsa; sliced peaches.

Breakfast-As-Lunch Box: Sliced strawberries and fresh raspberries, blackberries, and/or blueberries; healthy yogurt; sliced almonds or unsalted sunflower seeds; low-sugar granola or toasted oats cereal.

Hummus Dipper: Carrot sticks and bell pepper strips; container of hummus; whole-grain crackers; unsalted pistachios; apple slices tossed with cinnamon.

Deconstructed Tuna Sandwiches: Cucumber slices; container of tuna salad (tuna, lemon juice, touch of mayo); whole-grain bread squares or crackers; cantaloupe chunks.

Nut Butter Dips and Mini-Wraps: Apple and banana slices (spritz with lemon juice to prevent browning); small container of almond, cashew, peanut, or sunflower seed butter; raisins; whole-wheat wrap cut into fourths. On the surface, your own brain may be your furthest consideration when you are trying to improve your relationships. Yet it is the very place that processes where you perceive, understand, remember, evaluate, desire, and respond to people.

The somewhat bizarre fact of life is that the people who are in our lives are not simply who they actually are. They are some interesting mix of who they are and what we make of them in our brains. If we understand the ways in which relationships impact our brains, we can likely change our brains to alter the ways in which we interact with others too.
Transference

Transference is a psychological phenomenon in which conversational or relational partners activate earlier memories. As a result, we may unconsciously repeat conflicts from the past that have nothing to do with the current relationship.

For instance, you may be having an off day and may be a little short with a colleague. The colleague may snap at you in a way that is out of proportion to your actual interaction, since your manner may remind them of a conflictual and bossy relationship earlier in their lives. These kinds of knee-jerk responses occur in the brain due to the brain’s propensity to make non-conscious predictions based on early life experiences. They may be unwarranted, but we are usually not aware of them.

What you can do: To prevent this kind of situation, introduce new self-reflections, and possibly even points of discussion when you find yourself engaged in a conflict. Ask yourself, “Am I responding to this person, or am I mixing them up with someone from the past?” This can also make for an interesting discussion when you are trying to resolve a conflict.
Emotional contagion

Our emotions can be easily transferred to another person without us even knowing about this. This can also happen through large-scale social networks without in-person interactions or nonverbal cues.

Interact with a disgruntled group online, and you are likely to feel disgruntled as well. On the other hand, interacting with a positive group will probably make you feel more positive. Often, our negative emotions such as anger are transferred more easily than positive ones. It’s meant to be to our evolutionary advantage to be able to pick up emotions that quickly, but sometimes it can interfere with relationship dynamics. The culprits responsible for this contagion in the brain are called mirror neurons. They are specialized to automatically pick up the emotions of others.

What you can do: When you are interacting online, ensure that you know that whatever content you are consuming is likely to impact your mood. Be judicious about this depending on what you want to feel.

In interactions with friends, colleagues, or romantic partners, be aware that their negative emotions could throw you into a negative state, even if you do not actually feel negative. Many a fearful dating partner has turned off the other person automatically because they somehow start to feel afraid as well.

Be aware when your partner or colleague “makes” you angry. You may not actually be angry with them, but instead, mistaking their anger for yours when your brain reflects their feeling states.
Cognitive empathy

When you are trying to negotiate with someone, you may think it helpful to reflect their emotions, but this emotional empathy could backfire. In most instances, it’s far more effective to use cognitive empathy instead. When you use cognitive empathy, the other person becomes less defensive and feels heard too. While there is some overlap, cognitive empathy activates a mentalizing network in the brain, which differs from the emotional mirroring mechanisms of emotional empathy.

What you can do: When trying to resolve a conflict, try using cognitive empathy rather than emotional empathy to resolve the conflict. This means that you reflect on what they are saying, and then neutrally paraphrase what they are saying or intending. Paraphrasing can actually decrease their anger and reactivity. It’s a form of cognitive empathy, indicating that you are able to walk in their shoes.

Changing your own brain’s automatic reactions can help you navigate relationships more effectively. By knowing when to examine and explore transference, emotional empathy, and cognitive empathy in different situations, relationships have the potential to deepen too. For many people receiving care in a hospital or emergency room, one of the most common occurrences (and biggest fears) is getting an IV, the intravenous catheter that allows fluids and medications to flow into a vein in your arm or hand.

A trained health professional puts in an IV by sticking a needle that’s inside a thin tube (catheter) through the skin into a vein. Once inside the vein, the needle is removed. The catheter is left in the vein and taped down to keep it from moving or falling out. While IV lines are typically painless, the initial needle stick can be quite painful, especially for those who are a “difficult stick” (when the needle misses the vein, requiring multiple attempts).

IVs can be medically needed when the digestive system isn’t working well, to receive more fluids than you’re able to drink, to receive blood transfusions, to get medication that can’t be taken by mouth, and for a host of other treatments. In cases of massive bleeding, overwhelming infection, or dangerously low blood pressure, IV treatments can dramatically increase the chances of survival.
Drip bars: IVs on demand

And this brings us to a relatively new trend: the option to receive IV fluids even when it’s not considered medically necessary or specifically recommended by a doctor. In many places throughout the US, you can request IV fluids and you’ll get them. A nurse or physician’s assistant will place an IV catheter in your arm and you’ll receive IV fluids right at home, in your office, or at your hotel room. There’s even a mobile “tour bus” experience that administers the mobile IV hydration service. Some services offering IV hydration include a “special blend of vitamins and electrolytes,” and, depending on a person’s symptoms (and budget), an anti-nausea drug, a pain medication, heartburn remedies, and other medications may be provided as well.

And no, it’s not covered by your health insurance — more on the cost in a moment.
Why would anyone do this?

When I first heard about this, that’s the question I asked. Why, indeed? People may seek out IV fluids on demand for:

    hangovers
    dehydration from the flu or “overexertion”
    food poisoning
    jet lag
    getting an “instant healthy glow” for skin and hair

Many of the early adopters of this new service have been celebrities (and others who can afford it) including Kate Upton, Kim Kardashian, Simon Cowell, and Rihanna. Or so I’ve read.
Are IV fluids effective or necessary for these things?

Some people who get the flu (especially the very young and very old) need IV fluids, but they’re generally quite sick and belong in a medical facility. Most people who have exercised a lot, have a hangover, jet lag, or the flu can drink the fluids they need. While I’m no beauty expert, I doubt that IV fluids will improve the appearance of a person who is well-nourished and well-hydrated to start with.

And it’s worth emphasizing that the conditions for which the IVs-on-demand are offered are not conditions caused by dehydration or reversed by hydration. For example, jet lag is not due to dehydration. And while oral fluids are generally recommended for hangover symptoms (among other remedies), dehydration is not the only cause of hangover symptoms.

Finally, there’s a reasonable alternative to IV fluids: drinking fluids. If you’re able to drink fluids, that’s the best way to get them. If you’re too sick to drink and need rehydration, you should get care at a medical facility.
Is it worth going to a drip bar?

I’ll admit I’m skeptical. (Could you tell?) It’s not just that I’m a slow adopter (which is true) or that I’m dubious of costly treatments promoted by anecdotes on fancy websites (which I am). What bothers me is the lack of evidence for an invasive treatment. Yes, an intravenous treatment of fluid is somewhat invasive. The injection site can become infected, and a vein can become inflamed or blocked with a clot (a condition called superficial thrombophlebitis). While these complications are uncommon, even a small risk isn’t worth taking if the treatment is not necessary or helpful.

I can see how the idea of IV fluids at home might seem like a good idea. We hear all the time about how important it is to drink enough and to remain “well-hydrated.” It’s common to see people carrying water bottles wherever they go; many of them are working hard to drink eight glasses of water a day, though whether this is really necessary is questionable.

And then there’s the power of the stories people tell (especially celebrities) describing how great they felt after getting IV fluid infusions. If you have a friend who says they feel much better if they get IV fluids to treat (or prevent) a hangover, who am I to say they’re wrong? The same can be said for those who believe they look better after getting IV fluids as part of getting dolled up for a night on the town.
What about the cost?

While the benefits of IV fluids on demand are unproven and the medical risks are low (but real), the financial costs are clear. For example, one company offers infusions for $199 to $399. The higher cost is for fluids with various vitamins and/or electrolytes and other medications. Keep in mind that the fluids and other therapies offered can be readily obtained in other ways (drinking fluids, taking generic vitamins, and other over-the-counter medications) for only a few bucks.
The bottom line on drip bars

In recent years, more and more options have become available to get medical tests or care without actually having a specific medical reason and without the input of your doctor. MRIs, ultrasounds and CT scans, recreational oxygen treatment, and genetic testing are among the growing list of options that were once impossible to get without a doctor’s order. While patient empowerment is generally a good thing, IV fluids on demand may not be the best example. Some of these services are much more about making money for those providing the service than delivering a product that’s good for your health. Recent news reports described an “ethical lapse” by a prominent New York City cancer specialist. In research published in prominent medical journals, he failed to disclose millions of dollars in payments he had received from drug and healthcare companies that were related to his research. Why is this such a big deal? Disclosing any potential conflict of interest is considered essential for the integrity of medical research. The thinking is that other researchers, doctors, patients, regulators, investors — everyone! — has a right to know if the researcher might be biased, and that measures have been taken to minimize the possibility of bias.
Is it an advertisement or research?

One way to think about the importance of full disclosure regarding medical research is to ask: is the information I’m reading or hearing about coming from a paid spokesperson? If so, it may be the equivalent of an advertisement. Or, is it from a researcher without a financial stake in the results? The answer matters. While the information may be valid either way, the way it’s delivered, how alternative explanations for the results are considered, and the skepticism (or enthusiasm) surrounding the findings can vary a lot depending on whether the source has a vested interest in a study’s results.

One of my favorite examples of how bias can affect how medical information is delivered is the way pain relievers (such as ibuprofen or naproxen) are described in ads. There are more than 20 of them available, and for most conditions their effectiveness is about the same. And that’s exactly how a researcher with no financial ties to the makers of these drugs might describe them: in clinical trials, they are equally effective. But a company’s television ad might claim that “nothing’s proven stronger for your headaches” than their medication. Factually, both ways of presenting the information are true. But knowing the source of the information and whether it might be biased can make a big difference in how you interpret that information.
Why you should care about conflict of interest in medicine

Medical schools, hospital systems, and other institutions that employ doctors generally require disclosure of outside income. But do their patients want to know? Would it matter to you if your doctor accepted gifts, meals, or cash payments from drug companies?

There’s been enough concern about the answers to these questions that the federal government set up a website to post information about payments doctors receive from drug companies, medical device makers, and others. Perhaps you’ve heard of it. It’s called OpenPayments,* a disclosure program mandated by the Sunshine Act that posts these financial relationships online for public viewing. It’s been up and running for several years. But the impact of this program is not clear; many of my patients have never heard of it, and most people have never looked up their own doctors on the site.

*In the interest of full disclosure, my name appears in Open Payments: However, it’s for consulting with the Institute for Healthcare Improvement, an independent healthcare organization. They provided grants to encourage shared decision making and understanding of treatment options for patients with rheumatoid arthritis. A pharmaceutical company sponsored the program but has no role in promoting any particular medication.
Other ethical issues your doctor might face

Even if your doctor doesn’t accept payments from pharmaceutical companies, he or she may have to consider other ethical questions, such as:

    Is it acceptable to own his or her own testing equipment? While it may be more convenient for patients, studies show that when a practice performs (and charges for) its own lab or imaging tests (such as a scanner for osteoporosis screening), more tests tend to be ordered.
    Should he or she meet with representatives from pharmaceutical companies who are promoting their latest drugs? Some physicians get updates regarding new medications from drug reps (along with gifts of minor value, such as pens or lunch), but this may lead to higher rates of prescribing newer, higher priced drugs when older, cheaper options would be just as good.
    Should your doctor attend medical meetings where drug companies sponsor the speaker (complete with dinner in a fancy restaurant)? Again, the information presented may be accurate but biased.
    Is it reasonable for doctors to receive payments to enroll patients in a study sponsored by a drug company? This is a common practice, and it’s likely that the financial arrangement is not always disclosed to the patient.

And these are just a few of the many ethical dilemmas that many doctors face.
What do you think?

Many doctors I know are insulted by the suggestion that they “can be bought” by a charismatic drug rep bearing gifts. But a number of studies show these practices work. Large pharmaceutical companies spend millions on doctors to market, educate, and perform clinical trials. They would not invest so much money if it didn’t work.

Does any of this concern you? Do you think the case of the NYC doctor is unusual and that most doctors navigate the ethical minefields of modern medicine successfully? Let me know!

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