organized curiosity

Improving health care through research


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POOP… Not Just Another Four Letter Word

 Clostridium difficile (or C. diff) infection has gotten a lot of press in the last few years and has recently been named as one of the top three urgent antibiotic resistance threats by the Center for Disease Control and Prevention (CDC).  C. diff is a bacteria that is an opportunist, it often lurks in hospitals where it is transmitted from patient to patient often on the hands of health care workers.  When it gets ingested by someone it waits patiently until the person is given antibiotics which kill the normal bacteria in that person’s colon, then C. diff can then take up residence and flourish.  It produces toxins that cause damage to the bowel which leads to diarrhea and in severe cases can lead to severe inflammation of the colon requiring surgery to remove the infected bowel.  From an evolutionary perspective (assuming you believe in that sort of thing), C. diff, like many other pathogens, is quite clever.  Its only purpose in life it to go forth and multiply and it relies on human hosts to do this – and what better way to transmit and infect others than by causing wicked diarrhea….but that is for another blog.

People who get this infection are miserable.  They have pain and diarrhea multiple times a day.  While most people can be treated with more (but different) antibiotics, some can have recurrent bouts of infection and some have chronic or “refractory” infections that are very difficult to cure.   Over the last decade a simple but effective treatment has gained increasing acceptance and coincides with an explosion in research into the diversity of bacteria that live in or on us: stool transplantation.  Stool transplantation (which some have referred to as “repoopulation”) is exactly what it sounds like.  You have a donor (preferably someone you know well like a spouse) who supplies “healthy” stool which is then blended into a poop slurry and put back into the recipient using a scope up the back passage where they spray it on the colon like Miracle-Gro on a garden.  Alternatively the slurry can be fed through a tube that is inserted down the throat and into the recipient’s stomach. This simple procedure has been very effective at curing patients who have been miserable for months because they cannot get rid of their C. diff diarrhea. However, even when the definitive scientific trials are published will this become a common treatment option? Currently stool transplants are not available in Nova Scotia but doctors are working on developing guidelines and a protocol so it can be an option in the future.  All that said, I think that people may still be reluctant to embrace stool transplantation.

The problem is the “ick” factor.  Poop is “dirty”, it smells, it can certainly transmit disease (Salmonella, Shigella just to name a few) and people are embarrassed by it.  But our poop is very important to our bodies. Each of us has billons of bacteria in our gut that help to keep us healthy.  This microbial flora or microbiota is made of up thousands of different species of bacteria, some of which we cannot even grow in the lab.  It is a unique signature and the composition of the bacterial population is different in everyone.  It is thought that our microbiota starts when we are born and exposed to our mother’s bacteria.  As children we constantly sample the environment. How often have you seen babies put things in their mouth?  People have assumed that this oral sensing was part of how a child learns about his environment.  What if this is our inherent way to ensure we are increasing our biodiversity and maintaining a balanced bacterial environment.  But what happens when this microbiota balance is disrupted?  Alterations in the diversity of this flora can have significant impact on many different diseases from inflammatory bowel diseases to other autoimmune conditions.  There is even data to suggest that the microbiota in your gut can influence how fat you are.  Studies have shown that if you have stool from a skinny mouse and put it in an obese mouse it can influence their body weight even when they are on the same diet.  While I would not advocate stool transplantation as a form of weight management, you can see the potential for this therapy.  If you can repoopulate your colon, you could logically regenerate your microbiota and get back to a healthy state.   In the future, one could envision submitting your poop to a “bank” of stool samples that could be used in the event that you get C.diff or another modifiable illness.  Have you ever wondered why a dog eats his own poop?  Maybe it is because it is actually keeping them healthy.

 

 

~ Todd F. Hatchette MD FRCPC

Chief,Division of Microbiology

Department of Pathology and Laboratory Medicine

Capital District Health Authority

Associate Professor, Dept of Pathology, Dalhousie University

 

 

 


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Chronic pain patients shunned by family doctors?

Chronic pain patients shunned by family doctors?

Note from a patient sent to the blog:

“It is hard enough to find a physician who is willing to take you on as a new patient. Finally, I found one but when I met with him I was told “I am willing to see you if you are off the narcotics.”  He was too scared because I am on a high dose of narcotics for my chronic pain.

When someone is in chronic pain it is hard enough to function let alone have a major stress like this hanging over you. I need a GP to fill in LTD pension forms every year and if I don’t have one then chances are I will also lose my only means of income. As of the beginning of September, unless I have a GP, I have no more access to all the medications I take including insulin, thyroid med, nerve pain med, fluid and BP meds.

I went to the pain clinic and tried all of the treatments. Nothing helped. So, I was put on narcotic pain medication for some quality to life in the late ’90s. I have been managing quite well since then until this problem.  The doctors refuse to write the prescriptions we need because they are too afraid of being investigated, or that was the excuse anyway.

So where does that leave me? Dying from severe sudden withdrawal of all my medications, thanks to the hands of the so called medical system of which I used to be part of. Yes, I used to be an RN, but look at me now and how the system is taking care of me.”  

Comment by Dr. McGrath:

The use of opioid (the medical term for narcotics) pain relievers for chronic pain that cannot be managed by other methods is well established. Although the research could be better, because there are not many long term studies, it is clear that some patients with chronic pain can have their lives dramatically improved by opioids.

There are problems with misuse of prescription opioids. Sometimes, they are not properly prescribed, properly stored or they are sold or given to friends. The inappropriate use of prescription opioids is due to some people selling their drug, stealing or sharing drugs, by visiting multiple doctors to obtain prescriptions or by lying to doctors about their symptoms.

There have been a rising number of deaths from overdose of opioids and it is clear that opioids must be carefully managed. The Canadian Drug Policy Coalition sees overdoses as entirely preventable and has outlined an evidence-based, five-step plan for reducing overdoses in Canada.

The Nova Scotia Prescription Monitoring Program (NSPMP) was established in 1992 to promote the appropriate use of, and reduce the misuse and abuse of, narcotics and controlled drugs in Nova Scotia. It is a government-funded program administered by Medavie Blue Cross.

The NSPMP reviews prescribing patterns throughout the province; individual prescribing practices; and patient use of controlled drugs through the use of individualized triplicate prescription pads.

A recent Canadian study of 13,032 individuals and a review of prescriptions for opioids from a representative sample of 2700 retail pharmacies across Canada found that in 2009, the prevalence of prescription opioid use was 19.2%. Use of prescription opioids outside of what was intended was 4.8% and the use of opioid pain relievers to get high was 0.4% i.e. less than half of one percent. Many of the people using opioids outside of what was intended probably got drugs from family or friends because they had pain and could not get proper pain management.

Pain experts generally emphasize the need for pain management; addiction experts usually emphasize the problem of addiction. Unfortunately, many family doctors are not trained in managing chronic pain and thus may decline taking patients with chronic pain especially if they are using opioids for pain management. They may fear being monitored or investigated by the NS Prescription Monitoring Program and may not want the burden associated with the additional administrative requirements for opioid prescriptions.

The International Association for the Study of Pain asserts that adequate pain care should be considered a fundamental human right that should not be denied.

Pain patients are often caught in the middle and can be totally vulnerable.  The consequences to patients of inadequate pain management or drug overdose are often catastrophic.


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My Doctor Doesn’t Believe Me

My Doctor Doesn’t Believe Me

 

I recently tried a small experiment. I googled the phrase, “my doctor doesn’t believe me” both in quotes and without quotes.  Google told me there were about 969,000 results when I used the quotes and over 70 million results when I left the quotes off. When I googled “I don’t believe my patients” there were six results, and several of these sites weren’t even about not believing the patient.

In my experience with patients who experienced chronic pain, about half of them said: “my doctor does not believe me” or “thank goodness, you are the first one to believe me.”  A variant on this theme is the implication that the pain is not real – especially when tests come back normal – but that ‘it is all in your head’ or “there is nothing wrong with you.” It is disrespectful and demoralizing to patients and destroys their sense of trust in doctors and the medical community when their experiences are denied.

It is often not just doctors that can be dismissive and disrespectful. Nurses, psychologists, dieticians, physiotherapists and anyone in a medical, care-taking role can fail to treat patients as they deserve and when this happens, it destroys the whole purpose for our health system to exist.

Failure to accept patients’ experiences is not only disrespectful, it is bad medicine. A patient’s report of their symptoms is one of the most valuable tools to diagnose and treat illness. Not listening and believing one’s patients is a recipe for disaster.  Patients may not always be accurate in what they think is wrong, but neither are we.

These complaints by patients may be most common when there are symptoms that we cannot figure out. We often dismiss the complaint outright or imply it is psychologically caused. Patrick Wall a distinguished neuroscientist called this tendency to ascribe psychological causes when we don’t understand symptoms ‘the leap to the head.”

There is a movement to listen to patients better. It is often called “patient or family centred care”.  The Cleveland Clinic is probably the best known institution for its focus on the patient experience. They have a whole department focused on it. I really like the credo of Dr William E Lower, one of the founders of the Cleveland Clinic when he said in 1921:

  • A patient is the most important person in the institution – in person or by mail.
  • Patients are not dependent on us – we are dependent on them.
  • Patients are not an interruption of our work – they are the purpose of it.
  • Patients are not an outsider to our business – they are our business.
  • The patient is not someone to argue or match wits with.
  • The patient is a person, not a statistic.
  • It is our job to satisfy them.

Is keeping patients happy just a frill? I don’t think so! The research literature backs up my view. A recent large study of 2,953 US hospitals compared the hospitals with the highest 25% of patient satisfaction ratings with those in the lowest 25%. There were better care processes, lower readmission rates and lower death rates in the hospitals with higher patient satisfaction.

So what should we do?

  • Teach William Lower’s principles to students in all the health professions.
  • Transform our services to be much more patient-focused. Re-think all aspects of how we deliver care:

o    Why do we work 9am-5pm when many patients would find it better to have evening appointments?

o   Why do we keep patients waiting, sometimes for hours?

o   Which services can we deliver closer to home?

o   Why can’t patients get some care by internet or phone?

o   Why is arrogance and rudeness to patients ever tolerated?

  • Teach all staff, patient-focused skills. Capital Health has undertaken a program  to do this.
  • Remember that following William Lower’s credo, not only is good medicine and will make patients feel better but also makes professionals feel better.
  • As corny as it sounds, courtesy and helpfulness to patients is contagious.

I dedicate this blog to Andrea Crowe who taught me to listen carefully to patients.

 

~Dr. Patrick McGrath


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More thoughts on Mind the Gap Between the Rich and the Poor

An interesting paper on socio-economic status (SES) and surgery for children just came out in Pediatrics, a prestigious journal. The paper was a very careful examination of 39, 287 surgical procedures between 2005 and 2011 at the Hospital for Sick Children. They used postal codes to derive SES measures of families. They found that “SES does not predict the timeliness of delivery for pediatric surgical services”  at Sick Kids. This is very good news and probably is similar for other Canadian children’s hospitals. Once poor kids get into the pediatric surgery system, they get as timely treatment as other kids.

What the study did not examine is whether the problems of poor children that can be corrected by surgery are detected as early as other kids.

~Dr. Patrick McGrath


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Mind the Gap Between the Rich and the Poor

Inequality in income has been a hot topic of late. In 2011 the occupy movement drew attention to the gap between the rich and the poor, and while they could be dismissed as a bunch of radicals, it is the establishment that have been drawing attention to income inequality in recent months.

A recent Conference Board of Canada study detailed income inequality in Canada and how that fits with the rest of the world (see figure below). The Conference Board states that “Canada’s 12th-place ranking suggests it is doing a mediocre job of ensuring income equality.” They gave Canada a ‘C’ grade.  The UK, Italy, Australia and Japan are marginally worse than we are with the US ranking worst overall.

Income inequality refers to how income is shared throughout a population. The number used is called the Gini coefficient. If everyone had the same income, the Gini coefficient would be zero. If one person had all the income, it would be 1.

Gini Coefficient

 

Why is everyone upset about inequality?  Inequality is unfair.  Most people agree that the CEO of a company should earn more money than the average worker.   Even 20 times what the average worker makes might be fair. But when a CEO makes 100s of times what the average worker does, most people think that is unfair. In a recent speech, Barack Obama, President of the United States, noted that today’s CEO in the US now makes 273 times more than the average worker.

In his recently published blockbuster “Capital in the Twenty-First Century,” French author and economist Thomas Piketty, stated that inequality is increasing. The International Monetary Fund even went so far as concluding that inequality is bad for economic growth.

In Canada, the top 20% money earners make about 40% of the income – the bottom 20% make just 7%.  The top 1% of Canadians earnsover $191,100 a year and the average income among the top 1% was $381,300 a year or about ten times the average Canadian income of $38,700 a year.

Why is inequality bad for health care?

Poverty is linked with poorer health. Almost every physical and mental health problem is greater in poverty. In fact one of the most powerful health interventions is having a job that pays well. Poor people live in worse housing than those with money, live in places where there is more air pollution and less clean drinking water, and they cannot afford nutritious food.  Early stress from poverty also alters human biology and results in long term health effects.

Being poor in the midst of plenty, has an additional effect on health. If one is poor in an environment where everyone else is poor, the effects are not as great. In our society, however, wealthy lifestyles of fancy cars, foreign travel, opulent homes and decadent meals are flogged incessantly, and the extremely wealthy in the realms of sports, entertainment and business are idolized while the myth that anyone can become rich is perpetuated. Nowhere is a modest lifestyle idealized.  Wealth is constantly flaunted in the face of those less well off.

Knowing that one is poor in the midst of plenty leads to a wide range of complications including mental and physical health problems. Stress is thought to be the major culprit.

How does poverty and inequality impact health care?

First of all, policies that decrease inequality and poverty will improve health.  These policies may also decrease health care costs. Policies that create more affordable housing and better wages for the working poor mean better health. The effects of poverty on children are especially devastating since they can last a lifetime. Growing up poor means a shorter, more illness filled life.

Secondly, we need to ensure that health care is available to the poor since they have the greatest burden. We think Canadian health care is free but much of it is not. About 30% of our health care requires private payment, usually by private health insurance. The working poor are excluded from many public subsidy programs and most do not have private insurance. Most minimum wage jobs do not have health insurance benefits. Moreover, there are many incidental costs to free health care. This includes time off of work, transportation costs and restaurant meals. These expenses can quickly add up and put a real burden on poor families. Direct and incidental costs of health care should be reduced.

Thirdly, groups outside the mainstream such as Aboriginals, the disabled, immigrants, refugees, homeless and some in rural areas do not have ready access to health care.   The reasons are many and include a lack of culturally sensitive health care, transportation, language and stigma. Health care should be designed to ensure access by these groups and any others in need.

By focusing a bit more on the groups in need and on such great inequalities, perhaps we can begin to see ways to bridge this wide and unfair gap.

~Dr. Patrick McGrath