By SAUL GREENFIELD
September 7, 2010
The auditorium was filled with young, newly minted physicians sitting nervously in white jackets. When the chairman of surgery mounted the stage to address me and my fellow surgical interns, we immediately hushed and gave him our attention. I don't now recall most of what he said, but one remark has stayed with me through my 25 years of surgical practice: "You can't practice medicine by committee."
He didn't mean that we shouldn't listen to associates or seek their advice, or that we shouldn't be aware of scientific literature conveying the opinions and research of others. He meant that every physician must, at some point in the patient-care process, make decisions and take responsibility for them. And unless the doctor does so, the outcomes will be compromised. He was warning against groupthink and telling us that patients often present challenges that cannot be solved by easily consulted algorithms.
The chairman's admonition was a succinct definition of the parameters of the doctor-patient relationship. And in the eyes of many contemporary medical thinkers—those who seek to reorder the universe of medical care in this country—it would be heretical.
In recent political debates, the autonomous physician has been portrayed as a problem to be solved, an out-of-control actor motivated by greed—and a major cause of rising health-care costs. Insurance companies and the federal government have sought to control physician behavior with the dual aim of decreasing costs and improving care. In their view, individual and regional disparities in rates of medical testing, hospitalization and surgical procedures are ipso-facto demonstrations of physician autonomy run amok.
In the United Kingdom, the National Institute for Clinical Effectiveness (NICE) provides guidelines for clinical care in order to ensure greater uniformity of practice and, it claims, better care. In this country, the recent health-care reform law established a Comparative Effectiveness Institute with the same aims.
Such institutions are illegitimate and undesirable. My field of pediatric urology is only a small subset of medicine, but recent experience demonstrates the dangers of bureaucratic, committee-based practice.
In 2007, NICE published guidelines for the care of children with urinary tract infections. A committee of diverse specialists reviewed the literature and voted on the final recommendations. Without going into great detail, these guidelines enacted a significant departure from then-current practice by recommending against thorough radiographic evaluation in many instances.
One member of the committee who was out-voted on the final guidelines publicly castigated NICE and accused the committee of misusing statistics, failing to involve the proper specialists, and seeking mainly to decrease costs. The criticisms were correct.
Since the NICE recommendations were promulgated, publications in peer-reviewed journals have shown that many children with significant underlying conditions—some leading to serious kidney disease—would go undiagnosed if the NICE guidelines were followed.
Over a decade ago, researchers at Dartmouth College documented disparities in rates of tonsillectomy in children. They famously asserted that certain high rates of tonsillectomy were inappropriate and did not improve health outcomes. To do this, they relied only on insurance claims and hospitalization rates; they had no data on the prevalence of recurrent tonsillitis or long-term cardiovascular morbidity from obstructive sleep apnea. In fact, they had no data comparing the quality of life of individuals denied the procedure with that of individuals who underwent surgery. Their broad statistical overview was simply unable to answer many important questions.
Physician autonomy is a major defense against those who comfortably sit in remote offices and make calculations based on concerns other than an individual patient's welfare. Uniformity of practice is a nonsensical goal that fails to allow for differing expression of disease states.
This is not to say that clinical research, randomized controlled trials, literature meta-analyses and guidelines are not necessary and useful. They are all essential. It is also not an argument against rigorous oversight of physician behavior, licensure and training. But we must recognize that many physicians will often make decisions that deliberately do not conform to "community standards"—and that patients will be better for it.
Dr. Greenfield is director of pediatric urology at the Women and Children's Hospital of Buffalo and a professor at the State University of New York at Buffalo School of Medicine and Biomedical Sciences.
Monday, September 27, 2010
Tuesday, September 14, 2010
Why Trainers Say, 'Slow Down'
The Wall Street Journal
September 7, 2010
By KEVIN HELLIKER
When his running coach implored him to take rest days, Bill Carr didn't listen. Slated to run a 100-mile ultramarathon this month, the 36-year-old cranked up his workouts over the summer, running more and harder miles than his coach recommended.
"I wanted to make sure that I got to the event fully prepared," he says. But Mr. Carr won't get to the 100-miler at all. Last month, his ankle sustained an over-use injury during a workout, sidelining the Rancho Cordova, Calif., project manager for a vision-benefits company.
"Type A personalities will increase their training load until something backfires," says Julie Fingar, Mr. Carr's running coach, who says her biggest challenge is convincing her clients to take an adequate amount of rest. "In their minds, taking rest means they're not working hard enough."
Today, says Mr. Carr: "I'm taking Julie's advice and starting to cross train."
Roughly 10% of athletes preparing for an endurance event are training too hard, estimates Jack Raglin, director of graduate studies at the Indiana University's department of kinesiology. Research in the field has shown that injury rates rise as runners increase their weekly mileage. Besides injury, excessive training can contribute to or cause major depression, loss of sleep, anorexia and sometimes death.
"The overtrained athlete is so fried by race time that he either performs very poorly or can't perform at all," says Dr. Raglin, who specializes in overtraining problems.
A more-is-better mentality permeates the endurance-exercise culture. Novice runners in particular tend to think that finishing a marathon requires no end of training. In fact, however, under-training is rare. After all, more than 95% of marathon starters reach the finish line.
Statistically, the harder line to reach is the start line. Of the tens of thousands of Americans who pay as much as $180 to register for marathons, as many as 25% fail to make it to the race. Injury, illness and loss of motivation as a result of overtraining are major reasons for this.
But moderation is a hard message to promote among runners determined to reach extremes. For such athletes, no matter how conclusively science may prove the value of rest and recovery, the culture of endurance sports lionizes those who seemingly never rest.
"In running circles, there is huge pressure to do big mileage, to do the big training, to do the biggest races," says Sandra Ross, a 47-year-old runner in Auburn, Calif.
It also can be difficult for runners to know when they are training too hard. One red flag, sports-medicine specialists say, is an intensifying obsession with performance. Exercise, after all, is supposed to be stress-reducing, and amateur competitions by definition are recreational. Yet marathon fields are populated with runners who are visibly stressed out about whether they'll set a personal record or win their age group.
To head off overtraining, some coaches urge athletes to remain alert for the point at which greater doses of exercise cease to produce improvement.
"The body responds beautifully to the right schedule of training stresses," Lynn Bjorklund, who in 1981 set the still-standing female course record for the Pikes Peak Marathon, wrote in an email. "However, too much stress and not enough nutrition or recovery pushes your body toward injury and illness. You need to stay in that zone of just enough, and that takes a very high tuned and honest appraisal of yourself."
Ms. Ross, the California runner, says that for years she would suffer injuries while training for marathons. To help pace herself, Ms. Ross hired Ms. Fingar, the running coach, who enforced rest days, cross-training and trail-running as a lower-impact alternative to pavement.
The discipline paid off, and this summer Ms. Ross completed a 100-mile race. That accomplishment wouldn't have been possible if she hadn't resisted the impulse to match the weekly mileage of her younger running partners, she says. "If I ran as much as they do I'd be faster. But as an older runner I need more rest, and I also have a child, a husband and a career," says Ms. Ross, who works as an environmental consultant.
Overtraining can contribute to exercise-related anorexia, a potentially fatal syndrome that strikes nearly half of all women in so-called lean sports such as running, according to a book published this year, "Eating Disorders in Sport."
"I was diligent about cutting down the calories and increasing my workout schedule. The pounds fell away and it seemed to result in better racing," recalls Ms. Bjorklund, who says that soon after setting a Pikes Peak Marathon record she entered a hospital near death from anorexia.
"It is easy to think that if a little is good, more should be better. After a period of time, however, I would always crash and be forced to cut back," the 53-year-old wrote in an email.
Ms. Fingar, the running coach, says that early in her athletic career she was prone to overtraining and exercise-related anorexia. As a result she says she studies her clients and friends for signs of chronic fatigue, depression, compulsive training or privation. "It can be really destructive," the 35-year-old says. "When someone becomes addicted in a non-healthy manner, all other things suffer—work, family, friends and of course their performance."
Ms. Fingar says she tries to set an example for her clients. She refrains from aerobic exercise one day a week. Often, if she listens to her body instead of her mind, "I'll realize that I'm tired and I'll take another day," she says.
September 7, 2010
By KEVIN HELLIKER
When his running coach implored him to take rest days, Bill Carr didn't listen. Slated to run a 100-mile ultramarathon this month, the 36-year-old cranked up his workouts over the summer, running more and harder miles than his coach recommended.
"Type A personalities will increase their training load until something backfires," says Julie Fingar, Mr. Carr's running coach, who says her biggest challenge is convincing her clients to take an adequate amount of rest. "In their minds, taking rest means they're not working hard enough."
Today, says Mr. Carr: "I'm taking Julie's advice and starting to cross train."
Roughly 10% of athletes preparing for an endurance event are training too hard, estimates Jack Raglin, director of graduate studies at the Indiana University's department of kinesiology. Research in the field has shown that injury rates rise as runners increase their weekly mileage. Besides injury, excessive training can contribute to or cause major depression, loss of sleep, anorexia and sometimes death.
"The overtrained athlete is so fried by race time that he either performs very poorly or can't perform at all," says Dr. Raglin, who specializes in overtraining problems.
A more-is-better mentality permeates the endurance-exercise culture. Novice runners in particular tend to think that finishing a marathon requires no end of training. In fact, however, under-training is rare. After all, more than 95% of marathon starters reach the finish line.
Statistically, the harder line to reach is the start line. Of the tens of thousands of Americans who pay as much as $180 to register for marathons, as many as 25% fail to make it to the race. Injury, illness and loss of motivation as a result of overtraining are major reasons for this.
But moderation is a hard message to promote among runners determined to reach extremes. For such athletes, no matter how conclusively science may prove the value of rest and recovery, the culture of endurance sports lionizes those who seemingly never rest.
"In running circles, there is huge pressure to do big mileage, to do the big training, to do the biggest races," says Sandra Ross, a 47-year-old runner in Auburn, Calif.
It also can be difficult for runners to know when they are training too hard. One red flag, sports-medicine specialists say, is an intensifying obsession with performance. Exercise, after all, is supposed to be stress-reducing, and amateur competitions by definition are recreational. Yet marathon fields are populated with runners who are visibly stressed out about whether they'll set a personal record or win their age group.
To head off overtraining, some coaches urge athletes to remain alert for the point at which greater doses of exercise cease to produce improvement.
"The body responds beautifully to the right schedule of training stresses," Lynn Bjorklund, who in 1981 set the still-standing female course record for the Pikes Peak Marathon, wrote in an email. "However, too much stress and not enough nutrition or recovery pushes your body toward injury and illness. You need to stay in that zone of just enough, and that takes a very high tuned and honest appraisal of yourself."
Ms. Ross, the California runner, says that for years she would suffer injuries while training for marathons. To help pace herself, Ms. Ross hired Ms. Fingar, the running coach, who enforced rest days, cross-training and trail-running as a lower-impact alternative to pavement.
The discipline paid off, and this summer Ms. Ross completed a 100-mile race. That accomplishment wouldn't have been possible if she hadn't resisted the impulse to match the weekly mileage of her younger running partners, she says. "If I ran as much as they do I'd be faster. But as an older runner I need more rest, and I also have a child, a husband and a career," says Ms. Ross, who works as an environmental consultant.
Overtraining can contribute to exercise-related anorexia, a potentially fatal syndrome that strikes nearly half of all women in so-called lean sports such as running, according to a book published this year, "Eating Disorders in Sport."
"I was diligent about cutting down the calories and increasing my workout schedule. The pounds fell away and it seemed to result in better racing," recalls Ms. Bjorklund, who says that soon after setting a Pikes Peak Marathon record she entered a hospital near death from anorexia.
"It is easy to think that if a little is good, more should be better. After a period of time, however, I would always crash and be forced to cut back," the 53-year-old wrote in an email.
Ms. Fingar, the running coach, says that early in her athletic career she was prone to overtraining and exercise-related anorexia. As a result she says she studies her clients and friends for signs of chronic fatigue, depression, compulsive training or privation. "It can be really destructive," the 35-year-old says. "When someone becomes addicted in a non-healthy manner, all other things suffer—work, family, friends and of course their performance."
Ms. Fingar says she tries to set an example for her clients. She refrains from aerobic exercise one day a week. Often, if she listens to her body instead of her mind, "I'll realize that I'm tired and I'll take another day," she says.
When training for an ultramarathon, Ms. Fingar runs about 70 miles a week, far fewer than the 100 miles that many other ultramarathoners log weekly. But unlike some other runners she is rigorous about cross-training weekly in the pool, on a bicycle and in yoga and Pilates studios. She says this training offers a break from the monotony and physical pounding of running, and provides flexibility, enhanced aerobic fitness and a strengthening of core muscles.
"Especially with trail running and endurance events, you need upper-body and core strength to ascend and descend the hills," she says.
Sunday, September 5, 2010
Mesquite High School 2010 Football Opening Night Win
Dr. Mattalino attended the opening night football game of Mesquite High School on Friday, August 27th. The game turned into yet another great performance by the Mesquite Wildcats as they faced off against their rival No. 5 Desert Ridge. The game was close, similar to the game the teams played last year against each other where Mesquite beat Desert Ridge and knocked them out of the 2009 Playoffs. Mesquite was not the favored team for this game, but they were still able to pull out a 28-27 win against Desert Ridge in the final minute of the game.
Dr. Mattalino served as the Mesquite HS team physician for the past 2 years and is excited to continue in this position for the 2010-2011 season.
Check out game highlights at http://www.azfamily.com/sports/high-school/Opening-Friday-high-school-football-highlights-101700643.html
Or read more about the team's win at http://varsity.evtrib.com/story/154576
Dr. Mattalino served as the Mesquite HS team physician for the past 2 years and is excited to continue in this position for the 2010-2011 season.
Check out game highlights at http://www.azfamily.com/sports/high-school/Opening-Friday-high-school-football-highlights-101700643.html
Or read more about the team's win at http://varsity.evtrib.com/story/154576
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