I stopped in and gave blood at the community blood drive last week. Liz and Vicki went down with me. As we were checking in, I got to thinking that maybe we'd all be rejected just because we come from America, a country with one of the higher prevalences of HIV and other blood bourne diseases. In fact, during the history process, they gave us a world map asking if we had "been to any of the countries colored red". Let me put it this way, the only countries on the map that were NOT red, were South American, European, or Australia. The rest of the world is "red" for HIV risk. But we went ahead with the screening process anyway. I passed the questionnaires, but Vicki and Liz were deferred- because they had both gotten their ears pierced in the preceeding month! I must confess part of my motivation was interest to see if there were any differences between US blood drives and those in New Zealand. For the most part they were the same: cold echoing church hall, equipment brought in big duffel bags, little stickers for donors to wear afterwards. The nurses proudly wore their uniforms, the juice was replaced with milk, and cookies with "bisuits", but it was mostly very familiar. Except that the nurses did not wear gloves.
I asked the nurse drawing me about it. "Oh, they used to give us gloves, but when they improved the donation kit they told us we didn't need them anymore. Blood stays inside the tubing and all that. Besides, the gloves were very expensive."
Now that got me thinking. You can imagine how that would go over in the United States, where we call in the Hazmat team for a nosebleed at nursery school! Yet in New Zealand, the prevalences of blood bourne diseases are very low. The nurses are surely immunized against Hepatitis B, and other blood bourne infections are difficult to transmit by "splash". It probably makes a lot of sense to save the money used for gloves, and use it for better needle-stick boxes and advanced punture-prevention kits.
In our office I am often the only one to put on gloves when dressing a wound as well. Even when my hands are cut and nick-free, I psychologically just can't stick my finger onto an oozing leg to check for tenderness or heat without a glove on. There is also a more relaxed attitude toward antisepsis. I don't mean that its not important, and that we don't follow it. However, every little cotton swab does not come in its own sterile pack. We often use clean, sterilized but not sterile packed instruments out of an autoclave tray for minor work like suture removal. And many of the wounds here are highly contaminated anyway- it is a farming community- so that strict antisepsis is rather silly, and quickly use antibiotics if there is any sign of a wound infection or if its a high risk wound.
All of this highlights a peculiarity of American medical culture. Lynn Payer, in her 1988 book, Medicine and Culture notes that British medical culture has been focused on the bowels, while the French favor the liver, and the Germans the heart in their explanations for the sources of vague symptoms. To this list, we should add Americans' obsession with infections. Dr Weil, not an author I always agree with, makes the point in one of his columns that this is a

"general American fear of foreign invaders. We are a big, isolated country and have always been obsessed with subversion and invasion. That cultural perspective distorts our thinking about illness as well. We commonly ascribe unexplained symptoms to viruses, get worked up about chronic yeast infections, and now are becoming paranoid about parasites."

Think about the major problem in America of patients with a minor cold, bronchitis or influenza presenting to their physician and demanding antibiotics. Many hours and dollars have been spent trying to educate both doctors and patients about this inappropriate prescribing, and yet we still have one of the highest uses of antibiotics in the world, at a time when antibiotic resistance is becoming a major problem. In almost 4 months here in New Zealand, I have not had one patient come in demanding antibiotics, and in many cases, I have had to talk patients into taking medicine that they clearly need for an infection. "I worry about taking antibiotics" is a common refrain here. New Zealand patients seem much more interested in "boosting my immune system", and indeed, reassuring patients that they "have a healthy immune system that will take care of this infection" is a very effective phrase, I have found. However, at the far end of that extreme, many patients take Buccaline Berna, a pack of 7 tablets, costing around NZ$65, containing "1000 Million PNEUMOCOCCUS I, II, III, 1000 Million STREPTOCOCCUS, 1000 Million STAPHYLOCOCCUS, 1500 Million HAEMOPHILUS INFLUENZAE, 25mg FEL BOVIS SICC", i.e. dead bacteria. These tablets are marketed as an adjunct to flu vaccination, to boost the immune system and "prevent the bacterial complications of the flu". A search on PubMed (National Library of Medicine) shows only 1 scientific article on this product, published in French, in 1977. The product is no longer sold in Australia, and the New Zealand Immunization Advisory Council recommends against it.

Yet is this so crazy? What about the recommendation by the USPHS Task Force, promoting the use of pneumococcal vaccine? In a previous blog I noted that Pneumovax is not recommended nor funded in New Zealand, and I wondered about this disrepancy. This vaccine is widely recommended for healthy older adults by health promotion authorities in the U.S. It is even funded by Medicare for any patient over 65 years old . But there is no evidence that it is effective in the general population. Brian Alper, the editor of Dynamed, kindly sent me a page listing all of the relevant studies, some of which show it may be effective in nursing homes, but not in high-risk patients. In particular, there is a Cochrane review that concludes that pneumovax is not effective in preventing pneumonia or death, just "invasive pneumococcal disease", with a number needed to treat of about 20,000 to prevent one case of infection, and 50,000 to prevent one death. At about US$25-40 per vaccination, that is a lot of moolah that might be better spent on smoking cessation programs (which by the way are funded for all patients in New Zealand, but not in America!).

So there is the answer to my question of "why is pneumococcal vaccine funded and promoted in America but not in New Zealand?". We fund it in America for the same reason that E.T. the extraterrestrial is locked away in a giant sterile bubble by men in spacesuits. For the same reason that we worry so much about bioterrorism and less about "two guys in a fishing boat with a nuclear weapon motoring up the Chesapeake". Perhaps we American doctors and patients should become more aware of this phobia, and rethink our attitudes. After all, there is some evidence that dirt might even be good for us!

We were awakened yesterday by a tremdous volley of gunshots at exactly 0700 AM. It was the first day of duck hunting season in Southland, which begins at exactly that minute. All weekend the valley has echoed to the sound of shotguns and barking dogs, which reminded me of the classic joke about the doctors who go duck hunting:

Five doctors go duck hunting -- a general practitioner, an internist, a psychiatrist, a surgeon, and a pathologist. They're sitting in the duck blind, telling doctor stories to each other, when a magnificent flight of ducks passes by.
The general practitioner raises his shotgun and aims at a duck. He says, "It looks like a duck, it sounds like a duck, but I need a second opinion." He lowers his gun and defers to the internist.

The internist draws a bead on the lead duck and says, "It looks like a duck, and it certainly sounds like a duck, but I read in the New England Journal of Medicine that it might not be a duck. Rule out goose, rule out pigeon, rule out penguin! I need a consult." And he signals to the psychiatrist.

The psychiatrist puts down his pipe and raises his shotgun. He says, "It certainly looks like a duck, and sounds like a duck, but it maybe it only thinks it's a duck."

He defers to the surgeon, who raises his shotgun and quickly squeezes off five shots -- dropping five ducks. The surgeon then kicks the pathologist into the water and says, "Go check those and tell me if they are ducks."

I've been thinking lately about the role of the GP (or FP) in making diagnoses. The old doc I worked with when I first went into rural practice, Jim Stansfield, used to say, "Chuck, the rare diseases as a group are common. The problem is, you only see one of everything". I think one of our jobs is to separate the wheat from the chaff, or the ducks from the geese as it were. One thing I notice in my own practice is that I rely a lot on intuition in order to do this. By intuition, I mean "having a hunch", or "getting a funny feeling", or as they say in Star Wars, "I've got a bad feeling about this". Its the impulse to just "add on a TSH" test that comes while I'm working, not as a conscious decision or as "rule I always follow" in a type of case. Its waking up in the morning and "knowing what that patient had". Its feeling sleepy in the middle of the afternoon, listening to a routine visit history and then suddenly pay close attention because the patient just said something that "set off a bell" in your head.

An example. A young fellow came into the office with back pain a few months ago. He was very tall and skinny, and his pain was around the upper spine, and appeared to result from reptitive movements at his job. He didn't really look that out of the ordinary, but as I examined him I remarked that he was really tall and slender. "Yeah, no one in my family looks like me, " he said. At his next followup visit, I remarked that he was very flexible and loose-jointed. We were wondering if that might have something to do with his being injured. "Well, no one I know can do this," he said, taking his hand behind his back and touching the upper border of his scapula on the same side. His appearance kept bothering me, and we explored hyperflexibility on his exam. Ehlers-Danlos syndrome popped into my head, and before his 3rd visit, I went back to the textbooks and read about it. This guy just looked odd. And as I was reading about E-D, I read the rest of the chapter about connective tissue diseases. Like Marfan's syndrome. Yeah, Marfans. Something clicked. At his 3rd visit, I measured him. Armspan is greater than height. "Any problems with your eyes?" I asked him. "Yeah," he says "for the last year or two I can't see well out of the left one. I've been meaning to see the eyedoctor". A quick look with the opthalmoscope shows the left lens seems dislocated inferiorly. So we talked about this possible diagnosis and he'll see a specialist for further evaluation in August. Note that continuity was important in this case. I had a funny feeling about this, but it took awhile to really pin down what it was.

Example #2. A man came in with a cough. As I was listening to his back and asking him to breathe, I noticed a large mole on his shoulder. It was pretty big. "What do you think about this mole here?" I asked. "Is it changing?".
"I don't know" he said, "I can't see it".
"Well, it looks funny to me" I said. Because of its size, (and because he wasn't worried enough about it to want to be cut on I think) he elected to get dermoscopy. It took 2 months, but the result was "almost certainly a melanoma, scheduled for excision".

Example #3. A man in his 50s came in complaining of constipation. He had all kinds of reasons why he should be constipated; change in diet, he never exercised, etc. He just wanted some medicine to take care of it. Review of systems and symptoms all totally negative, "just give me a good laxative please, doctor". Something just didn't seem right. What did the stools look like? Well, this is a problem in New Zealand, because the design of the toilets here is different. They are very funnel shaped and deep and narrow at the bottom. Most of the time they are in dark bathrooms. And the water closets flush them with tremendous force. And no one "ever looks" anywhere in the world of course, but if they did they'd have a heck of a time seeing anything in these toilets. So he couldn't tell me, but as I pressed my history, it developed that he had not had a satisfyingly large stool ever in the last 6 months, and they seemed to becoming smaller and smaller. Now this is a classic "medical school" history of altered bowel habit. I had a heck of a time doing a rectal exam on this man, who could not relax; and an even harder time convincing him that he needed a colonoscopy. However, he finally relented. Result: rectal carcinoma. I just had a bad feeling about his history.

Example #4. A 4 year old came to see me urgently with a 7 day history of trouble urinating. It had become so bad that he would go to the toilet every 20 minutes, and stand there crying because he couldn't empty his bladder. His mother had even seen some blood come out. The rest of his history was totally negative, including stool habits which mom said were daily and normal. Wow, this was a really odd history. His urine was totally clear, so it wasn't an infection; and his exam seemed perfectly normal. What could this be? I had never really seen heard a story like this before in 25 years of practice, and that fact really alarmed me. Bells were going off in my head, something about "posterior urethral valves" or other congenital problems presenting outside the newborn period. I called the pediatric registrar, who as usual was never happy to hear I couldn't figure something out after hours, but agreed to see the child. This one bothered me so much, I copied down the mom's phone number and called her back 4 days later.
"Hi, its Dr. Zelnick, I was just calling back to check that your son got taken care of.." I began tentatively.
"Oh hi doctor, yes, the problem's not fixed yet, but we're working on it and he's doing better."
"I wonder if you'd share with me what they found at the hospital, I don't get any followup from the urgent care center on these cases."
"Well, he was really badly constipated. I couldn't believe it- he'd been using the toilet every day. But now that we're getting that cleaned out, he is doing better..."
Great. A simple diagnosis that a rectal exam would have revealed. "Most often an ususual story is a common disease with an unusual presentation" goes the rule. Sometimes intuition is just plain wrong, and a duck really is only a duck.

Do I make any conclusions from these cases? Only that I really enjoy the challenge of seeing a lot of patients and trying to figure out which 2 or 3 every week will have something odd or unusual. Southland has high incidences of leptospirosis, hemochromatosis, and celiac disease compared to Iowa, so I have had to read up and learn about those problems so I don't miss them. Oh, and never be afraid to do a rectal exam. And remember, duck hunters, "guns don't kill people, doctors kill people".