Sunscreens – Are You Buying Them Right?

Sunscreens – Are You Buying Them Right?

I read a very interesting research paper yesterday –published in the prestigious New England Journal of Medicine (read here- http://www.nejm.org/doi/full/10.1056/NEJMp1504912) - detailing the current research trends in melanoma – a skin cancer condition. And the research paper in passing touched upon something of interest to all of us- namely how effective were sunscreens in preventing skin cancer. Now the two commonest skin cancer types are Carcinomas and Melanomas. A melanoma (often called a malignant melanoma because it spreads so easily and so fast) is a cancer of the melanin pigment producing cells of our body. Melanin is the protein which gives us our skin colour- dark or fair and and also protects us from the radiation of the sun- in effect its a natural sunscreen. Dark skinned people have an abundance of melanin pigment in their skin naturally and require lesser quantities of sunscreen to protect their skin, while fair skinned people with less melanin get tanned and sun burnt easily and also have more instances of getting skin cancer- melanomas. So with that small introduction let me get onto the meat of the matter.

 Sunscreens as we all know are classified as over the counter cosmetic products which do not need a doctors prescription. But we must remember that cosmetic companies make certain tall claims regarding sunscreens and their effects touting them as wonder drugs as they contain certain chemicals which, in effect prevent skin-tanning, anti-aging etc. Now the American Food and Drug administration has specified certain guidelines for sunscreens based on recent research

1)    Anything less than SPF- 15 is no use for cancer prevention but can only be used for anti-tanning- so this means the FDA has now effectively barred anything which uses less than 15-SPF.

2)    Anything above SPF-50 has been shown to be useless for skin protection- which means that more than that is an overkill and unnecessary.

3)    Both cream and liquid based sunscreens work equally well when applied as a coating- but all of them last for only 90 mins to 120 mins for single application- which means you are protected for one and a half to two hours only with a single application. So covering up exposed areas with adequate clothing becomes important for long term prevention. And there goes my dream of ogling at all those bikini clad beach babes.

4)    Any sunscreen which only protects against UV-A is not effective as anti-cancer but only for anti-tanning. Hence check out for the sunscreen prevents both UV-A  and also UV-B rays from affecting the skin. So only broad-spectrum sunscreens prevent  skin cancer while others are just for the beach.

5)    Ingredients like  ecamsule and enzacamene come under banned substances – no longer safe and effective and hence check out that you are using a product which no longer contains these.

6)    And finally remember that background radiation exists even indoor- so anything which promises anti-aging should protect your skin all the time and not just under direct sun exposure.

So these few pointers should help you choose the best sunscreen for avoiding skin cancer and not be taken in by the tall claims made by cosmetic companies.

Look Before You, Uh....Cuddle...

Look Before You, Uh....Cuddle...

Can you tell the difference between something which is let’s say bony hard and something else which is stony hard? I mean how hard bone is and how hard a stone? Can you tell the difference by feeling with your hands, just your finger tips, eyes strictly closed? Well if you are able to do so, congratulations you just passed the general surgery paper. Hold on, wait a minute, before you start throwing things at me and let me explain the above example. Contrary to what is generally believed in surgery- treatment is only half of what you do, the other half- shall we say the better half- is diagnosis, the finding out of facts and deciding whether they are worthy of being operated on or simply require drugs to cure. No one wants to undergo unnecessary surgery do they? And that’s the reason learning diagnostic skills plays such a large part in medical training. If you can see it- you can kill it (probably) a concept which predates drone warfare

But there are diseases and diseases- some common place, some rare enough that you read about them only in text books and suddenly remember a particular line from the book staring at your face when quoted by a patient to you out of the blue. Your mind goes "oh wait, i know this, I know, now where did i read this? Which subject? Which book? Was it in so-and-so textbook? Yep I think so. So let me confirm it by going along that path and asking more questions". And that’s how the diagnosis for most of the common diseases gets done. But sometimes, rarely, no one knows what the actual disease is but we can still identify the symptoms and treat the disease without putting our hand on which specific organism actually causes the disease till the lab results come out positive and then you go "Hold on, oh shit, this one? Isn’t this a zoonotic (animal) one? How did it ever.....?" And based on those test results you start asking the patient specific questions like "how many pets do you have at home? Do you ever pet wild and rabid animals on the street out of the goodness of your heart?" and the answers finally make some sense.

So the story i am about to tell you started a couple days ago when i was a referred a patient for opinion on her enlarged lymph nodes in the neck area.  In India any enlarged lymph node is automatically (and rightly) suspected of being tuberculosis. But identifying Mycobacterium, the organism which causes Tb is fairly easy - you just need a chest x -ray or like i said in the first para if you can put an hand on the enlarged lymph node and press it down and it feels rubbery firm then you can suspect TB and go on to order blood tests. At the risk of repeating myself diagnosing mycobacterium tuberculosis is  easy but treating Tb is a different kettle of fish- that mycobacterium is one tough sonofabitch and doesn’t die easily.

Anyway to return to my story once you rule out TB as the cause of enlarged lymph nodes the next obvious suspect is a cancer - lymphoma, thyroid cancer and stuff like that. And again as I said in my first para, if you start pressing the enlarged glands and find them to be stony hard and fixed to a point -then you scratch your head and wonder how you are going to break the news to the patient that they "might, just might" have cancer pending further tests to confirm. But for this particular patient the diagnosis of cancer was ruled out because the doctor who had seen her just before he sent her to me had taken a CT scan which pretty much ruled out cancer as a possibility. He suspected an infection and he sent her to me.

I suspected an infection too- a chronic or longstanding infection - but like all the other doctors who had seen her before me I just couldn’t pin her down to which infection. So as i always do when in doubt, i went back to the beginning. I sat her down in front of me and asked her to tell me the whole story right from the beginning and assured her that there was no hurry and we had all the time in the world as if she was my only patient for the day. And that’s how i got my first glimmer of a diagnosis when she talked about her initial flu-like fever and a few weeks later developing those swellings and as she went on and on I suddenly noticed the profuse white hairs scattered all over her black salwar dress. The patient before me was in her mid-20's and still had most of her hair on her head and i could no way think of any reason why she should have so much hair fall in a single day- besides her hair (even if dyed/colored) was still black while the dress was covered in white hair. Voila...the violins sang somewhere and I had cracked the case in my best Hercule Poirot style.

"Do you have any pets at home" I asked interrupting her long story of how she hated eating only bread due her fever. "Yes" she said, "I volunteer with the animal adoption drives on facebook" she said and then continued "I have two cute little kittens at home, they very cute and playful animals doc, they can never be separated from me, they even sleep on my chest at nights" at which point I removed my spectacles (TV doctor style) to peer at her and then i wagged my finger at her (couldn’t resist) and said  in my best i-am-the-expert voice "Ah, Ah, You have a zoonotic disease passed from animals to humans. It might be Ebola- in which case you should be dead by now, might be Crutzfeld-Jakob - in which case you will go mad before you die. Anyway let’s send you for a blood test for the most commonest cat disease- Toxoplasmosis" and then i wrote her a PCR test for Toxoplasma gondii- a parasite which usually lives in cats but sometimes infects the cats owners too.

The rest as they say is history - the PCR test came back positive and we started her off on Clindamycin and Pyrimethamine- all good solid parasite killers which can take care of a little parasite called t.gonddi without breaking a sweat. And I sent her back with a warning to stop cuddling with those cute little kittens all the time (especially at bedtimes) and instead get a man to keep her bed warm at night (actually I didn’t say that outright but sorta implied it). I further pontificated generally on how dangerous animals are to human beings who don’t recognize the truth and gave a few examples like - bird flu, swine flu and HIV all of which had come to us humans (mostly to single ladies) courtesy of those cute little animals.

And that’s the point of this post. Actually there is no point to this post, but if you are still reading this the take home message is - stop cuddling animals and go cuddle with other humans.

Professional Back Biting

Professional Back Biting

 

The other day one of my patients gave me a shock, a massive shock, with of all things a few dozen complimentary words praising me. If you are as surprised as i was, let me explain from the beginning. This was a 45 year old diabetic patient who had suffered from a variety of ailments for the past few months without suspecting that it was all linked together due to a single cause- her uncontrolled blood sugar levels. Early into listening to her recite a litany of complaints I suspected her of diabetes and told her get her blood sugar checked and meanwhile started her off on drugs for her current problems.

When she finally came in with her test reports confirming diabetes i had counseled her on having her blood sugar levels within accepted range at all times and then had referred her back to her family physician for further care. And promptly forgot all about her. Consider my surprise when she turned up again in my room after a few months. She had cajoled the nurses to let her in out of turn, walked straight in, sat down in front of me and said in an inappropriately loud voice "DOCTOR, I am so happy. I told my family members, I told people all over my street and I told everyone that I am now completely cured, that you have cured me of my diabetes".

I flinched from the shock of the unexpected blow and glanced around to see who all had overheard this emphatic denunciation. Relieved that none of my colleagues could have possibly heard it, I decided to prevent her from continuing in this same vein of unbridled enthusiasm and pushing myself up straighter from my customary slouch in the chair and told her in a firm voice "Madam, I did no such thing, as I told you before you cannot cure diabetes, you can merely control it". "But, but" she stammered "I checked my sugar level and it’s all gone".

With a sigh borne out of exhaustion at repeating the same thing for the 50th time that day, I slouched back again in my chair and went over the same grounds again "Madam, diabetes is a lifelong disease, you have to keep taking drugs all your life to keep your sugar levels under control. If not they will rise again". She nodded her head and seemed to have at last got the message. I concluded my lecture by telling her "So what has happened with you is that your blood sugar is normal only because of the medicines and will be normal as long as you continue taking them daily. Leave alone me, no one can cure diabetes, so if someone says he can please don’t believe it" and with that parting piece of advice I sent her on her way.

Now to explain why i was shocked at her emphatic appreciation on my skills in curing diabetes was because I remembered the times I have been part of a crowd of doctors who laughed over these absurd advertisements on curing diabetes published by quacks (fake doctors) in vernacular newspapers. The way these fake doctors cured diabetes is to convince a normal person (healthy/disease free person) that they have diabetes, take a blood sample for testing, switch it with a diabetic patients and show the gullible patient the false result.

Once the patient believes that they have the disease, these quacks go onto prescribe medicines made of secret ingredients which they will guarantee to cure diabetes and after a proper interval challenge the patient to go to any lab and get a sugar test done. Naturally their blood sugar level would be normal and when the patient sees the normal result they immediately believe that the secret medicine has cured their diabetes- which they never had in the first place. So a simple sleight of hand trick like magicians do is behind all these fake diabetes cures. Which is why I didn’t want to be labeled as one of them people who can "cure" diabetes.

Whenever we doctors get together and relax - like in the changing rooms of operation theatres between patients- we do tend to gossip a bit just like others do. And sometimes the gossip is about the way innocent patients get cheated by other doctors. Most of this gossip would be just unsubstantiated urban myths - like the one about how people who go to fertility clinics advertising 100% guaranteed child- often go home with someone else's kids because the sperm used has been switched with a healthy donors sperm- a very persistent myth you keep hearing often. But mostly it’s about the different ways unscrupulous doctors rip off patients- some of them wholly original inventions.  But all that talk is in the dressing room only- rarely do doctors wash dirty linen in public- like all other professions the medical field too maintains a distaste for exposing other doctors wrongdoings to outsiders. But things are changing. Doctors have started talking to their patients about other doctors- especially their previous attending doctors. And unsurprisingly whatever they tell patients about their previous doctors is mostly uncomplimentary and all about fault finding – or so says a new study.

The Journal of General Internal Medicine (May 2013 ed) has an article which analyzed the number of times doctors talk to patients about other doctors- the results were 29% of positive comments, 4% as neutral and 67% as negative comments critical about other doctors. As surprising as this fact is, I guess its happens more often than we think or acknowledge. Some doctor’s exhibit this instinctive need to breast beat their prowess when compared to their patient’s previous doctors. While others merely offer on or two cutting comments on the line of treatment or choice of drugs previously given by other doctors. None of which is wrong ethically but still a frowned upon practice under the dictum- thou shalt not speak ill of a fellow physician. But doctors are not the Sicilian mafia- there is no code of omerta and hence such doctors who constantly criticize other doctors rarely feel the need to temper their criticisms unless one or more of their patients goes back to confront their previous doctor and says flat out "my new physician says like this, like that, that what you did for me was wrong and you must be stupid" at which stage a battle royal ignites followed by a feud for generations.

Anyway, unlike the previous example of American doctors criticizing other doctors publicly, most doctors in India are wiser (or more discreet) and rarely (never) tell their patients outright that such and such a doctor is bad. It’s all mostly winks and nudges when a patient asks about another doctor. It ranges from “well, I have not heard anything of him till now – which really means- anything good till now” to “why don’t you try someone else, I heard his success rate is not good- which really means half is patients die so why take the risk” all of which is trying to pass the message as subtly as possible that “although I would love to share the horror stories I have heard of the doctor you are asking about, I can’t come right out and say it because my professional ethics forbids me”. Some patients are wise enough to understand the subtle hints and knowing winks. Others are not. So the next time you ask your family physician about another doctor- please watch out for those tell tale signs and subtle winks.

The point of this post is - like all professional relationships the doctor patient relationship is based on trust and it works only if there is absolute trust both ways – second guessing leads to a lot of avoidable tragedies. Hence unnecessarily back biting colleagues and bad mouthing other doctor’s to our patients leads to an overall collapse of trust in all doctors, in the medical profession itself, which would be a tragedy for both patients and doctors. Likewise doctors have a duty to prevent their patients from getting bad treatment by incompetent doctors. But there are ways to do this properly- constructive criticism rather than negative criticism is the way forward. It helps if doctors keep gossiping about colleagues to a minimum- but I guess that we are all human and apt to slip up now and then. So the only way to do this ethically – is for doctors to directly call the other doctor and query him/her if they feel that their patient has received sub-standard care rather than badmouth to the patient. Both as a doctor and as a patient I would appreciate this gesture as it would lead to a solution rather than just blame. So what do you think? I would love to hear your views on this sensitive topic.

And to conclude- I can advice, counsel, prescribe for diabetes- but I cannot cure it and neither can anyone else at this point of time, ok?

Eat Shit And Lose Weight ?

Eat Shit, Lose Weight.

Believe me, I am not shitting you

                                                 

The internet serves a wholesome purpose in sharing a lot of vital and hard to get information to us in real time. Careful use of the net helps us to gain a lot of knowledge. But there are some real bloopers floating around the net in the name of science and it is actually hard to identify what’s real and what’s just plain old bull shit.

Talking of shit, reminds me of a rat shit thing I read just yesterday- a breaking news scientific paper on Science magazine which was being amped all over the internet- about how good bacteria from a thin persons stomach would cure obesity if given to a fat person. Intrigued, I went beyond the title and read the full article (as befitting my training as a BS deductor) only to see that it was a rat study and not a human study like the headlines subtly implied. The researchers had taken the fecal droppings (in plain words- rat shit) of a thin rat and fed it to a fat rat, an obese rat as they call it in the paper. This wholesome diet seems to have disagreed with the fat rat for on eating it he seems to have dropped a whole lot of weight which result the researchers immediately attributed to the beneficial effects of the shit, errr the bacteria in the shit from the thin rats stomach which must have shown the fat rats stomach bacteria how to digest the, errrr fat.

Anyway that’s what the researchers say inside the main body of the article unlike in the headlines where they scream in a bold font "New cure found for obesity". But personally I feel that though the result of the study is borderline believable, the reason for the weight loss might be something else entirely when you think about it. The fat rat that was being fed the fecal droppings of the thin rat must have developed an aversion to food and starved like our size zero models who just sniff at food when hungry. If you are a foodie of any sort, you can’t help but sympathize with that fat rat cant you?  I mean, made to eat something like that daily, is it any wonder he lost weight? And now as a follow up to the study, the researchers are planning to do human trials too.  Oh yeah, Eat shit (someone else's) and lose weight must be a very popular slogan to recruit people for the study. I can’t imagine a whole lot of people lining up to take that cure. Not even our desperate size zero models. They would rather starve wouldn’t they?  

Its a whole lot of crap, ain't it?

 

 Anyway the point of this post is to stress the point that medical news on the Internet is often highly hyped but factually incorrect. But a lot of people who see those screaming headlines go onto believe that the damn thing actually works. Very few take the time to read through the whole article to find out what it really says. Even if they do, they can’t understand the scientific jargon and the statistical magic tricks to make sense of the truth beyond the headlines. Besides most medical journals are pay-per-view only and never allow you to read the full thing- they just show you the sensational headlines and leave you to make your own interpretations. Often there is a very vast difference between what the title of an article says and what the real conclusion hidden inside the article says. And  even doctors find it difficult to interpret the real truth from the raw data included in the tables section like an afterthought- which is the only way to check whether a thing really works or the authors are just Bull S'ing you.

So even if the shit for food theory actually works, I don’t see much of a future for any shit-cure pills. What about you dear reader? Care to share your views? That is if you are still reading this post after all those shitty idioms I used above.