January 2004

Downer, Dude

By Michael J. Katin, MD

As each year comes to a conclusion there is hope that at the last minute an event will occur that will provide distraction from the holiday season, impact on popular culture, and provide one final reason to distinguish that year. 2000 gave us the hanging chad, which could have resulted in major revision of our election process. 2001 concluded with the introduction of the Segway, which could have revolutionized the way we travel. At the end of 2002 we first heard about SARS, which could have led to greater realization of our truly being citizens of one world, sensitive to things that happen even on the other side of the globe. This year the last big story was the discovery of mad cow disease in the United States, and revelations about the meat industry, which will probably produce as much change in our dietary habits as the events of the previous three years revolutionized our lives.

There are far too many diseases to keep track of all of them, and it's rewarding when some of them can be eliminated and some of the eponyms eliminated. This happens very rarely, and usually terms are continued in parallel for generations, similar to the combination of the metric and English systems in the United States, and the use of Spanglish in Texas. Years ago medical texts referred to Creutzfeldt-Jakob Disease (CJD) and Kuru in the same sections, perhaps with some premonition that there could be a link between these, but without anticipating a connection with Chronic Wasting Disease (CWD) in Wyoming and Montana elk and Wisconsin white-tailed deer, scrapie in sheep, and Bovine Spongiform Encephalopathy (BSE). Add to these the less common Fatal Familial Insomnia (FFI) and Gerstmann-Straussler-Scheinker (GSS) diseases and most letters of the alphabet have been covered. Possible transmissible spongiform encephalopathies have also been found in mink (TME) and cats (FSE), thus bringing into question the safety of wearing fur coats regardless of where purchased.

During the previous flurry of articles about mad cow disease, when it was "their" problem in Europe, it was charming to learn that cattle are fed with a variety of proteins, including the remains of Fido and Fluffy, and that in France cows' diets have included sewage sludge. We now learn that regardless of what happens to the cattle before they get to the slaughterhouse, not all those who go the last mile get there under their own steam. Granted, most of them wouldn't exactly be prancing in if they knew what was going to happen, but it turns out that at least 150-200,000 out of the 35,000,000 butchered each year have to be dragged in. These "downer cows" might not be expected to be prime quality but now there's concern that, just perhaps, there might be some medical reason they're not ambulatory. Chronic Fatigue Syndrome? BSE?

The term "downer" has immediately taken on a new life and it will probably be at least four months before the infatuation with this wears off ("shock and awe," "metrosexual," etc.). In the meantime, it can be applied to any situation in which organisms are still considered useable but need to be dragged or pushed into their venues. This would include tenured professors, government employees, and, unfortunately, radiation oncologists.

Our specialty was once distinguished as having the lowest death rate of any medical specialty. This was probably less due to the protective power of low-dose radiation exposure rather than to the recency of development of the specialty. There is now an increasing number of practitioners who are nearing retirement, as well as those who will be threatened by recertification, and even certification in the first place.

Certainly life was stressful enough thinking that recertification was coming in 10 years, starting with specialists certified in 1995. What is the risk of not being successful? I checked on the results of recertification from the American Board of Internal Medicine, to give some insight for the future. Between 1996 and 2003 there were 23,235 tests administered, with 91% passing the first time and 98% ultimately passing. This may not have included those who died of intercurrent disease, however. In the 2002 subspecialty recertification, the worst performance was in pulmonary disease, with 82%, but we should be proud of our medical oncology colleagues, who had a 96% pass rate.

This shows, unfortunately, that even with a selected group, excluding those who didn't think it safe to attempt recertification, there was still a failure rate, creating a class of downer physicians. Is it possible that once recertification hits our specialty, that there will be hundreds of radiation oncologists still able to get work but whose self-esteem and bargaining power are dramatically deflated. Is there a solution?

Yes. One final story hitting the press just as 2003 was closing was that the FDA has declared its intention to ban ephedra. This was announced on December 30 and was remarkable in the fact that anyone in the government was working on that day. Ephedra (ma huang, country mallow, Mormon tea) is used as a component of body-building and weight-loss programs in its role as a stimulant and in fact most of the supplements containing ephedra emphasize its value for increasing stamina and concentration. The ban is anticipated to be implemented in two months.

Don't forget to check that the expiration date on your stockpile does not predate your recertification year.

email: mkatin@radiotherapy.com