Correspondence
185
The Editors will be pleased to receive and consider for publication correspondence containing information of interest to physicians or commenting on issues of the day. Letters ordinarily should not exceed 600 words and must be typewritten, double-spaced, and submitted in duplicate (the original typescript and one copy). Authors will be given the opportunity to review the editing of their correspondence before publication.
Acoustic Neuromas TO THE EDITOR: I have just been rereading the otolaryngology Epitomes in the April 1989 issue and particularly the excellent review of acoustic neuromas.1 These fascinating tumors were described to all of us in medical school, and we reflexively think of the diagnosis when encountering unilateral hearing loss. Of course, the exquisite sensitivity of gadoliniumenhanced magnetic resonance imaging (MRI) scanning for acoustic neuromas has revolutionized the diagnosis in recent times. I agree with Drs Jackler and Lanser. An effective and parsimonious strategy would be to first do a full audiogram with speech discrimination; then, if the result of the audiogram is characteristically abnormal, an acoustic brain-stem response (ABR) should be measured. The ABR is quite sensitive for acoustic neuroma and, if the result is abnormal, an MRI scan will make a final diagnosis in nearly every case. What we were not told in medical school is that the acoustic neuroma is rare. In the largest population study reported to date, we found a yearly incidence of only 1 per 100,000 persons.2 This is a fact that should be more widely recognized and appreciated, and it shows the necessity of using cost-effective diagnostic strategies such as those discussed above. JAMES J. NESTOR, MD
Tfhe Permanente Medical 900 Kiely Blvd Santa Clara, CA 95051
Group
REFERENCES
1. Jackler RK, Lanser MJ: Improved diagnosis of acoustic neuroma with auditory brain-stem evoked responses and gadolinium-enhanced MRI, In EpitomesImportant advances in clinical medicine-Otolaryngology/head and neck surgery.
WestJ Med 1989; 150:452 2. Nestor JJ, Korol HW, Nutik SL, et al: The incidence of acoustic (Letter). Arch Otolaryngol Head Neck Surg 1988; 114:680
neuromas
Academic Medicine TO THE EDITOR: In reference to the commentary by Dr Francesco Gallatin Beuf in the October 1989 issue, I must agree with the author that academic medicine, in my opinion, is not providing the best patient care. Most full-time physicians and surgeons associated with university hospitals are more interested in their traveling professorships or their publications, which they feel they must continue in order to maintain their full-time salaries. In days gone by, when professors at teaching hospitals had large practices of their own and were respected for the expertise in their own fields, the institution did not pay these persons. They earned their own way in return for the privilege of being a professor at a university. They taught the students, and what they taught was heavily mixed with humanitarian attitudes toward patients. I doubt very much if, on rounds these days, one sees an academic surgeon or physician sit down by a patient's bedside, hold the patient's hand, and speak in a compassionate
and caring manner, or, further yet, come back after rounds to discuss directly with the patient any particular problem or question. No, rather, these leaders of medicine and surgery are more interested in getting back to their laboratories or to their transcription of the next article or the next speech that
they are preparing. I further doubt that without a thorough overhaul of the current system, we will see the likes of Professor of Medicine, Dr Francis Wood, or Professor of Surgery, Dr Isadore Ravdin, under whom I had the privilege of studying at the University of Pennsylvania in Philadelphia at a time when there were no such things as full-time academic professor-
ships. I write this in the hope that it will open a dialogue and a review of the way in which we are teaching our students of medicine and surgery. L. DAVID RUTBERG, MD 8851 Center Dr, Suite 412 La Mesa, CA 92042 REFERENCE 1. Beuf FG: Is academic medicine providing the best patient care?-Some personal observations. West J Med 1989; 151:477478
Trust TO THE EDITOR: I was somewhat surprised to see a letter in the November 1989 issue by Stuart Gherini, MD,I castigating me for my approach to the family and child with fulminant otitis as described in my article, "A Matter of Trust," in the August 1989 issue.2 The policy of many medical journals is that most letters in response to articles are sent to the author(s) for comment. Is this the policy of The Western Journal of Medicine? [EDITOR'S NOTE: We do it frequently but not always.] In any case, Dr Gherini is perhaps correct in one respect-Had there been an adverse outcome I might have "had a hard time justifying [my] treatment in front of a review board of [my] peers or-worse yet-a jury." That was never an issue. The point of the piece was not to suggest a community standard of herbal treatment of acute otitis media. That was not my approach then and is not now. It was merely to describe a fascinating case of a common pediatric illness treated in an unorthodox way with good result. Along with Dr Gherini, I, too, recall a patient of mine 18 years ago who developed chronic suppurative otitis media leading to a brain abscess and permanent sequelae. She was a Native American girl whose parents had a large family and lived in poverty on a reservation. Although the health care system, my services, and the antibiotic medications were free to them, she likely received inadequate therapy for a variety of social and economic reasons. Would Dr Gherini consider these parents noncompliant, as he obviously did the parents in my story?
186
CORRESPONDENCE ORSPNEC
Through the luxury of the retrospectoscope, we are all geniuses, maybe even wizards. The real issue here was one of trust-thus, the title of my piece. The basic trust was in the relationship between the child's parents and me. Despite their hesitancy to accept my advice of amoxicillin and my warnings about possible dire consequences of untreated otitis, there was a level of understanding in our interaction that seemed unique to the commonplace medical encounter. Neither the parents nor I could trust that the process would end up the way it did, with a total cure using unorthodox therapy. But in a mystical way, maybe the three of us knew something at the outset that we could not objectively define. Trust has many dimensions. In the last of a series of articles entitled "Beyond Conventional Medicine," Flora Kelly speculates about the reasons patients seek unconventional therapy.3 One of them is a change in the nature of the physician-patient relationship. All of us would do well to contemplate her words. LOUIS BORGENICHT, MD 850 East 300 South Salt Lake City, UT 84102 REFERENCES 1. Gherini S: Treating otitis media (Correspondence). West J Med 1989; 151:562-563 2. Borgenicht L: A matter of trust. West J Med 1989; 151:229-230 3. Kelly F: Beyond conventional medicine. AMA News, Nov 17, 1989, pp 37, 41-43
Alcoholic Cirrhosis and Cardiomyopathy TO THE EDITOR: The discussion by Dr Lee on the interrelationship between alcoholic cirrhosis and cardiomyopathy in the November 1989 issue was excellent.I As he pointed out, although alcoholic cirrhosis and cardiomyopathy share a common cause, their coexistence in the same patient is rare. In his extensive list of references Dr Lee failed to cite our paper, published in 1977, on the rare coexistence of the two conditions.2 Of the three explanations offered by Leeunderdiagnosis, Berkson's bias, and the protective effect of low peripheral resistance in unloading the ventricles-the last seems to be most plausible. TSUNG 0. CHENG, MD Professor of Medicine Department of Medicine Division of Cardiology George Wash. Univ. Med. Center 2150 Pennsylvania Ave, NW Washington, DC 20037 REFERENCES 1. Lee SS: Cardiac abnormalities in liver cirrhosis. West J Med 1989;
151:530-535 2. Bashour TT, Fahdul H, Sheikh M, Cheng TO: Rare coexistence of alcoholic liver cirrhosis and alcoholic cardiomyopathy-Fact or fancy? (Abstr). Clin Res 1977; 25:207A
Is It Fair to Blame the Victim? TO THE EDITOR: Four decades ago or so a young minister from New York City gained international prominence by preaching a catechism of hope that he called "The Power of Positive Thinking." He was Dr Norman Vincent Peale.' His doctrine, which some might be tempted to reduce to a simplistic philosophy of "don't worry, be happy," struck a vital chord in the American and western European psyches and has influenced not only current pastors' messages but obviously has had a great influence on modern clinical psychology.
It is reasonable to believe that by keeping a stiffupper lip through adversity, by whisfling by the graveyard in time of crisis, and by essentially adopting a doctrine of denial and keeping a positive, cheerful attitude throughout whatever the fates may bring, one may lead a happier and more productive life. That is what Dr Peale preached, and it is an all but unassailable position. Attempting to translate the quality of life to improvement in morbidity and longevity is less defensible. So seductive is the tenet, carrying with it the unstated but subliminal implication that our state of mind can influence our health and perhaps longevity, that it has made inroads not only into theology and psychology but into clinical medicine as well. It has generated and nourished the new and arcane science of neuropsychoimmunology. Norman Cousins, formerly the editor of The Saturday Review ofLiterature and no mental lightweight, has parlayed a belief in laugh therapy into a chair at the UCLA School of Medicine, although he has gradually modified his enthusiasm for humor as medicine. There may be evidence that some stress does lower the level of helper T cells, rendering one more vulnerable to disease. Other evidence to date appears anecdotal. So far, who can argue? The slogan, "sound mind, sound body," has reverberated through our conscious and unconscious minds for two generations. If you believe that without reservation, it is difficult to understand the existence of Stephen Hawking, PhD, who many think is the most brilliant theoretical physicist since Einstein, and whose best-selling book, A Brief History of Time: From the Big Bang to Black Holes,2 was written while Hawking was so crippled by amyotrophic lateral sclerosis that he spends his entire life in a wheelchair unable to talk or write without the aid of sophisticated computer equipment. There must be another side to the coin. If one is philosophically willing to accept the benefits of the power of positive thinking, one must be willing to accept the punishment for negative thinking. It would, then, not require a Nietzsche or a Schopenhauer to conclude that if you have an accident or lose your job, it is because in some way you did not maintain sufficient positivity in your life. If you are sick and disabled, it must be in some way because you want to be. The sick have enough misery from their illnesses. Should they now have to put up with the burden of their physicians and their relatives harboring a subliminal suspicion that it is their own fault? It would be cruel enough if it were proved. It is not. It is merely theory. I know I am stepping on some colleagues' deeply felt belief systems. Some physicians escape their own occupational angst by a strong denial mechanism and a very strong sense of maintaining control. We all would like to feel that a positive attitude tends to confer invulnerability. There are many ingrained folk beliefs that persist despite the lack of scientific proof. Influenced by generations of concerned parents insisting that we wear an extra sweater to school, it is still hard for some of us emotionally to accept the fact that being chilled will not make us sick. It is hard even now for me to accept the expert opinion of infectious disease specialists that being cold will not give me a cold. It always seems to.
The correlation of cancer and depression has been described in an editorial in The Journal of the American Medical Association (JAMA) as being centuries old.3 I cannot
185
The Editors will be pleased to receive and consider for publication correspondence containing information of interest to physicians or commenting on issues of the day. Letters ordinarily should not exceed 600 words and must be typewritten, double-spaced, and submitted in duplicate (the original typescript and one copy). Authors will be given the opportunity to review the editing of their correspondence before publication.
Acoustic Neuromas TO THE EDITOR: I have just been rereading the otolaryngology Epitomes in the April 1989 issue and particularly the excellent review of acoustic neuromas.1 These fascinating tumors were described to all of us in medical school, and we reflexively think of the diagnosis when encountering unilateral hearing loss. Of course, the exquisite sensitivity of gadoliniumenhanced magnetic resonance imaging (MRI) scanning for acoustic neuromas has revolutionized the diagnosis in recent times. I agree with Drs Jackler and Lanser. An effective and parsimonious strategy would be to first do a full audiogram with speech discrimination; then, if the result of the audiogram is characteristically abnormal, an acoustic brain-stem response (ABR) should be measured. The ABR is quite sensitive for acoustic neuroma and, if the result is abnormal, an MRI scan will make a final diagnosis in nearly every case. What we were not told in medical school is that the acoustic neuroma is rare. In the largest population study reported to date, we found a yearly incidence of only 1 per 100,000 persons.2 This is a fact that should be more widely recognized and appreciated, and it shows the necessity of using cost-effective diagnostic strategies such as those discussed above. JAMES J. NESTOR, MD
Tfhe Permanente Medical 900 Kiely Blvd Santa Clara, CA 95051
Group
REFERENCES
1. Jackler RK, Lanser MJ: Improved diagnosis of acoustic neuroma with auditory brain-stem evoked responses and gadolinium-enhanced MRI, In EpitomesImportant advances in clinical medicine-Otolaryngology/head and neck surgery.
WestJ Med 1989; 150:452 2. Nestor JJ, Korol HW, Nutik SL, et al: The incidence of acoustic (Letter). Arch Otolaryngol Head Neck Surg 1988; 114:680
neuromas
Academic Medicine TO THE EDITOR: In reference to the commentary by Dr Francesco Gallatin Beuf in the October 1989 issue, I must agree with the author that academic medicine, in my opinion, is not providing the best patient care. Most full-time physicians and surgeons associated with university hospitals are more interested in their traveling professorships or their publications, which they feel they must continue in order to maintain their full-time salaries. In days gone by, when professors at teaching hospitals had large practices of their own and were respected for the expertise in their own fields, the institution did not pay these persons. They earned their own way in return for the privilege of being a professor at a university. They taught the students, and what they taught was heavily mixed with humanitarian attitudes toward patients. I doubt very much if, on rounds these days, one sees an academic surgeon or physician sit down by a patient's bedside, hold the patient's hand, and speak in a compassionate
and caring manner, or, further yet, come back after rounds to discuss directly with the patient any particular problem or question. No, rather, these leaders of medicine and surgery are more interested in getting back to their laboratories or to their transcription of the next article or the next speech that
they are preparing. I further doubt that without a thorough overhaul of the current system, we will see the likes of Professor of Medicine, Dr Francis Wood, or Professor of Surgery, Dr Isadore Ravdin, under whom I had the privilege of studying at the University of Pennsylvania in Philadelphia at a time when there were no such things as full-time academic professor-
ships. I write this in the hope that it will open a dialogue and a review of the way in which we are teaching our students of medicine and surgery. L. DAVID RUTBERG, MD 8851 Center Dr, Suite 412 La Mesa, CA 92042 REFERENCE 1. Beuf FG: Is academic medicine providing the best patient care?-Some personal observations. West J Med 1989; 151:477478
Trust TO THE EDITOR: I was somewhat surprised to see a letter in the November 1989 issue by Stuart Gherini, MD,I castigating me for my approach to the family and child with fulminant otitis as described in my article, "A Matter of Trust," in the August 1989 issue.2 The policy of many medical journals is that most letters in response to articles are sent to the author(s) for comment. Is this the policy of The Western Journal of Medicine? [EDITOR'S NOTE: We do it frequently but not always.] In any case, Dr Gherini is perhaps correct in one respect-Had there been an adverse outcome I might have "had a hard time justifying [my] treatment in front of a review board of [my] peers or-worse yet-a jury." That was never an issue. The point of the piece was not to suggest a community standard of herbal treatment of acute otitis media. That was not my approach then and is not now. It was merely to describe a fascinating case of a common pediatric illness treated in an unorthodox way with good result. Along with Dr Gherini, I, too, recall a patient of mine 18 years ago who developed chronic suppurative otitis media leading to a brain abscess and permanent sequelae. She was a Native American girl whose parents had a large family and lived in poverty on a reservation. Although the health care system, my services, and the antibiotic medications were free to them, she likely received inadequate therapy for a variety of social and economic reasons. Would Dr Gherini consider these parents noncompliant, as he obviously did the parents in my story?
186
CORRESPONDENCE ORSPNEC
Through the luxury of the retrospectoscope, we are all geniuses, maybe even wizards. The real issue here was one of trust-thus, the title of my piece. The basic trust was in the relationship between the child's parents and me. Despite their hesitancy to accept my advice of amoxicillin and my warnings about possible dire consequences of untreated otitis, there was a level of understanding in our interaction that seemed unique to the commonplace medical encounter. Neither the parents nor I could trust that the process would end up the way it did, with a total cure using unorthodox therapy. But in a mystical way, maybe the three of us knew something at the outset that we could not objectively define. Trust has many dimensions. In the last of a series of articles entitled "Beyond Conventional Medicine," Flora Kelly speculates about the reasons patients seek unconventional therapy.3 One of them is a change in the nature of the physician-patient relationship. All of us would do well to contemplate her words. LOUIS BORGENICHT, MD 850 East 300 South Salt Lake City, UT 84102 REFERENCES 1. Gherini S: Treating otitis media (Correspondence). West J Med 1989; 151:562-563 2. Borgenicht L: A matter of trust. West J Med 1989; 151:229-230 3. Kelly F: Beyond conventional medicine. AMA News, Nov 17, 1989, pp 37, 41-43
Alcoholic Cirrhosis and Cardiomyopathy TO THE EDITOR: The discussion by Dr Lee on the interrelationship between alcoholic cirrhosis and cardiomyopathy in the November 1989 issue was excellent.I As he pointed out, although alcoholic cirrhosis and cardiomyopathy share a common cause, their coexistence in the same patient is rare. In his extensive list of references Dr Lee failed to cite our paper, published in 1977, on the rare coexistence of the two conditions.2 Of the three explanations offered by Leeunderdiagnosis, Berkson's bias, and the protective effect of low peripheral resistance in unloading the ventricles-the last seems to be most plausible. TSUNG 0. CHENG, MD Professor of Medicine Department of Medicine Division of Cardiology George Wash. Univ. Med. Center 2150 Pennsylvania Ave, NW Washington, DC 20037 REFERENCES 1. Lee SS: Cardiac abnormalities in liver cirrhosis. West J Med 1989;
151:530-535 2. Bashour TT, Fahdul H, Sheikh M, Cheng TO: Rare coexistence of alcoholic liver cirrhosis and alcoholic cardiomyopathy-Fact or fancy? (Abstr). Clin Res 1977; 25:207A
Is It Fair to Blame the Victim? TO THE EDITOR: Four decades ago or so a young minister from New York City gained international prominence by preaching a catechism of hope that he called "The Power of Positive Thinking." He was Dr Norman Vincent Peale.' His doctrine, which some might be tempted to reduce to a simplistic philosophy of "don't worry, be happy," struck a vital chord in the American and western European psyches and has influenced not only current pastors' messages but obviously has had a great influence on modern clinical psychology.
It is reasonable to believe that by keeping a stiffupper lip through adversity, by whisfling by the graveyard in time of crisis, and by essentially adopting a doctrine of denial and keeping a positive, cheerful attitude throughout whatever the fates may bring, one may lead a happier and more productive life. That is what Dr Peale preached, and it is an all but unassailable position. Attempting to translate the quality of life to improvement in morbidity and longevity is less defensible. So seductive is the tenet, carrying with it the unstated but subliminal implication that our state of mind can influence our health and perhaps longevity, that it has made inroads not only into theology and psychology but into clinical medicine as well. It has generated and nourished the new and arcane science of neuropsychoimmunology. Norman Cousins, formerly the editor of The Saturday Review ofLiterature and no mental lightweight, has parlayed a belief in laugh therapy into a chair at the UCLA School of Medicine, although he has gradually modified his enthusiasm for humor as medicine. There may be evidence that some stress does lower the level of helper T cells, rendering one more vulnerable to disease. Other evidence to date appears anecdotal. So far, who can argue? The slogan, "sound mind, sound body," has reverberated through our conscious and unconscious minds for two generations. If you believe that without reservation, it is difficult to understand the existence of Stephen Hawking, PhD, who many think is the most brilliant theoretical physicist since Einstein, and whose best-selling book, A Brief History of Time: From the Big Bang to Black Holes,2 was written while Hawking was so crippled by amyotrophic lateral sclerosis that he spends his entire life in a wheelchair unable to talk or write without the aid of sophisticated computer equipment. There must be another side to the coin. If one is philosophically willing to accept the benefits of the power of positive thinking, one must be willing to accept the punishment for negative thinking. It would, then, not require a Nietzsche or a Schopenhauer to conclude that if you have an accident or lose your job, it is because in some way you did not maintain sufficient positivity in your life. If you are sick and disabled, it must be in some way because you want to be. The sick have enough misery from their illnesses. Should they now have to put up with the burden of their physicians and their relatives harboring a subliminal suspicion that it is their own fault? It would be cruel enough if it were proved. It is not. It is merely theory. I know I am stepping on some colleagues' deeply felt belief systems. Some physicians escape their own occupational angst by a strong denial mechanism and a very strong sense of maintaining control. We all would like to feel that a positive attitude tends to confer invulnerability. There are many ingrained folk beliefs that persist despite the lack of scientific proof. Influenced by generations of concerned parents insisting that we wear an extra sweater to school, it is still hard for some of us emotionally to accept the fact that being chilled will not make us sick. It is hard even now for me to accept the expert opinion of infectious disease specialists that being cold will not give me a cold. It always seems to.
The correlation of cancer and depression has been described in an editorial in The Journal of the American Medical Association (JAMA) as being centuries old.3 I cannot
