The good stuff always comes towards the end. After the "pertinent" information has been gathered: how long noticed memory problems, episodes of falling, do your own cooking, shopping, manage finances, med list, orthostatic hypotension, focal neuro findings... Then we fill in the gaps and add some color to the snapshot. Sometimes we hear about a traumatic event from earlier in their adulthood, travel between countries and continents, impressive careers, hearts broken, love lost. I like to save my notes from these evaluations because they become experience for me. They have the potential to stick with me for the rest of my life. The header is just an age and a sex. The rest of the page is the beating heart as told by the patient and if we are lucky by the patient's family too.
I think it is the ultimate goal of the family physician to get to a point in the relationship with the patient where you can acknowledge all the aspects of a person's well-being. You will probably not be able to fix everything. But you can always address things. And what we should really be doing with people is having conversations; letting the patient tell their story and interpreting it back to them; commenting on their story; giving our (hopefully) experienced opinion. Unfortunately our primary source of "opinion" has become the faxing of a script for a pill. And people, hold your hats because I am about to write something very disturbing. You know how people go fishing to relax and feel better by being in the outdoors, maybe relieve some depression? Well fish are now showing up with levels of prozac. That is just one example. I like the irony of the whole relaxing fishing vacation/depression med thing. But the thing is is that there are a lot of meds in our water now. And it is not just from flushing unused meds down the toilet but it is also from excreting swallowed meds via the flush. FYI
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This is a huge/frightening issue--estrogen excreted by women on birth control (and I suppose, hormone replacement therapy) causes huge problems in the aquatic environment, including male fish turning female and alligators with undersized man-bits. I think science (and certainly not the general public) is only just beginning to comprehend the implications on our ecosystems and eventually, ourselves.
Guess you've probably heard by now that I got the job. I'll be running the new ARIZONA LABORATORY FOR EMERGING CONTAMINANTS beginning Jan 2008.
A seminal publication about this environmental problem is by Dana Kolpin at al. in Environmental Science & Technology, 2002, vol. 36, pp. 1202-1211.
Pharmaceuticals, Hormones, and Other Organic Wastewater Contaminants in U.S. Streams, 1999-2000: A National Reconnaissance
http://pubs.acs.org/cgi-bin/abstract.cgi/esthag/2002/36/i06/abs/es011055j.html
To provide the first nationwide reconnaissance of the occurrence of pharmaceuticals, hormones, and other organic wastewater contaminants (OWCs) in water resources, the U.S. Geological Survey used five newly developed analytical methods to measure concentrations of 95 OWCs in water samples from a network of 139 streams across 30 states during 1999 and 2000. The selection of sampling sites was biased toward streams susceptible to contamination (i.e. downstream of intense urbanization and livestock production). OWCs were prevalent during this study, being found in 80% of the streams sampled. The compounds detected represent a wide range of residential, industrial, and agricultural origins and uses with 82 of the 95 OWCs being found during this study. The most frequently detected compounds were coprostanol (fecal steroid), cholesterol (plant and animal steroid), N,N-diethyltoluamide (insect repellant), caffeine (stimulant), triclosan (antimicrobial disinfectant), tri(2-chloroethyl)phosphate (fire retardant), and 4-nonylphenol (nonionic detergent metabolite). Measured concentrations for this study were generally low and rarely exceeded drinking-water guidelines, drinking-water health advisories, or aquatic-life criteria. Many compounds, however, do not have such guidelines established. The detection of multiple OWCs was common for this study, with a median of seven and as many as 38 OWCs being found in a given water sample. Little is known about the potential interactive effects (such as synergistic or antagonistic toxicity) that may occur from complex mixtures of OWCs in the environment. In addition, results of this study demonstrate the importance of obtaining data on metabolites to fully understand not only the fate and transport of OWCs in the hydrologic system but also their ultimate overall effect on human health and the environment.
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