Douwe Rienstra, MD

Educational Activities

2006 | 2005 | 2004 | 2003 | 2002 | 2000 - 2001 | 1988 - 1999

December 5th, 2003 - Cynthia Tobias, M Ed, spoke at Virginia Mason Hospital about learning and working styles. The pediatrics department arranged the lecture to help us learn that chidren have many different ways of learning. Failure to recognize this and to teach appropriately can lead to the mistaken diagnosis of Attention Deficit Disorder or other learning disorders. Learning styles are important in adulthood, too, and most of the audience was obviously quite interested on a personal level as well. Some of us, for instance, learn by talking to ourselves!
You can read more about her ideas at http://www.applest.com/

November 21st, 2003 - A trust fund sponsored this all-day conference at Swedish Hospital about cell signaling. We have known for decades that the trillions of cells in our bodies talk to themselves and to each other. (See the talk for December 5th; talking to ourselves is built into our very cells.)
Today we know the physical structure of the molecules involved, which has allowed the development of drugs for rheumatoid arthritis, for erectile dysfunction (Viagra, etc), and many others. This program addressed the basic science and specifically, treatment of prostate cancer. You can learn more about cell signaling at http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/C/CellSignaling.html

November 18th, 2003 - Arthur Lee is a cardiologist in Bremerton who spoke at Jefferson General Hospital about treatment of acute cardiac conditions. His talk discussed technical details; the message for you is that if you think you may be having a heart attack, call 911 and then take half of an adult aspirin (unless you are allergic to it.) This will improve your chances of survival considerably.

November 14th, 2003 - Residents at the Virginia-Mason clinic discussed cases of elevated blood calcium, heart inflammation due to an immunosuppressive drug, a rash that was due to HIV, and hearing loss due to syphilis.

November 7th to 10th, 2003 - Drs Alan Gaby and Jonathan Wright gave a four-day review of nutritional therapy in medical practice. These are very intelligent and innovative physicians who not only have studied nutrition and health exhaustively, but have put their knowledge into practice and made contributions to the research themselves.

November 7th, 2003 - Lindsay Machan, MD, is an interventional raddiologist at the University of Vancouver in British Columbia who spoke at the Virginia Mason clinic. As he began his talk, he joked that an interventional radiologist "intervenes between the surgeon and his wallet." That means that when the interventional radiologist places a stent (a tiny sleeve) inside a blood vessel to open the vessel, the patient will not need a coronary artery bypass.

The human body doesn't like foreign materials placed inside it, and will try to bury the stent under scar tissue. So, interventional radiologists are using stents that contain drugs to inhibit the formation of scar tissue, or stents that dissolve away once they've done their job, so the scar tissue has no reason to form.

October 31st, 2003 - David Cummmings, MD, spoke at the Virginia-Mason Clinic about his research on a hormone that's been recently discovered to increase appetite. The hormone is called ghrelin and it is produced by the stomach. Bariatric surgery may have most of its effect by reducing production of ghrelin. Drugs to reduce levels of ghrelin are in development, and may be effective in producing weight loss.

October 24th, 2003- Debra Wechter and Keith Paige MD of Virgina-Mason clinic discussed breast cancer. Some women with cancer in one breast, a strong family history and genetic tendancy to breast cancer will have both breasts removed as a preventive measure. This is called prophylactic mastectomy. Understandably, even for those women at extremely high risk, this is an unpleasant option.
It is unfortunate for women that the medical authorities place more emphasis on procedures such as prophylactic mastectomy than they do on educating women about means of preventing breast cancer. Contrary to the popular impression, a great deal of research has demonstrated that estrogen chemistry has a strong effect on the risk of breast cancer. Estrogen subfractions vary between women, and relatively easy dietary measures can reduce the production of toxic forms of estrogen. For more information, ask to see our videotape on female hormones.

October 10th, 2003- Erane Myint, MD of Virginia-Mason clinic reviewed oral contraceptives. These increase the risk of stroke and heart attack in women who smoke, have high blood pressure, have migraines, or have a certain genetic constitution. The newer oral contraceptives are less likely to raise the blood pressure, the cholesterol, or the blood sugar. Whether or not oral contraceptives increase the risk of breast cancer is uncertain, but if they do, the risk is very small. Work progresses on safer contraceptives, but in the meantime, remember that for most women, pregnancy carries even higher health risks.

Oral contraceptives seem to reduce the risk of ovarian and endometrial cancer, can improve painful periods or acne, improve bone strength, and reduce the risks of unintended pregnancy.

September 26th, 2003- John Ryan, MD of Virginia Mason Clinic reviewed current diagnosis and treatment of parathyroid tumors. He outlined the methods Virginia Mason has adopted to reduce patient risk and cost. Physicians there studied and utilized the quality-control and efficiency measures used at Toyota and other leading industries. The result has been a great savings in surgery costs and shorter (and less expensive) hospital stays.

September 19th, 2003- Howard Muntz, MD of Virginia Mason clinic reviewed current diagnosis and treatment of ovarian cancer. In general, this is a tumor that usually spreads before it produces symptoms, so the odds of survival are less than even. For women who have many family members with breast and ovarian cancer, genetic testing can determine whether or not they have a gene that predisposes to this cancer (We have a videotape on this topic at our office).  Women who know they have this gene can take preventive measures.
Current treatment is surgical removal of as much tumor as possible, followed by chemotherapy with carboplatin and taxol. Even though relapse is common following this treatment, this does relieve symptoms and there are methods of treating relapse.

June 13th, 2003- C Porter, MD of Virginia Mason Clinic reviewed current diagnosis and treatment of prostate cancer. Although there is no clear evidence that men live longer as a result, screening for prostate cancer using a blood test called the PSA (prostate-specific antigen) does pick up prostate cancer about six years earlier than it would otherwise become apparent, at a time when it is more localized. The difficulty is that a moderately elevated PSA (between the high-normal value of 4 and 10) is not due to cancer about 80% of the time. And, the needle biopsies used to figure out which of these men actually have cancer are often inaccurate as well. Virginia-Mason clinic is pioneering a new computer-analyzed ultrasound that is more accurate for diagnosis.

June 6th, 2003- Edward Gibbons, MD, a cardiologist who also chairs the pharmacy and therapeutics committee at the Virginia Mason Clinic moderated a presentation on the role of the pharmaceutical companies in medicine. These companies spend in the range of $10,000 per year per physician to market their products.

• Half of this money goes towards providing physicians with samples of drugs.
• Money is used to sponsor physician education. Across the country, training programs that have trouble raising money will turn to drug companies for sponsorship. On the average, physicians in these programs get one free meal per month. One medical center analyzed pharmaceutical representives' presentations at these meals and found that 11% of the statements they made were inaccurate, that every inaccuracy was to the drug company's benefit, and that the training physicians picked up only a quarter of the inaccurate statements. Interestingly, the greater the level of pharmaceutical company support, the lower the pass rate of the trained physicians.
• Money is used to sponsor conferences and provide informational materials such as books.
• A great deal of money is used to sponsor research. Sometimes drug companies will sponsor research and prohibit publication if the study shows no benefit from their drugs. Research centers with more clout, such as Virginia Mason, retain more control over research they do, resist interference from the sponsoring drug company, and publish their findings no matter where the chips may fall.
• Published studies show that drug company marketing efforts do influence physicians to prescribe those drugs more, and influence physicians to lobby on behalf of those drugs.
• One academic medical center analyzed all pharmaceutical promotional material they received over a seven month period. Forty percent of this material did not meet FDA guidelines for fair representation.
• No physician can keep up with all the research that informs medical practice. When needed, we consult "clinical practice guidelines" which are compiled, supposedly, by the best and the brightest physicians in that area of medicine. Sixty percent of the authors of those guidelines received research support from the drug companies, and forty percent were consultants for or employees of drug companies! On average, the authors of those guidelines had contact with ten pharmaceutical company representatives.

May 23rd, 2003 - John Espinola, MD from the University of Washington at Harborview spoke at Virginia Mason Clinic about the Medicare program. He notes that the first state health insurance program was initiated by Otto Von Bismarck, Chancellor of Germany, in 1893. Bismarck set the retirement age at 65. The first US president to propose such a program was Teddy Roosevelt when he ran as a Progressive candidate in 1911 or so. When Medicare was instituted here in 1965, the tax increase was delayed so legislators could tell their constituents, "we didn't raise your taxes." (Sound familiar?) It was called an insurance program, and was packaged with a 7% increase in Social Security benefits, which made it hard for the opposing legislators to vote against it. As the legislation was about to go to vote, only hospital services were covered. The last weekend before the vote, proponents added part B, which pays for physician services, which ensured passage of the bill. No cost control was designed or contemplated. Long-term care, dental care, hearing aids, eyeglasses, and prescription drugs were not covered.

Medicare Part A (hospital coverage) is entirely funded from payroll taxes. People have the choice of paying a premium which covers 25% of the expense of Part B (physician services) coverage. The other 75% of the cost of Part B comes from general tax revenues. Some politicians are pushing to make Part B mandatory, making premium payment for part B coverage a universal requirement.

In the 1980's or so, Medicare added an HMO option, but the program was given 20% less funding and asked to provide more services. Not surprisingly, these programs are failing.

Despite what the politicians say, a prescription drug benefit would not primarily benefit the poor, most of whom obtain medication through the Medicaid program. It would apply equally to seniors of all income categories. The greatest proponents of a prescription drug benefit for seniors are the states, because they are going broke paying for Medicaid, and the drug companies.

Medicare pays physicians more to see patients in the office than they pay them to see patients in the hospital. (And where are the sickest, most time-consuming patients?) They pay both physcians and hospitals less than the cost of providing services. I repeat, they pay less than the cost of providing services. If you live in certain counties in Eastern Washington, you will not be able to find a single physician who will treat you under the Medicare program. In the state as a whole, 12% of physicians accept no Medicare patients at all.  Another 45% continue to take care of existing Medicare patients, but are taking no new ones.

Technology is one factor pushing Medicare costs up, from about $1000 per year per benefiiciary in 1965, to about $6000 per year currently (adjusted for inflation). A second factor is that there are more physicians and we are easier to access. So, in populous eastern cities costs are about double what they are in western counties where people have more difficulty getting to a doctor, yet there is no difference in how long people live or how healthy they are.

Dr Espinola sees no major political change until the programs are much more dysfunctional than they are now. He projects that reform will take this form.

1. Reduce the number of beneficiaries through means testing or raising the age of eligibility.
2. Reduce benefits.
3. Increase premiums and/or taxes.
4. Cover only services shown to be of benefit.
5. Find other sources of revenue.

May 9th, 2003 - Robert Wilburn, MD, works with the donor acquisition arm of the Virginia-Mason transplant center. You may recall that you have a chance to volunteer as an organ donor at the driver's license bureau. When a donor is located anywhere in Alaska, Washington, Idaho, or Montana, the program is ready on a 24/7 basis to start the complex process of donor evaluation. Surgical teams are always ready to travel anywhere in the region to harvest the organs. Once tissue typing and blood group typing is complete, a search is made nationwide for an exact match. In such a case, the organ will be transported to that individual, wherever they may live. Failing an exact match, a search is made in our region for the closest match. When you consider other factors that must be taken into account, such as the recipient's length of time on the waiting list, the recipient's availability and state of health, many decisions have to be made in a very short time. Dr Wilburn described this complex process with the immediacy of the experienced participant that he is. The drama of his presentation would have kept the interest of any nationwide prime-time television network audience.

Thomas Hefty, MD, described new "bandaid" surgical techniques used to harvest organs from living donors.

May 2nd, 2003 - Thomas Goodnight, MD of the University of California, discussed estrogen, cancer, and the drugs used to block estrogen's effects on the breast. The Women's Health Initiative showed that the common form of estrogen replacement, derived from pregnant mares, increased the risk of breast cancer when given along with synthetic progesterone. This left open the question of whether or not identical-to-human estrogen replacement could do the same. Dr Goodnight pointed out that women who have had their ovaries removed are less likely to develop breast cancer, which certainly points to increased risk even from the estrogen a woman makes on her own. He studies the effect of drugs (tamoxifen is one example) that block the effects of estrogen. Because different tissues respond differently to estrogen, drugs can be tailored to block the estrogenic stimulation to the breast (therefore reducing the risk of cancer), while allowing estrogen to strengthen the bones.

These are important facts. I would have been happier had he not lumped all forms of estrogen together. Humans make at least ten forms of estrogen, some of which are kinder and gentler than others. Women also have differing genetic patterns, which can alter their response to estrogen and their risk of breast cancer. These estrogen patterns and genetic markers can be measured, allowing prevention and treatment to be individualized.

April 25th, 2003- Gregg Fonarow MD from UCLA spoke at Virginia Mason Clinic about treatment of congestive heart failure. When the heart muscle loses strength, fluid builds up in the lungs. This reduces oxygenation of the blood, further reduces strength of the heart, and the vicious cycle leads to death within five years, half of the time. The hormonal signals involved in this process are better understood, and treatments have been improved. Current methods include beta-blockers such as metaprolol or carvedilol, angiotensin-converting-enzyme inhibitors, diuretics, and pacemaking techniques that synchronize contraction of the ventricles. These significantly improve survival.

Dr Fonarow did not discuss coenzyme Q10 and magnesium, both of which have been of major help in reducing symptoms in our patients, often after we have stabilized them with traditional pharmaceuticals. There are, in fact, a large number of other nutrients and herbs which have been shown to improve function and symptoms in people with congestive heart failure. The hormone testosterone strengthens muscles as every sports enthusiast knows. Testosterone is frequently low in people with congestive heart failure and, if low, should be replaced for full recovery.

April 18th, 2003 - Peter Lipsky, MD from the National Institutes of Health, spoke at Virginia Mason clinic about treatment of rheumatoid arthritis using agents that modify the immune response. These can help patients with rheumatoid arthritis in a dramatic way, but can also cause serious side-effects. For this reason, these agents are usually used mostly by rheumatologists (specialists in joint disease).  Long term benefits and safety are still unknown.

April 11th, 2003- George Triadafilopoulos, MD of Stanford University, spoke about Barrett's esopahagus. Sometimes reflux of stomach contents into the esophagus results not just in irritation and burning (heartburn) but also in changes in the structure of the tissues lining the esophagus, a condition called Barrett's esophagus. This condition increases the likelihood of esophageal cancer manyfold, although many people develop esophageal cancer without prior symptoms. For some time doctors have noticed that aspirin use cuts the risk of esophageal cancer in half.  Dr Triadafilopoulos and others have worked on the methods by which this occurs. He finds that the newer COX-2 inhibitors such as rofecoxib (Vioxx), and celecoxib (Celecoxib) have the same protective effect on the esophageal lining cells and should also lower the risk of esophageal cancer in patients with Barrett's esophagus.

April 4th, 2003 - James Moore, Ph D in physical medicine and rehabilitation at Virginia Mason, spoke about treatment of acute back pain and prevention of chronic back pain.   Most back pain is not due to infection, bony malformation, or other medical problems, but rather to muscular and ligamentous strain. In this case, our old advice to "take it easy" leads only to muscular weakness and a greater likelihood of chronic back pain. Usually the severe pain is much better after a couple of days. People who start activity early, even before the pain has resolved, usually heal faster. This is one illness where the stubborn person who relies on their own resources often does better than the person who depends too much on massage and other professional care.

March 28th, 2003 - Swedish Medical Center presented an all-day update on orthopedics for primary care physcians. We went through every joint of the body, from the bones of the neck to the feet. Of the many speakers, Phil Downer, MD, gave the most surprising talk, describing a newly recognized cause of hip pain called 'hip impingement.' Knowledge of this syndrome added to other techniques can help avoid the need for joint replacement surgery, a welcome idea to many people. Phil Mease, one of Seattle's leading rheumatologists, brought us up to date in the latest crop of anti-inflammatory drugs. They can be very useful when side-effects might be a problem, but most people will still want to use the old standbys, aspirin, ibuprofen, and naprosyn.

March 14th, 2003 - Jeffrey Carlin, MD, at Virginia-Mason Medical Center. His specialty of Rheumatology concerns itself with diseases of the muscles and joints. Some of these illnesses are called "connective tissue diseases" and affect other organ systems as well. He discussed various laboratory tests that can cast light on diagnosis of these illnesses. These tests may be falsely positive which means that they may indicate that you have a disease that you really don't. Alternatively, they can be falsely negative as well, telling you that you don't have an illness that you really have. The best diagnostic methods include your careful description of what you are experiencing, the physcian's examination, and then some careful thought. This category of illness, by the way, sometimes doesn't fit any pigeonhole perfectly.

March 7th, 2003- William DePaso, MD, at the Medical Director of the Virginia Mason Sleep Disorders Center, spoke about a common type of sleep disorder, obstructive sleep apnea. This is more common than most people realize. For example, about one in three persons with high blood pressure has obstructive sleep apnea. Treat their obstructive sleep apnea, and their blood pressure falls.
Of people with obstructive sleep apnea, about one quarter will not be sleepy during the day. People with obstructive sleep apnea have about three times the risk of severe heart disease as do those people without obstructive sleep apnea, as well as a much higher death rate. Treatment of obstructive sleep apnea reduces these risks. Though not everyone with obstructive sleep apnea has all these signs and symptons, sleep apnea is more likely in people who have 1) daytime sleepiness 2) snoring 3) neck size greater than 17 inches in men or 16 inches in women. 4) high blood pressure, congestive heart failure, or other heart disease 5) body mass index greater than 30.
Dr DePaso pointed out that cessation of breathing during sleep, with the resulting strong negative pressure as the person tries to get a breath, results in increased demands upon the heart coupled with decreased oxygen supply. This is truly a condition worth treating. Interestingly, some patients will improve with the use of a cardiac pacemaker. Other people require other measures.

February 28th, 2003- Neil MacIntyre, MD, of Duke Medical Center spoke at Virginia Mason about blood transfusion. He discussed the difficulties in maintaining the supply of blood for transfusion, of the complications of blood transfusion, and the physiology of transfused blood. Most importantly, he outlined in detail methods we can use to decrease the need for transfusions.

February 21st, 2003- Edward Gibbons, MD, at Virginia Mason discussed prevention of cardiovascular disease. Teresa McMahon, a pharmacist, noted in her presentation that weight loss had a more protective effect than did Metformin, a popular and effective antidiabetic drug.

February 6th, 2003- Carol Cahill, librarian, gave a workshop at Jefferson General Hospital on use of health information resources on the internet.

January 31st, 2003 -A Virginia-Mason physician discussed the various kinds of thyroid cancer.

January 13th, 2003 - Dr Michael Frederich, Director of the Hospice Program in San Diego, gave a three hour talk at Jefferson General Hospital about palliative care and care of the dying. In the United States, we treat illness aggressively until all hope is gone, then we consider hospice, palliative, or comfort care. In other parts of the world, the "comfort care" is offered from the beginning. Dr Frederich comprehensively reviewed medication for the treatment of pain, nausea, and other discomfort.

January 10th, 2003 - Dale McClure, MD, of Virginia Mason Clinic, gave a talk most of us older physicians listened to very carefully, a talk about andropause. With poetic license, you can translate this as "male menopause." While this is not a time when a man's periods stop, he does share a woman's risk of depression, osteoporosis, and sexual dysfunction. Tests can reveal the condition, and testosterone treatment is effective and safe when certain guidelines are followed. Treatment with testosterone can lessen the risk of heart disease and diabetes, and reduces the tendency of the blood to form clots.

3/29/05 ms L