Douwe Rienstra, MD

Educational Activities

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

December 3, 2004 - William Lutin, MD from the Medical College of Georgia, discussed treatment of heart defects in infants and children. New technology is reducing mortality among these children greatly.

December 2, 2004 - Frederick Buckner, MD of the University of Washington, discussed methods used to develop and test drugs used for tropical diseases. The best drug currently available for African sleeping sickness kills 5% of the people it is used on. Since the disease is 100% fatal, the drug is in demand. In the past 25 years, only 13 drugs have been developed for treatment of tropical diseases, compared to about 1200 drugs overall. There is little profit in the third world, but development costs are still very high. In fact, development of antibiotics in the developed world is flagging as well, as drug companies realize that there is more profit in drugs taken long term (as for high cholesterol) than in antibiotics, which are taken for only a few days.

However, development does continue. Knowledge of the genetic make-up of the parasites that cause these diseases allows scientists to go through the huge libraries of chemical compounds and predict which ones are most likely to kill the parasite.

November 19, 2004 - Dan O'Connell, PhD, a clinical instructor at the University of Washington School of Medicine, discussed good communication with patients.

November 5, 2004 - Hugh Allan, MD and James Moore, MD of Virginia Mason Clinic, reviewed treatment of chronic pain.

October 29, 2004 - David Belfie, MD of Virginia Mason Clinic, reviewed the diagnosis and treatment of knee problems in athletes.

October 22, 2004 - Gregory Poland, MD of the Mayo Clinic presented his argument that all health care workers should have an influenza vaccinations each year. The reason is that sometimes a person can carry and transmit the influenza virus and have no symptoms. Some studies have shown that death rates are lowered in hospitals where the staff has a high rate of inmmunization against influenza, not just from influenza, but from all other illnesses as well.

October 14 to 16, 2004   - I gave a talk about reforming the medical malpractice system in the United States at the annual meeting of the Association of American Physicians and Surgeons. Arthur Robinson, PhD, reviewed his experience in medical research. He argued that federal reimbursement systems corrupt and stifle medical research. Greg Scandlen of the Galen Institute reviewed proposals for consumer driven health insurance. Laurence Marsteller, MD, discussed the problem of counterfeit drugs. For example, some criminals set up a company that sold wholesale drugs to Rite-Aide and other pharmacies. After some months providing good service, they sold millions of dollars worth of erythropoietin to Rite-Aide. (This hormone maintains normal blood counts in people with kidney failure.) After a bit of time, it became clear that the bottles of injectable drug contained only water. Calls to the vendor went unanswered, and investigators found that the company had entirely disappeared, leaving empty warehouses. This just a high-profile example from the United States. In Nigeria, up to 60% of drugs can be fake or adulterated, with lesser rates in other third world countries.

Other speakers addressed the relative merits and discontents of private and socialized medicine. One physician spoke who had been accused by the state of California of inappropriate prescribing of pain medications. He was imprisoned for a while as a result and addressed the meeting to help other pain specialistists avoid that outcome.

September 10, 20004- Jerry Molitor, MD of Virginia Mason Clinic ,reviewed methods to protect patient safety during clinical medical research.

June 11, 2004 - Drs O Lin and P Sicuro of Virginia Mason Clinic, discussed prevention and early detection of colon cancer, the third leading type of cancer in the US. Eighty percent of cases occur in people who have no risk factors. Risk factors include family history, previous colon polyp, inflammatory bowel disease, and the metabolic syndrome (weight gain, high blood pressure, abnormal cholesterol profile, elevated blood sugar). The standard recommendation is colonscopy, in which the colon can be examined and any pre-cancerous polyps removed. The risk of colon cancer is reduced by exercise

Colonoscopy misses 6% of polyps over 1 centimeter in size, and 20% of those under 5 millimeters. However, polyps less than a centimeter in size are only 1% likely to be cancerous.

He recommends screening for all people over the age of fifty, but notes that it is still unclear whether the procedure is cost-effective.

June 4, 2004 - Rob Moser, who works in the emergency response system here in Jefferson County, met with several of us from our office to review basic life support.

May 28, 2004 - Paul Fredlund, MD, the director of clinical research at a pharmaceutical development company, outlined contemporary methods of drug development.

May 13, 2004 - Janet Schlecte, MD of the University of Iowa Medical School, reviewed diseases of the pituitary gland. Of most interest was that certain adrenal tumors will shrink with medication, and even become dormant, which is a great improvement over the surgery commonly done some years ago.

May 7, 2004 - Frank Lewis, MD, Executive Director of the American Board of Surgery, was scheduled to speak about how organized medicine is losing touch with the American public. This promised to be an interesting talk, but he announced to his 7:30 a.m. audience that he had a more pressing topic on his mind. He discussed residency training of surgeons. (Medical training comprises four years of medical school, then three to twelve years of residency training to cement the practical skills.  The word "resident" survives from the days that these physicians lived in the hospital where they trained.  They still spend many nights in the training hospitals working or, when possible, sleeping. New rules are reducing the work hours for residents to 80 hours per week.  Many physicians believe such limits on working hours will produce less skilled physicians.)

Medical students now end up with debts of about $150,000. Since resident physicians make $7 to $10 per hour, the longer they spend in residency, the higher that debt rises. Any wonder that they charge so much for their services when finally they are able to start repaying their debts?   And even with that reward at the end of the ordeal, the number of medical students entering surgical training is falling, and has been for years.

Lewis points out that current training programs are not just too long, they are poorly organized and frequently fail to provide the education a surgeon needs.  The result is that about 30% of physicians will fail their first attempt at passing their examinations for certification by the American Board of Surgery.

Lewis proposes to shorten the length of training by trimming unnecessary years from the programs, and to improve the teaching methods. He notes that virtual reality techniques have been shown to produce much better surgeons in a more rapid fashion, and should be widely used in surgical training. He proposes testing students frequently through their training, rather than only at the end.

Atul Gawande in his book "Complications" describes a clinic which outperforms the top medical centers at doing hernia surgeries. The surgery is less expensive. The patients return to work more quickly, have fewer complications and operative failures. Most of the surgeons have not completed residency training, but have completed a one year intensive course at the clinic, in which they gain more experience at their one specialty, hernia repair, than would be possible in any medical center. Gawande suggests that we use this technique for other medical procedures as well.

As Dr Lewis concluded "We have gotten a lot of mileage out of a surgical training system developed in the late 1800's. It is time to change."

April 22, 2004 - Thomas Gallagher, MD of the University of Washington, spoke about disclosing medical errors to patients. Surveys show that 40% of physicians have lost sleep because of worry over errors they have made, but many are reluctant to tell the patient about the error. Although some patients consider an adverse drug reaction, an excessively long wait, or poor bedside manner to be a medical error, he defines a medical error as failure to execute a procedure as planned (say, leaving a surgical tool inside the patient), or failing to follow proper protocol in diagnosis or treatment (say, failing to identify diabetes from an elevated blood sugar).

Most physicians (as well as patients) consider a medical error to be a moral failing. Gallagher thinks medical care is better when no moral blame is made, but only causal blame. For example, anethesiology apparatus used to have a round knob on every tank of gas, be it oxygen or an anesthetic agent. Sometimes the anesthetist or anesthesiologist would give the wrong combination of gases and harm the patient. Some years ago, the knobs were changed, so that shape of the knob was different for each gas. The critical oxygen valve was designed never to turn off.  Anesthesia death rates fell dramatically. By turning attention from the perceived shortcomings of those making the errors, towards what could be changed in the system, many lives were saved.

Gallagher prefers to think of error analysis and disclosure as quality improvement. He notes that given the trust that people must place in their physicians, that physicians have an absolute obligation to their patients to disclose errors that they make, and to take positive steps to prevent such errors in the future.

April 23, 2004 - David Patterson, MD and Drew Schembre, MD at Virginia Mason, discussed inflammatory bowel disease, which includes Crohn's disease and ulcerative colitis. The main treatment for flares of illness is sulfasalazine; newer forms of sulfasalazine have a lower incidence of side-effects but are no more effective. The speakers mentioned some non-traditional treatments including probiotics and diet only to condemn them. I disagree, for while they are not uniformly effective some people benefit greatly. Most effective is Saccharomyces boulardii, a nutritional yeast often helpful for people with Crohn's disease. Finally, they did not discuss antibiotic treatment for Crohn's disease; several published studies have found this effective, and this has been our experience as well.

As I listened to this talk, I recalled a man who consulted me years ago with such severe ulcerative colitis that he weighed about 110 pounds. His gastroenterologist at Virginia Mason had been recommending removal of his colon for many years, which this gentleman resolutely refused. He wanted me to try every possible alternative treatment so he could get over his illness and back to a normal life. We did try every such treatment, treatments I had seen succeed in previous patients. For him, however, each one failed.

At the end I told him he had no other choice, that he should return to Virginia Mason and have his colon removed. So he did, and he did well in surgery. I think this was in part because he now had no second thoughts, and was convinced surgery was his best and only course of action. The surgeon was able to maintain normal elimination through the anus and avoid a bag on the abdomen.

In any endeavor, we often do not succeed on our first try. In this talk Drs Patterson and Schembre listed their protocol of what they do first, what they do if that fails, and so on. By eliminating non-pharmaceutical, natural, and nutritional remedies with the lame excuse that they don't always work or that no one has poured millions of dollars into researching and promoting them, these physicians follow an all-too-common pattern. And by closing their eyes to potentially useful therapies, they lose the trust of their patients as they did with the man who consulted me.

April 16, 2004 - Paul Mystkowski, MD of Virginia Mason Medical Center, discussed the adrenal gland, which makes cortisol, adrenaline, DHEA, and aldosterone (a hormone thta regulates salt balance and blood pressure). He addresses cortisol in detail, deficiency of which can produce subtle symptoms. We perform adrenal testing in our office and, while familiar with treatment of this condition, did learn some useful wrinkles from Dr Mystkowski's talk.

April 9th, 2004 - Drs Kathryn McGonigle and Christina Isacson of the Virginia Mason Clinic, reviewed newer techniques of screening for cancer of the cervic. Or, in plain English, the Pap smear. Pap smear technology is now more expensive on a per-test basis, but is more accurate at detecting cervical cancer and cancer risk. So, women with normal pap smears can be screened less frequently, and women with abnormal pap smears can be evaluated in a less expensive fashion. We have been using the new pap smear technology (called the "thin-prep") for several years. This new technique includes testing for high-risk forms of human papilloma virus, or HPV, which are part of the cause of cervical cancer.

March 11th, 2004 - Gary Firestein, MD of UCLA, spoke at the University of Washington about rheumatoid arthritis.  He notes that bone changes from this illness have been found in ancient skeletons in the Americas, but not in Europe. In fact, rheumatoid arthritis did not appear in Europe until the 1600's. The significance of this clue is still unknown, as work progresses on the ultimate cause of this terrible illness.

February 26th, 2004 - David Schwartz, MD from Duke University, studies the genes associated with certain lung diseases. Environmental factors interact with our genetic makeup to produce disease. Schwartz and other workers are identifying those genes and their varient forms and working to see why some people with those genes become ill when exposed to an environmental stimulus, and others with the same genetic makeup do not become ill.

February 20th, 2004 - Jan Hillson, MD is a rheumatologist at Virginia Mason Clinic. Rheumatologists concern themselves with arthritis, and so are familiar with the many types of inflammatory diseases that may or may not affect the joints. The inflammatory process often is initiated and maintained by a substance called tumor necrosis factor. Drugs such as infliximab can greatly improve these inflammatory processes, but sometimes can have devastating side effects. She discussed the evolving uses of these drugs.

February 19th, 2004 - Douglas Paauw, MD of the University of Washington, outlined new information about drug interaction. For example, celecoxib (Celebrex), contains a sulfa group and can cause a severe allergic reaction in people allergic to sulfa drugs. Another example is Saint John's Wort, which can be helpful for depression but interacts with many prescription drugs. Then there is the story of grapefruit juice, which slows the metabolism of a number of drugs including the statin agents which people take to lower cholesterol. So, for some drugs, this can be dangerous; in the case of the statin drugs, the grapefruit juice can allow the patient to take a lower and less expensive dose of the statin.

The most important points are that pharmaceuticals can interact with each other and with over-the-counter supplements. You can reduce the risk by telling your physician about all the supplements you may be taking, and by always filling your prescriptions at the same pharmacy, whose computer should then be able to detect potential drug interactions.

February 13th, 2004 - Daniel Paull, MD, cardiac surgeon at the Virginia Mason Clinic, discussed surgery on the beating heart. For several decades, many cardiac procedures, such as coronary artery bypass, have been performed on hearts that are stopped while the patient's life is maintained by a heart-lung machine. Actually, cardiac surgery pioneers did not have the technology to stop and restart the heart, and so all procedures were performed while the heart continued to beat. The history is fascinating. For example, a physician in training at the Boston Children's Hospital in the 1930's wanted to repair a congenital heart defect in two children. This had never been tried before and his boss forbade him. The boss went on vacation, the physician did the surgery, the chidren improved dramatically, and the boss came back and fired him. The physician went on to become an outstanding innovator in cardiac surgery.

Today techniques are being developed to do coronary bypass surgery while the heart continues to beat in order to avoid the complications and risks of the heart-lung machine. Suction devices hold parts of the heart still, and new instruments and devices allow for coronary arteries to be repaired while the heart continues to function. Miracles, in heart surgery as in life, are made up of small parts, each one difficult but do-able.

February 6th, 2004 - Kathleen Neuzil, MD and Janet Englund, MD of the University of Washington, spoke at Virginia Mason Clinic about epidemic influenza. The influenza epidemic of 1918 killed more people than the First World War. This could happen again. The best defense is surveillance of poultry in Asia, and immunization.

February 5th, 2004 - William Young, MD of the Mayo Clinic, spoke at the University of Washington on the hormonal causes of hypertension. That is, high blood pressure can be the result of tumors in the pituitary gland (cushings syndrome and acromegaly), the adrenal gland (pheochromocytoma and aldosterone-secreting tumor) and so forth. These types of hypertension repond much better to surgery than they do to medication.

February 2nd, 2004- Dr Jak Nikomborirak gave an overview of sleep disorders, then focused on sleep apnea. Althouogh a sleep study costs $2000, many times he will give a patient a trial of treatment without it. This is often successful and saves the cash-paying patient a good deal of expense. I had an opportunity at this presentation to experience using the new generation of respirator and was impressed with the comfort of the mask and the ease of using the machine.

January 29th to 31st, 2004 - The Tacoma College of Medical Education sponsored an update on general treatment and prevention topics at Whistler, BC. The first speaker, Timothy Schubert, MD, pointed out that screening for colon cancer prevented more mortality per dollar spent than many other prevention strategies. He did not address adequately, in my opinion, the importance of folic acid. Folic acid and other nutrients can, over time, reduce the risk of colon cancer by up to 50%. As well, newer laboratory tests can detect colon cancer in many, but not all people.

Richard Schneider, MD, gave one of the best presentations I have heard on the diagnosis and treatment of mood disorders. Mood disorders include anxiety, depression, and bipolar disorder. There are three elements of our mood. One is our background mood - are we generally happy, sad, or what? Second is our "trip-wire" for unpleasant emotionss - do we become depressed with some minor set-back, or does it take a major disaster? Third is the "volume control" - when the "wire is tripped", how bad do we feel? Do we experience a minor case of the blues, or do we commit suicide? People with an anger-management problem are having trouble with this "volume control."

Because we all have variations in our neurochemistry, one antidepressant may work better for one person than another. I have been using a system from a Virginia Mason psychiatrist to help me choose the most effective drug for each person based on their symptoms. Dr Schneider presented an elegant scheme based on neurochemistry to choose the best drug to try next, without wasting time on drugs that are unlikely to work when the first one didn't.

Bruce Snell, physical therapist, discussed prevention of anterior cruciate ligament (ACL) tears. Female athletes tear their ACL up to eight times more frequently than males. This is because they usually plant their feet and bend the knee in a slightly different way. Training can change these habits. A pilot study looked at girls competing in over 100,000 games of soccer, and found that those girls who had training to improve their knee mechanics had only 10% of the ACL tears of a control group in the first year of the study, and only 25% the tear rate in the second year.

Rod Graf, MD, pointed out that the current obesity epidemic is leading to an avalanche of new cases of type 2 diabetes (DM2). (As opposed to type 1 diabetes, which usually starts in childhood, requires insulin always, and is due to destruction of the insulin-producing tissue in the pancreas in children with a particular nutritional and genetic makeup.) Given the current situation, a child born today has about a one in three chance of developing diabetes in his or her lifetime. That means that the child faces a one in three chance of developing the complications of diabetes as well, which include heart disease (including sudden cardiac death), kidney failure, blindness, impotence and infertility, amputation, painful feet, and others.

Can the development of DM2 be prevented? Yes, a 2002 study showed that vigorous attention to diet and exercise delays the onset of DM2 even better than the best available pharmacologic agent, metformin. Statin drugs can reduce the frequency of heart disease dramatically. Aggressive treatment of high blood pressure also reduces the risk of cardiac disease.

Suzanne Meyer, MS, RD, from Bastyre University gave an overview of her favorite nutrition strategies, strategies that I think all our patients become familiar with.

David Heller, MD, a radiologist gave an intensive tutorial on CT colonograpy, a procedure also called "virtual colonoscopy." He disagrees with this term, because the word colonoscopy means to visualize the colon. As practiced, the operator has also the option to biopsy and remove certain lesions, and can determine other illnesses by seeing the color, texture, and pattern of the mucosal lining of the colon. "Virtual colonoscopy" provides none of these things, and is better described as CT colonography, meaning to produce a picture by means of Xrays.

To condense his talk, the radiation required to provide optimal images is about two/fifths of the maximum allowable annual exposure allowed in industrial workers, and is equivalent to about 40 chest Xrays. To obtain the best study, a patient still has to put up with a fair amount of pain with laxatives prior to the procedure, with painful inflation of the colon with air, and with some pain after the procedure. Dr Heller reported that he had undergone both colonoscopy and CT colonography and thinks that the former is less distressing.

Finally, MRI colonography is coming down the pike, offering much better images with no radiation exposure.

In any case, as per the first talk, attention to prevention and early detection of colon cancer can save your life.

Janes Cook, MD, a cardiologist, discussed prevention of heart disease, hitting all the current notes of obesity, high cholesterol, and high blood pressure, discussing details of treatment as applicable to different kinds of people.

January 25th, 2004 - Jeffrey Bland, PhD gave a talk on nutritional methods of influencing genetic disorders. Bottom line, many conditions such as heart disease, arthritis, cancer, and hormonal disturbances occur because our genetic makeup fares poorly in our particular environment. Genetic tests to help detect this kind of predisposition are becoming more cost-effective. Once identified, you can take steps to prevent or ameliorate these and other disorders.

January 23rd, 2004 - Members of the Stroke Team at Virginia Mason Clinic made several important points. I'll spare you the details, as the techniques are developing rapidly. The summary is that if you can reach a major stroke center within a couple of hours, and they know you are coming, then you may qualify for rapid diagnostic procedures that can lead to early interventions that lessen the risk of death and disability.
To save you the need for their services, let me suggest fresh fruit and vegetables daily, fish consumption and exercise several times a week, and antioxidants. In addition, be sure you maintain a normal blood pressure, weight, and that you avoid significant elevations of cholesterol.

January 21st, 2004 - Richard Thirlby, MD of Virginia Mason Clinic, described his experience as a surgeon treating obesity. Over fifteen years ago he began performing gastric reduction surgery at a time when the procedure was still new. He finds that the roux-en-Y gastric bypass is most effective. Most surgeons limit this surgery to people with a Body Mass Index (BMI) over 40, or BMI greater than 35 if the person has two or more conditions that should improve with weight loss, such as diabetes or high blood pressure. He has seen diabetes resolve in many patients within days of this surgery. Currently over 99% of his patients survive this surgery, compared to the national average of over 95%. On the average, people lose weight rapidly after surgery, then stabilize at about 130% of their ideal body weight. So far, he has been tracking these patients about ten yeaars, and their weight tends to remain stable.

Marc Sobrino, MD in Port Townsend has trained with Dr Thirlby and will be doing this surgery here at Jefferson General Hospital.

January 16th, 2004 - Fred Govier, MD of Virginia Mason Clinic, spoke about erectile dysfunction, its causes and treatment. There are several causes and treatments, but most of his talk was on sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra). Users of these drugs have a lower heart attack rate than placebo users. Tadalafil has a longer duration of action. Sildenafil will not work as well when taken with a fatty meal. All cost about the same.

January 15th, 2004 - Alan Chait, MD of the University of Washington, discussed C-reactive protein and its role in heart disease. Blood tests for C-reactive protein can give a more accurate estimate of heart disease risk than do other tests.  We provide this test.

January 9th, 2004 - Linda Mihalov, MD from Virginia Mason Clinic, discussed the Women's Health Initiative Study on hormone replacement in women. She covered some of the points we have addressed in our newsletters on this subject. She mentioned black cohosh and said, "it may be beneficial, but there are no long term studies on safety." Of vitamin E, she said, "the studies are all small, the dose is 800 milligrams, and the studies conflict as to whether it is helpful or not. Watch out for bleeding with vitamin E, especially if low in vitamin K." She stated, "I will not address natural hormones as there is little research on long term safety." She discussed raloxifene, bisphosponates, selective-serotonin re-uptake inhibitors, and numerous forms of synthetic estrogen and progesterone.

My comments: black cohosh is very helpful for many women, and much less likely to cause long-term problems than a synthetic agent. Vitamin E is more effective for menopausal symptoms at a dose of 1400 units a day. It may help, may not, and is very unlikely to cause bleeding.

Regarding natural hormones, it is very nice to be concerned with long-term effects of natural estrogen and progesterone, but there is no reason to believe that anyone will step forward to spend millions of dollars to study this. For many years there has been evidence that estrogen from mares has an unusually stimalating effect on the human breast. And the Women's Health Initiative Study showed that indeed, this form of estrogen conbined with synthetic progesterone did increase the risk of breast cancer. So, what do you choose, something we suspected was bad and has been shown to be so? Or something we have reason to believe is more benign?

Women who have their ovaries removed in their thirties have less breast cancer. This leads to two conclusions.

1. Even a woman's own hormones can lead to breast cancer; come to the office and see our videotape on female hormones to see why, and learn what you can do to lessen that risk.
2. Woman should take estrogen only if no other treatment is effective for their menopausal symptoms, osteoporosis, or other problem. The most useful fact I learned is that oral estradiol may have to be given twice a day for optimal effect.

January 8th, 2004 - Doug Merrill, MD from Virginia Mason Clinic, spoke on the physiology and treatment of chronic pain. I learned a new benefit of tylenol and the new COX-2 inhibitors, which is that they cross the blood brain barrier and provided benefits that aspirin, Advil, Aleve, etc. do not. Specifically, COX-2 inhibitors and tylenol calm receptors for pain in the brain that cannot be reachced by ordinary NSAIDs.

Dr Merrill noted that nerve stimulators can now be implanted in the spinal column to relieve chronic lumbar pain and diabetic neuropathy.

People who have real pain and take pain medication do not get addicted.