Letters to the Editor
Use of Breakfast Cereals for Constipation in Elderly Persons
TO THE EDITOR: Sometimes a trip to the grocery store can be very informative. Because constipation is a prevalent problem in elderly persons and insoluble fiber is an important treatment, an examination of fiber-containing breakfast cereals is enlightening. Deciding which breakfast cereal to use in the treatment of constipation can be difficult considering the names of cereals, such as 100% Bran, All-Bran and Complete Wheat Bran. The fine print on the box reveals that 100% Bran contains only 7 g of insoluble fiber per 29 g serving--a disappointing 24.1 percent insoluble fiber for a product that claims to be 100 percent bran.
Several other breakfast cereals contain nearly double the amount of fiber that is found in 100% Bran (see the accompanying table).
PAUL C. CREELMAN, M.D.
712 South Burlington Blvd.
Burlington, Washington 98233
Common Breakfast Cereals Suggested for High Fiber Content
Cereal
Total fiber per serving (g)
Insoluble fiber (%)
Serving size (g)
Serving (volume)
Insoluble fiber (g)
Fiber One, General Mills 13 40.0 30 1/2 cup 12 All-Bran, Kellogg's 10 29.0 31 1/2 cup 9 100% Bran, Post 8 24.1 29 1/3 cup 7 Bran Flakes, Post 5 <=13.3 30 3/4 cup 4 Raisin Bran, Kellogg's 8 <=13.1 61 1 cup * Complete Wheat Bran, Kellogg's 5 13.8 29 3/4 cup 4 Shredded Wheat, Post 5 10.9 46 2 biscuits 5 Grape-nuts, Post 5 <=8.6 58 1/2 cup *
* --Not itemized on box.
Increased Incidence of Prostate Cancer in Black Patients
TO THE EDITOR: I read with great interest Dr. LeFevre's article, "Prostate Cancer Screening: More Harm Than Good?"1 in the August 1998 issue of American Family Physician. Dr. LeFevre provided a great overview of the general principles of prostate cancer screening. He pointed out that the tests currently available for prostate cancer screening do not meet the criteria to justify mass screening because the data suggest that screening often detects what may be indolent, nonaggressive prostate cancer. The data also suggest that the treatment of such a cancer with radiation or prostatectomy could result in significant morbidity without a proven decrease in mortality.
Unfortunately, Dr. LeFevre neglected the data that black men and white men do not have equal stage-specific rates of survival when adjusted death rate ratios are computed.2 Compared with whites, blacks have a poorer rate of prostate cancer survival.3 This finding is most consistent with the hypothesis of increased tumor virulence in blacks.2
Blacks have higher incidence rates for prostate cancer than do whites at every age-specific interval.4 Although the rate of mortality related to prostate cancer has decreased in both whites and blacks, it is much higher in blacks than in whites among younger age groups, when the prevalence of prostate cancer is relatively low. As a result, fewer blacks with prostate cancer survive to older ages.4
Over the past decade, blacks have shown a decline in tumor cells burden at the time of diagnosis as reflected by a decline in the mean levels of prostate-specific antigen.5 Current diagnostic trends toward the persistent, increased detection of localized prostate carcinoma in younger men, combined with a marked reduction in the distant stage disease, suggest significant potential reductions in mortality.6 These trends have much greater implications for blacks.
More research and continued prostate cancer screening are needed, with a special emphasis on risk groups for whom current screening tests would have a significant yield.
GARRY B. BOWDEN, M.D.
2300 W. Park Place Blvd.
Ste. 122
Stone Mountain, GA 30087REFERENCES
- LeFevre M. Prostate cancer screening: more harm than good? Am Fam Physician 1998;58:432-8.
- Robbins AS, Whittemore AS, Van Den Eeden SK. Race, prostate cancer survival, and membership in a large health maintenance organization. J Natl Cancer Inst 1998;90:986-90.
- Boring CC, Squires TS, Tong T. Cancer statistics, 1993. CA Cancer J Clin 1993;43:7-26.
- Merrill RM, Weed DL, Feuer EJ. The lifetime risk of developing prostate cancer in white and black men. Cancer Epidemiol Biomarkers Prev 1997;6:763-8.
- Vijayakumar S, Vaida F, Weichselbaum R, Hellman S. Race and the Will Rogers phenomenon in prostate cancer. Cancer J Sci Am 1998;4:27-34.
- Littrup PJ. Future benefits and cost-effectiveness of prostate carcinoma screening. American Cancer Society. Cancer 1997;80:1864-70.
IN REPLY: Dr. Bowden accurately highlights racial differences in prostate cancer incidence and mortality. Indeed, the screening study cited in my article1 demonstrated a higher incidence of prostate cancer in black men than in white men, as well as a greater likelihood for distant spread at the time of diagnosis. I agree with Dr. Bowden's statement that the literature is consistent with the hypothesis of increased tumor virulence in blacks.
What are the implications of these data for prostate cancer screening? Blacks stand to gain more than whites from an effective screening program that truly detects aggressive disease at a stage in which curative therapy is possible and with treatment that does not have a significant probability of morbidity and mortality. To the extent that treatment does cause morbidity and mortality, and screening detects disease for which therapy does not significantly alter the natural history, then blacks also have more to lose than whites. I don't find a decline in PSA levels at the time of diagnosis to be compelling evidence of the efficacy of screening.
Ongoing randomized trials of screening and treatment for prostate cancer will provide important data; it is imperative that we be able to stratify by race in such studies, given the discrepancies noted by Dr. Bowden. Without significant changes in treatment, a dramatic drop in death rates from prostate cancer in the United States would also be highly suggestive evidence that screening is effective. Similar data ultimately demonstrated the efficacy of Papanicolaou smear screening in the prevention of deaths related to cervical cancer. Unfortunately, it is likely that meaningful answers regarding prostate cancer screening are five to 10 years away. Until then, an honest portrayal of the limitations of existing information is necessary for truly informed choice.
MICHAEL LEFEVRE, M.D., M.S.P.H.
Department of Family and Community Medicine
University of Missouri-Columbia
MA303 Health Sciences Center
Columbia, MO 65212REFERENCE
- Smith DS, Bullock AD, Catalona WJ, Herschman JD. Racial differences in a prostate cancer screening study. J Urol 1996;156:1366-9.
The Hospitalist Debate
TO THE EDITOR: I am writing with regard to the editorials on hospitalists that recently appeared in American Family Physician.1,2 While I found Dr. Bagley's editorial1 to be a good discussion of the many issues involved, I was offended by Dr. Brown's editorial.2
I am a family physician who provides only outpatient care. I have been in this practice setting for 5 years. Before that, I provided full-spectrum family medicine care, including intensive care, obstetrics and residency teaching.
I agree with Dr. Bagley that the use of hospitalists should be a choice. Family practice is a specialty in which many different practice settings exist, and we should all be supportive of each other. Family physicians should not be limited by privilege requirements that are set by subspecialties, but neither should we impose on each other the idea of an "appropriate" practice setting. We are all family physicians whether we practice obstetrics or not, perform only outpatient care, work in urgent care, or have a more traditional practice.
Dr. Brown implies that a doctor who provides only outpatient care is not being a "good" doctor. I disagree wholeheartedly. Many physicians, myself included, have realized that to be good physicians, they must be happy with themselves. Many family physicians find that if they spend all of their time on medicine, they "burn out" and can no longer provide good care. Many of us who do not work in hospitals provide excellent care because we limit our practices.
In summary, this is an important time for family practice. We should not criticize each other for the type of practice we choose. Rather, we should stand together to be sure we can all have the types of practices we want.
SONI ANDREINI, M.D.
Arnold Family Medical Center
P.O. Box 67
Arnold, CA 95223REFERENCES
- Bagley B. Hospitalists and the family physician [Editorial]. Am Fam Physician 1998;58:336-9.
- Brown RG. Hospitalist concept: another dangerous trend [Editorial]. Am Fam Physician 1998;58:339-42.
TO THE EDITOR: In his editorial on the hospitalist trend,1 Dr. Brown ignores the sobering statistics on physician suicide, divorce and substance abuse. Another observer might just as easily conclude that the trend represents a well-intentioned effort to repair a seriously flawed system of medical training and care.
One of the appeals of family practice is that it is a field broad enough to accommodate myriad different interests and practice styles. It is difficult enough to contend with our subspecialist colleagues, against whom we all too often must defend our right to perform certain procedures. Now we have to defend ourselves against colleagues in our own field who want to force us into roles we don't choose.
If a particular family physician provides hospital services, obstetric services, cardiac stress testing, colposcopy, upper and lower endoscopy and nasolaryngoscopy in addition to his or her usual office-based service, the continuity of the patient's care is certainly enhanced, but I disagree that this then entitles him or her to criticize colleagues who choose not to provide one or more of these services.
SCOTT A. MURKIN, M.D.
197B NC Hwy 42N
Asheboro, NC 27203REFERENCE
- Brown RG. Hospitalist concept: another dangerous trend [Editorial]. Am Fam Physician 1998;58:339-42.
IN REPLY: Clearly the use of hospitalists will remain a choice, and I did not argue against that. I did, however, intend to warn family physicians about what to expect if too many of us choose not to see patients in hospitals, emergency rooms, nursing homes or anywhere else besides our offices. We should expect resentment from our patients and their families. Our specialty has been sold to them as one of comprehensive and continuous care. If too many of us opt out of that commitment, what can we expect other than patients who feel betrayed?
I did not say that doctors who practice only in an office are bad doctors. But, I do believe that they will not be as good as they might be if they had remained active in a hospital setting. In his own editorial, Dr. Bagley stated that "skill in caring for sick hospital patients . . . allows for better treatment of those patients who are not as ill."1 Clearly, if we choose not to practice in a hospital, our skill in that arena, and thus our skill in general, will wane quickly.
I also did not say anything about family physicians performing any sorts of procedures--stress testing, colposcopy, endoscopy and the like. Of course these are matters of personal interest, competence and motivation. Whether or not family physicians perform a particular procedure is a different issue from their willingness to remain involved in the care of a long-time patient who is admitted to a hospital or a nursing home.
My greatest disappointment is that the move toward "hospitalists" is based on the market and/or convenience rather than on our patients. Again, Dr. Bagley acknowledges "that the optimal care for hospitalized patients should be accomplished by a skilled family physician who knows the patient and the family." He adds, "When this is not possible . . ."1 Well when, exactly, is this not possible?
I suppose that in answering this question, every family physician must take stock of his or her own principles and commitment to our profession. I want family physicians to be good mothers and fathers, good husbands and wives. No family should suffer because of a physician/parent's "devotion to medicine." We deserve time to maintain our closest friendships and to sustain a hobby or two. Few of us have the devotion of an Albert Schweitzer, who inscribed on the light outside his jungle hospital, "Here, at whatever hour you come, you will find light and help and human kindness." But, most of us can set the bar a little higher than we have it now, and we can do it without compromising the things outside of medicine that make us whole. How high should we set it? Perhaps the most practical guideline was set forth by a physician from a generation past, Dr. Robert Loeb: "The patient should be managed the way the doctor or a member of his family would wish to be treated if he were that patient in that bed at that time."2
ROBERT G. BROWN, M.D.
McLennan County Medical Education and Research Foundation
1600 Providence Dr.
P.O. Box 3276
Waco, TX 76707REFERENCES
- Bagley B. Hospitalists and the family physician [Editorial]. Am Fam Physician 1998;58:336-9.
- Seegal D. JAMA 1961;177:641.
Corrections
The January 15, 1999, cover article "Flexible Sigmoidoscopy: Screening for Colorectal Cancer" (page 313) contained a number of errors in the figure layout. Because of an editorial error, 10 figure captions were each accompanied by two photographs. Each caption, however, applied to only one photograph. The entire article is reprinted with corrected photographs in the printed version of this issue (page 1537). The original online version of the article has been corrected as well.
The article "Practical Management of Treatment-Resistant Depression" (December 1998, page 2059) contained an incorrect dosage. The dosage range suggested for the thyroid hormone tri-iodothyronine (T3 [Cytomel]), given in the first complete paragraph of the second column on page 2061, should be 25 to 50 µg.
Send letters to Jay Siwek, M.D., Editor, American Family Physician, 8880 Ward Pkwy., Kansas City, MO 64114; fax: 816-333-0303; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.
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