Category Archives: General Health

Epidemic of Aggressive Care vis-a-vis Breast Cancer

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In many areas of medicine, the need for increased certainty of cure and diagnostic certainty leads to other problems; sometimes, “the perfect is the enemy of the good.” While this happens in pediatric gastroenterology, the frequency is probably greatest in oncology.  A recent terrific article in the NY Times by Peggy Orenstein highlights an epidemic of contralateral prophylactic mastectomy (CPM) in the care of patients with breast cancer.

Here are a couple of points and the link –Wrong Approach to Breast Cancer:

  • According to a study published in the Journal of Clinical Oncology in 2009, among those with ductal carcinoma in situ — a non-life-threatening, “stage 0” cancer — the rates of mastectomy with C.P.M. jumped 188 percent between 1998 and 2005. Among those with early-stage invasive disease, the rates went up 150 percent between 1998 and 2003. Most of these women did not carry a genetic mutation, like the actress Angelina Jolie, that predisposes them to the disease.
  • Overestimation of their actual chances of contracting a second cancer. In a 2013 study conducted by the Dana-Farber Cancer Institute in Boston, for instance, women under 40 with no increased genetic risk and disease in one breast believed that within five years, 10 out of 100 of them would develop it in the other; the actual risk is about 2 to 4 percent.
  • Underestimated the potential complications and side effects of C.P.M. Breasts don’t just screw off, like jar lids: Infections can occur, implants can break through the skin or rupture, tissue relocated from elsewhere in the body can fail. Even if all goes well, a reconstructed breast has little sensation. Mine looks swell, and is a remarkably close match to its natural counterpart, but from the inside it feels pretty much like a glued-on tennis ball.
  • The most comprehensive study yet, published earlier this month in the Journal of the National Cancer Institute, showed virtually no survival benefit from the procedure — less than 1 percent over 20 years.
  • How can that be? Well, first of all, it is extremely rare for a tumor on one side to spread to the other. Cancer doesn’t just leap from breast to breast.

Related blog post:

Facts, “Misfearing” and Women’s Health | gutsandgrowth

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

 

Medical School Student vs. Dr. Oz

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A recent link from Vox (highlight on KT Park’s twitter feed) highlights a medical student’s actions against Dr. Oz’s pseudoscience.

Here’s an excerpt:

Benjamin Mazer is a third-year medical student at the University of Rochester. Last year, after becoming increasingly concerned with the public-health impact of Dr. Mehmet Oz’s sometimes pseudoscience health advice, he decided to ask state and national medical associations to do something about it.

“Dr. Oz has something like 4-million viewers a day,” Mazer told Vox. “The average physician doesn’t see a million patients in their lifetime. That’s why organized medicine should be taking action.”…

We had all of this first-hand experience with patients who really liked his show and trusted him quite a bit. [Dr. Oz] would give advice that was really not great or it had no medical basis. It might sound harmless when you talk about things like herbal pills or supplements. But when the physicians’ advice conflicted with Oz, the patients would believe Oz….

I wrote policy for the Medical Society of the State of New York [where Dr. Oz is licensed] and the American Medical Association asking them to more actively address medical quackery on TV and in the media—specifically Dr. Oz.

Related blog posts:

How Soccer Can Be Bad for Your Health

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When people complain that “everything is bad for your health,” they just might be right.  After yesterday’s soccer match, the NEJM posted a link to a 2008 article (N Engl J Med 2008; 358:475-483).  Here’s part of the abstract:

Methods: Cardiovascular events occurring in patients in the greater Munich area were prospectively assessed by emergency physicians during the World Cup. We compared those events with events that occurred during the control period: May 1 to June 8 and July 10 to July 31, 2006, and May 1 to July 31 in 2003 and 2005.

Results: Acute cardiovascular events were assessed in 4279 patients. On days of matches involving the German team, the incidence of cardiac emergencies was 2.66 times that during the control period…On those days, the highest average incidence of events was observed during the first 2 hours after the beginning of each match.

Conclusions: Viewing a stressful soccer match more than doubles the risk of an acute cardiovascular event.

Take-home point: Some people are not lying when they say they live and die with their favorite team.

Pancreas Transplantation -Moving Personal Story

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A recent lengthy article describes the story of one man’s wait and ordeal after pancreas transplantation (due to diabetes).  This article, written as a first-person account by a Cincinnati reporter, provides a detailed view from the patient’s viewpoint of both medical aspects and the social/emotional aspects of undergoing a transplantation.

Here’s the link, from USA Today: John Faherty, “How an Organ Transplantation Changed My Life.”

Vaccine Safety -Put into Perspective

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For anyone concerned about vaccine safety, putting the risks into perspective may be helpful:

“The most dangerous aspect of giving your child vaccines is driving to the office to get them,” according to Paul Offit, chief of infectious disease at Children’s Hospital of Philadelphia, in Vaccine Safety Article from USA Today.

With regard to exemptions, a recent study has shown that private schools have higher vaccine exemption rates (4.25%) than public schools (1.91%) (J Pediatr 2014; 165: 129-33).  Using CDC data for 35 states (& district of Columbia), the authors noted that there were 48,931 exemptions in 2009-2010 with only 7146 for medical reasons.  For individual states, Hawaii had the highest private school exemption rate at 14.88% and Washington had the highest public school exemption rate at 6.08%.

The authors note that parents with “higher income and educational levels expressed more concerns about vaccine safety.”  However, they state that “parents who object to immunizations have been considered ‘free riders’ as they take advantage of the benefit created by children who assume any potential risk of adverse reactions.”

In a brief summary, Sarah Long, an infectious disease expert and associate editor of The Journal of Pediatrics, questions how these parents can be “so mistrustful of doctors…and yet so confident in their own musings? At the same time that they are attempting to advantage their children by attendant a private school, they are putting their children in harm’s way.”

Related blog posts:

ACA -A Report Card

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A recent succinct commentary describes the ~20 million people who gained coverage as a result of the Affordable Care Act/Obamacare; the exact number who were uninsured prior is not known.  While the article provides a clearer picture of this expansion, it also makes the point that there are many issues that need to be addressed including cost containment.  Other subjects:

  • Cancelled policies
  • Risk pools and premiums (lower than projected thus far)
  • Narrow Provider Networks
  • Crucial Younger Age Group Enrollment
  • Small Business and Mandate
  • Individual Marketplaces
  • State Marketplaces
  • Medicaid Expansion (limited in many states)

Here is the link –the entire report is worth a read: ACA -20 million Americans

Here is an excerpt:

Taking all existing coverage expansions together, we estimate that 20 million Americans have gained coverage as of May 1 under the ACA (Figure 3 Categories of Expanded Health Insurance Coverage under the Affordable Care Act (ACA).). We do not know yet exactly how many of these people were previously uninsured, but it seems certain that many were. Recent national surveys seem to confirm this presumption. The CBO projects that the law will decrease the number of uninsured people by 12 million this year and by 26 million by 2017. Early polling data from Gallup, RAND, and the Urban Institute indicate that the number of uninsured people may have already declined by 5 million to 9 million and that the proportion of U.S. adults lacking insurance has fallen from 18% in the third quarter of 2013 to 13.4% in May 2014.

However, these surveys may underestimate total gains, since some were fielded before the late March enrollment surge and do not include children. With continuing enrollment through individual marketplaces, Medicaid, and SHOP, the numbers of Americans gaining insurance for the first time — or insurance that is better in quality or more affordable than their previous policy — will total in the many tens of millions.

As we look to the future of the coverage provisions of the ACA and their effect on the U.S. health care system, several observations seem justified. First, as the number of individuals benefiting from the law grows, its wholesale repeal will grow less likely, although the law could still be importantly modified in the future.

Second, experience with the ACA will vary enormously among states. Those deciding not to expand Medicaid will benefit far less from the law, and since many of these states have high rates of uninsured residents and lower health status, the ACA may have the paradoxical effect of increasing disparities across regions, even as it reduces disparities between previously insured and uninsured Americans as a whole.17

Third, the sustainability of the coverage expansions will depend to a great extent on the ability to control the overall costs of care in the United States. Otherwise, premiums will become increasingly unaffordable for consumers, employers, and the federal government. Insurers who seek to control those costs through increasingly narrow provider networks across all U.S. insurance markets may ultimately leave Americans less satisfied with their health care. Developing and spreading innovative approaches to health care delivery that provide greater quality at lower cost is the next great challenge facing the nation.

Why Dr. Oz Has Not Lost His Medical License

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An interesting article from Vox (link from retweet by Eric Benchimol) provides insight on why Dr. Oz can make numerous false claims of ‘miracle’ cures and not lose his medical license.

Here’s an excerpt:

The fact that Oz hasn’t lost any credentials speaks to a larger challenge in modern medicine: Once you get a medical license, its actually really difficult to lose it.

“This has been a longstanding complaint with medicine and the professional regulation. You either need to have sex with patients who file a complaint, be a really bad substance-using person… or you’re malpractice-level bad as a doctor,” David Jones, professor of culture of medicine at Harvard University, says. “Nothing in Dr. Oz’s conduct is even close to getting the attention of the state boards because they are dealing with sex criminals, alcoholics, and gross misconduct.”

Ouch!

The article details why the American Medical Association, New York State Dept of Public Health, Columbia University, and the Federal Trade Commission are all unable to take action against Dr. Oz.

Related blog posts:

Here’s John Oliver’s takedown of Dr. Oz: Dr. Oz on Last Week Tonight 

An Inside Look at the VA: “Hidden Lists” and “Watershed Moment”

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Here’s a different view of the VA, from a practicing physician, and an excerpt:

“Nowhere else than at the VA have I felt as much that I was a part of something greater than myself. We “care for him who shall have borne the battle” in a system that, for all its woes, remains a singular presence in the confused patchwork of medical care that is American medicine. Enter the VA medical system and you know that your critical medical data are available to every provider at every VA hospital in the country in ways unimaginable in the private sector; you know that care delivered in the VA system often meets or exceeds the quality standards of the private sector.1You know, moreover, that you and the person sitting next to you in the waiting room will get the same level of care, because there is no mysterious and fickle insurer to reckon with at the end of the appointment.

I don’t know what happened in Phoenix or elsewhere, what those hidden lists hold, what grief lies there. I wish those reporting on this scandal would do more to separate issues of access to care from problems with the quality of care. I do know that, all around the country, physicians who trained at the VA or who have chosen to live out their medical career with the VA have their own hidden lists, their indelible memories of men and women who entrusted their care to us. Let us continue to work for them.”

A second article “Watershed Moment,” summarizes the current problems and what needs to be done.  Here’s an excerpt:

“Yet access to care, particularly to outpatient appointments, has been an enduring problem for the VA, as documented in multiple reports from the OIG and the Government Accountability Office (GAO)… A key reason was inconsistency in the recording and tracking of wait times according to the “desired date,” defined as the date by which a patient wants to be seen or a health care provider wants him or her to be seen.1 A preliminary VA audit showed that 13% of scheduling staff — at 64% of the 258 surveyed facilities — had been instructed to enter a different desired date than that requested by the veteran, though it remains unclear what proportion of these changes represents willful falsification.2

There is anecdotal evidence that scheduling issues led to adverse health outcomes for veterans in Phoenix and elsewhere; more systematic assessments are under way. However, there is precedent for concern, since a September 2013 OIG report concluded that delayed gastroenterology consultations for colon-cancer screening had led to delayed diagnoses for more than 50 veterans, some of whom ended up dying of colon cancer.3

Beyond access to care, health system performance should be evaluated on the basis of health outcomes, the quality and safety of the care delivered, patient satisfaction, and costs. In many of these domains, the VA has kept pace with or surpassed private-sector health systems

 

The VA is a historic institution with a long tradition of providing care to former military service members. In recent years, the agency has made progress in addressing a backlog of disability claims and in sharply reducing veterans’ homelessness. In the 1990s, VA health care, facing a similar crisis of confidence and bipartisan calls for privatization, was transformed into a more technologically advanced, decentralized, and quality-oriented system. Now it needs to protect the best elements of its infrastructure, built around longitudinal, holistic care of each veteran, while embarking on another round of reforms.“

 

“Do Unto Others”

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A recent article from NY Times discusses the topic of advance directives and how physicians are likely to choose a “no code” status for themselves rather than heroic measures if faced with a terminal illness.

Here’s a link:  What doctors would choose and an excerpt:

Young doctors… 88.3 percent would choose a do-not-resuscitate or “no code” status. An allow-me-to-die status, in other words.  “Doctors see a lot,” Dr. Periyakoil told me later that day. Resuscitation attempts are so aggressive — likely to break an older patient’s ribs but unlikely to restore them to their previous state of health or function —that after witnessing several, “you know too much and you’re much more wary,” she said.

Perhaps readers here remember a much-circulated web essay by Dr. Ken Murray, a retired family practitioner, called “How Doctors Die.” He claimed that his fellow physicians largely reject the sort of high-tech care they routinely dispense to their patients.

Take-home message: Physicians frequently provide high-intensity heroic measures to many of their patients which they usually would reject for themselves.  Even in pediatrics, frequently parents demand that “everything be done” when many physicians would advise otherwise.

When “All-Natural” Really Isn’t

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A recent tweet from David Kessler provided this link, fooddive.com/news/the-case-…, regarding all-natural products and recent spate of lawsuits:

Here’s an excerpt from “The case against ‘all-natural’:

But how “natural” is the “natural” label? It might be a bit more misleading than you think. The U.S. Food and Drug Administration admits it doesn’t even have a hard-and-fast definition on what the term means. The agency also doesn’t object to a product being labeled as such, so long as “the food does not contain added color, artificial flavors, or synthetic substances.”

However, some consumers just aren’t buying that “all-natural” claim, and there have already been many notable court cases to prove it. Here’s a roundup of five recent lawsuits forcing food producers to cough up cash and remove labels after products didn’t live up to their farm-to-store promise.

Five recent lawsuits -highlighted in article

  • Kashi
  • Nature Valley
  • PopChips
  • Naked Juice
  • Tropicana Orange Juice

In a related post, ClarkHoward.com discusses how labels are misleading:

Here’s the link: 5 Label Tricks

“Food labels like “organic,” “free range,” “all natural,” and “multigrain” don’t necessarily mean what you think.”  He provides specific advice to avoid buying a misleading product.