Sunday, May 29, 2011

Medical Myths Exposed: Do We Want Truth or Zeus?

We have had many family conversations about education reform over the years. Whistleblower readers have seen some of this creeping through some prior posts. It’s an issue that affects every American and deserves the efforts of our most talented and innovative thinkers to elevate the system to a higher orbit.

One of the mantras of traditional reformers is that smaller classes for students are optimal. Indeed, local school boards and teachers’ unions often warn of expanding or exploding class sizes if requested levies are not passed. They know that we parents believe that class size varies inversely with the quality of education. Ask parents if they would prefer a class of 20 or a class of 30 students for their youngsters and all will opt for the former.

Are smaller classes really better, or do we just believe they are because our intuition instructs us that it is? Is something true because it seems self-evident to us?

I found recent New York Times article on this issue very enlightening. There are education experts who are not convinced that larger classes compromise educational quality. Are they right? I can’t say, but I’m happy to see that not everyone is drinking the Kool Aide. Assumptions are not data.

The medical profession is permeated by myths that we physicians and the public believe to be true, but may not be, or have not been rigorously tested. Practices and procedures that are done routinely and repeatedly are considered to be standard medical practice. In other words, evidence is not needed.

Consider the following medical procedures and offer a view if they are sound practices or medical myths.

  • Lowering your cholesterol level will have a significant impact on your risk of developing heart disease or stroke.
  • Influenza vaccine is a highly effective vaccine and should be administered yearly to all eligible individuals.
  • It is important for physicians to check patients’ reflexes during physical examinations to determine if subtle neurologic injury is present.
  • Vitamin supplements are important to maintain good health.
  • Early detection of disease leads to better outcomes.
  • Probiotics cure everything and should be mandated for all school children.
  • Periodic laxative use is advised to cleanse the colon of injurious toxins.
  • Adults should have their abdomens examined at least every 3 years to discover if any tumors or organ enlargement have occurred.
  • Yearly eye examinations are necessary to screen for glaucoma and other eye disorders.
  • Colonoscopies have been proven to prevent colon cancer.
  •  The prostate-specific antigen (PSA) test saves lives and should be measured periodically in men starting at age 50.
  • If a cardiac catheterization shows a narrowed artery, then a stent should be inserted to prevent a heart attack from developing.
  • Pelvic examinations in women are important opportunities to detect ovarian cancer at an early stage.
  • Mammography is proven to save lives.
  • Fiber supplements benefit patients with irritable bowel syndrome.
  • Patients with acute back pain benefit from an early MRI to guide medical treatment.
  • Medical bloggers always tell the truth.
Is our medical advice coming from sound evidence or from the mythological gods on Mount Olympus?

Sunday, May 22, 2011

Ronald McDonald Promotes Obesity: Call in the Navy SEALS!

Fast Food or Front for Evil?

As Whistleblower readers know, I have a 6 day-a-week love affair with The New York Times. I love the paper’s reportage, but not its editorial policy. However, it’s important to seek out other views on the issues of the day. This is an opportunity to defend your beliefs by disarming the opposition’s argument, or to change your mind.

The news these days is very dark. There’s an apocalyptic aura as we read about terror, war and natural disasters occurring all over the globe. And, since we all like reading about villains, the news media readily supplies us with demons to root against and to distract us from more serious challenges that hover over us.

In this past week, there were four prime villains that the national media offered up for us to consume.
  • Osama bin Laden
  • Mouammar Khadafi
  • Mahmoud Ahmadinejad
  • Ronald McDonald
Don’t let Ronald’s sunny visage fool you. Behind his painted smile and underneath his red hair is an evil mind who is devoting his life to promoting obesity and ruining our kids. To recall a bold pronouncement issued by a prior Republican president who was poised to send troops into danger across the globe, ‘this aggression will not stand!’ Ronald must be stopped.

Full page ads appeared in several major newspapers asking McDonalds to fire Ronald McDonald, whose nefarious purpose is to lure mindless kids to ingest too much fat, too much sugar and too many calories. Even Happy Meal toys were targeted by the organizing group Corporate Accountability. They properly recognized that these ‘toys’ were dangerous mind control devices that subliminally cause cravings for Big Macs with extra cheese.

Where’s the outrage? How has this purveyor of poundage been permitted to operate freely for decades?

Hopefully, the Patriot Act has given law enforcement and the intelligence community enough tools to gather damning evidence against Ronald. I suspect that the Hamburglar is wearing a wire. Legal experts are already debating whether a future trial should take place in a civilian court or a military tribunal. I lean towards the latter, not wanting Ronald to have a public platform to spew his poisonous propaganda, which might include coded language to awaken sleeper cells.

What punishment would be just for such a demon? Gitmo? Solitary confinement in a federal prison? Perhaps, an entire year requiring Ronald to swallow 3 Happy Meals a day would be enough to rehabilitate him and to flip him to our side.

Once Ronald has been taken out, then we can focus on other villains who are plotting evil against us. Do you really think that Mickey Mouse and Goofy are just innocent cartoon characters?


Sunday, May 15, 2011

A Near Miss ‘Never Event’: A Truly Futile PEG Tube

Photo Credit

I barely escaped from an embarrassing situation recently in the hospital. I was consulted to place a feeding tube, called a PEG, in an ICU patient. We gastroenterologists are rarely consulted for our opinion on whether these tubes make sense, which they often don’t. We are recruited to these patients simply to perform the technical function of inserting the tubes, so that Granny, or Great-Granny, or Great-Great… , won’t starve. Multiple medical studies have demonstrated that providing this nutrition to individuals with advanced dementia doesn’t benefit them. In addition, while it may seem intuitive that artificial feeding provides comfort, this may not be the case. It may provide more comfort to the physicians and family than it does to the patient.

The above paragraph is not a rigid presentation. Obviously, the decision to place and accept a feeding tube must be individualized. Regardless, it is inarguable that too many of these tubes are being placed for the wrong reasons.

An ICU nurse contacted me to place a feeding tube in one of her patients. There was a large group of visitors hovering around the bedside. As is every physician’s custom, I asked the nurse to summarize the patient’s hospital course and the active medical issues. The consulting physician had requested a PEG feeding tube and a tracheostomy tube. This latter tube is inserted surgically into the windpipe and is connected to a ventilator. (Patients who cannot be weaned off of respirators often have these ‘trach’ tubes inserted as the original breathing tubes cannot remain in the throat beyond a few weeks.) I asked how long the patient had been on a ventilator, and she replied that she was breathing on her own. Even a concrete thinking gastroenterologist thought it was odd to place a ‘trach’ tube in a patient whose own lungs apparently were functioning adequately. This would be analogous to placing a PEG tube in a patient who had just supersized his fast food order.

While this scenario never achieved ‘never event’ status, it does illustrates how medical mistakes can happen. The consulting physician confused two of his patients. The patient assigned to me needed neither a PEG nor a trach, but one of her neighbors did. I was relieved that I didn’t enter the patient’s room to discuss the pros and cons of feeding tubes to the large group assembled there. What if I did enter the room and there were no visitors? What if the patient was demented and wasn’t eating well? One can imagine how a ‘never event’ can happen, especially if necessary safeguards and checks are bypassed or ignored.

I have already expressed in a prior post about why unnecessary PEG tubes are placed. I left one reason off the list. Luckily, it didn’t happen in this case.

Sunday, May 8, 2011

New York Times Charges Web Readers: Whistleblower Wondering

A few months ago, the publisher of my beloved New York Times issued A Letter to Our Readers, which presumably includes many Whistleblower readers.

Non-subscribers to The New York Times will no longer be permitted to use the Times website without limit. I always wondered why they gave it away for free. I have paid my fair share for the past several decades as I wanted the ink and newsprint version in my hands every morning. The Times internet version has been an all-you-can-eat news smorgasbord, where everyone was invited for free. If you build it, and it’s free, they will come. And they did.

Now, frequent freeloaders will have to pay $15 for a month’s subscription to the Times website, still a bargain to gain access to great reporting and hyperpartisan liberal columnists that raise my blood pressure several times weekly. The first 20 articles accessed from the website are gratis. Once you click on article #21, you will be greeted by an invitation to pony up. (Times articles accessed through search engines are not counted toward the 20 article limit, but there are restrictions here as well.)

This gives me an idea.

Why should I be handing out weekly Whistleblower masterpieces for free? I would publish my weekly blog stats here, but I don’t want to provoke envy from ├╝berbloggers Kevin Pho and Val Jones, who are racing feverishly to catch up to me. (Just a joke guys. Please don’t retaliate and shut me down!) I put plenty of sweat into these weekly posts and receive only an intangible reward. There is no advertising on the site, and no charge for access. Why am I leaving money on the table?

I was considering asking readers how much they would pay for Whistleblower access, but I demurred as I feared the responses. Here were some proposals that were meandering in my mind.

  • Free access to readers who offer laudatory comments
  • Charge a contingency fee to plaintiffs’ lawyers. My fee would be contingent on the reasonableness of their comments
  • Honor system – pay me what you think the post was worth
  • Readers’ Reward – I pay readers for every new follower they deliver
  • Self-censorship fee – I charge readers who use any of the following 5 adjectives to describe my posts: Absurd, Moronic, Greedy, Idiotic or Jealous
  • Status Quo – Charge nothing and be grateful that anyone invests time to stop in and hear the weekly Whistle.
I hope that readers find their time here worthwhile. If not, contact me and I will be happy to provide you with a full refund.

Sunday, May 1, 2011

Are Plavix and PPI Medicines Safe Together? The Surrogate Marker Strikes Again!

When the medical press seizes a story, it can become an obsession. Any physician who is reading any journal is aware of the reported interaction between clopidrogel (Plavix) and proton pump inhibitor (PPI) drugs, including Prilosec and her cousins. PPI medicines are not exotic elixirs known only to medical professionals. They are known to any person with a working TV set or who still reads a newspaper, since ads for these drugs are omnipresent. Just google ‘purple pill’ and begin your entrance into the PPI Chamber of Advertising.
PPI medicines are highly effective for peptic ulcers and gastroesophageal reflux, although I suspect that most patients on these medications do not have any true indication for them. (Disclosure: I’ve pulled the PPI trigger too quickly on many patients who do clearly require acid blocking medicines.) PPI medicines are prescribed to hospitalized patients almost by reflex, and are often administered by the intravenous route, even when patients can swallow pills adequately.

Medical studies in 2009 reported that PPI medications appeared to make Plavix less effective. Since thousands of patients are on both of these medicines, this drug interaction could affect a large cohort of patients. Plavix serves to keep coronary stents open and to prevent heart attacks and strokes. Clearly, any force that could diminish Plavix’s potency could have serious ramifications for patients. But, is it really true?

Various studies gave conflicting results, as is typical in medical science. Some showed that PPI medicines had no effect on Plavix efficacy and others suggested that a true interaction might be present. Of course, some data that supported that PPIs weaken Plavix were from ‘test tube’ experiments, and not in studies with real patients. Beware the danger of the surrogate endpoint!

At first, this was causing consternation for PPI-loving gastroenterologists and Plavix-pushing cardiologists. Who would prevail in this conflict?

  • The endoscopers?
  • The cardiac catheterizers?
  • The plaintiffs’ lawyers?
It was nearly impossible to peruse a medical journal that was not reprocessing this issue. Search this subject on the internet, and then take a month off so you can read through all the hits. Of course, after reading the first half dozen, you will then be reading reruns.

While I now offer speculation, which is not data, I doubt that combining these drugs, as is done thousands of times every day, will harm patients. I expect in the next year or so to read medical studies that will argue that the PPI-Plavix combo meal will not lead to doomsday, and that the initial reports were hyped. The FDA, despite the weak evidence, has issued a warning regarding prescribing Plavix and Prilosec (omeprazole) together. These government caveats are like tattoos; they are easier to affix than they are to remove.

We have read about other PPI risks over past years. They are associated with pneumonia, C. difficile colitis, vitamin B12 deficiency and hip fractures. Once again, the FDA issued a warning regarding PPI and associated bone fractures, despite the absence of persuasive medical evidence that these drugs can actually break bones.

As journalists know, ‘if it bleeds it leads’. Well, we gastroenterologists know that Plavix causes plenty of bleeding. I guess that’s why it became front page news.