Sunday, October 28, 2012

Breast Cancer Screening of Dense Breasts - Dr. Government Prescribes Bad Medicine

This blog is about freedom and personal responsibility.  I have opined that cigarette smokers should not be permitted to transfer total responsibility for the consequences of their choices to the tobacco companies, even if this industry has committed legal and ethical improprieties.  I do not support the politically correct beverage ban in New York City, sure to spread elsewhere, where the government decides the content and dimensions of beverages that the public desires to purchase.  With regard to Obamacare, don’t get me started or I’ll never get to the intended subject of this post.

First, let me refute a point in advance that is sure to be leveled against me by the pro-breast crowd.   I am zealously pro-breast and want all breasts foreign and domestic to remain free of disease. I am against breast cancer and support the goal of striving for early detection of this disease and medical research to prevent it.  Indeed, I am against all cancer and boldly express this controversial view in print for all to see.

Breasts and politics have been intertwined for years.  Many medical advocacy groups admire and envy the huge amount of research money that is garnered for breast cancer research.  Some argue that breast cancer, while worthy, receives a disproportionate share of research dollars at the expense of other crippling and deadly diseases. 

There is no clearer example of the contamination of breast cancer with political interference than Mammogate, when the federal government cowardly rejected the sound and impartial recommendations of its own expert panel for political reasons.

Now, a new scene in the government's Breast Fest has appeared where our elected legislators play doctor.  States are passing laws that require medical facilities to inform patients who have undergone mammograms if they have dense breast tissue and that they should discuss with their physicians if additional testing is necessary. More details are found in the New York Times report on this issue.

I will defer expressing a medical view if women with dense breasts are adequately protected by conventional mammography. If medical professionals, unelected but presumably trained in actual medicine, believe that ultrasound exams or M.R.I. scans are necessary to illuminate dense breast tissue, then brace yourself for an avalanche of unnecessary scans which will generate anxiety, cost a few zillion dollars and identify false positive lesions which are entirely innocent and lead to a breast biopsy bonanza.  This cascade will be fueled also by the medical malpractice system, the raptor present in every mammography suite that is ready to sink talons into its prey.  Am I exaggerating here?  Ask any radiologist why he has stopped reading mammograms.  The guys that still do are scared stiff. These breast images are not sharp iPad images with futuristic resolution.  Instead, they look like grainy collages where it can be agonizing for a doctor to decide if a small smudge is nothing or everything.  Understandably, in today's litigious climate, radiologists join OperationOVERCALL, rather than risk the opportunity to serve as a defendant years later.  

The government are not physicians and should not legislate medical advice.  It’s hard enough for actual doctors to sort through conflicting and controversial medical data and evidence to determine what is best for our patients.  We struggle with this every day.  Will the clumsy axe of government be a helpful player in this effort?   Do we want folks who are beholden to lobbyists and are political animals by definition to force physicians to practice in certain way?

Why stop at breasts?

Pass laws that will require physicians to
  • Obtain a CXR if a patient has a cough and a fever
  • Tell every patient who has a negative cardiac stress test that the patient can drop dead of a heart attack within a week and that a cardiac catheterization should be considered
  • advise patients who are scheduled for surgery to obtain a second opinion in case surgery is silly
  • advise patients to pursue the probiotic promise of a panacea.  
Sure, there's dense breast tissue out there.  But, not nearly as dense as the government.  I suppose we should trust them with our lives and our health judging by the sterling performance they demonstrate as legislators.  Congress' approval rating is now soaring at 21%.  

Sunday, October 21, 2012

Weight Loss and Exercise Fail to Prevent Heart Attacks and Strokes? A Skeptic Scoffs

Photo Credit

A theme woven throughout the Whistleblower blog is skepticism.  I endorse and rely upon this in my medical practice and in my life. I admit that there were times that I argued a point that was not truly my own at the dinner table simply to stimulate the minds of my progeny.  As the kids are not readers of this blog, I trust that actual readers will be protective of this knowledge that if released could sow a storm of familial strife.

I am reluctant to incorporate new medical breakthroughs into my practice until enough time has passed to convince me that these medicines or treatments are truly safe and effective.  Often, the test of time exposes the vulnerabilities and hazards of new remedies for old maladies.  This is to be expected.  Once a new medicine is released into the marketplace, its true risks may not be known until thousands of patients have taken it.  On other occasions, new science retires old treatments.  When I was a younger physician during the Pleistocene Epoch when I used to take my pet triceratops out for a walk, we gave nearly all women hormone replacement as a guard against the heartbreak of bone breaking osteoporosis.  Now, a physician who would make such a recommendation would be labeled as a medical fossil from the Jurassic Period, and would be labeled as a medical dinosaur and would be encouraged to limit his practice to administering influenza vaccines.

In medicine, and beyond, don’t believe stuff that sounds as if it should be true.  This is one of the dangers of the surrogate marker, a medical research sleight of hand that tries to substitute an outcome of limiting meaning for another that the researcher wants to be true.    

Of course, it’s a fact that there is excess obesity in the United States and in many other countries.   Weight loss has become a national crusade that has even entered corporate America who increasingly incorporate weight loss and fitness into their wellness programs.   It is also a fact that obesity is associated with many medical conditions such as heart disease, arthritis, strokes and cancer.  Many folks, however, confuse a medical association from actual causality.  For example, exercising in a gym may be associated with better health, but these workouts may not be the cause of the desirable outcome.  Gym freaks may be healthier because of their diet or lifestyle.  They may have access to higher quality medical care.  So the headline, Gym Users Have Fewer Heart Attacks, is rather misleading.

It is taken as fact that weight loss, which is associated with many diseases, will reduce the risk of these diseases, but is this really true?   I know that even posing this question constitutes medical heresy, a charge that has been leveled against me from time to time.   The New York Times reported that a study of weight loss was stopped two years ahead of schedule because an aggressive program of diet and exercise did not reduce heart attacks, strokes or cardiac mortality even though the study group lost 5% of their weight, a significant amount.

Those who are biased over the true medical value of weight loss will criticize the study.  Medical skeptics, however, will gloat about it on their blogs.  

Sunday, October 14, 2012

Fighting Obesity in America: Has Weight Loss Gone Too Far?

One cannot escape the issue of rising obesity rates in the United States. A current statistic predicts that by the year 2030, 42% of us will be obese. The ramifications of this ponderous eventuality could indeed weigh down and sink the nation. Some of the consequences include:
  • Zillions of health care dollars spent treating obesity directly.
  • Gazillions of health care dollars treating medical consequences of obesity.
  • Loss of economic productivity from a bloated workforce.
  • Diminished economic activity from corpulent citizens who limit travel and recreational activities.
  • Loss of quality of life for those who have expanded far beyond their desired BMI.
  • Phasing out of Whoppers and Big Macs, two national gastronomical treasures.
Of course, the percentage of us who are deemed to be obese depends upon how we define the condition. Look what the medical experts have done with blood cholesterol levels, with the assistance of Big Pharma. As the threshold for a normal cholesterol value has steadily been lowered, more and more of us will be diagnosed with hypercholesterolemia. If the trend continues, the entire nation will be diseased and we will be urged to ‘statinize’ ourselves.

What harms one person saves another. Even natural disasters create jobs and keep entire industries profitable. Similarly, the movement against obesity threatens many livelihoods. Here are a few folks whose incomes would suffer if the nation slims down.

  • Magic weight loss supplements that promise to melt pounds off.
  • Big & Tall clothing stores.
  • Funeral homes. Fewer deaths per year will bury many of these businesses.
  • The medical profession. How would physicians and hospitals make a living? There’s no money in preventive medicine.
  • Tailors and seamstresses who won’t have to let our pants out each year.
  • Gastric bypass centers that would have to market their services to overweight pets.
  • Weight loss programs that view the obese as worth their weight in gold.
  • Big Pharma who will suffer huges losses as there will be fewer diabetics and hypertensives to treat.
  • Medical device companies who manufacture cardiac catheterization equipment.
  • The exploding sleep apnea medical industry will be gasping for breath.
  •  Splenda and Sweet & Low companies. Slender folks won’t be scared to ingest real sugar.
  • Kentucky Fried Chicken and other ‘finger lickin’ good’ delicacies.
Obesity has been demonized and has created industries to combat it and ostensibly to improve the nation’s health. Crusades have arisen, spearheaded by the First Lady to protect kids from the heartbreak of heft. Dietary police will be roving the countryside targeting establishments that are pushing poisons on us, including doughnuts, chicken wings, funnel cakes, movie popcorn and Haagen Dazs ice cream, which creates the best vanilla ice cream in the world.

But before we create a national movement to stamp out corpulence in our lifetime, consider the economic consequences. (Why do you think that cigarettes are still legal?) Many folks depend upon our excessive poundage to feed their families and run their businesses. Weight loss is a job killer. To those who aim to destroy America one pound at a time, where’s the outrage?

Sunday, October 7, 2012

Medical Ethics: Why I Wouldn’t Write a Prescription

Medical ethics is woven into the Whistleblower blog. I have presented vignettes exposing ethical controversies in the medical profession. I have pointed out scenarios when patients test the steeliness of our ethical scaffolding. I have admitted when my own ethics can be fairly challenged. Indeed, this blog does not take a ‘holier than thou’ posture, though at times I have been accused of this. I have directed as much criticism at myself as I do elsewhere.

Recently, I received a request to assist someone whom I was told was in dire need of a physician’s assistance. While I am a physician who has taken an oath to heal and comfort, in this case I turned away from a person in need. I present the anecdote not because it will stimulate a discussion of the competing ethical angles of the case. Indeed, the case has no angles and no reader will challenge my decision. I present it as an example of an outrageous and improper request that was made to a doctor. Indeed, while I have received numerous improper requests from patients over the past two decades, which I routinely declined, this request was the ‘mother of all ethical outrages’.

Valtrex Structural Formula

A woman whom I know called me with a medical request. She is not my patient. Her niece, also not my patient, was desperate to receive a prescription for Valtrex, a medication she needed for oral herpes. Her own physician would not refill the prescription. The niece did not want to see another doctor for a prescription, as this would create a paper trail that her husband, who opens the mail at home, might discover. The niece was frightened that her husband would discover this infection, and worried that this would result in a marital strain. The woman who phoned me asked if I would call in a prescription for Valtrex under her name, although the pills would be transferred to her niece.

This case poses no ethical quandary for any physician.

The woman who called me is a wonderful and caring person. I wanted to offer some counsel beyond a rebuke of her request, and I did so.

I am interested in what advice readers would have offered, as well as potential explanations for the niece’s anxiety. Once a discussion has hopefully developed, I will share the advice I rendered, and will look forward to readers’ response to it. I always welcome criticism because I am holier than no one.