Wednesday, September 12, 2007


Medical Adventues (C)

Some Practices to Watch Out For

There are many areas where Medical knowledge is limited and one should use published guidelines with caution. However, not all practitioners use such caution, so patients should be aware of the limitations. I list here a few of them only, mainly cases where I have had personal experience with the problem.

Normal Range: How is the normal range for a measurement (say cholesterol level in the blood) defined? You may think that there is some investigation of the body biochemistry behind it. No folks, it is based on statistics. Some medical board looks at values of the measure for several "healthy" people, the average (A) and standard deviation (SD) is computed and the range is usually set from A-SD to A+SD. The trouble with this approach is the definition of healthy. The sample may include people who may appear healthy but are going to develop the pathology in the near future (that results in too broad a "normal" range) and exclude people who have been misdiagnosed (that tends to narrow the range). The practical effect is that if your results are in the middle of the normal range you are probably OK, but if they are away from the middle the information is of limited value.

Risks Factors: Here I am going to give a personal example. My father died from a heart attack, my mother and both grandmothers died from strokes and my uncle (mother's brother) suffered a major heart attack and although he lived for another 20 years, he had been crippled because of the damage to his heart muscle. Yet, my family doctor insisted that I was not at risk from heart disease. Why? Because the medical guidelines define death of relatives as a risk factor only if it occurs before the age of 60 (or something like that) and my uncle was 68 when he had the heart attack and all the others over 70. I was 66 when I got into a big argument with my family doctor. He had given me a resting EKG that was normal and when I asked for a stress EKG his answer was "What do you need a stress EKG for?" Fortunately, I remembered a conversation I had with another doctor 25 years earlier. He had pointed out that the resting EKG was of limited predictive value and a stress EKG was far more likely to predict heart problems rather then just confirm that something bad had already happened. So I kept insisting and my doctor prescribed a stress test. Not surprisingly, I failed the stress test and that started the process that lead to open heart surgery in October 2000. I should add that my brother in Athens had stress tests every year because his doctor accepted a definition of risk factors more in line with common sense.

"It is all in your mind" is a common and erroneous diagnosis when a doctor cannot figure out your ailment. (See post of September 10.) I experienced such a diagnosis in November 2006 when a cursory examination of my urinary system revealed no problems and the doctor decided that my frequent night-time urination was the result of anxiety. I argued (too meekly in retrospect) that anxiety would have been causing more problems during the day but my argument was dismissed off hand. After I accepted the "in your mind" diagnosis I was prescribed and started taking psychotropic medications that while they seem to help in the short run (placebo effect?), eventually they seem to leave me worse off. That is when I called my daughter (a clinical psychologist) who, after listening to me, insisted that my problem was physical and not in my head. Of course that left me searching for the physical problem but I reduced the psychotropics and I felt better. (I stopped them completely after the diagnosis of sleep apnea that in many cases causes excessive nightime urination.) What was happening was that the psychotropics did not affect the source of my problem (sleep interruptions) but made me feel drowsy and more tired during the day. My suggestion is that if your doctor says "it is all in your mind" ask for a second opinion, and a third, a fourth. Under no circumstances start taking psychotropic drugs (antidepressants, anti-anxiety, etc) until you talk to a clinical psychologist and discuss your problems with him/her. Clinical psychologists specialize in dealing with problems in people's minds and are better qualified than MDs to say whether a problem is "only in your mind".

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