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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Tuesday, September 11, 2007


Medical Adventures (B)

Looking for the Right Doctor

The key point to remember is that, like in any profession, the gap between the best and the worst practitioners is very wide. Not all of them keep up with advances in medicine. Here is another quote by Osler: "The average non-reading doctor might play a good game of golf or of bridge, but professionally he (is) a lost soul." This was said in 1909 and it is quite valid today. In addition, you have to consider compatibility of personalities between the doctor and the patient. Here are some suggestions:

(1) Be an educated consumer. Educate yourself as much as possible about human physiology and health issues so that can think better of your needs. But do not delude yourself that you can be your own healer. For one think, you are not objective.

(2) Look for doctors who are willing to listen and stay away from those who are in a hurry or seem to feel insulted when the patient proposes a diagnosis. Certainly, stay away from dogmatic and arrogant doctors.

(3) Be sure to ask for a second opinion for anything extreme. Either when a major treatment is proposed or when your doctors says "there is nothing wrong." Of course you have to be prepared to hear conflicting opinions, that is why (1) is important.

(4) If you have something very serious, such as cancer, go to a major medical center (in the case of cancer, Sloan-Kettering in New York and Anderson in Houston are examples of the kind of center I mean). At the very least try to select a doctor who is on the faculty of a major medical school. Physicians at such places are far more likely to be up to date with the literature and the newest developments in their field. They are also more likely to be genuinely interested in their profession and not consider it just as means of earning a living. I should add that in my own experience I have found the highly regarded specialists more humble and willing to listen than many ordinary physicians.

(5) Plan ahead. The best doctors tend to be heavily booked and it may take several months before you can get a new patient appointment (some of them may see patients only one day a week because they do surgery or research or teach the rest of the time). Decide what are your risk factors, find who is the best specialist in the area and make an appointment with him/her even if you do not have an immediate need.

(6) In addition to the specialists find a doctor who takes a broad view to medicine to be your primary care provider. You want a of doctor who takes a systems approach to medicine and places emphasis on nutrition and the treatment of the whole person. I was planning to use the term holistic medicine to describe such a practice but, unfortunately, the term is loosely used and it is often confused with alternative medicine and other unorthodox practices. The fact that mainstream medical practice maybe wrong on an issue does not make other views on the issue automatically right. When we deal with hard problems there may several wrong solutions.

There are various list of "Best Doctors" but not all of them are reliable. Probably, the most reliable indicator of the quality of a physician's training is the hospital where he/she was a resident. But you have to find that information first and then you have to find out the reputation of the hospital. A good indicator for surgeons is the number of operations they perform each year.

(To be continued)

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Monday, September 10, 2007


Medical Adventures (A)

How I am Alive Thanks to Some Doctors and in Spite of Others

Starting today I will write over several days a critique of some medical practices. It is by no means a critique of the medical profession as a whole. I am alive today because of the advice, efforts, dedication, and high skills of several physicians. But choosing the right doctors and ignoring unsound advice was essential. I also want to counteract the tendency of some people to reject modern medicine altogether because of a negative experience with a particular practitioner. I am a strong believer in modern medical science even if I have lost respect for some of its practitioners. If an inept mechanic messes up the tuning of my car engine I will not reject the laws of thermodynamics; I will simply look for a competent mechanic. Of course, choosing doctors is more critical than choosing mechanics because you may not get a second chance. Because the human organism is so complex, even the best doctors make mistakes sometimes. What patients should be looking for is doctors who will do as well as the current state of medical science allows.

These writings are motivated by my medical problems during the winter of 2006-7. I am detailing that story in where I also present more extensive comments than I do on the blog.

My most severe problem with doctors has been the unwillingness of many of them to listen to the patient and their extreme self-confidence, if not arrogance. Of course, such attitude goes against the advice of Sir William Osler (a Canadian MD, one of the founders of Johns Hopkins School of Medicine) who said: "If you want to find what is wrong, ask the patient" and also "The greater the ignorance, the greater the dogmatism."

This attitude is troubling enough by itself, but it is often coupled with a tendency to make a diagnosis based on the most common cases. If you have symptom A, then the cause must be B because that is the case with, say, 60% of the people who exhibit symptom A. Too bad if you happen to be in the remaining 40% and your symptoms are caused by something other than B.

The situation becomes even worse if your symptoms have multiple causes (which was the case with me last winter). Superposition effects seem to be beyond the grasp of many physicians. When I tried to explain the issue to some of them, they looked baffled and even impatient; it was clear they thought I was wasting their time. The tragic side of this is that in older people several systems may start functioning below the optimal level but, because each system is still within "normal limits", the MD cannot find what is wrong.

Another bad practice is that whenever physicians are puzzled they claim that the patient's problems are in his/hers mind. (This was the initial diagnosis for me.) This is the modern equivalent of been ill because of "foul airs" or the "evil eye". Because of the frequency of such a diagnosis in older people we have the myth of the "elderly depression".

You may say that I demand too much from doctors because the human body is a far more complex mechanism than any technological device. Well, doctors cannot have it both ways. If they want sympathy from their patients for their tough job, they must also have sympathy for the patients who suffer from a tough to diagnose ailment.

I am not dealing with practices that are clearly unethical, such as doctors who order unnecessary (and often painful and expensive) procedures to make money. Or doctors who prescribe medication because of their links with the pharmaceutical industry. What I am trying to convey is that some doctors may be harmful even if they commit no ethics violations or even if they use their best judgment in the interest of the patient. The problem is that their best judgment may not be that good.

There is an excellent book dealing with the problems of medical diagnosis: How Doctors Think by Jerome Groopman, MD that came out while I was struggling with my own doctors. Two of the most memorable (for me) observations in the book are: (1) 15% of all diagnoses are wrong; and (2) doctors often attribute to psychological causes ailments that are unable to diagnose ("it is all in your mind", "you are too anxious", etc). They seem to fit with what I was experiencing.

(To be continued)

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