When I was a resident (over ten years ago!) we were taught that there was no evidence that breast self-examination saved lives.  A new review puts another nail in the coffin of breast self-examination.  This week the Cochrane Review published a re-analysis of a review of the scientific studies on breast examination.  The conclusion: women who perform breast self-examination undergo more breast biopsies but die of breast cancer at the same rate as women who do not examine themselves.  The same applies to periodic breast examination by a clinician.  The authors’ conclusion is quite clear.

“Data from two large trials do not suggest a beneficial effect of screening by breast self-examination but do suggest increased harm in terms of increased numbers of benign lesions identified and an increased number of biopsies performed. At present, screening by breast self-examination or physical examination cannot be recommended.”

It’s important to note that any lumps or other breast changes that are noted should still be reported to a doctor.  The message of this finding is simply that it doesn’t help to look for such changes periodically.

This review has generated much attention in the general press this week.  (See the link to the WebMD article below.)  Interestingly, despite the clear conclusions of the study, the American Cancer Society doesn’t recommend for or against breast self-examination, but rather says that it remains “an option”.  What kind of position is that?  Of course it’s an option.  Stuffing marshmallows in my ears is an option too.  Are they for it or against it?  Given that the evidence is entirely lopsided against it, why won’t they advise women not to examine themselves and spare them the needless biopsies?

The answer is that the American Cancer Society derives its mission (and its funding) from diagnosing and treating cancer.  Their recommendations are consistently skewed towards recommending more testing than the evidence supports, since more testing leads to the diagnosis of more cancer cases.  That is an important reason to rely on recommendations from groups that are entirely unbiased and whose income doesn’t depend on whether they recommend for or against any intervention.  The Cochrane Review and the US Preventive Services Task Force are such groups.

Learn More:

WebMD: Breast Self-Exams: No Survival Benefit

Cochrane Review: Regular self-examination or clinical examination for early detection of breast cancer

US Preventive Services Task Force recommendations for breast cancer screening

Tangential Miscellany:

There won’t be a medical news post next week.  Posting will resume in two weeks.  I’ll miss you too.

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This week the Food and Drug Administration (FDA) requested a new warning on a family of antibiotics called fluoroquinolones.  This family includes ciprofloxacin (Cipro), levofloxacin (Levaquin), moxifloxacin (Avelox) and others.  The warning has to do with the increased risk of tendonitis and tendon rupture due to these antibiotics.

This information is not new.  The increased risk has been known for a few years, but as additional cases have been reported, the FDA chose to act.

This complication is more frequent in patients over 60, patients taking corticosteroid medications, and patients who have had an organ transplantation.  It is a rare complication (though I couldn’t find a numerical estimate of its frequency) but in the case of tendon rupture can be quite disabling and can require surgery.  In my practice, this complication has happened exactly once (to a patient who is probably reading this!).

Doctors and patients will almost certainly continue to rely on this family of antibiotics.  Doctors should be more cautious in higher-risk patients.  Patients should know to call their doctor immediately and discontinue the antibiotic if they develop tendon pain, and to avoid exercising the sore area.

Though in general the medications available to us have steadily become safer and more effective, we should not hold our breaths for an era of perfect safety.

Learn more:

Wall Street Journal article:  FDA to Add Warning to Antibiotics

FDA press release:  FDA Requests Boxed Warnings on Fluoroquinolone Antimicrobial Drugs

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“Summertime,
And the livin’ is easy”
– George Gershwin

Summer is here, and especially in Southern California, that means opportunities to enjoy lots of outdoor activities including fun days at the beach and in the pool.  Unfortunately that also means more accidental drowning.  In 2005 there were 3,582 drowning fatalities in the United States, a quarter of them in kids 14 and under.

So this is a good time to remind ourselves never to leave children unattended in or near a pool.  With kids younger than 5 an adult should be within arm’s reach.  Teach your kids to swim.  Learn CPR.  Fence your pool.

So let’s all enjoy America’s two hundred thirty-second birthday in a way that will keep us around for the next one too.  Oh, and wear sunscreen.

Learn more:

The Centers for Disease Control and Prevention Water-Related Injuries Fact Sheet

American Academy of Pediatrics Pool Safety for Children

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Dementia is not a single disease.  Dementia is a family of diseases that cause progressive memory loss, usually in older patients.  The most common cause of dementia is Alzheimer’s disease.  Dementia is progressive, and while some treatments exist, their efficacy is only modest.  In addition to memory loss, patients frequently suffer personality and behavior changes.

Dementia is common, affecting 3.4 million Americans as of 2002, and this number is sure to increase as our population ages.

The most difficult problem in the management of dementia is managing the agitation and hallucinations that patients frequently experience.  Besides being obviously disturbing to the patients, agitation and psychotic symptoms contribute significantly to caregiver stress and burnout.  It’s no surprise then that antipsychotic medication – medication developed for use in patients with schizophrenia and other psychotic disorders – has a long history of use in patients with dementia.  There’s only one problem; they don’t work.

Randomized studies have shown that patients with dementia and psychotic symptoms are no more calmed by antipsychotic medication than by placebo.  Worse than that, in elderly patients some antipsychotic medications increase the risk of stroke.

Despite this evidence, faced with an agitated patient with dementia, many physicians (sometimes me included) out of desperation reach for an antipsychotic medication.  A New York Times article last week summarized the controversy well.

There are therapies that have been proven to help with agitation in patient with dementia, but they’re not medicines.  The therapies are behavioral: calmly redirecting the patient, reorienting him to where he is, distracting him with a less stimulating activity, etc.  This is more effective but requires more caregiver time, a resource that will certainly become scarcer in the future.  Unless better treatments are developed, caring for dementia patients will become increasingly challenging in the next decades.

(Thanks to Michelle H. for sending me the article.)

Learn More:

New York Times article: Doctors Say Medication Is Overused in Dementia

Neuroepidemiology article: Prevalence of Dementia in the United States

Tangential Miscellany:

Two years ago I wrote about the looming shortage of primary care doctors and their increasing dissatisfaction with the practice of medicine.  A New York Times article last week reiterates the point that a lot of doctors no longer enjoy what they do:  Eyes Bloodshot, Doctors Vent Their Discontent.

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This week, a large national survey of physicians’ use of electronic health records (EHRs) was published in the New England Journal of Medicine.  The results generated a lot of attention in the general media.

The good news is that physicians with EHRs are largely very satisfied with them and believe that EHRs improve patient care.  The bad news is that nationally only 4% of doctors use EHRs.  The largest barrier cited as preventing physicians from adopting EHRs is the expense.

In any other industry, that would be unthinkable.  Imagine if a hotel came up with an easier way for guests to make a reservation.  If the new technology was very expensive, only those hotels with the most resources would be able to afford it initially.  But eventually the price of the new technology would drop and almost all hotels would use it.  Within a few years the older way of making reservations would be gone.  That’s why you can’t listen to an LP record anymore or find a public phone booth or send a telegram.  Better technology spreads like wildfire through a marketplace, regardless of how expensive it is initially.

So if EHRs are better for patients, why the slow adoption?  For that matter why haven’t CT scans dropped in price?  Or pacemakers or MRIs?  Most medical technology should be dirt cheap.  My son’s laptop is much more powerful than the desktop PC I had in high school and cost less.

The answer is that the insurance model corrupts the incentives that work in other marketplaces.  By fixing the price for care, insurance companies make it impossible for doctors to make more money by providing better care.  Doctors in the insurance model can only make more by seeing more patients.  In such a system there’s no reason to invest in an EHR, because the investment will not lead to increased revenue.

The same perverse incentives keep prices high.  Since the insurance company sets the price for a CT scan, there’s no incentive to drop the price for a CT to compete against other providers.  The incentive is to get as many patients through the scanner as possible.  So while Dell keeps making better computers cheaper, CT scan prices stay the same.

Now academicians and lobby groups are clamoring for insurance companies and government to pay doctors to adopt EHRs.  But insurance companies and government got us in this mess.  Having them subsidize EHRs misses the point, and would keep EHRs expensive forever, like CTs.

A few doctors dedicated to excellent care have already taken the financial risk to invest in an EHR.  Some of us have abandoned our relationship with insurance companies so that we can work for our patients.  Some patients who are also discriminating consumers have looked for such physicians and are willing to pay more to see them.  More doctors and patients, increasingly dissatisfied with the insurance model, will hear about us and follow our lead.  That’s the solution.

Learn more:

New York Times article:  Most Doctors Aren’t Using Electronic Health Records

New England Journal of Medicine article:  Electronic Health Records in Ambulatory Care — A National Survey of Physicians

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In February I wrote about the results of the ACCORD trial, a study designed to test whether strict glucose control in patients with diabetes helps prevent strokes and heart attacks and prolongs life.  The startling results were that the patients with diabetes who were randomized to have their glucose lowered to normal levels died sooner than those with more lax sugar control.

This week the New England Journal of Medicine published the results of another study, the ADVANCE trial, which was designed to answer the same question.  Over eleven thousand patients with type 2 diabetes were randomized to two groups.  One group was managed intensively with a goal of normal blood glucose.  The second group had less strict sugar control.  The groups were followed to measure the frequency of strokes, heart attacks, worsening of kidney disease, diabetic eye disease and death.

Again, in this trial, strict sugar control did not save any lives (though at least, it didn’t cause extra deaths like in ACCORD).  Strict sugar control also didn’t prevent strokes, heart attacks or eye disease.  The one benefit that was detected was that patients with strict control had less kidney disease than patients with lax sugar control.

The common theme seems to be that normal sugars are not the goal of diabetic treatment, or at least not the only goal.  Heart attack and stroke prevention in patients with diabetes involves many other proven therapies like smoking cessation, cholesterol lowering with statins, blood pressure medications and aspirin.

Learn More:

My post in February about the ACCORD trial:  What We Don’t Know About Diabetes

The New England Journal article publishing the results from the ADVANCE trial:  Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes

The New England Journal article publishing the results from the ACCORD trial:  Effects of Intensive Glucose Lowering in Type 2 Diabetes

Tangential Miscellany:

I hope us dads all get to spend some time with our kids this weekend, and all of us who are fortunate enough to still have our fathers in our lives have a chance to express our love and gratitude for everything they’ve done for us.  Happy Father’s Day!

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As summer approaches, researchers at Auburn University have performed a study demonstrating the dangers of that ubiquitous summer accessory, the flip-flop.  They recruited volunteers and recorded their gait in both sneakers and flip-flops.  In flip-flops the subjects took shorter steps and didn’t raise their toes as far as they did in sneakers.

This makes sense, if you think about it.  When we wear flip-flops we curl our toes down to keep the sandals from flying off our feet.  This keeps us from taking a long step and also has our heel hit the ground at the wrong angle for optimal walking.

The investigators warn that this abnormal gait could contribute to foot and knee pain in people who walk long distances in flip-flops.  I’m sure this news ruins your day, if not your summer, but don’t despair.  The authors reassure us that wearing them for short distances like around the pool should be fine.

So when you see me at the beach in my wingtips, now you’ll know why.

Learn More:

ABC News article: Flip-Flops Can Cause Long-Term Health Problems

New York Times Health blog: Summer Flip-Flops May Lead to Foot Pain

Tangential Miscellany:

This week, I’d like to leave you with the eloquent rant of my patient Stephen J. who emailed me to vent about the problems with medical insurance.  I couldn’t have said it better.

Reason 4,327,602 to be critical of health insurance: “The Ticket Punch.”

Here is how it works.  Medical insurance companies pay by the visit.  Doctors need volume.  When a patient visits a doctor with a new complaint the doctor may need to “waste time” errr “spend time” diagnosing the problem.  The flat payment doesn’t cover the time.  So when the doctor sends the patient for an MRI, reviews the MRI and concludes that the patient should see a surgeon, he makes the patient come in before telling him that.  The patient would be better off to hear that in a phone call.  The other patients in the crowded waiting room would be better off too but the doctor can’t bill for the call and needs to “punch his ticket” in order to be paid.

Doctor’s used to validate parking; now patients punch billing chits for doctors.

I like the idea that a doctor can value a patient’s time and be paid to do so.  And I like parking validations.

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I’ve written before on the increasing danger of bacteria that are resistant to multiple antibiotics.  This resistance is a side effect of the use, and frequent misuse, of the many antibiotics physicians have at our disposal.  I’ve also written about the pressure that physicians sometimes face from patients to prescribe unnecessary antibiotics.

Last week Slate published an article by Dr. Zachary Meisel, an emergency department physician who recounts facing a very common dilemma.  He took care of an infant with a cold whose mom clearly expected a prescription for antibiotics.  Knowing that antibiotics won’t help the baby, but not wanting to dissatisfy the mom, what was he to do?  (Why an infant with a cold would be in an emergency room rather than in her pediatrician’s office is a vast subject for a different post.)

Dr. Meisel cites a recent study that examined patient expectations for antibiotics and their satisfaction with the care they received.  The study concluded

“Patient satisfaction was not related to receipt of antibiotics but was related to the belief they had a better understanding of their illness.”

So for most patients, education about the disease is more valuable than a prescription.  This is an important lesson for us doctors to learn.  A prescription may take only 30 seconds to write, but ten minutes of teaching is better for the patient and for society.  This is another example of an instance in medicine in which efficiency and quality diverge, and doing the right thing takes some time.

So what did Dr. Meisel do?  To find out, I urge you to read the Slate article.

(Thanks to Luetrell T. for pointing me to the Slate article.)

Learn more:

Slate article:  The Pink-Bubble-Gum- Flavored Dilemma – Why doctors give out antibiotics you don’t need

My post about the pressure to prescribe unnecessary antibiotics: Acute Bronchitis

My post about resistant bacterial infections: Serious MRSA Infections More Common

Annals of Emergency Medicine Study: Antibiotic Use for Emergency Department Patients With Upper Respiratory Infections: Prescribing Practices, Patient Expectations, and Patient Satisfaction

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“But he can’t be a man ’cause he doesn’t smoke
The same cigarettes as me.”
– Rolling Stones, (I Can’t Get No) Satisfaction

An article in this week’s New England Journal of Medicine illuminates the social dynamics of smoking and quitting, and generated a lot of attention in the media.  The study followed twelve thousand people, many of whom were initially smokers, from 1971 until 2003.  The large group was all connected in one large social network, meaning all of them were connected to each other through friendship and marriage.

The study followed this large group for 32 years and studied the social patterns of those who quit smoking.  The results showed that smokers very frequently quit in social groups, not alone.  So when one smoker quit, it was very likely that much of the social network directly connected to her quit as well.  This suggests that quitting smoking is much more of a group behavior than an individual decision.

Interestingly, as time went on, those who remained smokers became increasingly marginalized in the social network, as those with the most social connections became the least likely to smoke.  So it appears that the social status associated with smoking a generation ago has reversed.  It’s finally cool to quit.

Learn more:

New York Times article:  Study Finds Big Social Factor in Quitting Smoking

New England Journal of Medicine Article:  The Collective Dynamics of Smoking in a Large Social Network

New England Journal of Medicine Editorial:  Stranded in the Periphery — The Increasing Marginalization of Smokers

A fascinating animation of the data in the study

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Osteoporosis, which means very low bone density, is a major risk factor for fractures.  Fractures can be catastrophic for older people, and effective medicines exist to treat osteoporosis and prevent fractures, so detecting osteoporosis before a fracture happens is very important in older patients.  Since osteoporosis is very common in postmenopausal women, screening them for osteoporosis is a well-established part of preventive care.

Though men are less likely then women to have osteoporosis, a fracture in an older man is just as potentially catastrophic.  Until now, no clear guidelines have been available to guide physicians about whether or when to screen men for osteoporosis.  Frequently, therefore, osteoporosis has been diagnosed in men after the first fracture.

This week, the Annals of Internal Medicine published a review of the medical literature about screening men for osteoporosis, and on the basis of this review, the American College of Physicians issued a clinical practice guideline for screening men for osteoporosis.  Their recommendations are:

• Clinicians should periodically perform individualized assessment of risk factors for osteoporosis in older men.
  Risk factors for osteoporosis are
  • age (>70 years)
  • low body weight (body mass index <20 to 25)
  • weight loss
  • physical inactivity
  • corticosteroid use
  • androgen deprivation therapy
  • previous fragility fracture
• Clinicians should obtain dual-energy x-ray absorptiometry (DEXA bone density scans) for men who are at increased risk for osteoporosis and are candidates for drug therapy.

Though much is still not clarified, like the number of risk factors that should prompt screening or the frequency with which screening should occur, this is a valuable start.  So if you’re an older skinny sedentary guy (or if you love one) ask your doctor about getting a test for osteoporosis.

Learn more:

The American College of Physicians clinical practice guideline:  Screening for Osteoporosis in Men

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