Monthly Archive
What a better topic for Halloween than fear?
All of us when hearing of a coworker or loved one who has been diagnosed with a life-threatening illness wonder if we could be next. “What if I have lung cancer? Should I get checked out? There must be some tests I can get to make sure I’m OK.” Those who take an active role in staying healthy are confident that they could do more to make sure they don’t get some dreaded disease. Most cancers, after all, are preventable, right? Or at least they can be caught early?
The scary truth is that most cancers are not preventable and can not be caught early by any test we currently have. What’s even worse, for many cancers there is no evidence that an earlier diagnosis makes any difference in outcome.
That doesn’t mean that no prevention is effective. For a few cancers (breast, cervical, colon) there are proven tests that are recommended periodically for everyone. That’s why I’m an enthusiastic advocate for colonoscopies for people over 50. Also, testing blood pressure and cholesterol in healthy people helps prevent strokes and heart attacks.
So how can we know what we should be doing to stay healthy? Should I get a head-to-toe CT scan? What about that “executive physical” with the fancy heart tests that my neighbor says I should have?
This is the job of the U.S. Preventive Services Task Force. They are the most unbiased national group that evaluates the evidence for preventive tests and treatments. Check out the links below to see what you should be doing to prevent what’s preventable. Just as important is learning what tests are unproven (or proven to be worthless). The second link, the Electronic Preventive Services Selector is especially handy. You enter some simple data about yourself and it displays all the proven preventive services for you.
That’s how you can have the confidence of knowing that you’re doing everything you can. Having tests that have been proven to be useless isn’t being proactive; it’s making an irrational decision based on fear.
There are plenty of terrible diseases out there that outmatch our best tests and treatments. But after a moment of reflection, this is not a reason to panic. It’s a reason to do what is sensible to stay healthy and then to focus on your life, not your health. The rational fear is not “What if I have pancreatic cancer?” but rather “What if I’m healthy and spend the next decade worrying about pancreatic cancer?”
Have a happy and calm Halloween. And face the future unafraid.
Learn more:
Infectious Diseases, Prevention
Diversity of opinion is a mark of any free society. Whenever I hear the latest conspiracy theory, see a commercial for a ghost-investigating “reality” show, or hear the latest quack cure advertised on radio, I remind myself that the spread of wacky fringe ideas is a consequence of liberty. And, though I wish my fellow citizens would develop a bit of skepticism, I wouldn’t want anyone preventing them from hearing, watching or believing all that nonsense.
So it’s a major victory when facts finally win out in the court of public opinion—rare but sweet instances when science scatters away panic, rumor and superstition. This seems to be happening about vaccines. The fact that vaccines are very safe and that they save lives is gaining popular traction. This is very encouraging.
It means that people who believe that organic food has health benefits (it doesn’t) or that vitamin C helps treat colds (it doesn’t) are at least rejecting the fear-mongering of the anti-vaccine movement. A recent article in the Atlantic (link below) is another step in spreading the truth. It’s not long. Please read it.
Of course, none of that matters because the Mayan calendar predicts the end of the world in 2012. I better stock up on vitamin C.
(Thanks to my friend, Tom, for pointing me to the Atlantic article.)
Learn more:
The Atlantic article: The New Pandemic of Vaccine Phobia
My previous posts about vaccine refusal:
Vaccine Refusal: Turning Back Two Centuries of Progress
U.S. Measles Cases at Highest Numbers Since 2001
Dementia isn’t one disease. Like cancer, dementia is a family of different diseases that have important similarities. The diseases that cause dementia all lead to progressive memory loss and brain dysfunction. Dementia is caused by Alzheimer’s disease, vascular dementia, Parkinson’s disease and several other rarer brain disorders. The different diseases that cause dementia cause different symptoms initially and have different treatments. But unfortunately all the treatments are temporary and only slow the progression of dementia. Advanced dementia has the same constellation of symptoms regardless of the cause – profound impairments in memory, language and mobility.
Dementia is a progressive incurable fatal illness. I learned that in my residency over ten years ago, and the newer treatments haven’t changed this fact. On average, patients survive for 4.5 years after diagnosis, but some live as long as a decade. There are incurable cancers with better survival rates.
Even though the poor prognosis of dementia isn’t news, apparently the word hasn’t spread. An important study in this week’s New England Journal of Medicine studied the prognosis of patients with advanced dementia and followed the care they received, their family’s expectations and their medical complications. Over 300 patients with advanced dementia who were admitted to nursing homes were followed. They all were unable to recognize family members, had minimal verbal communication, were completely dependent for all daily living activities, were incontinent and were unable to walk independently.
The results of this study were depressing. Over half of the patients died within 18 months. In their last 3 months of life over a third had distressing symptoms like breathlessness and pain. Only a fifth of the patients were referred to hospice care. Despite their terrible prognosis, over a third of the patients underwent a hospitalization, emergency room visit, tube feeding or intravenous feeding. The one bright point was that patients whose families understood the poor prognosis of dementia were less likely to receive intensive intervention. Though the study doesn’t state this, I pray this translated to earlier hospice referral and better symptom relief.
As we all live longer and as we are better able to treat and prevent heart disease and some types of cancer the incidence of dementia will increase. Families deserve honesty about the course of this terrible illness, and patients deserve comfort.
Learn more:
Time article: Redefining Dementia as a Terminal Illness
New England Journal of Medicine article: The Clinical Course of Advanced Dementia
The source of the statistics about survival after dementia diagnosis is this Medscape article: Survival After Dementia Diagnosis Depends on Age, Sex, Disability (click on the first search result)
Around the turn of the last century medical practice was in a sorry state. Despite dramatic advances in physics, chemistry and physiology, the day-to-day practice of medicine was still entirely estranged from the scientific method. Medical training and medical practice was still what it had been for thousands of years – an apprenticeship in which treatments were passed down from teacher to student and applied by doctor to patient for generations without rigorous testing. At about that time leaders in medical education sought to bring the scientific rigor of other disciplines to medical education and medical practice. We can’t say that their work is complete. The rigorous testing of therapies in randomized trials and the deliberate attempt to base clinical practice on the results of those trials (what we now call evidence-based medicine) is only a few decades old. And even now, many physicians are deeply skeptical of evidence-based medicine, preferring to rely on their own experience or on traditionally accepted treatments.
I have no objection to relying on my experience or my judgment in the many cases for which scientific evidence is lacking. Every day doctors face clinical situations for which no large randomized trials provide data. That is the time for experience, improvisation, the art of medicine. But some physicians resist relying on science even in cases in which studies exist and are clear. They assert the importance of their autonomy and experience and refuse to follow “cookbook medicine”. The problem with that approach is that our experience frequently fools us. We remember best the cases that conform to our biases and expectations, and tend to forget the ones that challenge us. We overestimate the frequency of dramatic outcomes and underestimate the more common boring cases. We deceive ourselves to maintain our preconceptions. That’s why to get at the truth studies have to be blinded and randomized. The experience of every living person suggested that the sun revolved around the earth. It was only Galileo’s data that convinced him otherwise.
Though medicine has a long way to go, we’re moving in the right direction. But there’s another field which is now approaching the scientific revolution that medicine started a century ago – psychology. Much of clinical psychology remains the transmission from teacher to student of untested but long-used therapy methods. At the same time, the last few decades have seen remarkable progress in the science of mental illness and psychotherapy. A specific kind of psychotherapy called cognitive behavioral therapy has been proven in many studies to be helpful for many disorders, especially in the family of anxiety disorders. This scientific proof is startlingly lacking for many other forms of psychotherapy. But there is a schism between the scientific findings and the education and practice of psychology. Most psychologists have not been trained in cognitive behavioral therapy and most do not practice it, relying instead on unproven techniques.
This is not my criticism. It is the criticism of three psychologists led by Dr. Timothy Baker in the University of Wisconsin who authored an article in Psychological Science in the Public Interest. (See link below.) The article details the many evidence-based psychotherapy techniques available and then shows how infrequently these techniques are used in practice. The editorial that precedes the article is a clarion call for the field of psychology to reform itself if it is to continue serving patients.
I have the pleasure and honor to take care of several psychologists and have psychologists as friends. (I look forward to their emails about this.) My intention in this post is not to point fingers or criticize. It is to highlight an important positive development in psychology and to encourage psychologists to trust science.
Learn more:
Newsweek article: Ignoring the Evidence. Why do psychologists reject science?
LA Times Booster Shots: Do therapists know what they’re doing? Don’t bank on it, 3 psychologists say
Psychological Science in the Public Interest article: Toward a Scientifically Principled Approach to Mental and Behavioral Health Care
Infectious Diseases, Prevention
Countless of you (well actually, several of you) have asked me in the last few weeks “What about the swine flu vaccine?” “Should I get it?” “When will it be available?” “Is it safe?” “Does it not herald the coming of the zombie apocalypse?” Well, your long wait for answers is finally over.
So far the H1N1 infection has caused symptoms very similar to garden variety seasonal flu, except that diarrhea and vomiting have been more common and that most hospitalizations have been in people younger than 65. Remember, this is overall not a worse disease than the regular flu, though some groups have been particularly vulnerable.
Physicians will begin receiving shipments of the H1N1 vaccine later in October. The H1N1 vaccine is prepared the same way as the regular influenza vaccine, so it has the same side effects and is just as safe. Fortunately (despite conflicting reports a few months ago) one dose of the vaccine is sufficient.
The vaccine is recommended for the following five groups.
If you’re in one of the above groups, see your doctor later this months and get the vaccine. If you’re not, don’t. Our office expects to receive the vaccine in the next few weeks.
Learn more:
Centers for Disease Control recommendation for H1N1 vaccination