There is an important study in the Archives for Internal Medicine last month, which escalates an ongoing row as to whether patient satisfaction is in any way correlated with positive medical outcomes. The answer is yes, and the correlation is negative.
This finding is of critical importance, not just in understanding why American medicine is a hopeless, costly mess, but also as a window into how easy it is for buyers of complex services to be hoodwinked by their servicer provider, whether via the provider being incorrectly confident about his ability to do a good job or having nefarious intent.
Let’s deal with health care case first. The study in question was large scale, of 52,000 patients from 2000 to 2007. This summary comes from the Emergency Physicians blog (hat tip Julie W):
Results of the study showed that patients who had the highest satisfaction ratings spent 9% more on health care and prescription medications than did patients who had the lowest satisfaction ratings. In addition, the most satisfied patients had a 26% greater risk of death compared to least satisfied patients. When patients in poor health were excluded, the risk of death for these highly-satisfied “healthy” patients increased to 44% more than their least-satisfied counterparts.
In commentary accompanying the article, Dr. Brenda Sirovich suggested that discretionary testing is likely the cause of both the increased costs and the increased mortality in highly satisfied patients. Patient perceptions, even if medically inappropriate, drive testing and treatment. Antibiotics are harmful in patients with viral infections, yet a substantial subset of patients are not satisfied without an antibiotic prescription for their colds. Large studies show no link between PSA screening and either overall survival or prostate cancer survival. However, any patient whose life has been “saved” by a PSA screen is often quite satisfied. In both scenarios, there is no perceived negative effect from treatment. Patients will recover from their colds with or without antibiotics. Patients likely would not have died from their prostate cancer even if it was left untreated.
And consider: drug research shows a fairly significant placebo effect. So one would assume that satisfied patients would show positive results merely from placebo effect. The fact that the overall results are decidedly negative doesn’t merely say that more treatment and more testing are ineffective, it suggests they actually do harm.
The article uses the PSA test as an example of ineffective screening. I’m pretty healthy, yet I’ve seen this bias to overtest and overtreat first hand, and I can’t imagine what people who are less than robust must go through.
Readers have seen me rant upon occasion in comments about mammograms. They are a terrible test. They are bad at capturing the dangerous-fast moving cancers and produce a lot of false positives (benign slow moving growths which won’t kill you even if you live to be 100) which lead to unnecessary procedures. Oh, and no one factors in the risk of annual exposure of soft tissue to radiation. Manual breast exams by an experienced examiner are far better at detecting the dangerous growths, and thermal imagining is also more accurate than mammograms and does not involve radiation. But radiologists have an installed base of equipment and will hector you if you refuse to get a mammogram.
Similarly, there are only a few knee operations (surgeries for a torn medial meniscus and torn ACLs) that have a high efficacy rate. Yet with my long-standing knee problem (which is my case is due to foot and ankle instability but the overwhelming majority of orthopedists won’t even look at my gait), the standard answer from an orthopedist is, in the absence of ANYTHING sus on an MRI: “Let me go in and have a look and I’ll clean it up.” I’m not about to let a doctor go on a fishing expedition in my knee, yet that seems to be considered acceptable.
The inherent problem of medicine American-style was set forth longer form in the Maggie Mahar book, Money Driven Medicine which shows why the market has failed. One big culprit is information asymmetry. One of the conditions for a market to function well is that buyers and sellers have perfect information. In the medical arena, there is often a lack of good data as to what constitutes optimal practice. Among the many examples are the backing and forthing on hormone replacement therapy and the above mentioned mammograms. Now condiser: these treatments have been the subject of multiple large scale studies. Most protocols haven’t been investigated this intensely. And even when there is good information, the patient is at the mercy of his medical providers, the drug companies, and device makers. He can’t challenge their views; his best hope is to shop for a better practitioner, which is a costly, time consuming, and deeply flawed process (how can he judge whether a doctor is making sound recommendations?).
The other major element of market failure is the considerable disparity in buyer and seller power. If you are very sick, you will do anything to get better, which includes spending a lot of money. And our can-do, technology-loving culture favors doing more, whether beneficial or not.
We’ve seen how resistant patients are to evidence-driven medicine, particularly when the finding is less is more. Women seemed distressed to be told that mammograms were being overadministered (the old recommendation had been to get them annually starting at age 40, the new recommendations are ex a family history of cancer, to start getting them at 50 and have them done every other year through age 74). And patient confusion was not helped by self-serving radiologists taking issue with the study conclusions. And we have drug companies expertly playing on patients’ “more must be more” bias: advertising aggressively for new drugs, when they are typically much more expensive than older ones, often with little or no improvement in efficacy. Doctors seem remarkably disinclined to argue with patients who want a particular drug (indeed, I’ve seen how trigger happy doctors are to hand out pills. Say you are tired and in NYC that’s treated as code not for a vitamin B-12 shot, but either Adderall or anti-depressants).
The bigger issue is that in many fields, customers have no real ability to judge service quality. Like the satisfied patients, they too often rely on proxies, like bedside manner or being with the “right” firm, when big firms have first and second strings, and if you aren’t an actual or prospective big ticket you are usually better served finding a good partner at a smaller shop. I’ve been more exposed to top lawyers and litigation by virtue of working on complicated deals, having some clients get involved in lawsuits, and often talking shop with some savvy lawyer friends. As a result, I’ve mainly have very good experiences the few times I have had to hire a lawyer, but even I had one stuff up. And I’ve seen too many times in client situations where they appeared not to understand that their counsel was not up to snuff for the task at hand, but it would have been close to impossible to get them displaced.
I’ve similarly seen friends make bad decisions because they trusted their advisor when they shouldn’t have. I remember a long argument with a savvy investor friend who liked and trusted her broker at Citigroup, and took his advice to buy Citigroup at $45. She wouldn’t listen to contrary information, in fact, she was convinced he had some special insight by virtue of being at the bank (as opposed to he might be getting bonus credits). We know how well that trade worked out.
And that’s one reason I’m more sympathetic with duped investors than other readers probably are. Hindsight is always 20/20. The mortgage securities market had seemed to work well for nearly two decades. Bernanke kept insisting household balance sheets were fine and there was no reason to worry about housing prices, that prices would at worst stabilize. And most people trust people they do business with. That’s a big factor that enabled looting by the securities industry. People simply don’t want to believe that someone who seemed sincere and should have an interest in keeping them as a client would fleece them.
The message, sadly, is clear: satisfaction is not always in a customer’s best interest. But most of us don’t have the time or psychic energy to be vigilant.
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My knee, ankle and hip pain were highly reduced by strengthening my legs. Strong leg muscles protect the cartilage like an organic brace, and allow it to repair itself faster.
I’ve been focusing on Crossfit for my strength training. It’s the most effective program I’ve ever tried.
I’ve been weight training for 25 years with pretty heavy weights (and I come from a gene pool disposed to be strong). My issue is not muscle strength. You don’t have much in the way of muscle in your ankles and if your feet and ankles are compromised, there is really not much you can do. As physical therapists like to say, the injuries move up the chain.
I’ve been weight training for over 20 years with pretty heavy weights … Yves Smith
Dang it! I’ve been tempted to go back on drugs and then you have to mention a healthy way to get the same results.
Oh, well [getting out the push-up stands].
Sigh…
If you do have persistent issues, Drs. Delmonte and Greenberg of Belvedere Podiatry Group (near the Museum of Natural History) are excellent for feet and ankles; the therapists of Bradley & Monson (near Columbus Circle) have worked wonders for me by addressing gait issues.
You may also have good luck with a sports med doctor named Dr. Simonetta Sambataro, who I think is open to investigating gait issues. The comments filter should have my email if you need contact info (I think her google-fu is weak).
I hate to tell you but I have spent a fortune on this and have seen everyone from orthopedists to witch doctors. I was seeing orthopedists as soon as I was walking. Everyone is convinced they can help me, I’m very good about compliance (for instance, I spent two years doing Alexander technique, with the best person in the city, 2-3x week), and without exception, I get at most marginal improvement and they are flummoxed.
This worked for my ‘since childhood’ gait deviation……
http://www.amazon.com/Walk-Yourself-Well-Structural-Forever-Without/dp/0974779113
Winslow, thanks but trust me, I’ve seen tons of top people already. And I don’t have pain. My feet don’t absorb shock properly, and it’s for structural reasons (issues in combination that are not supposed to happen in combination). So everything above them takes too much stress.
I know someone who has serious knee problems due to arthritis.
She finally realized that the smartest thing to do was to stay off her feet when she could. So she got a wheelchair.
Honestly, if you have a structural problem in your feet and ankles, I doubt any surgeon will actually know how to fix it, but using a wheelchair is about as simple as it gets for avoiding problems originating below the hip. Tried it?
Oh right — NYC still isn’t ADA-compliant in its public services. That makes it harder.
Yeah, mileage varies. You have to work with whatever you’ve got.
What I was trying to get at is that many leg related problems in mature people can be helped with general strength training. We start to lose muscle around 40 if we don’t pay attention to keeping it. Losing that muscle means we lose control around the joints and wear out the cartilage faster. Strong leg muscles stabilize and protect the joints.
I received some benefit from a Eurhythmy therapist for my gait too, FWIW.
Muscle is not a problem. My Olympic medalist great uncle hauled lobster traps into his 80s without a winch and I lift heavier weights than any other woman in my gym (and I’m over the average age).
I messed up my knees from exercising, not from not exercising. This was a trainer induced injury. When he showed up in a gym I was at, I mentioned to one of the guys, “That’s the trainer that messed up my knee.”
The guy said, “Oh, you mean Johnny? We call him Johnny Kevorkian. His other nickname is 007, licensed to kill.”
First, this was a fantastic post. I can’t tell you how many times people have harangued me for not “trusting” my doctor more. Ummm, medicine is hard, and doctors are not magicians, but humans subject to cognitive bias as much as anyone else (maybe more, based on all the inane suggestions for prescription medicine I have received over the years).
Second, I’m sure you understand a lot more about your situation than I do, but I just want to relate my own experience, and this is that my knee and ankle pain was dramatically reduced with a huge focus on core strength and transforming my walking and running gait to make it come overwhelmingly from my core (abs, gluts, lower back). Another (very!) anectdotal piece of evidence is the case of the NBA player Grant Hill who lost years and years of his career to what was termed degenerative ankle problems, but were “miraculously” cured when he was put with a trainer who taught him about core strength and completely changed his gait. The guy who could barely walk in his late 20s is still in the NBA at 39, and he has played almost every game for the last few years (he had a five year stretch where he basically played about one season’s worth of games). Anyway, I have no idea whether this is applicable at all, but just wanted to pass along my own personal experience. Sorry in advance if it is useless.
One of my takeaways from a circa 1980 MchEng Degree was from a girlfriend doing a masters in biomechanics.
If you insist on “weight training” keep the weights close to your bodies centerline (big wght x extention= big torque loads on joints.)
Do yourself a favor and swim-cycle-iceskate(indoors in summer in shorts is great). All good for joints, bone density, slow and fast twitch muscle fiber cardio etc.
Skip running, but we all know that already, right?
Does that mean I am healthy because I am scared of doctors and never visit one?
Yes. From experience yes.
There is an obvious explanation for this result and it is not that satisfaction with your doctor results in higher health care costs. The causal link is much simpler. Healthy people for the most part do not spend much time thinking about doctors or health care in general. They also have very low health care costs. People with health issues do think more about their medical care and get more emotionally involved with their doctors. They also have higher health costs.
This is a problem with the study that cannot be easily resolved by controlling for patient health.
I don’t see how you can claim that when the study DID screen out unhealthy people in a separate analysis and focused only on people who were comparatively healthy and found that made the “satisfaction is correlated with worse outcomes” finding even stronger. You are doing the equivalent of putting your fingers in your ears and saying you don’t believe the study findings.
You also misstated what the article seemed to think the causal chain was: ineffective overtesting and treatment leads to higher patient satisfaction, not that patient satisfaction leads to overtreatment. Your inaccurate summary suggests you read only the headline and at best skimmed the rest.
I did not like the doctor who told me to keep an eye on the lump in my breast and tell him in six months if it changed because I was too young to have cancer. True, I did not have cancer and the outcome would have been the same if I had not had the biopsy, but I would have had six months of anxiety and in fact it might have been cancer. When I read this types of studies I wonder if this is what they are talking about. Maybe the people who have more tests and more treatment are more anxious about their health and feel more need to understand their symptoms. I know people who are able to ignore symptoms for years and convince themselves that nothing is wrong, and of course usually it really isn’t anything important. But I cannot do that. I’m a different person. Cancer screenings and routine tests contribute greatly to my peace of mind. And if I have worse outcomes, maybe it’s because I’m a more anxious person. I don’t believe that means that giving me less testing or less treatment would make me healthier – more anxiety would I’m sure not be a good thing.
“…I’m sure not be a good thing”
Denise, at 34 my sister was diagnosed with breast cancer and later she tested positive for the BRCA gene mutation. Like an idiot I had the test and I too had the mutation. I allowed myself to be fear mongered into getting over screened and it will cost me my life. I now have a scleroderma type diagnosis. I am in pain 24/7. And it infiltrated my brain, specifically my hypothalamus. It altered the way my body handles stress, basically I can’t stress anymore. What I’m trying to say is I went from being terrified of cancer to not caring if I lived or died. I’m not saying what you should do about your anxiety but my anxiety allowed me to be fear mongered into getting scans I didn’t need and now I have a disease that is likely going to take my life. There are no free lunches.
Sorry yves you are completely wrong on this one. I like your economics but your medical knowledge verges on the junk medicine end of the spectrum. Stay with what you know.
I happen to know this stuff (about medicine) and you do not.
And your evidence is???
You say it can be explained by healthy people getting less emotionally involved with their doctors, and then say that one can’t control for this by choosing healthy people for the study. That doesn’t make sense.
I’ve worked in the medical field for 30 years and this study makes perfect sense to me. People who like their doctors do get prescribed more tests and medications, generally speaking. And generally speaking, physicians who prescribe tests and medications liberally are more popular. If a patient sees a physician complaining of a “slipped disk” and is told an MRI will be ordered in 60 days if his back is still hurting, how satisfied do you think that patient is likely to be? I have a good friend who decided to quit drinking, not that he thinks he has a problem, mind you, but because he wants to lose weight, and persuaded his GP to prescribe Antabuse in case he were to be tempted. He just loooves his GP. I could give many more similar examples. Surely you aren’t denying that doctors succumb to pressure from their patients to prescribe medications they don’t need and to order unnecessary tests. And then we could add the unnecessary surgeries to the mix that weren’t even mentioned in the study.
+1 ToivoS. Just this one article and the resulting comments are a garden of medical misinformation. For one, it reflects a misunderstanding of the economics of mammography. It is the radiologist who benefits from doing the test, and they might do lobbying in favor it it.
HOWEVER, it is a different physician who orders the test – a family doctor, a GYN, a breast surgeon, etc. They have no direct financial incentive for them to order the test.
It’s no surprise that the ER docs came out with this study. They get a druggie demanding Vicodin, refuse to prescribe it, and then the patient fills out a Press-Gainey form trashing the ER doc.
Please note, Yves, that among genuinely ill (but treatable) patients, greater satisfaction might be associated with better results. They have more incentive to really care about better results. Hell, my favorite doctors are the ones who rather than running tests sat and actually DISCUSSED my symptoms with me.
It’s no surprise that the screwed-up correlation is true among relatively healthy patients.
There is definitely an app for that. In rural India they have clinics set up that are all computers. They analyze blood, spit, skin, urine, etc and pop out a reliable diagnosis. You are prescribed anything you need to recover, etc. Very cheap. And just consider genetic testing in conjunction with the tests we currently have. Medicine is going down proportionally to sophistication of testing-analysis. And it is high damn time.
Saw this on Book TV last weekend, this frustrated cardiologist wants to help consumers make change by demanding from their doctors better use of technology as you describe is being done in rural Indian clinics (as you say, it’s about time!):
“The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care”
Eric Topol
About the Program
Eric Topol, director of the Scripps Translational Science Institute and cardiologist at the Scripps Clinic, contends that digital technology can make medical care more efficient and effective. However, due to what the author argues is the medical community’s resistance to change, technological advances have yet to be fully accepted. Mr. Topol presents his thoughts on how to re-imagine health care and the doctor-patient relationship at Kepler’s Books in Menlo Park, California.
About the Authors
Eric Topol
Eric Topol is a cardiologist at the Scripps Clinic and genomics professor at The Scripps Research Institute. He is director of the Scripps Translational Science Institute and co-founder of the West Wireless Health Institute.
http://www.booktv.org/Program/13279/quotThe+Creative+Destruction+of+Medicine+How+the+Digital+Revolution+Will+Create+Better+Health+Carequot.aspx
Re: “And we have drug companies expertly playing on patients’”
Experience has me reading thusly . . .
“And we have drug companies expertly PREYING on patients’”
And we have insurance companies preying on patients.
And we have Congress, the President and the Supreme Court preying on patients — er, Americans.
Further, we have 1000s die before they even get to see the doctor. The number could be as high as 50K annually, but this usually brings forth squealing denials from the luddite vested interests. The ‘hands off my for profit entitlement’ groups.
Yves, please pay attention to the really important studies in The Lancet on aspirin and cancer. I am thinking of you comment on breast cancer. The studies are critical to know about.
http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045%2812%2970112-2/abstract
March 21, 2012
Effects of regular aspirin on long-term cancer incidence and
metastasis: a systematic comparison of evidence from observational studies versus randomised trials
By Annemijn M Algra and Peter M Rothwell
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%2961720-0/abstract
March 21, 2012
Short-term effects of daily aspirin on cancer incidence, mortality, and non-vascular death: analysis of the time course of risks and benefits in 51 randomised controlled trials
By Peter M Rothwell, Jacqueline F Price, Gerald R Fowkes, Alberto Zanchetti, Maria Carla Roncaglioni, Gianni Tognoni, Robert Lee, FF Belch, Michelle Wilson, Ziyah Mehta, and Tom W Meade
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960209-8/abstract
March 21, 2012
Effect of daily aspirin on risk of cancer metastasis: a study of incident cancers during randomised controlled trials
By Peter M Rothwell, Michelle Wilson, Jacqueline F Price, Jill FF Belch, Tom W Meade, and Ziyah Mehta
If what you say about patient satisfaction is accurate, then the WHO study of health care world wide would have to rank the U.S. even lower…! (WHO used a comprehensive set of public health measurements like life expectancy, vaccination rates and infant mortality, plus patient satisfaction).
The U.S. ranked 37th in that study, between Costa Rica and Slovenia. McClatchy said that it was as though the U.S. had the health care of Costa Rica, but paid six times more for it.
…
Marcia Angell writes in the NY Review of Books: “The problems I’ve discussed are not limited to psychiatry, although they reach their most florid form there. Similar conflicts of interest and biases exist in virtually every field of medicine, particularly those that rely heavily on drugs or devices. It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine.” See http://www.nybooks.com/articles/archives/2009/jan/15/drug-companies-doctorsa-story-of-corruption/.
Thanks for highlighting this research!
I’ve read (most recently, in Stephen M. Davidson’s book, “Still Broken”) that when insurers or Medicare or Medicaid squeeze reimbursement rates, many doctors seem to react by increasing the services they provide each patient – by roughly the amount necessary to maintain a steady income.
We desperately need a wholesale shift to evidence-based medicine, for BOTH cost control AND patient safety. Outcome data need to be collected and analyzed on a large scale, and the results made widely available.
Ouch, ouch OUCH! Girl, you have nailed it on the head with this post. As some readers know, I am now a professional patient/cripple, and spend most of my waking hours w/flamin’ physicians. I must constantly fight to avoid unnecessary, invasive testing. Yes, there’s a lot wrong with me physiologically, but I’m not stupid. I just aborted a 72 hour EEG (I’m having a lot of trouble w/vertigo, but I know the cause – landlord putting fumes and lead dust in my apt in December.) 14-16 hours overnight was more than enough to observe the available phenomena. My job is to get to the bottom of the diagnosis, not to bolster their bottom line.
I think part of the overall problem, as far as the public judging what is appropriate or necessary, is ignorance. By which I mean the absence of hands-on science (Chemistry, Biology) in high schools. Here in NYC I know many schools have no science labs; and there is enormous push-back on including significant knowledge of human anatomy (reproduction). Even my very mediocre rural high school, 30 years ago, had this most basic training, but now it is rare in our city.
Another issue is very poor science reporting in the media. Many of the studies publicized, per Marcia Angell, are bogus; but even so, the garbled, sloppy and solipsistic (is that redundant)accounts only confuse and trivialize serious medical issues. How can the public stay abreast of new developments, or fill in old gaps, with this Entertainment Tonight approach?
VERY interesting and counterintuitive to modern minds… but would have been perfectly understandable to my grandmother.
Connects nicely with the well established but rarely published fact that 100k to 200k people are killed by medical errors each year.
The more time you spend on tests and drugs, the more risk of uncontrollable infections, bad prescriptions, cancer caused by radiation, etc.
Wonder if the study included people like me who are happy when a doctor hates tests and drugs, and uses them only as an absolute last resort? After 20 years without any doctoring at all, I finally found one with those characteristics, and I’m happy with him!
I strongly recommend the comment accompanying this article for those interested. Its discussion of the “positive feedback” dynamic is on-target. I’ll excerpt, as I think it is paywalled:
“Positive feedback systems abound in health care, for both physicians and patients. Diagnostically, almost any unnecessary, or discretionary, test (particularly imaging) has a good chance of detecting an abnormality. Acting on that abnormality has an excellent chance of producing a favorable outcome (because a good outcome was already highly likely). Having obtained an excellent outcome, ostensibly owing to a test that was seemingly unnecessary, a natural reaction would be thereafter to perform (or, for patients, undergo) even more discretionary testing in patients with an increasingly negligible likelihood of benefit—and greater risk of net harm.”
As the author notes, “positive” feedback does not necessarily result in better care. Rather, the term describes the ability of certain practices/attitudes to be self-reinforcing.
article at:
http://archinte.ama-assn.org/cgi/content/full/archinternmed.2012.62v2
According to these researchers, evidence-based medicine is the problem, not the solution.
Tarnished Gold: The Sickness of Evidence-based Medicine [Paperback]
Steve Hickey PhD (Author), Hilary Roberts PhD (Author)
“Evidence-based medicine, the “gold standard” of medical decision making, is increasingly unpopular with clinicians. They are right to have reservations. EBM breaks the laws of so many disciplines that it cannot be considered scientific or even rational. Decision science and cybernetics show the disturbing consequences of such flaws. EBM fosters marginally effective treatments, based on population averages rather than individual need. Its mega-trials are theoretically incapable of finding the causes of disease, yet swallow up research funds. Ultimately, EBM cannot avoid risking patients’ health. It is time for medical practitioners to discard EBM’s tarnished gold standard, reclaim their clinical autonomy, and provide individualised treatments to patients.”
http://www.amazon.com/gp/product/B00710Y1YI/ref=pd_lpo_k2_dp_sr_1?pf_rd_p=486539851&pf_rd_s=lpo-top-stripe-1&pf_rd_t=201&pf_rd_i=1466397292&pf_rd_m=ATVPDKIKX0DER&pf_rd_r=11HW478MHTFVY64J6AAW
Sounds like pure “leave us and our medieval guild alone” bullshit to me.
You nailed that one, liberal. Some don’t want to hear that their tonics and incantations are worthless, especially if they happen to own the place that sells the tonics and incantations.
I pretty much ignore my doctor’s advice to get a mammogram or other tests I feel I don’t need. There’s no history of breast cancer in my family though. However, I find myself constantly talking doctors into figuring out what’s actually wrong with me instead of pushing a pill at me, and usually have a better idea of what it is than they do at first. So I do subtly push for certain tests or sometimes request they try a certain medication.
I also do strength training and other fitness programs, watch my diet and take a few supplements. I hear you on the B12 thing. I did once have an osteopath that used them regularly for tired patients, other than that I’ve never had a doctor suggest one, and “tired” is a very typical symptom for me when I’m not feeling well.
I think creating patient awareness about their treatment would be a better goal than “customer satisfaction”.
Your pull quote includes one of my pet peeves. Unless the study pool included the Virgin Mary and/or the Prophet Elijah, the risk of death was 100% for all groups.
Just maybe, people are more satisfied with doctors who do not urge them to suffer unnecessarily. I certainly would be. I’m with you not only on mammograms, but on all cancer testing and treatment. The certainty of radical impairment of quality of life isn’t worth the 5-20% chance of greater quantity, in my judgment for myself.
Yves, thanks also for the link.
If you want to fix your problem with fatigue, then check out:
http://mpkb.org/
Its a big wiki, (over 400 pages) but if you are determined….. There is also a support group in New York city. This is an excellent example of patient led research/community which is making real progress.
Nick B
To ginnie nyc
> “I’m having a lot of trouble with vertigo”
See: Balance problems have been a part of my symptomology for many years. In fact in the early days of my illness before I received any treatment I had severe vertigo attacks. These issues have all cleared in recent years due to [the] MP.
read further here: http://mpkb.org/home/symptoms/neurological
Nick B
There is a fabulous little book written by Olivier Clerc and titled “Medicine, Religion and Fear”. Very quick read. In that book, he clearly explains how religion used to be the answer to every illness, since sin was at the root of it. Religion was “administered” by priests, the all powerful god-chosen individuals able to “chase” the demons. The soul was what needed to be treated. Every cold, every plague, every lumbago was caused by sin in people’s life. Priests were in attendance, dispensing their religious magic. People died, plagues spread but it wasn’t because of the priests incompetence: sin was powerful and the masses failed to adequately repent of it. Hence the constant illnesses.
Many countries became secular with the advent of medicine and science, both banned by the church, as they were the “tools of Satan”. All of a sudden, the physicians became the new priests and the root of every illness became known as “germs”. Germs were the culprits and they had to be killed at any cost. Science didn’t care if they were good or bad: they were “germs” (they had, in effect, replaced the “demons” of the middle-ages) and they needed to be eradicated. Our medicine kills germs and takes no prisoner.
Both are extreme. Neither could have succeeded without… the collective fear of the masses. Those same masses who would flock to church at the first sign of any epidemic and who, nowadays, flock to hospitals for any ailment, without ever changing their lifestyle or taking responsibility for their own well-being.
As I said, very good read.
Thanks Yves for finding this one. I’m part of the choir, but it’s always good to have supporting data.
Because I was poisoned by gadolinium based contrasting agents (GBCAs) I have done a lot of research trying to find the cause of my illness. It took ten years but I believe I have my answer, it was GE’s product Omniscan and Bayer’s product Magnevist two of the least stable GBCAs on the market. I allowed myself to be fear mongered into getting MRIs for my risk of breast cancer (have one of the mutations) and now I have this dreadful disease for which I can’t get a diagnosis, can’t get treatment and there is no cure. Mainstream medicine has abandoned people like me like they do with almost all medical mistakes. Many others are in the same boat as me and many still don’t know why they are sick. Three times gadolinium was found in my tissue and I have high levels of gadolinium in my urine without provocation four years after my last MRI. Already this disease has cost my insurance company about $200K and because it is a systemic disease it has affected my heart, lungs, liver and brain as well as my skin. I have a differential of scleroderma (wink, wink not NSF). And doctors will not help me and others like me. They are too busy covering up for the industry that pays them and covering for other negligent doctors to care about helping the patient. This is why I believe and hope their profession will go the way of the fresh-water economists. That would be the best possible outcome for patient safety.
At least 1% of every bolus dose of GBCAs administered is retained in the body and they are finding gadolinium in the brain tumors and reproductive organs of those exposed. It causes mitochondrial alterations. Over 300M doses of these GBCAs have been administered worldwide and some experts believe an epidemic is eminent when the retained gadolinium starts to get released from the bones. And another interesting tidbit is it fits the EPA timeline for when an environmental cause of autism is suspected. The EPA has said 1988 was the year. Magnevist was approved for widespread use in 1988 and after, the least stable product of all of the GBCAs, Omniscan was approved in 1993.
Now that I have provided background I would like to add that your post is timely and on target. We live in a predatory healthcare environment where profits come before patient safety. First do no harm has become, profit first and never cure. The CDC is coming out with a new number for children afflicted with autism. Rumor has it that number is 1 in 88 children. But of course the mercury they are exposed to before and after birth has nothing to do with autism. How many vaccines are we up to now? Last I heard it was around 69 before a child reaches 18. And why are the pharmaceutical companies so rabid when anyone questions the sanity of accumulated mercury in the number of vaccinations now being recommended or that number even without mercury. What is the limit a body can take? Is it 250 vaccinations or 350 vaccinations? The pharmaceutical companies will never do the studies on efficacy of that number of vaccinations or studies that show that number of vaccinations may actually be harmful. Perhaps their finance department can teach them the law of diminishing returns. If you kill or sicken the host, eventually you won’t have any more victims to jab.
My guess is predatory medicine is the next bubble to burst or has that one already burst? After all pharma’s profits are down, internationally, due to the current state of the global economy. We just might get a reprieve from poisoning with impunity by pharmaceutical companies and medical device and equipment manufacturers. Another question, if I may, is pharma furious at the banks too? This has to be interfering with their predatory healthcare plan and poisoning with impunity medical industrial complex.
Here’s a link that will back up much of what is in this post. http://www.scribd.com/gasfgd
Yves,
it sounds to me from your story about anti-biotics is that the profession needs to invent a placebo anti-biotic.
oops
should read .. anti-biotics, THE LESSON is
There is an information bias in medical screening that epidemiology is trying lately to fix. And God bless them. The public does not understand yet, but here’s an analogy: If you are driving 100 miles, you can start paying tolls at mile 10 or mile 90. But either way you are still driving 100 miles and no further.
Just because a disease is discovered earlier, and a patient starts treatments earlier and possibly for longer (at more expense), that does not mean life has been extended or morbidity alleviated. Simply people can (and do) spend more time being sick because they have been classified as sick sooner, before they felt sick. It is easy to mistake this as extended survival; it is not. Upon closer investigation, extended life is often not the case. And in some instances health is subject to increased risk because each medical intervention has a probability of failure and complication (underestimated by physicians who like to think of themselves as doing good).
It is an ethical dilemma to recommend screening people that feel healthy, knowing that many could become subject to false positive diagnoses, and uncomfortable and potentially dangerous procedures. Epidemiology is trying now to discourage those persons with low risk of a disease from being screened, but they do not yet understand. They perceive it as being deprived. Moreover, some parts of the medical industrial complex may not want them to understand.
Also Yves, re blog thread about exercise… I think you used to work out at a women’s gym in midtown many, many years ago (think green shag rug). If my recall is correct, you had/still have very high arches in your feet. Such anatomy can achieve a beautiful ballet point, but as you rightly identify, such feet and ankles are difficult to strengthen. Weight lifting will not do it; that only targets large, gross muscle mass. Ballet exercises would better do it, but these require time and patience; some people might consider them boring; but thereby the many, smaller muscles that are so critical for balance, coordination and placement are exercised. If you pursue ballet exercises, having weak knees, be careful to avoid twisting at the knees. Rotate/strengthen at hips.
I’m a little under-exercised myself compared to what I think is desirable. Alas.
Just because a disease is discovered earlier, and a patient starts treatments earlier and possibly for longer (at more expense), that does not mean life has been extended or morbidity alleviated. Simply people can (and do) spend more time being sick because they have been classified as sick sooner, before they felt sick. It is easy to mistake this as extended survival; it is not. Upon closer investigation, extended life is often not the case. And in some instances health is subject to increased risk because each medical intervention has a probability of failure and complication (underestimated by physicians who like to think of themselves as doing good).
excellent point
This is not junk science. This is a very important debate we must have. The wake up call for me was in the middle of the ACA debate, the release of new recommendations on screening guidelines for mammograms. What a disaster!
They still recommend MRIs with contrast for women with a BRCA mutation even though there is a black box warning for all of the GBCAs. My radiologist continues to send me letters about my six month exams and even sends notices to my ob/gyn. I’m going to get thermography but it is going to cost me money out of pocket because insurance won’t pay. More effective screening tests that are non-invasive are available including proteomics (Ovacheck) but these highly accurate cost effective screenings are either suppressed by the FDA or not paid for by insurance.
I finally went in for thermography last month. I decided to do both the breast thermography and the whole body scan figuring I might as well get the whole body overview. Yes, it cost me money (and it will every year when I go back), but when I finally got my full report, with the full color scans of various body areas and the accompanying doctor’s analysis of the scans, it was unexpectedly very empowering and I decided that feeling alone was worth every penny spent. What’s great about thermal imaging is that it is easy to see and understand the results, and the doctor’s analysis was also easy to understand. When asked the nurse who had the thermography practice how she got into it (guessing she was in her early 60’s), she said “23 mammograms” and a huge amount of frustration with the system. She had so many false positives (due to dense breast tissue, which I also have) they kept sending her for more tests and ever more mammograms and she finally got fed up with the whole process and all the radiation she had received and starting researching other options. This lead her to set up one of the very few independent thermography practices in Massachusetts. btw, she sends her scans to a group of doctors (with many years of experience interpreting those) who analyze them and write up the official report. I had copies of the scans & report sent to my primary care doctor’s office and to my ob-gyn’s office. Both had been pestering me (though not excessively) in recent years to get a mammogram (I am 55 and never had one for all the same reasons Yves has mentioned) and I had been putting them off. In the next couple of months I will have my annual exams at both offices and it will be interesting to see what they have to say about the thermography reports.
About the title of this post… I did find it a bit offputting. After a few years of looking around, I am finally very happy with all 3 of my doctors (2 of whom are really NPs) because they don’t try to overmedicate or overtest me, and they actually listen when I tell them about my own medical treatment research and treat me with respect. I tend to rely on acupuncture and chiropractic to take care of most of my personal health issues and I need to see doctors that can deal comfortably with that.
I’m also happy with my doctors but that is after flying all over the country to be told I don’t have a disease I know I have…it’s just they are lying and bought and paid for by pharma. The diagnostic guidelines were funded by the manufactures that are being sued. And guess what? No conflicts reported.
I called today about a thermography appointment because I want to get checked annually for ovarian and breast cancer but also to see the extent of the fibrosis and to get a baseline. I still have hope I can get better but the scar tissue will be tough. The woman I talked to didn’t have a clue what she was talking about regarding fibrosis so I sent her an article on thermography being used on localized scleroderma. I wouldn’t be surprised if the test never got off the ground because of suppression by competitors or liability. In any case if you check back I would love to know the name of the clinic you go to. I’m from the East Coast but live out west now. I could hop on a plane and go to the clinic if they offer what I’m looking for which is a full body scan.
http://rheumatology.oxfordjournals.org/content/41/10/1178.full.pdf
Sharon,
This is the clinic I went to http://insideoutthermography.com/thermography_ma_nh.htm It’s in Byfield, MA, which is close to the NH border near the coast (~1 hr from Boston). Janice is great, very knowledgeable and spiritually attuned as well (she’s a holistic nurse). She has been doing thermography since 2005 and trained at Duke http://insideoutthermography.com/janice_anderson.htm . As with anything else, not all thermography clinics are of the same quality nor are all the training programs, but her background is excellent. You may not need to fly to New England to get a scan… I’m guessing she would know a reputable thermography clinic closer to where you live and would be happy to refer you.
yves, re: reports of mammo’s are better at 50 than 40.
Yves, i mention this because, as you say, how do we know what report is correct. Yves, remember the “eggs are bad” scare. And then 1 year later, “eggs are good”. Then the next year, “eggs are bad” again. How are you supposed to know which is true? How do we not know that there was a shortage of eggs one year and then a surplus the next year?
Or to get even more conspiratorial, how do we know that the 1% aren’t using the rest of us like cattle? They say ‘let’s do a test. let’s let them go without mammograms until later in life to see how they do. Regardless that as elites, we get full body scans every 6 months because we are so important’. But just think about it. What if they discover that the tests need to be increased? Who would be the first to get tested? A bunch of broke young people with no insurance. Or a bunch of wealthy ppl with trust funds.
“Antibiotics are harmful in patients with viral infections….”
???? really. is this true?? what is the basis for this suggestion??
Simple reason:
1) antibiotics do absolutely nothing to cure viral infections
2) While pointless use of antibiotics may not be immediately harmful, it increases the long term risk that bacteria will become immune to those antibiotics, rendering them useless sooner.
I think Yves touches most of the right bases. Basically, it comes down to this: Healthcare is not a commodity. It is a right. There is no healthcare “market”, just as there is no market for other rights.
Various observations:
Americans are woefully ignorant about even the simplest and most common disease processes. I have often thought that by the time someone finishes high school they should have a basic understanding of the half dozen most common conditions: heart disease, hypertension, high cholesterol, diabetes, a few cancers, and the effects of tobacco, alcohol, and obesity. And they should know the difference, at least, between a virus and a bacterium. I am not talking about anything super in depth and it should be possible to develop a curriculum given over 6-8 years that addressed all this. Of course, I also think such a curriculum should be required to teach the basics of US history, government, and the Constitution.
Because Americans even college educated ones, even most of those who go to the internet for information, don’t really know what is going on in their own bodies, they have no way of assessing either their physicians or their medical options. And those options by the way usually correspond to their ability to pay or get their insurance to pay.
Overtesting is sloppy medicine. It is different from a screen. In a screen you expect a certain level of false positives. An ineffective screen is one where that returns many false positives. Physicians need to be upfront about how many of these there are. An initial screen is just that. It eliminates a certain percentage of the population and targets a subset of it for further testing and evaluation. The value of a good screen is in how many more people it correctly identifies as having a disease, and what the health consequences would have been if those patients had not been identified.
A bad screen is one that delivers false negatives, that is people who have the disease which the screen misses.
One aspect that is not treated in the post is what is euphemistically referred to as medico-legal issues or defensive medicine. This is what results in a lot of overtesting. Some physicians will identify a patient or family as “litigious” and correspondingly test the hell out of them, not because they need it, but to avoid any a lawsuit. It is sort of important to realize that even good physicians can get hit with malpractice suits. Of course, even good physicians can make mistakes. And to be honest, many stories people have told me about their medical experiences or those of family members shock me at the level of malpractice that goes on, that they do not sue over. But to return to my point, a malpractice suit can have a devastating impact on a physician and their practice of medicine. I knew of one neurologist, a good one, who got hit by such a suit. Ever after when he was brought in on a consult, he would order thousands and thousands of dollars of testing, pretty much everything including the kitchen sink. This was fundamentally at odds with the whole consultative process. A consult is ordered to determine what needs to be done. “Do everything” is both extremely expensive and hardly helpful.
The way around overtesting is effective best care standards. Such standards can cover the vast majority of patients and should give physicians ironclad protection in the courts, that is it should be up to a judge to determine whether best care standards were met before a suit can go forward. I think this approach would have a positive impact on both the medical and legal professions.
Nothing personal, but the very mention of the word “healthcare is a right”, drives me freaking nuts.
Mind you, I live in Canada.
Health care is the word used to brainwash people. What the gov can do is provide MEDICAL CARE when one gets sick. However, in order not to get sick very often and be energetic, one has to work out and eat healthy.
Work out = 80% “no impact” cardio 40 min every 2nd day. This is the only natural or evolutionary thing, walking, running. Do not use treadmills, only elypticals. Any impact on joints must be avoided. 20% very light weights. This is just for muscle strength, but muscle bulging is not evolutionary, only walking is.
Eating healthy = Eating old style mediterranean food, which is basically my mother’s food back home.
Please, do not brainwash more people.
The discussion on healthcare has been around for years now, and you decide to make your stand on my comment? Bizarre. It is called healthcare because it is about your bleeding health. Health is much more than problems needing medical attention. It is a social good. Trying to make the distinction you seem to be making is just a step toward commodification of healthcare which is precisely what we need to move away from.
Brainwashing? Do your really expect to be taken seriously making such over the top statements?
Sir, everything is a commodity. Nothing escapes the absolute law of supply and demand, absolutely nothing.
Trying to abolish supply/demand is like trying to abolish death.
First of all, you are wrong about the definition of “commodity”. Many many things which are subject to supply and demand to some extent are not commodities; they are differentiated.
Second, you are wrong about supply and demand. They apply only to scarce goods. Information is infinitely replicable, therefore not scarce, and is therefore not subject to supply and demand.
This is actually first-week Econ 101, but all the economists forget it after the first week….
My husband is a gastroenterologist who dreads the day that reimbursement is tied to patient satisfaction, which is what is currently being recommended. Overtesting and overtreating are at best wasteful and often harmful, and yet patients are most satisfied when they leave the doctor with a prescription in hand and a test scheduled. My husband keeps up in his field and adheres to recommendations made in accordance with large-scale studies that weigh the risks and benefits of endoscopy in different subsets of patients, yet patients are annoyed if they do not feel that they are getting endoscoped often enough or getting the CT or MRI they feel they deserve. A physician will be in a difficult position until there are clear evidence-based guidelines that give doctors immunity from malpractice claims if the guidelines are followed. Every test has its risks, and a physician is vulnerable (as he should be) if there are complications and the test was done at the request of the patient, but was not necessary according to the literature. On the flip side, lesions can be missed following guidelines and not testing, even if the finding would have been totally serendipitous if the test had been done, and under our present system the physician will be sued for lesions missed by not testing, even if he was following guidelines. One can only imagine how much more unnecessary testing and treatment will be performed once patient satisfaction determines physician reimbursement.
BTW, Yves, I love your blog.
I think physicians have brought on a lot of their legal problems by allowing themselves to be hoodwinked by the medical industrial complex – all the time. I mean come on why don’t we know what causes autism, MS, CFIDS, FM, scleroderma, ALS, Parkinson’s, Lupus, sjogren’s syndrome, and on and on. I’ll tell you why, they are afraid of industry and even when a cause is found it is quickly covered-up like what is happening in my case. I have gadolinium-induced fibrosis (they call it a differential of scleroderma but gadolinium was found in three different tissue samples and at toxic levels in my urine four years post exposure), sjogren’s syndrome (they call it dry eye syndrome) Fibromyalgia, lichen sclerosis and CFIDS. And let’s add in secondary adrenal insufficiency (the endocrinology professor said it could be an infiltration of metal, gadolinium being a toxic metal, into my hypothalamus) and Hashimoto’s. And when less expensive tests become available the FDA quickly squashes any opportunity to get them on the market as in the case of proteomics and Correlogic, a company the NIH and the FDA likely drove into bankruptcy. There is a non-invasive test for colon cancer that requires just a drop of blood so why isn’t this on the market?
http://www.correlogic.com/research-areas/colorectal-cancer.php .
And I have waited ten years for Ovacheck which was jointly developed by the NIH and Correlogic so even though we as tax payers paid for the development of this diagnostic test I can’t get it here in the US but it’s approved in Europe. How silly is that? You might find your answer in this Congressional Testimony.
http://www.correlogic.com/newsandevents/congressional.php .
In conclusion I have no sympathy for doctors and I hope they lose their power. They certainly deserve it. I was in finance, auditing and accounting for my entire career. I’m totally disabled now because I was poisoned by GE and Bayer. If I once said I don’t know what is causing that variance of $1M or $1B I would have been fired. That’s right no questions asked. And yet the medical profession is allowed to say they don’t know over 90% of the time.
The US is especially horrible medically. I don’t know why the chicken pox vaccine took DECADES to be approved in the US after it was approved in Europe, but after that I don’t trust the FDA approval procedures at all.
Your husband should simply be competent and know a lot about obscure possibilities, and spend time really talking to patients about their symptoms; word of mouth will spread the news and he’ll end up with happy patients.
I saw three gastroenterologists. The first ordered an endoscopy & a colonoscopy. Fine, I said, I’ve never had either before. Well, he found nothing! The second wanted to repeat the same tests. I said to hell with him.
The third sat and talked to me for half an hour and ran through all the possibilities, including the more obscure ones. No tests, just talking. We then tested the possibilities through experimentation (entirely through relatively nontoxic drugs.) It turned out to be an unusual combination of genetic predisposition and drug side effect from something I was already taking for something else. *He’s* the one I’d rate with high satisfaction — but more critically, *the consensus in town agrees with me* — he’s the one people recommend by word of mouth.
The practise of medicine is so culturally specific that one almost might think the diseases themselves are different.
The first time I went to France, I was surprised to discover that the treatment for practically any illness there is administered via a syringe to the buttock – à chacun son gout, I suppose.
Nor is homeopathy sneered at there, as it is in many places, though there is still a statue of Hahnemann in Washington DC, I gather:
http://www.nlm.nih.gov/hmd/medtour/hahnemann.html
For many scarcity-oriented cultures, the first line of defense has always been diet, starve a fever, feed a cold. When you looked at our denatured provisioning, is it any wonder the state we find ourselves in? Bacterial antibiotic resistance via soil treated with animal manure is also becoming a big issue in this respect:
http://www.ncbi.nlm.nih.gov/pubmed/22203596
I always ask my physician for dietary recommendations and/or exercise regimen, will not accept pills until I have tried to find a solution under my own power, so to speak.
I solved borderline hypertension this way, via diet and exercise, successfully resisting the strong pressure being exerted on me a couple of years back go onto HBP meds for the rest of my life.
The nurse on my annual check-up this year said, “I don’t know what you did, but it seems to have worked.” All the relevant indicators bar one were down, back in the “normal” range, as is my BP itself.
All I did was eat differently.
A lot of people may well have a culture of “doctor, DO something!” And a lot of doctors may well have a culture of
aggressively DOing things, with the very best of honest intent.
So people who want lots of things done are happier the more things their doctor actively or even aggressively does.
Even if their health outcomes turn out poorer, they are happier, because their doctor met their cultural expectations that a doctor is supposed to DO things . . . LOTS of things.
And in fact LS up above had already before said better what I have just now said here. So go back up and read LS’s comment.
This is probably the shortest summary of what is going on here in this comment thread. I think that is exactly what is happening.
Patients expect doctors to “DO SOMETHING!” even when doing little or nothing is actually the medically superior decision. But of course, getting little or no treatment isn’t satisfying.
Obviously not a friendly place for doctors …..
Have to remember that …..
We like good doctors here. We don’t like crap doctors.
There are a lot of crap doctors. I can’t tell you how many I’ve dumped for acting like they know it all while refusing to actually pay attention to my symptoms (which are generally atypical). The best often can diagnose and treat with no tests, but they have to actually SPEND THE TIME TO BOTHER.
Forgot to mention two more issues:
1) Daily aspirin as a chemopreventative antagonizes the COX pathways. This reduces tissue renewal and tilts the immune system toward autoimmunity. Both effects are bad for the joints. A better approach is to interrupt the cell cycle and induce terminal differentiation of transformed cells. In the breast, low-dose naltrexone should do this, as should melatonin, butyrate, fish oils (which antagonize prostaglandin pathways differently than COX inhibitors) and vitamin D3 (as long as the dose isn’t too high).
2) Most of the studies on estrogen replacement fail to look at net lifespan of the participants, which improves on estrogen – despite the increase in cancer risk and stroke. These studies also fail to check the homocysteine levels of participants. Estrogen stimulates nitric oxide production in the arteries. When folate, TMG/betaine, B12, SAMe or other elements of the homocysteine recycling pathways are low, homocysteine rises and nitric oxide release turn dangerously pro-oxidant. There are risks to using folate to rehabilitate the tetrahydrobiopterin complex with aging (e.g., feeding a preexisting cancer), but this simple fact from metabolic/nutritional medicine may explain many of the “problems” reported with estrogen replacement.
I have been a practicing physician for over 25 years. I find this study to be very interesting, but I don’t know if the causality is easily understood. I have so many comments that I will keep them short or use some of my favorite aphorisms.
In reply to Yves’ question, “how can he judge whether a doctor is making sound recommendations?” Some of my favorite aphorisms:
The success of a physician (or other provider) is dependent on the 4 A’s in decreasing order of effect: Appearance, Affability, Availability, and Ability (dead last).
You can have 10 years of experience or 1 year’s experience 10 times. With regard to some of the senior partners I have worked with, I think the latter is often the case.
It takes more time to explain to a patient why he/she does not need an antibiotic than to prescribe the antibiotic. So what do think usually happens. (I am very stingy with antibiotics BTW). Some common conditions for which antibiotics are prescribed but for which guidelines say they are unnecessary except in extraordinary cases: acute bronchitis, acute sinusitis, ear infections in >2 yr olds.
When azithromycin (Zithromax) came on the market several years ago, it was the first antibiotic with a 5 day indication for common respiratory tract infections. So many patients with viral infections have had this prescribed – “what the heck, it’s only 5 days” – that bacterial resistance against it is probably quite high (I base this on recent hospital antibiograms – resistance tables using blood specimens).
My hospital system surveys our patients’ satisfaction. I believe the state (MN) or perhaps federal government mandates these surveys. They are a boondoggle for the survey companies like NCR-Picker. 2/3 of my surveyed patients rate me as a 9 or 10, where 10 is “Dr. __ is the best possible physician I can imagine.” I think that is pretty good, but it below the benchmark set by my organization. Maybe now I won’t feel so bad.
A friend did research on health anxiety (aka hypochondriasis) several years ago. He mentioned that these patients believe that everyone else feels perfect all the time. It is part of the human condition to not feel perfect. Our bodies are imperfect. We need the wisdom as patients, providers, and society to know when we need to act, and to think carefully about the unintended consequences of what we may do. The Hippocratic oath says “do no harm.” I think more providers and patients need to account for the urgency or lack of urgency of a problem and to consider that sometimes doing nothing or following the least costly, least invasive, least side-effect-prone path is sometimes the best path.
Lastly, I applied for (but did not receive) a fellowship several years ago to study cognitive biases in physician decision making, à la Tversky, Kahneman. I think someone needs to address the pitfalls of clinicians’ decision making.
I think part of this is that most people really are, fundamentally, stupid, and judge by surface appearances.
The doctors I like best are sometimes the doctors other people like least; with a brusque manner, but willing to actually spend the time to think about and research my specific problems.
“2/3 of my surveyed patients rate me as a 9 or 10, where 10 is “Dr. __ is the best possible physician I can imagine.” I think that is pretty good, but it below the benchmark set by my organization. Maybe now I won’t feel so bad.”
Good effing God, that’s a ridiculous standard.
I mean, ridiculous benchmark.
(My first post didn’t appear so I’m reposting part of it.)
1) Certain antibiotics do have antiviral properties, depending on the method of viral entry into cells and propagation. Minocycline, an MMP-9 inhibitor, springs to mind. It’s also used in the treatment of autoimmune inflammation. (To be frank, the best broad-spectrum antiviral is probably 50K-100K vitamin D3 for one or two days.)
2) The best orthopedists I ever had were a dentist with TMJ himself and a physical therapist who read the pain journals. She actually knew more about how nerves worked than any neurologist I’ve ever met. But that was all years after my knee surgeries (that I never really needed), once my TMJ/bruxism problem had turned into mercury poisoning.
3) Nothing worked for my knees back in high school like college swimming. My idiot knee surgeon even put me on NSAIDs which made my autoimmune inflammation worse. (Yeah. Seems we’ve known for about five years now that COX-2 inhibitors like Celebrex cause autoimmunity by blocking the regulatory T-cells that protect us from our own immune system. Which is why the company that advertises Celebrex to rheumatoid arthritis patients also pushes it on cancer patients who actually do need to become autoimmune.) If you want to help your knees, you should probably take up swimming. If you lived in Australia like I did, I’d be surprised if you didn’t know how.
4) The problem isn’t really information asymmetry between you and the doctor. The simple fact of the matter is medicine lives in the 19th Century. There’s a flood of very valuable information coming out but no way to organize and search for it. Most doctors are clueless about any new results that occurred in their field after they left college. Continuing Medical Education (CME) is a ridiculous fraud and the methods the profession uses to organize, collate and disseminate new information makes quality control in the software industry look like something out of Star Trek. The people who really manipulate this are pharma. The more a drug is advertised to doctors, the more expensive, riskier and less effective it is compared to its rivals. (Which makes sense. Why advertise something old that works well. People have an incentive to find out about it.) A good example of this is the ketogenic diet for Alzheimer’s, often used for intractable epilepsy. It was tried once in a trial and achieved great results… but pharma can’t stick it in a pill or patent it so nobody ever discusses it and doctors probably don’t want to prescribe it for fear of getting their licenses challenged.
5) For low-risk prophylactic treatment of pain and inflammation of the joints, as well as mitigating your cancer risk, let me suggest low-dose naltrexone (1-4.5mg daily) and inulin. The inulin takes about eight months to kick in, does the same thing as GLP-1 agonists and costs about 5% as much. DMSO is also cheap and effective for joint pain – but if you didn’t like your radiologist laughing at you, just wait until they hear you tried DMSO. I learned about these interventions and much, much more by doing my own reading. When I was interviewing for a new doctor, almost all of them demonstrated that they hadn’t read a relevant result in immunology, neurology or G.I. in at least ten years.
“Inulin” ? Do you mean “inulin” or do you mean “insulin”?
It’s inulin. Definitely NOT insulin.
fiber -> inulin -> butyrate -> beta oxidation -> GLP-1 -> improved INSULIN sensitivity (more or less)
“4) The problem isn’t really information asymmetry between you and the doctor. The simple fact of the matter is medicine lives in the 19th Century. There’s a flood of very valuable information coming out but no way to organize and search for it. Most doctors are clueless about any new results that occurred in their field after they left college. Continuing Medical Education (CME) is a ridiculous fraud and the methods the profession uses to organize, collate and disseminate new information makes quality control in the software industry look like something out of Star Trek.”
This is so true it’s not funny.
The one area which is actually relatively well organized is drug side effects. Most doctors have electronic searchable PDRs now — the earliest version of this saved my mother’s life during a surgery, when a young doctor ran to the computer and plugged every drug she was on into the database and then searched the results for the catastrophic symptom she was having.
The older doctors were just all asking around the hospital, saying “does anyone know what might cause this?” She would have died if the younger fellow hadn’t come running back with a computer printout telling them what drug it was they had to remove from her system.
Nowadays, most doctors use the electronic PDR search.
But that only handles drug side effects. The same needs to be done for actual disease diagnosis, and it hasn’t been. Doctors are just asking other doctors by “word of mouth” what they know about diagnosis — it’s TERRIBLE.
And for disease treatment, of course.
There’s a major opportunity for a database organizer here. Even if the starting data is a mess (it is for the PDR too), any sort of searchable system would be more helpful than what we have now.