Wednesday, August 31, 2011

Just Say No!

It looks like I'm not the only one who wrote about the study published earlier this month in the Archives of Internal Medicine about inappropriate colonoscopies. And I'm not the only one who wrote about the JAMA study about cardiologists performing unnecessary angioplasties and placing stents just a bit too frequently. It turns out that Newsweek put out a cover story regarding these two recent articles and more, attesting to the lack of benefit demonstrated by much of the advice we dispense daily.

What's really intriguing are the comments at the bottom of the page. Many of those who wrote in support continued screening because that's how they found their cancer earlier than they would have otherwise. So I'm glad for them. But they neglect to understand that most who were screened received no benefit and in fact, some were actually harmed from follow up procedures.

On the other hand, I can certainly empathize with the physicians who wrote in about over-testing to ward off the malpractice attorneys. Yet other physicians admit to over-prescribing antibiotics because that's what patients really want, even after a 15 minute dissertation about the lack of benefit and actual possibility of harm.

So where does this leave those of us in the trenches vs what's promulgated from on high in the ivory towers? Having made grand pronouncements from on yonder during an earlier time in my career, I now see things from a different light along w/my colleagues. But that fact is that both sides have good points to make. Too often we perform procedures unnecessarily. Too often we perform tests that haven't been proven to have an outcome benefit, just one of improving a physiologic marker.

But in this day & age of quantity over quality, where we need to see more & more patients to meet our ever increasing overhead, too often we cave in to a request for antibiotics for something we suspect is most likely viral in nature because our patients want a pill now rather than to wait a few more days for the disease to take its course. Just like they want to gain muscle, lose fat, and have a longer, larger erection, all from some magic pill rather than regular exercise & good nutrition.

So maybe the answer isn't to just say no to unnecessary screening & procedures but to also say no to unnecessary antibiotics. In other words, patients need to stop pressuring us to prescribe the latest & greatest drugs they've just seen advertised on the television. And for that matter, unnecessary anti-hypertensives, hypoglycemics, and cholesterol lowering agents if we/they can just say no to bad food choices and physical inactivity.

Dietary Supplements: Is the Fox Guarding the Hen House? Part 3

When it rains, it pours. Remember last Friday's post about a recent Men's Health article regarding contamination issues due to lack of 3rd party oversight of dietary supplements? Well, over the weekend, the New York Times published their expose of a few bad apples in the barrel.

It's unfortunate that the laws are currently written in favor of the manufacturers who are expected to self-police while the Food & Drug Administration has its hands tied, unable to prevent injury & death from contaminated and adulterated supplements. Granted most of the supplements on the market are of reasonable quality, such as most vitamins & minerals.

However, those that promise to pack on muscle, strip away fat, and improve/increase erectile function are probably the ones most likely to be contaminated as we search for short cuts to avoid the hard work of exercising regularly, eating nutrient-dense foods, and getting healthy. As long as we continue our quest for a miracle pill, we remain vulnerable to injury from those who would separate us from our hard earned dollars as quickly as possible in this miserable economy. Caveat emptor!

Dietary Supplements: Part 2
Dietary Supplements: Part 1

Tuesday, August 30, 2011

Eat More Chocolate!

Hot on the heels of my post last Thursday about eating (dark) chocolate to lower your cholesterol, the results of a meta-analysis were presented to the European Society of Cardiology yesterday and simultaneously published in the British Medical Journal, concluding that consumption of chocolate was associated with lower risk of cardiovascular disease and stroke.

Of course, some of the news agencies misrepresented the findings in their headlines as "Chocolate lowers heart, stroke risk". Sure it's semantics, but in the case of medical research, there's a world of difference between associative conclusions derived from observational studies and cause & effect relationships derived from randomized controlled studies.

In this particular situation, the authors had to sift through 4,576 references to obtain 7 studies that met all their inclusion criteria, leading to a population of 114,009 participants followed for 8-16 years in 6 cohort & 1 cross sectional study. More telling is the fact that none of these studies were randomized controlled trials, so all the data is observational in nature and thus any conclusions derived can only be used to generate hypotheses.

Of course, to make matters more difficult, each study used its own measure of chocolate consumption. Worse, there was no differentiation between dark, milk and white chocolate, much less cacao (cocoa) content. Therefore, the authors could only analyze greatest consumption vs least with respect to cardiovascular disease and stroke risk, noting 37% and 29% relative risk reduction respectively, regardless of the usual confounders, such as sex, age, body mass index, smoking, and other dietary factors, but without any benefit for heart failure.

So what's the bottom line for you and me? Well, this study is consistent with all the other observational studies extant about which I've posted. But due to the calorie & fat content, I would suggest moderation in consumption with focus on high quality, high cocoa/cacao content, dark chocolate. Enjoy!

Monday, August 29, 2011

Insurance Companies vs Physicians: Who's on first?

Does anyone remember the Abbott & Costello routine about "Who's on first"? There was quite a bit of confusion since Costello didn't realize that "Who" was the name of the first baseman, and not a pronoun used to describe an unknown person.

I bring this up because I stumbled upon a New York Times article about the insurance maze physicians have to deal with here in the States. It turns out that a recent study published in the journal Health Affairs documented a four fold variance in the cost of dealing with insurance in Canada ($22K/physician/year) versus here in the States ($83K/physician/year) and a ten fold differential in terms of time spent (<2 staff-hours/wk in Canada vs 21 staff-hours/wk in the US).

Granted many of us are not thrilled with the idea of a single payer system as exists in Canada, the United Kingdom, and elsewhere. We don't want the long interminable waits for tests & procedures that are accepted as routine by our neighbors to the north. And who hasn't heard of some Canadian with means who crossed the border to get some test or procedure done sooner than if s/he'd waited patiently in line.

On the other hand, the idea of healthcare as a right and not a privilege has a nice ring to it. Of course, I'm not about to offer free plastic surgery and Botox(R) to everyone. After all, remember that phrase about inexpensive, great and quick healthcare? Well, it turns out you can only have two out of the three - but at least it's your choice as to which two you want.

Admittedly, I'm not smart enough to have the answer to a policy conundrum that has stumped our brightest minds for years. However, given the number of insurance companies and their almost infinite plans/products, each with its own rules & regulations, it seems to me (and others) that convincing the insurers to play by the same rule book would simplify matters dramatically, and in doing so, decrease wasted & bloated expenditures to the tune of $27B per year.