Maggie's Farm

"Nine out of ten doctors would not recommend anyone go into medicine today," the headline of an online news post read.

An article in Forbes Magazine last month cited the selfless dedication physicians bring to the practice of medicine caring only for the well being of their patients. Both statements are gross exaggerations. While many doctors are unhappy with the changes in medical practice they are not retiring in droves, and while most doctors care a great deal for their patients there are also those who care more about their compensation. Certainly more of the older generation of practitioners, my generation of physicians, have been stunned by the changes that have occurred over the past 25 years in the delivery of health care, but also by the loss of a sense of power doctors once had. The axis of physician, nurse, patient is now a mosaic which includes many other "providers" not anticipated twenty years ago.

One of the first changes was to remove the doctor from his pinnacle by calling him (his/him will stand for both genders in the interest of brevity) a "health care provider." Thus, medical care deliverers became like Dr. Pepper drinkers, "I'm a Pepper, she's a Pepper, wouldn't you like to be a Pepper too?" We groused about it but only a few of us saw the dark clouds on the western horizon, managed care was approaching. Up until that time the community hospital was basically a doctor's club complete with private dining room. As care became more complicated and sophisticated - intensive care units and CAT scans did not exist in the 1960s when I was an intern and resident - the hospital became more of an independent institution that could serve patients with its own staff to service physician referrals.

A patient of mine sought admission to a small psychiatric hospital. He was feeling depressed and anxious and wanted to be cared for. The hospital had no beds and placed his name on a waiting list. He was admitted to the emergency department holding area of our local hospital and after two days felt well enough to return home. The next week the psychiatric hospital called to say they had a bed. He told them he didn't require admission at this time. They asked if he had a doctor and he told them he did. Then they asked if he owned a gun. He took offense.

"They want to know if I own a gun so they can take it away."

"You don't own a gun," I said, "and maybe they were asking because they were concerned you might be suicidal when depressed or violent when angry. They know your moods and behavior, you've been at that hospital in the past." This is a middle aged man with autism spectrum, what used to be called Asperger's.

"No, they want to take our guns."

Foolish consistency.

For me, a climate change agnostic, the mocking of climate change  is no better than the strident protests that the sky is falling. Charles Krauthammer, hardly a liberal voice, says, "I'm not a global warming believer. I'm not a global warming denier. I've long believed that it cannot be good for humanity to be spewing tons of carbon dioxide into the atmosphere." The last statement is critical because it implies that driving your kids to school in a Hummer is potentially hurting all of us.

The earth is an ecosystem, not an organism. Volcanic eruptions and asteroid collisions have serious consequences on the planet, on species (extinctions, for example), on climate and who knows what else. If the carbon density is a factor leading towards an environmental disaster, and it is a big if, what suffer you to reduce your carbon footprint? Or would you rather be the thirty-five year old who doesn't buy health insurance because "statistically I am at low risk for serious illness." You do the math.

Also, and this is dicey, no one factors the amount of carbon dioxide put into the atmosphere every minute by 7 billion plus people not to mention the bovine methane from the cows contributing to your McDonald's diet. I'm just sayin' . . .   

"Decisions, decisions, decisions!" This often is spoken in a mixture of ennui and smug irony for decisions such as "should I buy the Audi, the BMW or the Lexus?" But this piece is nothing like that, it is about the general confusion and questionable value of our medical establishment.

The three "decisions" are apt because the diagnosis and treatment of three major illnesses have been called into question in the past year and this is disconcerting if not alarming. If you are unfamiliar with the work of Dr. John Ioannidis I recommend you find him on the web. His view of the state of medical research is summarized as "Lies, damned lies and medical research."

The original quote actually was by the British prime minister, Gladstone: "There are three kinds of lies, lies, damned lies and statistics."

The recent study out of Canada declaring the value of mammograms in women under fifty without value is noted. One doctor at Sloane Kettering has already balked and we have yet to hear from the Susan Komen foundation. The other disqualifying report identified antidepressant medication as simply placebo with no valid clinical evidence to the contrary. As a clinician my experience does not support that position, but there are facts that are hidden from us. For example, the FDA requires two "positive" studies to approve a medication for the treatment of a condition. That there may be six negative studies is not required to be revealed to us, and, as Ioannidis points out, many of the "successful" studies measure the new product against drugs that are known to be less than effective, if effective at all.

But it is prostate cancer I want to focus on. To PSA or not to PSA, that is the question. (Excuse me Prince Hamlet.) I have learned a great deal about this question from a man whom I have known for many years and who has had prostate cancer diagnosed. There was a series of articles in the popular press questioning the need for and value of the PSA test around the time his PSA began to increase incrementally. "You will more likely die with the prostate cancer than from the prostate cancer." This is very reassuring, unless you have witnessed a patient or a relative die the excruciatingly painful death of metatstatic prostate cancer.

The concerns expressed, in our behalf, is that the PSA can lead to biopsies which can be painful and prone to serious complications. While I am not a urologist, I can say I have seen one man who complained of persistent pain following a biopsy. That is all. What most of the articles failed to make reference to is something called the Gleason Score, an assessment of the aggressiveness of the tumor's malignant cells. The numbers of the score range from low to high but what you need to know is that a score of Seven is at the dividing line of could be serious and is serious. Eight and up are without question serious. Without that information one cannot make sensible judgements about how to proceed and one can only have that with the prostate biopsy. You can see the circularity of this process. With that information in hand one is then given a menu of treatment choices to consider. Watch and wait, radiation, surgery - robotic and standard supra-pubic surgical removal of the prostate gland, proton beam treatment, cyberknife, aggressive sonic ablation - more than most doctors, let alone lay people, can assess when in a state of some anxiety. Every treatment brings its own list of complications and ill consequences. "5%" risk of whichever one sounds reassuring but, if it is you who experiences that ill consequence it is 100%.

And what is most important is, as my friend learned, there is no evidence that any treatment is superior to any one of the other treatments and there may never be a study to pit one against the other to determine which is best. He chose surgery and has done well now for a few years. His PSA is zero and hopes it will remain that way. So, we ponder these three conditions, each afflicting roughly 10% of the general population, and we are asked to act or not act on the basis of flawed and insufficient information. What else are we missing?

Makes you think, doesn't it?

Well, I certainly got your attention.

I appreciate many of your responses and found them educating, in particular those instances when having a shotgun or rifle may have prevented a home invasion or assault. I don't know of a site where these can be recorded and shared with a larger population and I am certain there would be concerns that this would be used against gun owners and individuals by some government agency but it might balance some of the anti gun arguments.

As for the stories in the media, dog bites man is not news, man bites dog is. A friend of mine who worked at CBS  said the news director in New York had one criterion for the line up of stories on the local evening in news: "If it bleeds it leads." That has not and will not change. The issue of carrying firearms at all times is probably more of a regional issue. But did the retired police officer really need to have his weapon with him at a movie theater with his wife in what sounds like a peaceful neighborhood? It doesn't matter who said what to whom, it matters that back in the day in the Bronx those words might have sent fists flying not bullets. And if the other guy is too big and intimidating, stand down or at least ask yourself if your pride is worth taking a beating for.

Sometimes Maggie's seems like an echo chamber because there is only one point of view, so try this one for me:

While everyone celebrates the freedom to blow your foot off or have your five year old shoot his four year old friend while playing cowboys and liberals, why are all of the news stories about men shooting other men for no justifiable cause? The retired sheriff who felt threatened by a man texting his babysitter was justified because the popcorn thrown at him had many hard unpopped kernels? The man who shot the black teenager for playing loud music in a parking lot PMWB (playing music while black) had cause because he didn't like the tunes? Please. Where are the stories of self defense? Oh, I forgot Zimmerman.

(Editor's note: If you disagree, do so kindly and explain yourself reasonably. No need to talk about deaths in car accidents. Azeff is a good-hearted guy who did not grow up with firearms in the farm kitchen, as I did. Somebody asked me the other day how many firearms I have. Between home and the Farm, I dunno, I replied. Never counted. I asked "How many hammers do you have? A hammer is a lethal weapon, just like a baseball bat. Nobody knows how many hammers they have. Firearms are just more expensive than hammers and baseball bats.")

Editor's note: Dr. Azeff will be a regular contributor on medical topics

"Surviving Anxiety" was the cover story of The Atlantic magazine for January/February written by its editor, Scott Stossel.

One is a little flabbergasted when reading this man's story. While portraying himself as virtually crippled by anxiety in all of its forms, generalized anxiety, post traumatic stress, panic disorder and multiple phobias, he functions as the editor of a prestigious magazine which means likely conflicts with aggressive publishers and super-sensitive, if not querulous, writers. He is a writer himself and therefore a person expected to show up for promotional talks and for lectures. How does he do it? He begins his article, excerpted from his book, by describing his drug regimen for public speaking; xanax, inderal and scotch or vodka. As a clinician one is immediately tempted to take the bait and challenge the doses of his medication and balk at his use of ethanol which he acknowledges is risky at best, dangerous more honestly. From there we are led on a trip through his life and through the evolution of psychiatric treatments over the past thirty years, the good the bad and the ugly.

His first doctor who started treating him at age eleven and saw him twice a week for 25 years is roughly of my generation, I'll be 75 in a few months, Dr. L as he is called is probably in his early eighties. Analytically oriented therapy mixed with play therapy mixed with pharmacotherapy at the outset, progressing over decades to everything as it came along including EMDR and self-actualizing therapy whatever that means. One can appreciate the changes over the years as a picture of the evolution of a modality seeking a scientific framework. Just as edema was initially seen as a unitary "disease" called dropsy until science deconstructed the multiple causes of this symptom, so many of our psychiatric illnesses may be no less than psychological dropsy. I'll wager in the next ten years "schizophrenia" will be at least four different conditions of different etiology, and anxiety may follow suit as well.

But what I take away from this verbose, sometimes wry, sometimes antic, sometimes prolix piece is the transgressions of some of his caretakers. Well into Scott's treatment, Dr. L takes his father into treatment as well and uses Scott's sessions to get information about Stossel senior. The porous boundary is something we all grapple with but this is a destruction of the boundary that calls the treatment into question, perhaps from the start. After all, we may change course with a patient but usually with caution and discussion. I hope we are beyond the point of arguing that one cannot do both psychotherapy and psychopharmacology, but can one start with a classic dynamic model and wander into EMDR? Then there is the behavioral psychologist, Dr.M (both of these caretakers are "Boston" and Harvard trained and perhaps even faculty so we all must be clear that they definitely and unimpeachably know what they are doing) who determined his core problem was emetophobia, fear of vomiting, which she would treat with exposure therapy. Using the emetic ipecac which had cured other emetophobes, Stossel attempts the exposure with two doses of ipecac that produce retching and gagging but no vomiting in the course of four hours.

The next day he speaks to Dr. M who eventually relates that she was so shaken by his experience she cancelled all of her afternoon patients and spent the day at home nauseated and vomiting and taking to bed. Once again a transgression of questionable purpose. That treatment was fractured and collapsed fairly soon afterwards. We all have seen patients who are difficult to treat, who have disabling symptoms of anxiety or depression or psychosis, which are not easily medicated. How often do we ask ourselves about the possibility that the patient is consciously or unconsciously engaged in an attempt to make us feel as helpless and demoralized as he feels? Is it "blaming the patient" to weigh this possibility as a cause of intractable symptoms?

There is nothing glaringly obvious pointing to this in the story Stossel tells us and his brave walking through fire story is to be admired, but I'm just saying . . .