We are a commune of inquiring, skeptical, politically centrist, capitalist, anglophile, traditionalist New England Yankee humans, humanoids, and animals with many interests beyond and above politics. Each of us has had a high-school education (or GED), but all had ADD so didn't pay attention very well, especially the dogs. Each one of us does "try my best to be just like I am," and none of us enjoys working for others, including for Maggie, from whom we receive neither a nickel nor a dime. Freedom from nags, cranks, government, do-gooders, control-freaks and idiots is all that we ask for.
It's fascinating how crowded Everest is becoming these days, with queues of mountain tourists for the rope lines. The highways are all mapped out, ladders installed, ropes installed, sherpas hired, etc., so it's almost like a rich man's chilly Disney World.
The medical part - and the risk of bad weather - seem to be the greatest challenges. First World Problems, if you will, because nobody needs to do this. However, if it is made too safe, where's the credit?
As with the Olympics, I think it's wonderful that some people want to try these sorts of adventures in life, but I do not admire the amateur tourists. Good film:
"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?
Of course, recommendations like this change all the time, just as do all dietary recommendations. I take it all with a grain of salt or, I should say, with plenty of salt. I love salt.
There apparently was too much swelling in his leg to do the needed surgery, so the current stabilization technique (photo yesterday) is temporary for a week or so, then I assume a tibial rod or other internal fixation.
Guys gotta do what guys gotta do, and sometimes they have to get banged up in the process. I applaud these male efforts - and female efforts - to remain in the game and not to quit despite the risks to bones, pride, etc.
A medical colleague emailed me a photo of his own left tibia this weekend, acquired when skiing at Jay Peak. Ouch. An MD degree is not required for this diagnosis. For a layperson, this is a version of a "broken leg." This will need pins or a plate or something. Some metal and some screws, and I think he'll miss a day or two of work.
An annual re-post, but re-posted again because we seemed to help a number of people with this:
Forget the "Obesity Crisis." That's a crock. Abundant, good food is a blessing and a rarity in human history so it is a great privilege and luxury to be overweight. It certainly is true that, when tasty food is cheap, people will eat a lot of it and their bodies will kindly store what they don't need to survive today, to the detriment of our knees, hips, appearance, comfort, and general vigor. Trouble is, we won't need that storage tomorrow - or ever. It's like hoarding.
We can all be as fat or fit as we wish to be. It's a free country, and being fat (but not obese) isn't terrible for your health unless you are diabetic or want to be able to get around energetically. But don't listen to the Dieticians and Nutritionists. They will want you to get in shape slowly and in a "sustainable" way. In your heart, you know that will never happen. If you are bothering to read this, you just want to get in shape as quickly as you can without liposuction or use of the vomitorium.
Eliminating carbs reduces or eliminates carb craving in most overweight people over several weeks.
This can be a one- to three-month program as desired. Maintenance is another topic.
OK class, take out a pen and piece of paper, I am going to tell you a bit about ICD 10.
First, don't be alarmed by the prophets of doom who say you docs will be required to use this carefully crafted taxonomy in order for the insurers to refuse to compensate you for your services. This is true. I had dinner with an oncologist friend who is in bankruptcy because even though his patient's insurance company gave prior approval for a $100,000 course of chemotherapy they maintained that did not obligate them to actually pay for the cost. He already had, and on multiple occasions.
Back to ICD 10. This document will allow you to kick back and have some laughs about the conditions you likely will not be called upon to treat. The Monty Python crew had a field day constructing this and they've arranged for the ICD 10 office to be right next door to the Department of Silly Walks. Viz:
V9733XA: Sucked into a jet engine, initial encounter V9733XD: Sucked into jet engine subsequent encounter (Should this person be allowed on runways?) V9733XS: Sucked into jet engine, sequelae ( this is for the litigators)
But, don't overlook, Index to External Causes of Injury Accident E919.1 Bore, earth drilling or mining
Land or seabed E919.7 Bulldozer E909.9 Cataclysmic: Earth surface movement or eruption
So, be grateful if you only have to deal with intangibles and won't get blood on your shoes.
I'll be back soon to discuss Scott Stossel's heroic battle with anxiety and transgressive therapists.
The US government recommends 9-11 servings of fruits and/or vegetables daily.
What are they smoking? Unless a stalk of raw celery or a leaf of spinach counts as one vegetable.
If you ate all that, you would be obese, especially with the fruit which, as I always say, is God's dessert. Unless you are at a starvation weight, you don't need fruit. Fruit is just sugar, and you might just as well have some ice cream.
The message is that magical thinking about health and food, etc., doesn't accomplish very much. Neither does magical thinking accomplish very much in any other area of life - except in fiction.
The best way to go, many feel, is to get pneumonia in old age and to die quietly, peacefully. Most are not so lucky and some darn doc will try to treat your pneumonia at age 92 to extend your life for a few weeks in the ICU on a respirator. However, for many, if you outlive heart disease cancer will get you: Why Everyone Seems to Have Cancer.
We don't call it "dying of old age" anymore because we have much better diagnostic tools. Everybody has to die from something or other.
The Heimlich Maneuver and CPR should be known by every responsible citizen. As I regularly remind readers, the CPR procedure has been revised and simplified.
The difficult thing about CPR is knowing who needs it. I have heard stories of people doing CPR on people who were choking, and on people who simply fainted.
Medical risks associated with being overweight include breast cancer and several other cancers, cardiovascular disease, arthritis (esp. knee), diabetes (obviously) along with other insulin-resistance-related metabolic syndromes and carbohydrate-craving, non-alcoholic liver disease, pancreatitis, stroke, hypertension, gall bladder disease, sleep apnea, and many more fun problems.
As a native Cape Codder and cranberry fan, it's a delight to report that they may have a powerful anti-atheroscletotic effect. Maybe this news might have a beneficial effect on a specialized family farming that has been bedeviled by low prices.
The big producers are Wisconsin, Massachusetts, New Jersey, Washington, Oregon and Michigan.
The sentence in Science Daily I don't understand is the following: "The researchers said that the next step is to determine which compounds in cranberries contribute to the benefits and then figure out how to incorporate them into the diet in a form palatable to humans." How about in cranberry juice, cranberry muffins, cranberry pancakes, 25 kinds of cranberry sauce, cranberry cobbler, and dried cranberry "raisins,"....for starters? You can buy unsweetened, undiluted cranberry juice now in most supermarkets.
We keep bags of them in the freezer, and they seem to last a year.
Cranberry sauce: it's not just for Thanksgiving turkey. It's good for chicken and almost any kind of game meat. Never use the junk from the can, though. Even if you think you like it, you will find you like the home-made better.
More on this native North American bog plant here.
I recall my first deaths in medical school, in the ER. Two ambulances, family of four after a parking lot accident. The cool efficiency of the ER senior resident doing five-second triage: the 7 year -old - "Dead." The ten year-old - "Dead." The Mom - "Dead." The dad, blue but not grey like the others - "Breathing. Get him in a room and let's work on him. Tube here now, chest tube, EKG, crash cart, IV. Get a surgeon down here. Let's go, team."
In just a couple of minutes the unconscious Dad was intubated, had an emergency chest tube, IV, monitor, etc., survived.
Since the 1970s, however, the World Health Organisation has defined health as ‘a state of complete physical, mental and social well-being’ and demands ‘Health for All’.
Good grief. I suppose that will ensure steady work for the public health people forever.
If $300,000 buys you a statistical chance of living a few more days with a terminal cancer, would you take it? Would you take it even if Medicare paid for it - which it probably would?
What is sobering about this booming business is that, as a group of oncologists wrote earlier this year, "most anti-cancer drugs provide minor survival benefits, if at all." They often (but not always) reduce the size of inoperable tumors, but they rarely eradicate the disease. For relatively uncommon malignancies like testicular cancer, some forms of leukemia, and lymphoma, drugs effectively cure the disease; for the common "solid tumor" cancers (lung, breast, colon, prostate, and so on), which account for the vast majority of annual cases, drugs buy some time-precious time, to be sure, but time usually measured in weeks and months rather than years. And even though many of the newer drugs are less toxic, they often still have to be given with older drugs whose side effects include nausea, hair loss, fatigue, and decreasing blood counts. One anti-cancer drug produces a skin rash so severe and disturbing, according to Saltz, that some patients have been asked by employers not to come to work.
When government gets involved in things, those things become politicized. Same thing goes for medical care. The death panels are meant to be a buffer against popular clamorings, but they won't work.
When it comes to medical care, nutrition, vitamins, exercise, etc, the loudest quacks and cranks tend to prevail: The Quackish Cult of Alternative Medicine - Dr. Paul Offit's battle against charlatanism
Three years ago, I was playing tennis during the final weekend of summer. The previous two weeks, I'd had some calf pain, nothing significant, I just kept stretching to keep it loose. Suddenly, while chasing a shot down the line, I collapsed with a sharp pain in my calf. At first, it felt like a hot stone had hit my calf. This feeling matched the description my brother had given me of tearing his Achilles, so naturally I was concerned. However, I was able to stand and walk, although stiff and in pain.
This past Friday, while on a golf outing with a client, I was walking down from the first tee when I was hit by the same 'stone' in my other leg. Luckily, this time I knew what the issue was and completed the round, though I used my clubs for support at times.
I suffered, both times, from a tear or strain of the Plantaris tendon. The Plantaris is a vestigial muscle in the calf, often harvested for repair work because it has a tendon which runs from the heel almost up to the knee, attaching a very small muscle. It's length and relatively low capacity makes it attractive for harvest when the need arises. The tricky part is that about 7-10% of all people don't even have this tendon.
Even though the injury is the result of an indirect mechanism, subjectively the patient may describe direct trauma to the calf region – often the athlete feels as though they were struck on the calf by an object such as a ball or piece of equipment.
Tennis players often suffer strains and tears of the Plantaris. My guess is this is due to less attention being paid to the calves by most workouts. At the gym I rarely see people stretching or even working out their calves. But the calves require more attention than they typically get. I'm resting it now and avoiding my usual leg workout at the gym.
The constant fuss about prescribed pain meds is puzzling to me. To Cut Abuse, F.D.A. Is Altering Painkiller Label Rules. I believe that pain relief is one of the best things doctors have to offer the suffering, so I believe in generous opioid use when needed.
Here's what I have learned, over time:
- Abusers of precribed narcotics are a trivial social problem - Habit-forming opioids can make a lot of people functional - The biggest social problems with narcotics are their illegality - Addiction is a psycho-social-spiritual challenge for the individual
Unfortunately, the advice to eat less saturated fat probably isn't going away anytime soon. Like the baseless ideas that calories are calories, or fat people simply lack willpower, fear of dietary fat has become entrenched in our thinking about nutrition, and won't die no matter how many times it's debunked. But if we're going to be lead to believe that saturated fat is harmful to our brains, the link should be based on more than observational research. I'm certainly not convinced that I need to eat less bacon, anyway.
This is part of why my high-meat, zero carb weight loss program (fixed) works: all calories are not handled the same way (and bacon and eggs are a good, healthy diet breakfast). More here:
There are and always have been populations around the world who are both poor and very physically active who have obesity rates very similar to those of the United States and other Western societies. Under this paradigm, there are certain foods — mainly carbohydrates — that stimulate an insulin response and cause weight gain. Avoiding these foods is probably a good idea for those of us who easily store body fat.
Like I said, if you want to lose weight, cut out the carbs and eat meat. Calory-counting does not work because it's the insulin that stores the carbs.
Emergency help on the street did work for Gerard, but the one time I did a sidewalk CPR the 45 year-old ended up with brain damage, but alive. Of course, the most difficult part for amateurs is to diagnose the need for it. People who turn pale and faint do not need CPR.
From the article:
Many veteran physicians have begun to opt out of the resuscitation practices they often administer to their patients. In a 2012 article published in The Guardian, "How Doctors Choose to Die," retired physician Dr. Ken Murray reveals that members of his profession frequently turn down everything from chemotherapy to CPR.
He notes that years of witnessing and administering "medical care that makes people suffer" leads many doctors diagnosed with terminal illnesses to choose to spend their last months or years at home and without medical treatment. Murray recalls some fellow physicians who go as far as getting tattoos that read "no code" to remind rescuers to forgo any attempts at revival.
Murray is still an advocate for learning CPR, but he warns against hoping for miracles.
Lyme Disease (Borreliosis) is endemic in the Northeast US, and probably always has been. That complicates diagnosis because so many people in the area have been exposed to the germ, and thus show some degree of antibodies to it. Many if not most cases of Lyme are subclinical and never diagnosed.
The spirochete-like bug is transmitted by the bite of a mostly-mouse-born tick called a Black-Legged Tick or Deer Tick. The Tick is much smaller than the common dog tick, and much harder to find on your body. Ordinary dog ticks are harmless, if annoying, and can not be confused with the Deer Tick.
Lyme Disease is readily treated with antibiotics, but about ten years ago one of those disease fads came along, so appealing to hypochondriacs and hysterics, called "Chronic Lyme."
As with other fake disease fads like Chronic Fatigue and, in my opinion, Fibromyalgia, Chronic Lyme believers often made themselves into invalids with vague aches and pains.
I thought the Chronic Lyme fad had passed into the history of medical faddism, but I see this odd and credulous article in The New Yorker: The Lyme Wars. The Lyme-disease infection rate is growing. So is the battle over how to treat it.
There are two serious errors right in the title. The infection rate is not growing: the diagnosis is growing and probably many people with aches and pains are being unnecessarily treated for Lyme just because they have been exposed to it at some point in their life. Second, I have never heard of any credible Infectious Disease doc in New England who had any question about how to treat real Lyme.
Here's one brief index to fad diagnoses but I am sure there is a better, more comprehensive one. The current fad is "gluten intolerance." There are a few quacks out there, but many more crocks.
Came home from a busy and exertional family day last weekend to notice some of Mrs. BD's Digitalis in glorious bloom.
Whenever I see Digitalis - Foxglove - in bloom I remember "the Shropshire Crone," renowned in medical history for promoting the use of it for "dropsy" - congestive heart failure. The astute and open-minded Dr. William Withering took notice and got all of the credit - hence the continued use of Digitalis for heart failure. Many people we see walking around would be either dead or bed-ridden without this herbal treatment. Digitalis increases the contractility of the failing heart, but in higher doses it kills you.
Digitalis is a biennial, and self-sows generously when in a happy spot - half-day sun, rich soil. That is Nepeta in bloom in the foreground, and the low-growing Little Lamb's Ear Hydrangea on the left, which will bloom white in late summer.
Up here in the land of snow, we treasure our gardens especially because our growing season is so darn short. Our plants have to know how to carpe diem even if we do not. We try to learn from them. Winter is coming.
I think everybody's ideal is to have an internist or family practice doc who knows you well personally as well as medically, and where you can call or come in anytime if you have a concern. For various reasons this has become elusive.
Based on what I have seen, three trends are growing. The first is the Doc-in-a-Box or, more likely, a PA in a pharmacy.
The second is concierge medicine in which, for a modest annual fee, you have unlimited contact - 24/7 - with your generalist.
The third is generalist docs who will not accept insurance but who charge modest fees and will offer a bill that you can send for your own reimbursement, if any. They can charge modest fees because they do not need to hire a large back office staff for coding and billing.
It's a good idea to have a generalist who knows you and your family. With ObamaCare, I think all three of these modes will grow in popularity, especially the last one. They are all working mostly outside the system. They are not likely to want to make time to see you, however, unless they have met you (except for the PA in a box trend).
Generalist physicians, whether Family Practice, Internal Medicine, or whatever, are the ultimate docs. They see everything, major and minor, and know when to refer. People who want to use their Medicare and Medicaid are going to have a tough time with office visits in the future.
I had always aspired to be a country doc, a generalist, in the New Hampshire countryside, but became too fascinated with what I now do. I had dreams of fixing broken arms, stitching up nasty cuts, treating poison ivy, delivering babies, consoling the terminal, sending appendicitis patients to a surgeon friend, etc. It's kind of funny, but my generalist friends tell me that half of their work is Psychiatry anyway.
With the training I had, I suspect that I could still do those country doc things pretty well, but my malpractice insurance does not cover it. In my training, I caught 42 babies. Some were dangerous and complicated. As I have admitted here in the past, I refused to participate in abortions not because I am so religious but because I did not want it in my memory.
I think everybody's ideal is to have an internist or family practice doc who knows you well personally as well as medically, and where you can call or come in anytime if you have a concern. For various reasons this has become elusive.