Maggie's Farm

My seatmate at a dinner on Saturday was a vascular surgeon who was touting the wonders of HCG for weight loss, said he lost 30 lbs. in 6 weeks with it. Said he felt no hunger with the 500 cal/day diet that goes with it, and hasn't felt particularly hungry since.

He also touted this book: King of Hearts: The True Story of the Maverick Who Pioneered Open Heart Surgery . Reads like a thriller, he says.

We docs see this all the time, and some docs seem to almost encourage it: "There is always hope," etc.

Aggressive treatment of terminal cancer can be the worst. Refusal to give in to nature's natural processes. Death as the great enemy. Guilt. There is always a time to let go of relationships, and a time to let go of life.

It is often said that "old age is not for sissies," but I have seen terminal torture treatment which the Geneva Convention would hold illegitimate. A friend lost her 52 year-old sister to pancreatic cancer yesterday. Due to heroic efforts, her last three months on earth were made hell when she could have had a peaceful, morphinized passage.

It's been repeated so often that it's become a mantra. Google search. If you walk or run or elliptical or stairmaster or hoeing the fields or whatever over 10,000 steps daily, you have an "active life;"  if under, you fall into the "sedentary life" category.

Nobody wants to think of themselves as leading a "sedentary" life because it sounds slothful and decadent, not luxurious. There are roughly 2000 steps per mile, but it's about the steps, not the distance. It is probably not a bad rule of thumb to do it, just to stay fit, energetic, and vigorous.

Urbanites walk far more, in the course of a day, than suburban or rural folks. My theory is that that is why city folk are trim, and country folk tend towards the bulky, but I am sure that fashion plays a role in it too. City people need to look like they have their act together or they won't get any respect.

Is age. Bad luck probably comes in second:

This is something that gets obscured in today's medical reporting--everyone, as they get older, will get sick for some reason and die at some point. The biggest risk factor for heart disease and cancer isn't BMI, cholesterol, blood pressure, etc....it's age. And to a large extent, the incidence of those diseases is random; doing everything right lowers your risk of disease, but not to zero, and usually not to that small a fraction of the risk for the general population.

The studies like this, of course, are more correlation than causation, but, in my experience, red-blooded men require more than three. The healthier fellows will be more vigorous and horny, so they will have more of these things. Strong young men in energetic relationships seem to need 2-3 per day.

But what about women? How many orgasms per week correlate with health and well-being?

Just kill off those nasty fat cells that you have been over-feeding: Obese Monkeys Lose Weight On Drug That Attacks Blood Supply of Fat Cells.

Assuming this will be somewhat safer than bariatric surgery, we'll all be able to eat all we want and as inactive as we want, and we'll all be as skinny as models. Being in shape will lose all of its virtue because it will be effortless.

Maybe being fat will then come into fashion.

One of my favorite topics to get annoyed about here are the American (and northern European) food fetishes.

Indeed it is a symptom of prosperity that a civilization can obsess about what they eat rather than whether they eat. This occurrence is an anomaly in the short history of Homo sapiens.  In the past couple of decades, many have fetishized their food as if what you eat were a major determinant of your fate in life (fatness aside - but recent studies say being fat isn't so bad for health either). "Eat this - it's good for you." Says who? Grandma? Brown rice and whole grains? Are you kidding me?

I have had four main categories of gripes:

1. What the latest research says. Eat Broccoli, then it's Avoid Broccoli. Avoid salt, but now salt is encouraged. Potatoes are carcinogenic. Avoid fats, but now it's avoid carbs (carbs will fatten you up and fat won't). My point is that whatever you read will be obsolete in a few years. Nobody on earth knows what the ideal human diet is, and that is because humans are basically opportunistic omnivores, designed to feed on whatever they can find.

2. "Supplements": A major scam and rip-off with a remarkable marketing machine, but I will not talk about that today.

3. "Genetic engineering": Unless you collect your food in the woods, pretty much everything you eat has been genetically engineered for thousands of years (except maybe mushrooms).

4. "Organic food": Back to clever marketing again directed to those who know no science or biology. Finally, Scientific American has a piece ripping apart the entire "organic" food fetish. Mythbusting 101: Organic Farming. Want to pay extra for "organic" for no reason whatsoever? Whole Foods shareholders thank you very much.

Sometimes I think that food fetishes must be a mild, verging on normative, form of eating disorder. I'll have my hot dogs with chopped onion and extra bright yellow mustard, thanks, with Lay's potato chips and a cold beer. Is there anything better on a summer day?

When I was in training, a wise old Doc told me to tell the old folks to eat all the salt they like, but to take their blood pressure medicines if they have hypertension.

It's Time to End the War on Salt. The zealous drive by politicians to limit our salt intake has little basis in science.

Still, if you have congestive heart failure, it might help your management to limit salt intake.

There are countless myths about diet and health. The truth is that most of it is driven by wishful thinking, the wish that we might control our fates as easily as by deciding what to have for supper.

The only dietary-related thing (besides basic sustenance) that probably helps health to some extent is to get your Vitamin D from plenty of natural sunlight (instead of from pills or diet) over much of your body, while avoiding sunburn and avoiding obsessive use of sunblock.

By Dr. Joel Levine: When the Doctor Goes Home: The Coming Indifference of American Medicine.

Thirty years ago, the training and practice of medicine was deeply rooted in "inherited" values as much as craft. Physicians were in a noble discipline recast into paladins protecting society, even a bit of its soul, against an implacable adversary. Training was both arduous and flawed (inflated egos and autocratic mice that roared) but with a central purpose. When done well, doctors successfully confronted their most difficult internal challenges, fear of the power of illness and the willfulness to make important decisions when the consequence was uncertain. This "old" medical culture was best expressed by a single term: "My patient." It was as far from provider and client as you could possibly get. "My patient" conveyed both bond and responsibility.

We are about to burn the bridges to this tradition from both ends.

Read it all, because this is what is coming to your town soon with Obamacare. Some of you have already seen it. Mass-market medicine, by the rule-book, "delivered" by anonymous "providers" to the masses. I plan to stick with the old ways for as long as I can.

While preserving my usual skepticsm about what "studies say...", it does make sense that humans would need a good dose of full- body sunlight daily.

Recent studies say 40 mins/day (without sun block), or 20 minutes per side or until done to taste.

With unblocked sunlight over enough of your body, your skin produces the right sorts of Vit D that you need for full health, vigor, and maybe even cancer prevention. Roofers get enough but, in my experience, roofers often tend to destroy themselves with crystal meth and/or alcohol. It's a roofer thing.

The alternative is to do the research yourself and try to figure out what kind and what amounts of Vit D a person ought to take as pills. As I have posted here in the past, Vit D is the only vitamin I take on the advice of all of my doc friends. However, I also take my shirt off whenever I can.

Happiness is a state of undress: why it’s time to stop worrying and love the bikini ...

Dietary Supplement Fact Sheet: Vitamin D

(Men, middle-aged and above, also probably need a baby aspirin and Vitamin L - Lipitor, but don't take medical advice off the internet. Including mine.)

We linked a a paper in Scientific American a while back, Health Care Myth Busters: Is There a High Degree of Scientific Certainty in Modern Medicine?

We know, for example, that when a patient goes to his primary-care physician with a very common problem like lower back pain, the physician will deliver the right treatment with real clinical benefit about half of the time. Patients with the same health problem who go to different physicians will get wildly different treatments. Those physicians can't all be right.

Overall, physicians are said to get it wrong around 50% of the time. I suppose that is possible. I get it wrong on a regular basis. Dr. DB says he trusts no-one in medicine, including himself.

More from the Scientific American article:

Give surgeons a written description of a surgical problem, and half of the group will recommend surgery, while the other half will not. Survey them again two years later and as many as 40 percent of the same surgeons will disagree with their previous opinions and change their recommendations. Research studies back up all of these findings, according to Eddy.

I would add, "Don't treat a test result." I have seen that end badly many times. 

I wrote yesterday about how Psychiatry is tending towards treating symptoms rather than people. Perhaps it is a general tendency in medicine today to retreat from the personal to the technological. See Treat the Patient, Not the CT Scan.

Medical care is not science. It is applied science - and an art. No checklist of symptoms, blood tests, and CT scans can sum up what is ailing an individual human, whether physically or mentally.

It must be clear by now that the dehumanizing trend in Medicine is something that I deplore. Good docs have to be more than good technicians who follow consensus protocols.

More on that in a letter to the New York Times here.

No, Virginia, there is not a little pill to fix everything that ails your heart and soul. It's the new fad, however. Your soul isn't troubled: you just have a little chemistry problem. Better living through chemistry!

In the New York Times, Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy.

It's not just about money. It's more complicated than that, but it's all very sad, in my opinion. I will not go into all of the reasons now other than to say that any doctor, Psychiatrist or not, who doesn't take the time to know you, and just wants to know your disease, isn't worth your time or your hard-earned money.

OK, now I'm depressed by my profession. Where's the pill for that?

I know two Oncologists who are being pushed out of private practice by Medicare price controls. Why are they losing money on their practices? Medicare price controls on their services, despite the huge costs of chemotherapies.

As I understand it, chemotherapy administered in a hospital can be charged at a higher rate than in an office. Thus it is viable for a hospital to take over a private practice and make money, or at least break even, on it.

Interesting article on government medical care price controls: Confessions of a Price Controller. A quote:

Medicare ignores the market, setting prices for physician services based on an academic theory with its roots in the Soviet Union and implemented by the American Medical Association. Those prices do not reflect the value patients receive from their care, and they do not reflect shifts in the demand for particular kinds of services (such as primary care) as the population ages or as more people have health insurance.

Here's what I do: I teach, for free. I work at an urban charity clinic where I donate my time. (I have no idea whether, if, or how the clinic is compensated.) I have a private practice in which I adjust fees in order to consult anybody who is referred to me. I accept no insurance plans, no Medicare, no Medicaid. All I have to worry about is covering my monthly bills.

Docs with high overheads - large staff, machinery, materials, high rents, high malpractice insurances, etc. do not have the luxury of operating as I do.

I count myself as very fortunate to be able to have an old-fashioned practice. I can do whatever I chose to do, and I like it that way.

From an article about the wonderful Dr. John Ioannidis of the above title in The Atlantic (my bolds):

In poring over medical journals, he was struck by how many findings of all types were refuted by later findings. Of course, medical-science �never minds� are hardly secret. And they sometimes make headlines, as when in recent years large studies or growing consensuses of researchers concluded that mammograms, colonoscopies, and PSA tests are far less useful cancer-detection tools than we had been told; or when widely prescribed antidepressants such as Prozac, Zoloft, and Paxil were revealed to be no more effective than a placebo for most cases of depression; or when we learned that staying out of the sun entirely can actually increase cancer risks; or when we were told that the advice to drink lots of water during intense exercise was potentially fatal; or when, last April, we were informed that taking fish oil, exercising, and doing puzzles doesn�t really help fend off Alzheimer�s disease, as long claimed. Peer-reviewed studies have come to opposite conclusions on whether using cell phones can cause brain cancer, whether sleeping more than eight hours a night is healthful or dangerous, whether taking aspirin every day is more likely to save your life or cut it short, and whether routine angioplasty works better than pills to unclog heart arteries.

But beyond the headlines, Ioannidis was shocked at the range and reach of the reversals he was seeing in everyday medical research.

Clinical research always must be taken with a grain of salt, and today's "best practices" will be tomorrow's worst. The general press is utterly incompetent at evaluating such studies. I think they just grab at potential headlines, eg Study: Broccoli Cures Causes Cancer.

I know plenty of folks who have been told to "Take it - studies say it might help, and won't hurt." Who knows? I find it amusing to think that today we are no longer certain of a direct relationship between cholesterol levels and heart disease.

As an intro, see the fourth toon down. I am not willing to pay $45. to post it. (I would pay up to $3. to use it.)

When I was a lowly intern, I was presiding over an ER when we got a radio call around 9 pm about an accident in a mall parking lot involving two cars with kids in them. A head-on, both cars going about 35 mph (that equals a 70 mph accident). When the ambulances arrived, four kids grey, not breathing. DOA. A Mom, still almost pink but dying with head trauma. A Dad, straight to trauma surgery for internal bleeding.

I have never assigned so many people, so quickly, to body bags and the morgue.

So when I read pious government utterances about "preventive care," I just have to laugh. People who talk about that have no idea what they're talking about. Doctors advise people to lose weight, to exercise, to quit smoking, to lower their carb intake, to drink only two wines/day, to wear bike helmets, to use condoms, to eat your vegetables (why? I don't know), to take their medicines, etc., every day. Blah, blah, blah. I might as well advise them to never leave the house because they might get hit by a bus. In the end, people do what they want, and adults are adults. Nobody lacks information and, in my view, if you want to be fat, then go for it.

Personally, I intend to remain trim, fit, athletic and energetic, but I am not interested in sacrificing my life and fun and adventure on the altar of "health" and "safety." There is no vitality or joie de vivre in that. I enjoy a little danger, stress, and excitement. I have crossed crevasses and climbed mountains and kayaked Grade 5 rapids (and almost drowned) and spent many hours on the back of motorcycles. I faced a p-ed off Cape Buffalo (and killed it. Regret it now - there was no point to it), and I sky-dived once. We always drove too fast. We quit all those things when we had young kids, despite the fact that my brother could have raised them very well indeed, and we had good life insurance.

Since everybody dies, and, with modern medicine, dies in a lengthy and expensive and often wretched drawn-out process (80% of US medical costs are in the last year of life), all "preventive medicine" can even hope to do is to delay the process a little bit.

However, it cannot even do that, really. It's 90% wishful thinking: The Big Lie of Preventive Care.

Another good toon from The New Yorker: "Tell me straight, Doc. How long do I have to ignore your advice?"

People love to make fun of Psychiatry, but here's a sample of what life could be like in a world without us.

Remember that Dr. Benjamin Rush, the founder of American Psychiatry, was a signer of the Declaration of Independence. He was vehemently opposed to the chaining of the mentally ill, and proposed treating them with compassion and understanding. He also opposed slavery.

Image is Benjamin Rush, MD. Charles Wilson Peale, 1818.