Sunday, December 6, 2015

The Negative Placebo - Why Fitness Buffs Avoid Doctors

My personal trainer never visits a doctor. Neither do many of the weightlifters at the gym where I go. Part of it probably has to do with unease about appearing naked in front of a near-stranger, as well as a dislike of needles and other painful features of medical treatment. But fitness buffs have more fundamental reasons for their negative view of doctors.

     1.  They anticipate that the doctor won’t respect their values.

Fitness buffs are people who have spent years of their lives studying and fine-tuning their bodies. They have learned exactly how far this muscle will stretch and how much weight that one will lift. They know what foods and supplements work best with their particular body type. One of the rewards for this hard work is a precise sense of what and how the body is doing (proprioception). If something starts to go wrong, they usually sense it. Fitness buffs believe that proper diet and exercise can keep most people healthy most of the time.

Doctors aren’t taught much about diet and exercise in med school and they don’t learn more afterward. Many don’t exercise themselves; some are overweight. Ads for hospitals and medical practices frequently display photographs of these out-of-shape physicians, a good indicator that they haven’t gotten the message about diet and exercise either.

Doctors tend to give more credence to test results than to the patient’s own intuition about how she is doing. 

Some believe that patients are actually better off taking an FDA-approved medication or than trying to exercise. “People who can take statins are the lucky ones,” an MD told me once.   

2.  They don't want to be exposed to a doctor's negative attitudes.

The pursuit of fitness is based on hope and aspiration. The workouts I do each year are harder than the ones from the year before. The increased strength, flexibility, and versatility have enhanced my confidence and sense of well-being.

In spite of scores of studies to the contrary, many doctors believe that exercise doesn’t work. I smiled when I read a post on Kevin MD by an orthopedic surgeon expressing appreciation for personal trainers and surprise that they could make a significant difference. 

Some doctors worry about injury; they recommend moderate exercise and advise people to “know their limits.” Fitness buffs believe that gently but persistently pushing against your limits is the path to better health. Each person needs to discover what amount and intensity of exercise works for him or her.

Doctors also believe that patients won’t follow a serious and consistent exercise program so they don’t even suggest it.

          3.  Doctors do crisis intervention, not health maintenance.

Although orthotics for problem feet can prevent devastating knee, hip, and lower back injuries in later life, this painless and inexpensive treatment is seldom recommended. Protein supplements and proteolytic enzymes can help older patients retain muscle but they are usually dismissed, along with supplements in general. If there were personal trainers in doctors’ offices, they might be able to implement some of these useful therapies and broaden a few minds in the process.
  
          4.    Doctors are relentless in their search for disease, sometimes finding it where it
    doesn’t exist
.

Fitness buffs like to think of themselves as healthy people. Doctors are trained to discover illness and to empathize with those who are suffering. Many fitness buffs don’t have annual physical exams because they fear that a misapplied test or misinterpreted test result will redefine them as sick, setting off a cascade of unnecessary interventions. I don’t have the option of staying away because I need renewals of the two or three medications I take and occasional blood tests to monitor my thyroid. Every year my doctor suspects me of harboring a different illness; every year I have to prove that I am healthy.


Heart disease and stroke are the major killers of people in the US. Stress can be a significant contributor to these illnesses. A recent study showed that women who had false positive mammograms had a greater risk of developing invasive breast cancer in future years. The researchers thought that the radiologist might have detected some subtle feature that anticipated the change. I would like to know whether these false positive women also had a greater risk of heart attack and stroke in future years. Perhaps the anxiety associated with the repeated tests contributed to future illness of several kinds.

For fitness buffs, the stress involved in visiting a doctor may be too high a cost for any possible benefits.

The truth is that both fitness buffs and doctors have important information to contribute. If those insights could be shared in a context of openness and mutual respect, everyone would benefit.

Maintaining an Imperfect Body: the Mini-Workout

Every body has them­­ – the trouble-making areas where pain, weakness, or disease tend to crop up. Sometimes they’re hereditary, sometimes the result of the wear and tear of decades of life. One of the perks of getting older is that these areas become familiar companions, not exactly friendly but no longer intimidating.

Over the years I’ve identified six or seven muscle groups or parts of my own body that are likely to cause problems. This year I’ve started doing a mini-workout of seven exercises every morning to monitore, stretch, and strengthen those areas. I also do an eighth move which is an experiment; if it turns out not to work, I’ll quit doing it. The whole series takes about 15 minutes.

Neck. When my father was in his sixties he developed a pinched nerve in the back of his neck that was very painful. Advised by his doctor, he started using a traction device to relieve the pressure on the nerve. To strengthen the muscles in the back of my neck and maintain flexibility I do this:

- Lie down on a flat surface and raise my head 2-3”. Stay in this position and count. Over several months I’ve worked up to 100. I take a break by bending forward toward my feet. I grab my heels (but that’s not essential for a good stretch).
- I return to the first position but this time I turn my head to the right and to the left as far as I can, like shaking my head “no” slowly and deliberately. I go up to 30 reps on this one.
- When I was a child I used to sleep on my stomach all the time, which meant that my face was turned to one side. As an older adult, I started to lose flexibility in the ligaments at the base of my skull so I work on them. I lie on my stomach, turn my face to one side and count. With all neck exercises it’s important to do them gently and work up gradually.

Calf and Hamstring Muscles, especially on the right side. My legs have pretty good strength and flexibility but my range of motion is limited in some exercises. This is not because of arthritis – I don’t have much of that – but because I have tight, bulky calf muscles, especially on the right side and little sore spots in the calf and hamstring. A massage therapist told me I have scar tissue in those areas.

- The sore spots are in different places each day so I start by doing sleeping child pose to see where they are. (Sleeping child is the yoga pose where you kneel with your forehead on the floor and sit back on your heels.) When I find a spot, I rub and push into it with a circular motion to loosen the area. Usually there are three or four spots.
- I check my work by standing up, then sitting down into a squat and counting. Then I stand up without using my hands. Sometimes I have to stop in the middle and work on more sore spots.

Lower Back. In old age my aunt and uncle on my father’s side both had lower back problems. (My uncle had a disastrous back surgery that crippled him for life.) With that in mind, I do five superman reps. Lying on my stomach with arms stretched out in front of me I lift my upper body for a count of 25. For this one, it’s important not to tilt the head up but to look down at the floor.

Upper Back. As a young adult, my upper back muscles were so weak I couldn’t do a single push-up. P90X changed that. I do 50 of these, though I don’t go very deep on the last 10.
Sit-ups. Rounding out the core group, I do 50 sit-ups.

Balance. My right leg is a bit shorter than the left so my balance is not great. I stand in a doorway on one leg and count to 10. Then I close my eyes and count to 30. If I get shaky, I grab the door frame. Same on the other side.

Back Strength and Flexibility. Using a pull-up bar, I lift myself as high as I can. I can’t do a full pull-up yet but I’m making progress.  Holding onto the bar but with my feet on the floor, I stretch through the whole length of my back and count to 75. If I’m in a hotel room I skip the pull-up and use the top of a piece of furniture for the stretch.

Jumping. My last bone density test showed that I was losing bone mineral density faster than I would like. I read about a study that showed that a 10 or 20 jumps with 30 second breaks in between significantly improved BMD in the jumpers as compared with the non-jumping control group.

We’ll see if this routine works for me. As for the cause of the lower BMD, I’m guessing that the dosage of thyroid hormone I take for hypothyroidism has been too high for too long. My doctor has lowered the dosage. I had also cut back on my intake of calcium supplement after reading scary stories in the media. That was probably a mistake and I’ve gone back to what I was taking before. 



Update 12/31/2015:

An article in the Wall Street Journal a  couple of weeks ago persuaded me that I shouldn't be doing situps anymore. I now do variations on plank for one minute, followed by 25 rollouts using an ab wheel. 

My personal trainer explained to me that the central ab muscle, the rectus abdominis, is designed to be a stabilizer and is meant to be stretched out flat, not curled up. Doing appropriate exercises will improve its appearance as well as being safer.

 

Wednesday, November 18, 2015

Mammogram Callback Follow-up, A Useful Conversation

After getting a mammogram callback about a dense area in my right breast I was urged by my doctor to get more tests ASAP. I decided to wait a few months and retest to see whether anything had changed. I made an appointment with a different radiologist with a different hospital affiliation. When I made the appointment I explained that I wanted one follow-up test – a mammogram or an ultrasound – and not a battery of mammograms like the ones a few years back.

This morning I got a call from the doctor at the breast center where I had made the appointment. On the one hand, any doctor who makes a personal call to a patient (especially a patient she has never met) immediately commands my attention and respect. On the other hand, this doctor had a definite agenda and she was prepared to push it very hard. She was also the fastest talker I have encountered in a long time (including on TV shows) so I had to listen intently to take in what she was saying.

I was impressed with the first point she made: that she and the radiologist hadn’t just read the reports from previous radiologists but had gone back and looked at my films for themselves. She said they saw calcifications associated with an area of density and that the dense area had increased in size from one film to the next. This was new information to me. As far as I had known up to that point, the dense area had just appeared this year. She said that in order to learn more about the dense area they would have to look at the appearance of the calcifications and this would require a “workup,” a series of mammograms. An ultrasound would not provide the necessary information, she said. If the results of the mammograms were worrisome, a biopsy might be necessary as well.

She said that because I was not young and not on hormone therapy a dense area was a cause for concern. I said, “But I am on estrogen-only therapy.” She said hormone therapy can contribute to dense areas in the breasts, especially as women get older. (I later read that estrogen therapy is associated with a higher incidence of false positives in mammograms.) I started to explain that I take estrogen because of research indicating that it can protect against heart disease which is common in my family. I started to say “and certain cancers, including breast cancer” but she interrupted me. I said, “Please let me finish.”

She stopped talking and let me finish. Then she said that reduced heart disease among estrogen users may be because estrogen users probably have better overall health care and that reduces heart disease rather than the estrogen. (This sounded to me like rationalizing speculation by the breast cancer establishment rather than proven scientific fact but I didn’t say so.) She said that a woman’s chances of getting breast cancer increase as she gets older. I said that we’re still talking about less than 5 percent. I also said that one of the reasons why I feel cautious about mammography is that it doesn’t take into account the general health of the person and whether they have diabetes and other health problems although these factors can be correlated with breast cancer. She said that she has to look at the situation from the point of view of breast cancer. I said, “Of course.”

She said she appreciated it when patients were well informed. I said I appreciated her calling me personally. I’m not happy about this new plan but, based on the information I now have, it seems inevitable. I can still veto the biopsy if and when the time comes. I told her I was cautiously optimistic about my situation and she said, “Good.” This conversation cleared up a couple of important misunderstandings and strikes me as a great example of why direct doctor/patient communication (rather than exclusive reliance on tests) is so essential. I'm sure that doctors don't necessarily enjoy talking with opinionated patients like me. On the other hand, they probably understand that patients who get their questions answered up front are less likely to sue if something goes wrong because responsibility for decisions about care was shared.

Two questions remain in my mind. Why do radiologists believe that they can accurately interpret films without knowing anything about the patient’s medical history, including relevant facts like my estrogen use? Is the doctor pushing her agenda so hard because she is pressed for time or because she herself has some doubts about it, or both?

Saturday, September 12, 2015

When I Say No To This Year’s Mammogram Callback, Who’s On My Team?

Peter Ubel’s article in Forbes, “Has Mammography Created an Epidemic of Pseudo-Survivorship?” makes for painful reading. By recounting the ordeals of a patient he calls Mary Vogt, he illustrates how the many women who have been aggressively treated for DCIS (ductal cancer in situ), aka cancer 0, have been harmed by this therapy. In my opinion, another casualty in situations like this may be the relationship of trust between patient and doctor, a relationship that is at the heart of the healing process.

Several years back I wrote a post called “Mammograms and the Cost Conundrum.” 
There I recounted how radiologist who read my mammogram decided that the calcifications that had been there all along had changed in appearance and might now be dangerous. He recommended a biopsy (see Peter Ubel’s description). I got a second opinion, which was that nothing had changed. The calcification episode was actually the third mammogram callback I’ve gotten, each time with a different, vague-sounding story. Invariably, these come about when a new radiologist looks at my pictures.

After skipping last year, I went for a mammogram last week. A few days later the word came back that the radiologist (a new one) had seen a one-centimeter “dense area” on my otherwise not-dense right breast and wanted me to come back for an unspecified number of mammograms and perhaps an ultrasound. I said “No.”

The radiologist, an independent contractor located somewhere out of state, is telling me that he can’t see this area clearly enough. He probably would like to know exactly what it is. For me, the only essential question is “Is this invasive breast cancer?” I want to wait for three or four months and have another single test to see whether anything has changed. If there’s change, at that point we can bring in the heavy artillery. The offending area may be any of a number of benign conditions, such as a blocked duct, or it may be nothing at all. It could also be DCIS. In any of those cases, I want to leave things strictly alone. Additional mammograms might provide certainty but they might also lead to still more testing, radiation exposure, and expense for the system as a whole. Also, while mammograms are generally no big deal for me, the eight or so done during the calcifications episode are still vivid in my mind.

My primary care provider is clearly unhappy about this. She has already urged me once to get the recommended follow-up and, after I told her nurse what I had decided, wanted me to come in for “clarification” of the matter. I will try to avoid doing this because I believe it will only lead to more arguing and unnecessary stress for both of us.

Medical practice is supposed to be based on science. So what are the facts here? Any woman in her 60s has less than a 4% chance of developing invasive breast cancer. Many women in their 60s are overweight, have hereditary or environmental risk factors, or all of the above. I have none of those. My insurance company just refunded about half of my Medicare Part B premiums because I’m such a bargain. People in my family die of strokes and heart attacks, not cancer, and breast cancer is pretty much unheard of. (The breast cancer types like to talk about all the women with no family history who get cancer but those figures are suspect because they probably include a lot of DCIS, which is not a cancer.)

A couple of unusual circumstances. My mother took stilbestrol when she was pregnant with me but the women who have apparently gotten cancer from that cause were all decades younger than I am; I would be medically unique if it happened to me at 69. I've never had children, which raises my risk 40%, so let's say my risk of invasive cancer is as high as 5%. On the other hand, I take estrogen, which, when started early (age 32) may protect against breast cancer, unlike the mixed type of hormone therapy. For all of these reasons, I think breast cancer for me is a long shot. Would you bet on a horse that had a 5% chance of winning? Not impossible, but very unlikely.

In the current state of medical practice the burden of proof is on the woman with an “abnormal” mammogram to demonstrate that she does not have a dangerous condition. The burden is transferred to her in the form of radiation and to the system as a whole in the form of additional cost. The ostensible reason is to save the patient from dying; an important collateral reason is to protect doctors from liability – they’ve got to be able to show that they did everything they could. My doctor is determined to get me to do this; I am determined not to. I told her nurse that I would be glad to sign a release saying that she had recommended this option and I had refused it. On the other hand, if my doctor is simply unwilling to accept my decision, I will have to find a new doctor. I would be sorry to do this because we have had a pretty good relationship over the past four years.

My doctor is in a difficult situation. The large outfit she works for is undoubtedly putting pressure on her to take this approach and she has a family to support. On the other hand, even after the many articles like Ubel’s that have shown the damage done by aggressively treating a non-illness, for this medical organization it is business as usual. I sympathize with my doctor but I will not agree to repeat this retesting process every three or four years for the rest of my life. Ultimately, I must make my own decisions about my health care and take responsibility for them.

Monday, August 3, 2015

Three Important Reasons to Keep Hard Copies of Your Medical Records

This year, my annual physical was scheduled for late July. I always get the regular blood tests done a few weeks ahead so my doctor and I can discuss them face to face and renew any needed prescription. This year, though, my medication for hypothyroidism was about to run out. Once the blood test results were available, I asked the doctor’s office to renew the prescription immediately and not wait for the appointment. It didn’t get done.

1. When it comes to your medical records, the only constant is you, not your doctor or your doctor’s office.

The reason my prescription wasn’t immediately renewed was that my doctor did not have my medical records. The reason she didn’t have my medical records was that she had moved, from an office affiliated with one of our local hospitals to an office affiliated with the other.

2. Electronic medical records systems are not compatible with each other.

At some point after I had made the appointment for my physical, my records were faxed from one office to the other. Since the systems used at the two offices are not compatible, information sent by the old office will have to be entered by hand into the new office’s computer. This may take many weeks or months and will provide opportunities for data entry errors to be made. In the meantime…

3. Computer systems in medical offices are constantly being changed and upgraded.

Each time this happens there is more opportunity for error and for records to be lost entirely. Also, there seems to be no requirement that any new system be more universally compatible than the previous one.

On the day of my appointment I arrived at my doctor’s office with a fat folder containing the medical records I have been keeping over the past ten or fifteen years. (Even when she finally does get my electronic medical records my doctor will not have a history going back that far.) I had also made a separate list of my thyroid test results over the past two years so she would know immediately what dosage to prescribe. While I was there, she made photocopies of other test results that I had and she didn’t.

I was still mulling all of this over a few days later when I got a letter from a hospital affiliated with an Ivy League university on the east coast. When my mother died in 1986 of the effects of Alzheimer’s disease, some of her brain tissue was donated to this facility for research. “Regrettably,” the hospital said, they had lost track of backup data tapes containing information about my mother. And, by the way, the tapes were unencrypted.

Update: After writing this, I have been thinking about how enormously destructive the transition to electronic records has been. For millions of people, years of health-related data have been misplaced, lost or intentionally discarded. Why did anyone believe we could do without paper records without first having a reliable, universally compatible electronic system in place?

Saturday, July 11, 2015

Caution, Patients: Large Studies May Be Hazardous to Your Health
(and Incur Unnecessary Costs for the Health Care System)

When it comes to providing clear explanations of complex medical and health-related issues, there is no one better than Aaron Carroll. As a person who is regularly looking for answers in these areas, I am a huge fan. I watch his videos on Healthcare Triage, read his articles in the New York Times, and follow him on Twitter. His excitement about food, ideas, travel, and the latest exploits of his kids are fun to read about. You probably sense that there is a “but” coming – and here it is: Aaron’s enthusiasm about large studies makes me uneasy.

Large studies inform us about what happened to a particular group of individuals under a specific set of circumstances. They can provide guidance for medical practitioners when they deal with individuals who appear to be similar to that group; they can give doctors an idea of what to look for. What can large studies tell doctors for certain about any given individual? Absolutely nothing.

Problems arise when the guidance provided by studies morphs into a hard-and-fast rule about what must always or never be done. In some cases conclusions from studies are over-generalized and made to apply to situations which are beyond the scope of the studies.

Arthroscopic Surgery Isn’t Going to Fix Your Knee,” a recent HCT video, talks about a recent review and meta-analysis of studies on arthroscopic surgery for degenerative knee. Both the title and the video itself make it sound as though arthroscopic surgery is always a waste of time and money. Yet the studies were really about attempts to repair degenerative knees. They weren’t intended to address the issue of repairing knee injuries.

When patients fail to conform the rules derived from large studies, they may have great difficulty securing proper medical treatment. Here is what happened to a friend of mine, a man in his mid-seventies, a natural athlete who was then playing racquetball a couple of times a week. One afternoon he tripped as he was going up some stairs. In instant he went from normal to hardly being able to walk.

After an x-ray at the hospital, he went to a local orthopedics practice where the first doctor said, “You have a torn meniscus. It can be repaired with arthroscopic surgery – we do them all the time.” That sounded fine to my friend but when he was passed along to a surgeon in the same office he got a different pitch. The surgeon said, “You have advanced arthritis and surgery would not do any good.” He then gave my friend a cortisone shot, which had no effect on his pain or disability and told him that he would probably require a knee replacement in the foreseeable future.

The story about advanced arthritis didn’t sound quite right to my friend. Before the injury, he had been able to squat down and remain there for minutes at a time (the pose of cowboys in front of a campfire). He sought out a second orthopedist. This doctor, a woman, said, “We don’t normally do knee surgeries on people in their seventies but I think you are the exception.” Several weeks later, after performing the surgery, she said, “This knee was like a Ping-Pong ball. I’ve seen people in their forties who didn’t have knees as good as this.” This was an injury, not advanced arthritis. The first surgeon had lied because he didn’t want to operate on a man in his seventies. My friend went back to playing racquetball.

Doctors today have impossible schedules. They see each patient for fifteen minutes, if that. Under these circumstances, over-generalizations and rules based on large studies can become a tempting substitute for close observation and careful analysis of an individual situation. The likely consequences are improper care for the patient and unnecessary expense for the health care system. In thinking about my friend’s experience I have sometimes wondered how many older people with injured, but otherwise healthy, knees have been steered into having knee replacements when all they needed was a simple arthroscopic surgery.
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