When to Question Your Doctor: A Cautionary Tale

Most people are in awe of physicians.  Medical doctors are smart, well educated, and devote their working lives to helping others.  The least we can do, it would seem, is not to add unnecessary complication to their already-overstressed schedules by disagreeing with them.  The current New England Journal of Medicine has an important article, “SpeakingUp — When Doctors Navigate Medical Hierarchy,” by Ranjana Srivastava of the Monash Medical Center in Australia. 

It turns out that not only patients are intimidated by physicians; doctors are also intimidated by other doctors so that they do not always speak up when they sense that something is wrong.  Medical professionals are especially loath to interrogate those whom they perceive as outranking them in the medical profession’s pecking order.  Srivastava, an oncologist, was unwilling to express her sense of uneasiness about a patient to the surgeon about to operate on him.  Her account of the incident and its consequences is honest and moving.  
  
The message I took away from this article is this:  if something bothers you, speak up.  Be respectful, ask reasonable questions, but don’t keep silent.  To this I would add:  if the doctor becomes annoyed or brushes your reservations aside, get a second opinion.

Abdominal Migraines

My paternal grandmother would sometimes get abdominal pain severe enough to send her to the emergency room.  She had a number of exploratory surgeries that turned up nothing until finally, in her seventies or eighties, she said, “No more surgeries.”  My father used to get migraine headaches.  I don’t get those, but once in a great while (about every seven years) I get an abdominal migraine.  Usually at night after a big meal, maybe under stressful circumstances, I will get painful spasms below my navel (about 7 on a scale of 1 to 10), accompanied by sweating, vomiting, and diarrhea until my whole system is cleared out.  After that the pain continues; I can’t keep down any food or liquid; and of course I can’t sleep.

In 1989 that happened and I went to the emergency room.  That time I was lucky because the doctor there knew what this was.  He checked a few things, had an x-ray taken, and sent me home with pain medication.  He didn’t tell me the name of the condition; I found that out later for myself.  I stayed in bed the next day and after that I was fine.  Seven years later it happened again and I called my regular doctor.  I said, “I know what this is.  Please give me something for the pain and I’ll be OK in a day or two.”  My doctor was skeptical and wanted to be extra cautious.  She had me check into the hospital and lined up a surgeon.  The hospital ran various tests, found nothing, and let me go after a couple of days.  The next time, just as the pain was starting, I took a generic Pepcid AC (famotidine) and the pain stopped in its tracks: apparently this is the right thing to do.

Many doctors believe that only children get abdominal migraines but this seems to be wrong.  I get them, my grandmother probably did too, and I know at least one other adult who does.  In adults an abdominal migraine is probably mistaken for a stomach virus or food poisoning.  For people who get them often it probably makes sense to carry the pills around, just in case.

I get various kinds of muscle spasms too.  The best fix for these is to wet a washcloth with the hottest water you can stand and press it against the knotted up area.  Sometimes this has to be done a couple of times but after that the muscle will relax.  I’ve read that muscle spasms can be caused by deficiencies in any of various minerals.  I take potassium, magnesium, and calcium and the blood tests for these indicate that I’m where I should be.  Evidently this is just part of my genetic inheritance.

The Latest on Stilbestrol

In today’s paper I read about the Melnick sisters, whose suit against Eli Lilly and Company went to trial this week.  The sisters charge that a Lilly product, diethylstilbestrol (DES), which was given to their mother during four of her pregnancies, caused their breast cancers.  DES was given to pregnant women in the 1940’s and 50’s to prevent miscarriage.  It was later taken off the market when it was found to cause a rare type of vaginal cancer in the daughters of women who had taken the medication.  It was also found not to prevent miscarriage.

The circumstantial aspects of the Melnick case are compelling.  Four of the daughters developed breast cancer in their forties after their mother took DES during those pregnancies.  A fifth daughter, who did not receive in utero exposure to the drug, has not had cancer.  On the other hand, the pregnancies took place during the 1950’s; medical records no longer exist; and Lilly was not the only company that produced stilbestrol.  In addition, the prescribing doctor failed to follow Lilly’s recommendations, which called for using the drug after three or more consecutive miscarriages.  The Melnicks’ mother evidently did not have successive miscarriages.  

In “Stilbestrol and Me” I discussed my own experience with DES.  My mother’s doctor prescribed the drug after my would-have-been older brother was born a “blue baby” and died soon after, not really a miscarriage at all but a heart problem in the child.  DES is a good illustration of “The Twenty Year Rule.”  An apparently successful new technology appears; the medical profession gets excited and applies it to many patients.  Twenty years later (from the ‘50s to the ‘70s in the case of DES) unpleasant or dangerous side effects become evident and the medical profession backs off en masse.  You would think these experiences would lead all of us to be more cautious before trying out the latest thing on our irreplaceable bodies.

Update 1/10/2013:  Eli LIlly settled its case with the Melnick sisters for an undisclosed amount.  Lilly stated that, while it did not believe that its medication had caused the Melnicks' illnesses, the settlement was in its best interest.

“Dear CDC: BMI ≠ Body Fat”

Happy New Year!  Another year, another study apparently proving that being a little overweight is fine and may even reduce your risk of dying, as compared with being thinner.  This one, from the Centers for Disease Control and Prevention, re-analyzes data from 97 studies involving nearly three million people from various countries.  The study, which is being published in the Journal of the American Medical Association, has been widely publicized.  I counted two articles in the New York Times and one in the Wall Street Journal plus coverage on radio, TV, and the Internet.

This is the most recent illustration of “the obesity paradox,” the fact that, although excess weight is a factor in cardiovascular disease, obese patients with heart disease tend to live longer than those with no excess weight.  I would argue that the root of this “paradox” is in the definition of obesity.  When you used a flawed measuring device, you get incorrect results and BMI, which used as the index of fitness in all these studies, is seriously flawed, as I explained in my post, “What’s Wrong With BMI.”  

BMI is a ratio of weight to height:  multiply your weight in pounds by 4.88, then divide it by your height in inches, squared.  Anyone with a BMI over 25 is considered overweight; anyone over 30 is classified as obese.  This means that people who are fatter than average (unhealthy) are lumped together with people who are more muscular than average (very healthy).  Under this system, a person the same height and weight as Tony Horton would be treated as equally fit even if he had never exercised a day in his life!  Measuring the percentage of body fat for each individual would provide a more accurate picture of the situation.  Lots of people know that there are problems with BMI.  Melinda Beck’s article in the WSJ alludes to this.  A number of her readers know it too, as indicated by some of the comments on the article.  So why did the CDC use it in this case? The answer is that it is easier and cheaper to use existing data and the existing data all use BMI.

As a federal agency under the Department of Health and Human Services, the CDC is looked upon as a leader in the fields of science and health.  When it continues to use and endorse BMI as a measure of good physical condition, it sets an example that others follow, which does a disservice to all of us.  In my doctor’s office my weight is measured on a BMI scale.  I ask my doctor why there is no body fat scale and she says that BMI is the current standard.  As long as this continues, there will be no data on body fat for anyone to study unless they do original studies themselves.  Fortunately, some of this research is being done.  A Mayo clinic study found that people of normal weight can be at greater risk of heart disease if the levels of body fat are high.

The timing of this new study and the ensuing publicity could hardly be more damaging.  Scientists at the CDC are surely aware that fat people who lose weight through appropriate diet and exercise (not illness) will lower their blood pressure, reduce their blood sugar, and improve their cholesterol readings, all of which will contribute to better health.  At the beginning of a new year many people are pre-disposed to turn over a new leaf.  Instead of encouraging people to cultivate better habits, the CDC puts its imprimatur on the perverse message that it’s OK to be fat.