He came to the ER with chest pain, shortness of breath, and atrial fibrillation with a heart rate of almost 120 beats per minute. It wasn’t a heart attack, and it wasn’t some rare disease. He was emergently ill because his physician overreacted to blood tests, and prescribed a thyroid pill he didn’t need.
According to an article in JAMA Internal Medicine, the 72-year-old patient described above had gone to his doctor several months earlier, with mild, nonspecific physical complaints. The doctor ordered a blood test, which showed a slight elevation in his TSH, or “thyroid stimulating hormone.” TSH is the molecule your body releases when your thyroid isn’t producing enough hormone. When TSH is elevated, it can be a sign that your thyroid gland is underperforming.
In this patient’s case, even though his TSH level was high, the level of thyroid hormone was normal in his blood. That means his situation isn’t straightforward. Suppose his TSH had been elevated at the same time as his thyroid hormone was low. And suppose that he was also showing specific signs of thyroid problems—maybe he was cold all the time, or had a slowing of his heart rate. This constitution of signs and symptoms would be strongly suggestive of hypothyroidism—that extra TSH in his bloodstream might not be up to the task of prodding his thyroid to do its job. In that case, it would be reasonable for his primary care physician to prescribe thyroid hormone replacement, and see if he got better.
(To read the rest of this article, please visit Forbes.)
Cancer screening can save lives: Mammographies reduce the chance women will die of breast cancer; and colonoscopies reduce the chance people will die of colon cancer.
But should my 93-year-old father receive a screening colonoscopy? The test is uncomfortable, carries risks, and costs money. Even more importantly, my dad probably won’t live long enough to benefit from the test. That’s why most medical experts think people like my dad—people unlikely to live another decade—should not receive cancer screening tests like colonoscopies. But how in the heck is my dad’s doctor supposed to deliver this news to him?
My father’s primary care doctor could tell him: “I have good news for you. You don’t need a colonoscopy—you’ll probably die of something else before colon cancer gets you!” But according to recent research, that message isn’t likely to go over well with its audience. The study, out of Johns Hopkins, convened senior citizens and asked them what they thought about conducting screening tests in patients of advanced age. The people told researchers that they understood the concept of stopping testing when people get too old to benefit. But they did not like the thought of doctors telling them that their impending mortality is the reason they will no longer receive such testing. “You’re too old to benefit” is a harsh message.
So what should physicians do?
(To read the rest of this article, please visit Forbes.)
As a primary care physician, I have counseled thousands of patients to get cancer screening—blood tests to look for prostate cancer, mammograms to detect impalpable breast cancers, and colonoscopies to find precancerous colon lesions. I’ve even tried to find cancers on physical exam, palpating people’s necks for thyroid growths, for example. The goal of all these screening tests was clear to me—find cancers early and we can get rid of them before they become life-threatening.
All the while, I knew there was a downside to much of my efforts. I was potentially finding “lesions” that, if untouched, would have never harmed my patients. I wasn’t just diagnosing cancer and its predecessors; I was overdiagnosing it. Two studies from Dartmouth physician Gil Welch brings new evidence of the surprising frequency of such overdiagnoses, including surprising data on the epidemic of overdiagnoses in rich countries like the U.S.A.
(To read the rest of this article, please visit Forbes.)
My father is 92 years old, and I am beginning to wonder whether the best thing for his health would be to stay away from doctors. That’s because well intentioned physicians often expose their elderly patients to harmful and unnecessary services out of habit. That’s certainly the message I absorbed after reading a recent issue of JAMA Internal Medicine that published three studies documenting the worrisome frequency with which internists like me over-test and over-treat our patients. I am going to briefly describe these three studies before laying out some ideas about what’s going on here.
One study explored the use of PSA screening among men with limited life expectancy. The PSA blood test is used to screen men for prostate cancer. The test is controversial, with some groups saying there is no evidence it benefits anyone and others saying it is a crucial way to reduce prostate cancer deaths. Despite this controversy, almost everyone agrees that when people have limited life expectancy–when, because of age and other illnesses, they probably have fewer than five years to live–the PSA test does more harm than good. But some physicians nevertheless continue to order PSA tests, even in men close to the end of their lives.
The study, which analyzed data from Veteran’s Affairs medical centers, found out that patients receiving care from “attending physicians”–more senior physicians–were more likely to receive harmful PSA tests than patients receiving care from physicians still in training. :
The second study looked at carotid artery imaging in people 65 years or older. The carotid arteries are the large vessels on either side of your neck, the ones you can feel your pulse on. They are the main supply of blood to the brain. People who get blockages in their carotid arteries are at risk for strokes.
Carotid imaging with tests like ultrasound can identify narrowing of these important arteries, potentially revealing partial blockages in time to fix them before they fully occlude. In the old days, I’d place my stethoscope on a patient’s neck to listen to the harsh sound of blood squeezing its way through these blockages. Upon hearing a worrisome whoosh, I’d send my patient for imaging and then, if my suspicions were warranted, would refer the patient to a neurovascular surgeon, who would decide whether to perform a procedure to open up the artery.
But now, we physicians are being told to be more cautious. The benefits of all these tests and treatments aren’t so clear in many patients. The risks of the surgery can outweigh the benefits in people with no history of stroke or stroke-like symptoms. Nevertheless, many physicians continue to test and treat aggressively.
To read the rest of this article, please visit Forbes.
In the wake of the horrific floods that struck Colorado recently, many people have debated whether global warming is to blame. The same goes for wildfires that hit that state this summer and for the massive tornado that struck in Oklahoma this spring. In the wake of that tornado, for instance, Senator Sheldon Whitehouse from Rhode Island claimed that Republican opposition to climate change legislation was at fault, for trying to “protect the market share of polluters.” Senator Barbara Boxer was confident about the cause of the terrible twister too: “This is climate change” she said.
The same finger pointing occurred after super storm Sandy, with some people even claiming that global warming could make storms like Sandy into the new normal, occurring as often as every other year, and Governor Chris Christie just as adamantly denying that global warming played any role in this storm.
The problem with these debates is familiar to those of us in the medical community who have followed controversies about breast cancer screening—people mistakenly and all too understandably seek out explanations for individual events when science can only tell us about aggregate truths. For the same reason we cannot tell whether an individual mammogram saved a woman’s life, we cannot determine whether any specific storm is the result of climate change. Instead, we are left with what we can learn from statistics.
Wondering why we don’t know whether a specific mammography test saved a woman’s life? …(Read more and view comments at Forbes)
On May 8th, the makers of the oncotype DX Prostate Cancer Test presented results of a large study demonstrating that their test can help men decide whether their prostate cancer carries a low enough risk of progression to forgo surgical or radiation therapy, two treatments that typically eradicate prostate cancers but also cause most men to experience impotence and incontinence.
Lacking such a test, many men have felt compelled to receive these aggressive treatments even though they know that most men in their position—with low grade cancer localized to the prostate—will not experience aggressive, metastatic disease. Low grade tumors—what are called Gleason 6 and 7 tumors based on how they look under a microscope—do not usually cause fatal illness.
But there are a couple problems with our current staging system, at least in the minds of most patients. It’s phrases like “don’t usually cause fatal illness”. Those are troublingly vague words for someone who has just found out he has a cancer diagnosis. It must mean that some of those tumors turn nasty.
Enter the Oncotype test. If the test is as good as experts hope it to be (warning: the results have not passed peer review muster yet), if the test better identifies safe tumors that have almost no chance of spreading, then men should be able to avoid those nasty treatments. And they should also be able to avoid the costs of being monitored every six months with prostate blood tests and biopsies.
But will human psychology interfere with optimal use of the Oncotype test? … (Read more and view comments at Forbes)
On April 14, The United States Preventive Services Taskforce concluded that women with an elevated risk of breast cancer – who have never been diagnosed with breast cancer but whose family history and other medical factors increase their odds of developing the disease–should consider taking one of two pills that cut that risk in half. The Taskforce is an independent panel of medical experts who review the medical literature to estimate the pros and cons of preventive interventions. This is the same Taskforce that in recent years raised questions about the benefits of mammograms in 40 to 50-year-old women, and PSA tests for men of all ages, tests that screen respectively for breast and prostate cancer. Despite the popularity of both of these tests, the Taskforce concluded that their harms often outweigh their benefits.
The irony now is that with this report on breast cancer prevention pills, the Taskforce has switched from rejecting something patients believed in to endorsing something most patients will reject.
The seemingly strange way the Taskforce ping-pong’s between popular and unpopular recommendations is inevitable, because these kinds of recommendations must necessarily go beyond the medical facts – it is impossible to decide what preventive measures people need without making value judgments.
To understand the way facts and value judgments get mixed together in these kinds of recommendations, let’s take a closer look at these breast cancer prevention pills… (Read more and view comments at Forbes)
Imagine you are 17 years old again and applying to college. You have your heart set on Stanford, but know it’s a long shot. Your well-meaning aunt, aware of your interest in that fine Palo Alto institution, buys you a Stanford sweatshirt.
Would you wear it before you found out whether you had been accepted? … (Read more and view comments at Forbes)
In September the United States Preventive Services Taskforce, a panel of medical experts, concluded that tests to screen for ovarian cancer do more harm than good. As a result, insurers will not be required by federal law to pay for such tests.
And the announcement was met with near silence.
Why was this recommendation greeted with such malaise when the same panel’s… (Read more and view comments at Forbes)
JoAnn Pushkin’s breast cancer was diagnosed at an advanced stage because the density of her breasts obscured the tumor on her mammograms. That was shocking news to Pushkin, who only learned that her breasts were radiologically dense at the time of her diagnosis. Activated by this revelation, she has become a leading advocate of legislation, like that recently passed in the state of New York…(Read more and view comments at Forbes)