Saturday, August 21, 2010

Medical Myths and Magical Thinking

Everyone has a certain degree of belief, aka myths, about medicine, their body health, and illness. If we all took a course in human physiology as seniors in high school, we would understand our bodies better, but since a recent poll showed that 75% of Americans believe in the existence of angels, we still would have beliefs as well as facts controlling our reaction to illness and doctors. I recall my parents' friends all ate a lot of wheat germ because they listened to a weekly radio program by Carleton Fredericks, and Dr. Jarvis' book on Vermont country medicine and the beneficial uses of apple vinegar is certainly well written and convincing.

It is of vital importance for a doctor to talk to his/her patient in enough depth to understand the patient's belief system, and I do not mean Catholic vs. Protestant, or Jehovah's Witnesses, or Christian Scientists, but rather how much medicine is acceptable to the patient, both in words and prescriptions. All beliefs about medicine are true beliefs, in the sense that the patient is committed to them, the recitation of facts and research will not sway them, and they will feel stressed if forced by circumstances to act against them. For instance, I can usually convince a committed vegetarian to take 1 mg/day of Vitamin B-12, which is needed to make animal DNA but not vegetable DNA, but it is not easy.

I have tried, with some success, to convince the medical residents under my direction that a patient's refusal to take a medicine is not grounds for an immediate psych consult. The last study of pharmacology behavior (or " pharmacological autonomy" if you want to be politically correct) showed that 25% of patients who leave the doctor's office with a prescription never fill it, 25% of those who fill it never take it, and 25% of those who take it stop before the indicated date, or rarely take it 3 times a day when so prescribed. Medical residents are guilty of the same behavior. At the same time, the most frequently committed federal or state felony is taking one of your relatives' or friends' controlled substances for pain, to sleep or to relieve anxiety, but no one seems to get reported or arrested for this.

I have male diabetic patients who refuse to take insulin:They believe that if they take insulin, then they are admitting that have diabetes, but if they just take pills, then they only have a "sugar problem". I have patients whose blood pressure is normalized with medicine asking me if they can stop their medicine now that their blood pressure is under control, or stop taking their statin now that their cholesterol is below 200. 25% of female high school seniors in the upscale, medically knowledgeable area in which I practice have never seen a gynecologist; I don't know if their parents think that seeing a gynecologist = approval of sex, but a girl should have her first pelvic done by an experienced gynecologist, who has time to ask questions and make the patient feel at ease, and not some GP in a college clinic who is just looking for vaginitis and STD's (and I apologize to those college physicians who are true gynecologists).

I have thousands of wives telling their husbands what to eat, not realizing that eating cholesterol (egg yolks) does not raise your cholesterol as much as eating animal fat does. For that matter, french fries and potato chips, both of which contain no cholesterol, contain enough fat to raise your cholesterol, and when Frito-Lay wanted to advertised their potato chips as having absolutely no cholesterol (which is a true statement for any vegetable product), the FTC made them pull the ad, because they were afraid that the public would equate "no cholesterol" with " "no fat".

I don't believe there is any such thing as "junk food" or "useless calories", but rather eating too much or to little. I don't care what you eat so long as you gain no weight, and have a daily multivitamin to cover whatever you may be missing. One of my children lived for a year on peanut butter and fluff,(and Poly-Vi-Flor vitamins) with no apparent ill effects, since he made the Little Leagued All-Star team as a pitcher. Exercising for 30 minutes non-stop every other day helps as well. White potatoes (and French fries, of course) have the highest glycemic index of any of the common foods, and therefore put the most stress on the glucose-insulin-fat system, so if you are on a diet, white potatoes are absolutely verboten.

It is not true that if you make love standing up you will not get pregnant. And you can't possibly douche soon enough to keep rapid swimmers out of the uterus. And if you follow astrology, what counts is the configuration of the planets at the moment of insemination, because a sperm is easier to direct than is a whole embryo. So you must know the planetary configuration at the moment of insemination (even better is at the moment that the father's sperm entered the cervical os, or the Fallopian tubes).

It is not true that a bowel movement a day is necessary for good health. Some of my patients average three movements a day, some three a week, and some three a month. In my human physiology class we were told that the longest time between movements was recorded as a year and a day, but since they had to then operate on the patient and use a hammer and chisel, perhaps that is a bit too long.

Too many mothers overemphasize their effect in the nature-nurture result. His mother did not give Derek Jeter the ability to hit major league pitching, or Frank Sinatra the ability to sing. I'm not sure what Midori's mother ate on the night of her creation, or if she listened to Mozart while she was pregnant with her.

Some patients will always see the glass as half full, and others as half empty. (And I see the glass as too large, but I generally think "out of the box".)Some are born salesman, and some are born daydreamers. We should also remember that the result of all tests are effort-dependent: hearing, PSAT, GMAT, 4th grade arithmetic, stress tests, and pulmonary function tests. Many students do not give the test 100% effort, but this is impossible to determine. In fact, some free-thinking students realize that since the state-wide test results do not affect their grade then they are guinea pigs, and put down "(a)" or whatever suits their fancy for every answer; why should they study hard and work on a test that is promised not to affect their grade.? In fact, if they do poorly, their school district can get even more money for supplies, so perhaps they are really helping. I myself never rewrote any humanities term paper in college, because (a) I was a physics major, and (b) the required effort to rewrite a B+ into an A- paper wasn't worth it to me. The one exception was a paper on Zoroastrianism in my course on Oriental Religions, because I was really interested in the subject.

Patients also think that the less medicine they take, the less sick they are. So when 40mg of Zocor was replaced with the equipotent dose of 10mg of Lipitor, they were very happy, and even happier with 5mg of Crestor. And Vytorin is one pill, not two, which is also good. They also think that the less asthma medicine they can take, the less serious their asthma is, and they are forever skipping doses of inhaler and believing that their breathing is not affected. On the other hand, 50 mg of Viagra must be better than 10 mg of Levitra, because the Viagra pill is bigger, has a great blue color, and is a larger dose.

Along with the above, the most surprised patients are those who survive a heart attack and go home on five new medicines. These many medicines do not mean that you are very ill, but rather that physicians know from experimental studies that each of these five medicines will reduce your chance of a second heart attack (and remember that the single greatest risk for having a heart attack is already having had one). The medicines are: a platelet blocker (aspirin, Plavix, or Coumadin), a beta-blocker, a statin to lower your cholesterol and stabilize any atheromatous plaques in your coronary arteries, an ACE inhibitor or an ARB, and, if you are in any heart failure at all, spironalactone. Again, these are all to reduce your chance of having a second heart attack, and should be taken exactly as prescribed.

If your doctor and you have a clash of opinions that is too strong for you to feel comfortable with him/her, then you should find another doctor. Never feel guilty about this, because it is your body and mind, and therefore your privilege to see or stop seeing whomever you want to. Speaking for myself, I do not want my patients to feel guilty about calling me after hours or when I am not in the office; when I am on call, I expect to be called. Your "job" is to tell me your symptoms, and mine is to worry about them and interpret them. We are both partners in your physical and mental well-being.

Added note: If your doctor spends more time talking about his/her problems than listening to yours, it is definitely time to find another doctor!


  1. I read with great interest - and more than a smattering of belly laughs - this excellent stream-of-consciousness post. It's infused with all the right ingredients: intelligence, humor, whimsical anecdotal examples, to keep even the most ADD-addled reader such as me ENGAGED! Good job!
    However, toward the end, I puzzled at your rosy assessment of heart medications, though respect your experiential reasoning as to their efficacy within the context of MI patients. Why not include some discussion of myopathy and memory loss - clear, evidence-backed side-effects of statins - in future posts?

    My Dad bucked those prescriptions - as well as refusing stents or catheterization; open-heart surgery was flat out of the question - when he experienced his first and only MI in 1996.
    Now 86 and determined to remain prescription-free, he still writes a newsy letter each year to the doc who 'fired' him way back then.....
    He's the best example-setter I've ever had.

    Dave Hopkins

  2. I just wanted to explain to patients that they weren't as ill as they may have thought to be on 5 new medicines. You are absolutely correct about side-effects of statins--I think I mentioned this in an earlier blog on statins. Statins lower the cholesterol in the membranes of ALL animal cells---muscle cells in the legs as well as glial and nerve cells in the brain. This is the cause of the muscle cramps and difficulty concentrating that can occur in patients on statins. I tell my patients about the possibility of both these side effects when I prescribe them, and then let them make their own decision.

    Thanks for your comments.

  3. As I think I said in an earlier post, there is cholesterol in the cell membranes of ALL animal cells, so when you lower the cholesterol, you change the trans-membrane voltage potential. This makes muscle cells more jittery, which probably explains the night-time leg cramps that awaken some statin users. Similarly, the neuron-to-neuron connections in the brain are probably altered in some fashion, perhaps enhancing negative controls, so I am not surprised that some patients on statins can have trouble concentrating or doing the Friday crossword puzzle in the NY Times.