Monday, January 23, 2012

Test Blog # 3

"When a man marries a woman, he hopes she will never change,and she plans to change him, and both attempts are doomed to failure."---Albert Einstein, Nobel Laureate in Physics

Sunday, January 22, 2012

Medical Tests for Patients

     This blog is a follow-up to a previous blog on medical testing. Here I will discuss the philosophy that underlies most, but not all medical testing. As you will learn, many tests have no clinical evidence of  their usefulness, but that  may not stop a doctor from ordering it or a patient from requesting it.

     Firstly, I never worry about whether or not a test is "cost-efficient". My moral commitment is to my patient, and not to the amount of money his/her medical care may cost. That is not my decision to make. In other words, I am making a medical decision for one person and not for the 300,000,000 people who dwell within our borders, and I am sure you would want your personal doctor to think and act in the same manner.

     Secondly, even if I think a test is not needed, and am fairly certain that the test will be negative, if the patient wants it I generally order it. To me, the fact that the patient will be relieved when the test comes back negative is generally sufficient reason to order it. Often the test is requested because a spouse suggested it, or a best friend came down with a particular disease, or it was discussed on TV or read about on the internet. For instance, for a while the magnesium content of red blood cells was thought to be related to chronic fatigue syndrome, so patients wanted this measured. I do, however, refuse to do tests suggested by The National Enquirer.

     As I have mentioned in a previous blog,  if a patient comes in requesting an HIV/AIDS test because he/she is starting a new sexual encounter, I refer them to the Red Cross or their nearest hospital. I explain that not only will the blood bank test the blood for AIDS for free (as well as for hepatitis and a host of other blood-borne diseases) but that they will also be helping their fellow citizens by their donation of a unit of blood. I also suggest that their future partner do the same.

     Although there is absolutely no evidence that a vaginal ultrasound or the blood test CA-125 can detect ovarian cancer early enough to save lives, I will never deny a woman's request for these tests, because a negative test sharply reduces their worry/concern about having this dread disease.

     I have a moral antipathy to the traveling ultrasound trucks that pull up to a nursing home and offer to test the residents for narrowing of their carotid or femoral arteries or an abdominal aortic aneurysm They tell the residents that they are giving them a half-price special because Medicare does not pay for these screening tests. But then they give the results to the patient and tell them to consult with their personal doctor about any abnormal results. To me, this is equivalent to abandoning the patient, and should be outlawed. Any doctor who orders or performs a test on a patient is morally (and should be legally) required to do all the necessary clinical follow-up of any abnormal results.

     The same holds true for the total body CT scan that looks for calcium in your brain, your lungs, your coronary arteries and your abdomen. Again the patients are offered a "discount" and are told to follow-up with either their personal physician, or a physician at the hospital where the CT was done. The patient is never informed about the percentage of false positive tests, or if detecting calcium in a particular organ does indeed lead to an intervention that saves lives.

     No  comment is necessary  about the PSA blood test for putative prostate cancer.

     Patients should be made aware that the "normal" range for a given blood test is usually the average value of same sex adults plus or minus two standard deviations. This means, assuming the values of the blood tests are scattered "normally" (i.e. in a Gaussian distribution) throughout the test population, then for almost  any blood test 5% of those tested will have an "abnormal" lab test, i.e. a value outside the "normal" range WITHOUT having a medical disease.
It is trivial to show that it then follows that in a panel of 25 blood tests, the average patient has a 50% chance (one out of two patients) of having an abnormal blood test. I have not even mentioned that there are racial differences in blood tests as well. For instance, without any disease, the average white blood cell count of white American adult women is 4.5, while the average white blood cell count of black American adult women is 3.5, just as the normal hemoglobin count for adult women is lower than that for adult men, and the normal ESR (sedimentation rate) is higher for women than for men, and teenagers have a "higher than normal" alkaline phosphatase because their bones are still growing. To repeat: you can have an "abnormal" blood test without having any illness at all, much in the same way that any plain Xray of the neck or lumbar spine of every adult 40 years old or older will always show "arthritis", even when the patient is pain-free.

     The public is also blissfully unaware that the cutoff value for certain blood tests is determined (and not unanimously) by a group of doctors in Washington, D.C. much as one year the American Psychiatric Association voted that homosexuality should no longer be considered as evidence of a mental disease.
When I was in medical school, the upper value of "normal" fasting glucose was set at 140. It has since been lowered to 120, then 110, and most recently 100, with patients between the "normal" level and a glucose of 200 have been labeled "pre-diabetic". This label has increased their life insurance and long-term care insurance premiums without any demonstrated improvement in their health.

     I will close by mentioning that not all clinical laboratories are equally skilled in measuring all lab tests (e.g. N-terminal parathormone), that some "normal" values for the same test are different for different labs, and that the first thing that should almost always be done with any abnormal blood test is to repeat it, rather than to automatically assume that the patient is ill.








Saturday, January 14, 2012

Patients' Denials, Lies, and Forgetfulness

     This blog is not intended to be critical of patients, but to point out the various ways in which patients mislead their doctors, either consciously or subconsciously. Lawyers have told me that they  have a similar problem in that many of their clients do not tell them all the facts of the case. The people who lie the least to doctors are the parents of sick children (barring Munchausen by proxy or child abuse). I always tell my students and interns before I examine a new ward admission in front of them  not to feel surprised or embarrassed if I elicit different answers to the same questions that they asked. The patient may have been under more stress, or heard the question differently, or the spouse was present, or I phrased it differently, or they  are no longer as anxious as they were in the ER, or feel better, or didn't like the admitting doctor, or trust me more  because I am the same sex or the opposite sex or the same race or the same age or older or taller or they like my smile better or my voice better or whatever. There is also a psychological transference that takes place subconsciously in that the patient will, to a greater or lesser degree, involuntarily relate to me in a manner similar to his/her relationships with  previous authority figures such as doctors, parents, teachers, supervisors at work, ministers, spouse, older siblings, or whoever, and in addition  the admitting intern may have reminded the patient of someone the patient disliked intensely or had a negative interaction with.

     Many "lies" are memory lapses or a misinterpretation/misprocessing of the question. For instance, some men may  recall that they had a hernia operation as a child, but forget on which side. I myself broke my fifth metatarsal when I was 14 years old playing football, and I think  but am  not absolutely sure that it was on the right side. OTOH  I am certain  that I had a greenstick fracture of my right forearm because I vividly recall my inability to twirl spaghetti on my fork with my left hand when my right arm was in a sling. Many patients know that one eye is weaker than the other, but never remember which one, and often do not recall that their eyeglasses also correct for  their astigmatism, or if they were ever tested for color-blindness.

     A patient will answer "none" when asked if he/she had any operations, and then when you ask about a surgical scar on their abdomen they will say "Oh, I forgot". A female patient will answer "no" when asked if she takes any prescription medicine, but then answer "yes" when asked if she takes birth control pills, because  she associates medicine with treatment of an illness, and not the prevention of pregnancy. Patients will tell you they had open heart surgery as a child but have absolutely no recollection of what sort of surgery it was, or what condition it treated. Very few patients travel with a complete list of their medicines and their dosages,
and virtually no one recalls the date of their last tetanus shot, or if they ever had a skin test for tuberculosis unless the test was mandated because of work.

     Patients want to appear to be healthy and moral to their doctor, and this is where deliberate misconceptions come into play. They tend to minimize or forget to mention actions that they think the doctor will consider immature or unwise or immoral, not realizing that we have probably heard it all before. A wise and good family doctor will not appear to be a censuring moralist, lest the patient suppress uncomfortable truths. It is sometimes helpful to tell the patient  (and mean it) that you will not write down anything the patient does not want you to record in the medical chart for all the world (including the internet, the spouse, the employer and the medical insurance company) to see. I always do this----I keep a separate list of the patient's true medical problems that are not in the chart---(has a lover, had an abortion, uses cocaine) and I forward this information only verbally to the next treating doctor.

     Men deny many more symptoms than do women. The only symptom that I have seen to cause a man to come running to his doctor is when he urinates or ejaculates blood. Any other symptom, including rectal bleeding, coughing up blood, or chest pain usually has to recur at least two to three times before the doctor is notified (unless the wife is aware of the symptom). Patients who take their own blood pressure or measure their own blood sugar level at home usually do so two to four times at a single sitting, and write down the best numbers to give to the doctor at the next visit.

     As a final note, you can take it for granted that if the wife accompanies her husband into your consulting room and listens as you obtain his medical history, he will rarely tell you the whole truth. He will only tell you symptoms and worries that (a) he is willing to have evaluated, and that (b) he does not mind  his wife telling him what to do about. If the wife mentions a symptom, the husband usually promptly minimizes it. And if you interview the husband alone and the wife later calls you to ask you what you told the patient to do about his chest pain/erectile dysfunction/cigarette smoking/shortness of breath/overweight,  you are ethically bound to answer that you discussed the problem fully with your patient and that she is free to ask him about your answers, even if she has told  you of a symptom that the patient did not mention to you. It is a general observation of mine that wives worry more and show a greater concern about their husbands' health than the husbands themselves do. This seems to be a gender issue, in that husbands often do not want to have symptoms investigated if they think (a) they will not like the result or (b) they will not like the suggested intervention and treatment. I share space with a sleep-study lab, and I cannot begin to tell you how many men, when they come back to discuss their positive results, emphatically state that "If I had known that I would have to wear this d**mned mask every night, I would never have taken the d**mned test!".


Friday, January 13, 2012

Medical Mis-knowledge

This blog was triggered by a recent summary of the Cochrane reports, as published by the British Medical Journal. The Cochrane Reports evaluates all recommended medical practices to determine if there is any valid (experimental and clinical) reason for them. Usually there is not.

Test blog # 2. Please ignore the above. Bugs almost all out of system.

Male-Female Attraction: The Thunderbolt and others

This is only a test of the e-mail sending system of my blog.

Thursday, January 12, 2012

Anger Part III----Anger: One Cause of "Acting-Out"

     There are probably other causes of acting-out, and certainly there are other self-destructive manifestations of anger, but the following comments are derived from my tutoring of and therefore also life-coaching schoolboys from the 7th, 8th, 9th and 10th grades. In most cases, their acting-out in school was first officially commented on  in or near the 4th grade, when they were 10 years old; i.e. still pre-pubertal. They were generally given a diagnosis of ADD/ADHD, and referred to a psychologist for behavior modification and to a psychiatrist for medication, usually a CNS stimulant such as Ritalin or Adderall. They also usually developed insomnia at about the same time.

     Their parents referred the boys to me because they knew that I had been a professor of  physics, and that I also used to teach in  the science honors program given for  bright junior high school and high school students Saturday mornings at Columbia University. I was nominally supposed to tutor them in math and science, but of course it evolved into life-coaching since their societal attitudes had to be adjusted by the students themselves, with some input  from me. Remember that all of these boys had gone through nursery school in Bergen County, where they had learned to color within the lines, line up, be polite, follow orders, ask for permission, sit in their seats unless given permission to leave, etc. They also were in private school K-8 or 9-12, and the  private school would never allow a boy who was obviously acting out in the interview, etc, to be admitted, so we know that they knew how to "behave"; it was  just a matter of what they felt  like doing in school and why. By the 7th grade it was obvious to everyone that the students were performing way below their abilities, as evidenced by the downward deviation from their previous scholastic levels, and I was asked to tutor/educate/motivate them. They were still being followed by psychiatrists or other therapists.

     One common manifestation of their anger/acting-out  was their handing in  homework late, or incomplete, or not at all. The usual cognitive tricks such as asking the student to  place the finished homework by the front door, or giving the parents a copy of the homework assignment never worked, because like the act of doing the homework itself, it required the active cooperation of the student. You know you can't make a two-year-old eat spinach if he is unalterably opposed to it and you also can't push on a rope. Either analogy will do. I had to help the students to understand that this negative behavior, although it made them feel better by "rebelling" only hurt them because they would be labeled as unreliable and undependable.

    Another manifestation was that of doing poorly in tests, either by running out of time and not finishing the test, or leaving questions blank and unanswered. Like underperforming their homework assignments, they felt that they had demonstrated something by their actions. Again, I had to point out that all the teacher would note was (a) poor test results and (b) underperforming, and that this "rebellion" served little purpose since no one would understand or applaud their martyrdom.

     All of these actions are, of course, examples of passive aggression, taken to the extreme. They all affected "la belle indifference" as a response to all the negative comments about their actions, as though they were above it all, and that it all was of little consequence in the long run and could not possibly affect their lives as grownups. The problem could not be solved by addressing their anger directly, because the anger was disconnected from their self-picture of reality.

     Each student had to be convinced that the world at large didn't care if he was angry or unhappy, but was only interested in the results of his actions. They had to understand that actions or lack thereof did have consequences, and if a teacher labeled them as "unreliable", it would make their future lives quite difficult. They finally understood that their first recommendations come from their high school teachers, and that in these days of electronic records, once a comment was entered about their behavior or performance, be it good or bad, it would follow them for the rest of their lives, sort of like a scholastic Facebook.

     I have come to the conclusion that parents have to explain to their pre-adolescents that actions and society's opinions of their actions do have long-term consequences. Yelling at the boys to do their homework or make their beds or pick up after themselves usually has little effect. Boys seem to enjoy whatever rebellion against society they can get away with , especially if it also draws attention to themselves. Of course now with cellphones, the boys all talk with each other and give each other advice as to how to "handle" their parents or school. It's not as serious as the website that teaches anorectic girls how to hide their anorexia, but there is always a subculture and a background current of which parents are (blissfully?) unaware.