Back Pain Treatment Trends Worth Reversing

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It may just be the American way –pull out all the stops and try anything or everything at great expense when it comes to medical care.

Today’s post takes up how well the United States is doing at providing back pain care in accordance with evidence-based clinical practice guidelines for back pain (including neck pain). In original research and a commentary published online July 29, 2013 in JAMA Internal Medicine, John N. Mafi, MD, and coauthors from Beth Israel Deaconess Medical Center and Harvard Medical School, in Boston, MA, point out troubling trends in back pain care using nationally representative data from the Centers for Disease Control and Prevention’s National Ambulatory Care Survey and the National Hospital Ambulatory Care Survey.

Back pain is common, with surveys showing that 65% to 80% of Americans will report back pain at some point in their lifetime. So understanding what’s going on and managing it with the best science sounds good for patients. Back pain is a loaded category for sure: it involves how well patients can tolerate pain, patience because back pain is often temporary, yet it can be a springboard for all sorts of referrals. There are some relatively inexpensive ways to manage back pain that get a grip on back pain, but the study discussed here suggests that people want to throw everything at it and that the care people are getting is moving afield from science-based guidelines.

Prescribing Patterns

oxycontinBetween 1999 and 2010, opioid use for back pain climbed substantially from 19.3% to 29.1%, while recommended nonsteroidal anti-inflammatory drugs (NSAIDs: e.g. ibuprofen) and acetaminophen have declined by nearly half, from 36.9% to 24.5%.  The latter two drug categories are recommended as first-line for patients with back pain. Additionally, doctors in the south and west prescribed narcotic medications about 1.5 times more frequently than doctors nationally.

Not everyone gets opioids prescribed. The odds that women, black, Hispanic, and other racial/ethnic groups, and the uninsured were prescribed opioids was significantly lower. Commenting on this disparity, Richard Deyo, MD, MPH, Kaiser Permanent Professor of Evidence-Based Family Medicine, Oregon Health Sciences University, Portland, OR, said: “I think this is a situation where good insurance – and greater affluence – make overuse more likely. This may be a case where underinsurance has a protective effect!”

Imaging

MRI machine

MRI machine

Subgroup analyses revealed that neurologists and orthopedic surgeons had a far greater odds of ordering CT and MRI: more than 3.5 times higher than primary care doctors. MRI scans and CT scans rose between 1999-2000, at 7.3% to 11.3%, in 2009-2010.

Referrals

Physical therapy referrals remained constant over the ten-year period, but referrals to other doctors, especially neurologists and orthopedists, doubled by 6.8% in the first year of data collection to 14.0% in 2009-2010.

One Limitation: No Surgery Data

 The data are limited in that this data set cannot be used to see whether or not people got surgery.  However, lots of previous research suggests that with the cascade of advanced imaging and physician referrals, people are getting surgery more frequently.

What About Patients?

 In this study, trends in management of back pain suggest care is moving away from science-based medicine. Many of us have endured back pain that feels acute or chronic. Some of us know people who have had back surgery, seen lots of doctors, and gotten imaging studies. As I write this post, the news is calling attention to premiums perhaps not being that high as predicted with Obamacare. But you have to wonder: if these patterns of overuse to no good end for patients persist, the costs are going to get thrown back to patients. I’ve said this before, but I think we are at a standstill. We need to move beyond documenting overuse and inappropriate use and come up with ways to get doctors and patients on board with what works and does not.

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Cardiovascular Care and the Bush Effect

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Pres Bush at NIH

It’s too soon to tell whether former President George W. Bush’s stent to open his coronary artery will change how Americans receive cardiovascular care, but I certainly have my worries. If the argument to aggressively search for cardiac disease in asymptomatic people wins out, I see my healthcare premiums rising precipitously and continuing in that direction. It’s not just the premiums either, but putting healthy people into this perennial-patient or at-risk status for no good reason.

I don’t want to live in a world where we speak of how elevated each of our risk status is for cardiovascular disease, a stroke, or heart attack, as if it is a badge of courage. I learned recently that I have only a 4% risk of having a heart attack or stroke in the next ten years, apparently strong enough for my primary care physician to recommend a statin to lower my risk even further.

A month ago, I went for a routine physical at my primary care physician’s office. I got recommended immunizations, but there were aspects of the visit that troubled me. Once you are in a gown sitting at the exam table, you are fair game for consenting to a procedure right there, on the spot. How stupid I was not to pull out my smartphone to check whether a test was warranted. My doctor had moved from an academic medical center to open a new group practice.

Cardiovascular Testing Flourishing

I got hornswoggled into a carotid ultrasound test. The test evaluates blockages in your neck. What led to this test was my admission after persistent questioning (I am really well) that I very occasionally feel dizzy. Suddenly, the specter of a looming stroke was in the cards, perhaps a blockage in my neck. My blood pressure was 120/80 in both arms. When I asked the technician performing the test why it was being done, she said: “to prevent a stroke.” Now who would want to have a disabling stroke? It was a compelling argument on the surface.

Other contributing factors that were too daunting to address was the fact that a cardiologist sat in the office and owned the equipment. Who needs a fight with my doctor over whether the test is warranted and might be motivated by a conflict of interest? At another physician practice, on a rainy day, I once was offered a stress EKG, because: “He’s got the time. He had some cancellations because of the rain today.” The rationale: it was a few months after my mother died. I had occasional pounding in my chest.

Had I pulled out my smartphone and looked at the American Board of Internal Medicine Foundation Choosing Wisely site or a handful of other sites either time, I would have immediately learned that a carotid ultrasound test or stress EKG was unwarranted. I recommend readers bookmark this site and challenge their doctors before undergoing tests like these. It is a valuable reference. I should have known better. (Note: at press time, the link on the website was broken. It will be inserted as soon as ABIM Foundation fixes it.)

With my insurance, I only got stuck with a relatively small copay, but what would happen if everyone who walked in the door was seen unwittingly as a candidate for this procedure, stress EKGs, and more? Make no mistake about it, it’s happening. You tolerate it, fellow Americans, you are going to have to pay for it. Don’t be surprised if your premiums go up and if healthcare costs wipe you out. I may not pay for this kind of test this year, but it won’t be long before the economists make sure Americans fork out for these tests.

Oddly enough, when I returned home, in my mailbox, I found a glossy, oversize postcard from a teaching hospital touting its cardiovascular disease prevention program. They are popping up everywhere, offering a potpourri of risk assessment for heart attacks, strokes, and vascular disease, risk factor identification, treatment programs to reduce risk factors, secondary prevention, and screening before starting sports and exercise programs.

I don’t think that Bush was needed to propel overuse of cardiovascular procedures further over the top. It has been well on its way, but Bush’s stent underscores the trend. In this blog, in many posts, I have pointed to the numerous ways overuse is hazardous for your health, financial wellbeing, and more. It will be up to those concerned with overuse to devise new strategies to stop this train. Right now, it seems unstoppable.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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How Safe are Electronic Cigarettes? Not Everyone Agrees.

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Ads for Electronic Cigarettes are EverywhereMy friend lit up her electronic cigarette during intermission when we were on line for a bathroom at a Broadway theater. People on the line looked at her disapprovingly. She responded quickly: “I am not smoking. It’s only water vapor.” That’s the argument that the e-cigarette industry makes, and it is clearly one that my friend wants to believe. Her response put a stop to any questions about second-hand smoke. Nobody else said anything. Maybe nobody wanted an argument on a night out for theater or maybe people knew too little to comment confidently. She waited for a bathroom stall and continued smoking.

While questions about electronic cigarettes stayed below the surface in the ladies room, they are hotly debated in the world of tobacco control and public health. There are concerns about the exact benefits and potential harms of electronic cigarettes, second hand smoke, and air quality. Proponents see e-cigarettes as a safer alternative to traditional cigarettes, but skeptics question how safe they really are, both for users and people exposed to them as second-hand smoke. So far, they have been manufactured and distributed without oversight, data, or proof that they are a bridge to quitting more toxic cigarettes. Also, many experts question the industry line that just water vapor is released when users light up.

Product Regulation Considered

In Lancet Respiratory Medicine, two commentaries put forth opposing views on the question of regulating electronic cigarettes as medical devices. In one, Nathan K. Cobb, MD, and Caroline O. Cobb, from the Department of Pulmonary and Critical Care Medicine, Georgetown University Medical Center, Washington, DC,  warn: “Without oversight or consumer safety regulations, the manufacturers of ENDS produce products that are more widely available, much cheaper, and might contain more nicotine and contaminants than competitor products manufactured by pharmaceutical companies.”

Cobb and Cobb want regulation. They frame the issue this way: “The question should be what regulatory system will get safe and effective refined nicotine products into the hands of more smokers and promote elimination of the most lethal combusted products?”

In the second commentary, Peter Hajek, Director of the Tobacco Dependence Research Unit at the Wolfson Institute of Preventive Medicine, Queen Mary University of London, UK, and colleagues, argue that regulation will stifle innovation, the development of better healthier electronic cigarette designs, and hinder  competition of ecigarettes against more toxic traditional cigarettes.

Product regulation is only one part of the story. It is what the Food and Drug Administration can address. Local governments will have to decide where people can use e-cigarettes, and whether air quality statutes should issue standards.

E-Cigarette Use Patterns

I asked Stanton Glantz, PhD, Professor of Medicine at the Center for Tobacco Control, University of California San Francisco, and leading tobacco control expert, to comment on the Lancet Respiratory Diseases papers, and address concerns about the use and proliferation of e-cigarettes.

Q: What did you think about the opinions on e-cigarette regulation in Lancet Respiratory Diseases?

A (Glantz): The pieces were focused on e-cigarettes as products. They did not address what effect e-cigarettes have on use patterns. We’ve found very high levels of dual use [traditional cigarettes along with e-cigarette use]. Very few people have switched away from cigarettes or managed to use them as a bridge to eventually go off cigarettes. While many people believe e-cigarettes helped them quit smoking, neither of the available population-level studies showed such an effect.  One showed e-cigarette users and nonusers quitting conventional cigarettes at the same rates, the other showed e-cigarette users being less successful at quitting.

Q: Where do the authors stand on harm reduction and addiction?

A (Glantz): The articles reflect the polarization in the public health and tobacco control communities. The optimists – the harm reduction people (in this instance Hajek et al.)– essentially believe that electronic cigarettes are much less dangerous than traditional cigarettes and so their use should be encouraged. The pessimists (Cobb and Cobb) see electronic cigarettes as an addictive drug, that without regulation, are not going to market in a way that will disrupt the primary profit stream of cigarettes, and so could end up just keeping people smoking conventional cigarettes.

There’s an assumption among the harm reduction people that if you could snap your fingers and get every smoker to switch to e-cigarettes, you’d be ahead. One problem is that you can’t do that. While the industry uses social media and the internet to present e-cigarettes as a miracle way to quit, as noted above, no independent studies show that e-cigarettes actually help people quit. They may even discourage quitting.

Q: In what camp do you put yourself?

A (Glantz): I am a realist who is driven by data. I started out agnostic on e-cigarettes. While there is not a lot of information available now, what is there is pointing to dual use and ecigarettes impeding quitting cigarettes. All the big cigarette companies are now getting into this market. They are not going to market those products in a way that jeopardizes the cigarette market.

Q: Do you agree with the harm reduction people that e-cigarettes are a safer alternative for smokers?

A (Glantz): If smokers switched entirely from conventional cigarettes to e-cigarettes, no one started smoking because of e-cigarettes, and e-cigarettes did not discourage quitting, smokers would be better off.

Contrary to marketing claims, e-cigarettes do not deliver pure nicotine and harmless water vapor. In 1986, California passed a ballot initiative known as Proposition 65, which was intended by its authors to protect California citizens and the State’s drinking water sources from chemicals known to cause cancer, birth defects, or other reproductive harm, and to inform citizens about exposures to such chemicals. Annually, the Governor must publish a list of chemicals known to the state to cause cancer or reproductive toxicity. Ten compounds that are on the Proposition 65 list have been identified in mainstream (MS) or secondhand (sidestream/SS) e-cigarette vapor (See table).

Ten Compounds Found in E-cigarette Mainstream* or Secondhand Smoke**, Also on California’s Proposition 65 List

* Acetaldehyde (MS)
* Benzene (SS)
* Cadmium (MS)
* Formaldehyde (MS, SS)
* Isoprene (SS)
* Lead (MS)
* Nickel (MS)
* Nicotine (MS, SS)
* N-Nitrosonicotine (MS, SS)
* Toluene (MS, SS)

*MS – mainstream smoke
** SS – secondhand smoke

Credit: Stanton Glantz, PhD, Adapted from Gonewicz ML, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. doi:10: 1136/tobaccocontrol-2012-050859 and Schripp T, Markewitz D, Uhde E, et al. Does e-cigarette consumption cause passive vaping? Indoor Air 2013; (1):25-31.

Q: Do you think that, based on what we know, we should ban e-cigarette use in the same places that we ban cigarettes?

A (Glantz):  Yes.  Even though e-cigarettes are less polluting than conventional cigarettes, they still are putting a variety of volatile organic compounds, heavy metals, fine particles and other toxins into the air.  Regardless of the concentrations, there is no justification for reintroducing these toxins indoors after we spent 30 years getting rid of them.

Q: Do you think that any regulatory entity has taken the lead with a strong policy protecting the public’s health with e-cigarettes? What would such a policy look like?

A (Glantz): The FDA has the ability to regulate e-cigarettes as products and should do so.  The reality is, however, that meaningful regulation is probably years away because the tobacco and e-cigarette companies (that are more and more the same companies) will do everything they can to slow it down or stop it, including through the courts.

Where you can smoke e-cigarettes is a matter for local and state governments, who are already starting to act to include e-cigarettes in clean indoor air laws.

This post appeared previously on Scientific American’s guest blog. It is reproduced here in entirety. Have thoughts on this piece? Do comment here.

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The Smoking Wars: Menthol, Minors, and More Smoking Bans

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No_SmokingIn case you thought that the war against smoking was in our rear-view mirror, it’s not.  On Monday, I had a guest blog on Scientific American concerning electronic cigarettes, which provoked a lot of heat and discussion. I’ll put it up on this blog over the weekend. I learned a lot after posting and from the comments there, which were largely from electronic cigarette advocates. As comments revealed, users of electronic cigarettes claimed that they feel healthier with them, that they are not really smoking, and that substances released into the air are minimal and of no consequence to the environment.

Research on dual use and passive smoking cannot be ignored. When it comes to electronic cigarettes, it is not just the user, but the point of view of passive smokers. My bias is that electronic cigarettes should be regulated by FDA and subjected to the same environmental bans as regular cigarettes. We can’t fly blind.

The smoking wars are still ongoing.

Menthol Scientific Review by FDA

 The FDA released a scientific review on menthol this week. As a friend who reread this post before posting said to me: “I remember when I was 12 years old, menthol was really attractive to me.” FDA validates that issue. Its conclusions are concerning:

  • Menthol masks tobacco’s harshness;
  • Menthol makes it easier to become addicted, fosters greater dependence on nicotine, and increased difficulty quitting;
  • Menthol cigarettes account for about 1/3 of all cigarettes sold in the United States, but rates of use are disproportionally high among African Americans, other minority groups, teen smokers, and women;
  • Menthol use is linked to lower socio-economic status.

This could be the first step in a ban on menthol cigarettes. FDA invites public comment.

Beware Bills Targeting Minors

Interestingly, since posting, I learned that bills are cropping up, that on the face look as if they would ban electronic cigarette use in minors. Importantly, the American Cancer Society, American Lung Association,  American Heart Association, and Tobacco Free Kids oppose them.

At issue is whether passage of these bills are merely a Trojan horse that will aid in circumventing both product regulation and bans of electronic cigarettes in the same places that regular cigarettes are banned.  Earlier this month, Rhode Island’s Governor Chafee vetoed a bill that would have prohibited minors from smoking electronic cigarettes. According to an article in the Providence Journal, Chafee viewed it as an effort by the electronic cigarette industry to stave off further regulation.

Indoor Smoking Bans

New York celebrated its 10-year indoor smoking ban on Wednesday, July 24, 2013. Many U.S. cities limit indoor smoking. Research has shown that the indoor bans have been linked to improvements in public health, including fewer hospital admissions for heart attacks and lung cancer deaths. Extending these bans to electronic cigarettes is the next battleground.

 

 

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5 Wild Healthcare Stories Happening Right Now

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In my journal of “healthcare is going to hell in a handbasket” this week, I’ve got a few items that will either make you laugh or cry. Hopefully, after that, you’ll mobilize yourself to fight for equity in health care and for penalizing the crooks. Here are five absurdities in healthcare that you won’t want to miss:

1. Severe Memory Loss. That’s the explanation John Reynolds, former CEO (1997 to 2006) of the illustrious Hospital for Special Surgery, New York, NY, gave in his court appearance. He pleaded guilty to a $300K kickback scheme involving two hospital vendors and a British healthcare organization. Will “severe memory loss” be the avant garde explanation for corruption?  You have to wonder. As the New York Daily News reported, he’ll probably serve no more than 27 to 33 months, according to Federal guidelines.

According to Crains NY Business, the case was puzzling: Reynolds was one of New York City’s top-paid hospital CEOs. In his final year at the Hospital for Special Surgery, his salary was $1.3 million. When he retired, he got $1.4 million in severance.

2. “Choose Life” license plates. I didn’t know much about these until Felice Freyer, from the Providence Journal, Providence, R.I., tweeted earlier this month that the Rhode Island Legislature had authorized “Choose Life” vanity license plates. Here’s one from Texas.

It turns out, that the highly regarded Guttmacher Institute provides a nice overview of these license plates, noting that as of July 2013, 28 states have them. In what I consider a cruel irony, Guttmacher reports: “In some cases, money generated from their sale directly supports the activities of antichoice organizations or crisis pregnancy centers (CPCs), which often provide biased and medically inaccurate counseling to women seeking a pregnancy test or counseling with regard to an unintended pregnancy.” Think about it: is this constitutional or an acceptable use of state involvement? Is there some murky mix of church and state, endorsement of a political agenda? Reproductive rights groups have challenged the proliferation of these plates in some states, and successfully.

You know what I’d like to see: A “Choose Choice” vanity license plate. But I don’t have a car, and honestly, I don’t want to die because of some anti-nut. Note: since publishing this, Marilyn Mann points out in the comments below that opposing licensing plates have been approved in a handful of states. In addition, Providence Journal’s Felice J. Freyer reports that Governor Lincoln Chafee has vetoed the “Choose Life” license plates. 

3. More abortion regulation insanity (when you thought you heard it all). Here’s a new spin on state abortion-laws that are unconstitutional and outrageous. In Kansas, if you work in an abortion clinic, you cannot chaperone your kid’s class on a school trip, involve yourself in purchase of healthcare books, or in any way represent the School Board. You are drek and better stay away from school kids. The ACLU is fighting this as unconstitutional, along with the numerous other abortion-restrictive laws in Kansas. Carol Joffee does a good job here describing this section of Kansas abortion law.

4. “Obesity stigma du jour” – that’s what @stevesilberman calls this decision by the National Boy Scouts to ban obese Boy Scouts from its annual Boy Scout Jamboree.

Gee, America is the land of excess. I sure wish we’d go after corporate America more for the excesses than to take it out on those low on the food chain. How many more “blame the victim” for excesses are we going to have to see? And. as for the Boy Scouts, how many more fiascoes are they going to be involved in? Add this one to the Gay Boy Scout debacle and the organization could soon be history.

I’ll pass on the macaroons for now.

5. Looking forward to the health exchanges? Think again. This one makes me sad. This just in from today’s St. Louis Post-Dispatch: Large insurers in Missouri are opting out of health exchanges. What anybody who wants decent insurance does NOT want are health plans with absolutely zip experience in insuring large populations.

Plus earlier this year, Trudy Lieberman reported that the model health exchange in Connecticut was deemed unaffordable. Kind of makes me cringe. This is the tip of the iceberg. I am hoping it’s growing pains as Lieberman calls it. The Accountable Care Act was looking like the next big advance after Medicare. But lots of powers are out to sabotage it. Vigilance, my friends!

Do you have an absurd story about U.S. healthcare to tell? Tell me your story. You can send me an email to “patientpov” at gmail dot com. I’ll be sure to credit you.

Posted in disparities, Healthcare reform, obesity | Tagged , , , , , , , , | 5 Comments

Stand Up and Learn the Tradeoffs
Of Using Medical Imaging for Your Kids

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MRI machine

MRI machine

My last post raised questions about the overuse of CT imaging in children, which researchers projected could prove hazardous to kids in the form of excess solid tumors at some point in the kid’s lifetime. It’s one study, but as the study shows, a growing peer-reviewed data base points towards hazards that could be avoid.

Key issues that the researchers and editorialists raised include:

  • Around the country, pediatric radiation doses are not standardized and they could be reduced substantially to improve patient safety;
  • CT hits kids with 100 to 500 times as much radiation as standard x-rays.
  • In what cases, is sending your kid for another test distracting from real care and helping them get well?
  • What questions should parents ask to determine the tradeoffs in having their kid imaged or going through any test, or not?

Of all medical imaging tests, so far, CT stands out for the most compelling projection of harm –spelled out in terms of projected excess solid tumors that could have been avoided in a child’s lifetime if careful referral and dosing protocols were in place.

“It’s very well shown that CT scans for minor head injuries are usually of no benefit,” Ricardo Quinonez, MD, Director of Research and Quality, Pediatric Hospital Medicine, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, and Executive Chair, American Academy of Pediatrics, Section Chair of Hospital Medicine, said in an interview. “For simple abdominal pain, simply watching it is best.

Excess CT Scans Not Only Concern

Quinonez also addressed use of magnetic resonance (MR) imaging in children under age 7. “Most kids need sedation and safety is not a completely settled question, with anesthesia having negative consequences on brain function.” Quinonez questioned whether MR is being overused more and more. Even though no negative consequences from the magnets have been observed directly, there are downstream risks, potentially unnecessary surgeries.”

Another concern is the use of chest x-rays for asthma and bronchulitis. Quinonez stressed that diagnosing these problems can be done clinically, meaning hands-on physical exam of the patient. Chest x-rays subject kids to radiation. Depending on where it is done, the dose may be adjusted to the child’s weight, which should be standard, but you may not be assured of that outside of a children’s hospital. Quinonez also pointed out that if you give a chest x-ray to three radiologists to read, you may get three different interpretations. Armed with results from a chest x-ray, kids may end up with unnecessary antibiotics. When this happens often enough, antibiotic resistance may develop.

Repeat imaging is also widespread. How many times have you gone to one doctor, mentioned that you or your child had a specific study done, and you have been stonewalled, told: “We like to do our own.” Again, you have to wonder whether the second or third repeat study in a short interval was really necessary.

Resources You Can Use 

Projects aimed at dialing back unnecessary imaging are getting around. However, from the response to my first post, the news is not getting around enough. For example, the American Board of Internal Medicine/Society of Pediatric Hospital Medicine Choosing Wisely campaign has prepared a tip sheet listing 5 Things Physicians and Patients Should Question. An American Academy of Pediatrics tip sheet provides additional information.

The Image Gently campaign, organized by pediatric radiologists concerned with safety, has a slew of materials that you may find helpful when deciding whether or not to have an imaging study.  Included on their page is a link for a sheet you can use to track all of your child’s medical imaging studies.

The National Cancer Institute has a sheet for health care providers on appropriate use of CT in children. It includes issues that pediatricians and parents should discuss.

 

 

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CT Scans Overused in Kids, Upping Lifetime Risk for Cancer

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The next time that you take your daughter or son to the doctor, try to put out of your mind that the more tests done, the better. Fishing expeditions to come up with a diagnosis are all too common in medicine, and they may have adverse consequences. You might think that additional tests will allay your anxiety about what’s wrong, but CTs emit radiation, and cumulatively, it may lead to excess cancers. In many cases, they are medically unnecessary. In today’s journal JAMA Pediatrics, researchers point to widespread use of computed tomography imaging in children under age 15 and also to use of highly variable radiation doses. “The ionizing radiation doses of CT are 100 to 500 times higher than conventional radiography and are in ranges linked to an increased risk of cancer,” write the authors led by Diana L. Miglioretti, PhD, who holds a joint appointment at the University of California Davis, and Group Health Research Institute, Seattle, Washington.

CT Usage and Exposure Patterns

Reviewing use of CT imaging from seven US health care systems between 1996 and 2011, the research team found:

  • In children younger than 5 years of age, CT scan use doubled between 1996 and 2005;
  • In children age 5 to 14, CT use tripled;
  • Even though usage stabilized between 2006 and 2007, and then began to decline, overuse  remains a key concern;
  • Radiation doses used are not standardized, and in many cases, are higher than they need to be.

Estimated Cancer Risk

Next, the research team calculated organ dose (the amount of radiation absorbed by a specific organ) and effective dose (amount of radiation that the full body gets from the dose that contributes to cancer risk). “In other words,”  Miglioretti explained in an email, “doses to organs more likely to develop cancer contribute more to the effective dose.” The research team looked at abdominal/pelvic CT, chest, spine, and head CT scans.

 

Diana Miglioretti, PhD, the lead researcher, standing next to a CT scanner. Photo credit: UC Davis Health System, Sacramento, CA.

Diana Miglioretti, PhD, the lead researcher, standing next to a CT scanner. Photo credit: UC Davis Health System, Sacramento, CA.

What is especially troubling is that the estimated risk of cancers with some scans is higher than previously reported. Here are key findings:

  • “One in 300 girls younger than five years of age who undergo an abdominal/pelvis CT scan will develop a subsequent tumor,” write Alan R. Schroeder, MD, and Rita Redberg, MD, in a companion editorial titled “The Harm in Looking.”
  • Likewise, CT scan of the chest is projected to result in a solid cancer in one in 330 to 480 girls.
  • For spine CTs, one in 270 to 800 girls are estimated to develop a solid tumor.
  • Overall, younger children are more vulnerable to radiation. In fact, younger children and girls had far higher projected risks of cancers during their lifetime than for older patients and boys.
  • Children who got head CT scans before age 5 had the highest risk of leukemia, 1.9 cases per 10,000 scans, and brain cancer.

Miglioretti told Patient POV: “The radiation dose of head, abdominal, and chest CT scans was widely variable. Some kids got relatively high doses. By simply reducing the highest 25% of doses to the median dose, we may be able to prevent 43% of these cancers.” Reducing unnecessary scans also should be attempted.

More Scans Lead to More and More

Rebecca Smith-Bindman, MD, senior author of the paper, from the Department of Radiology, at University of California San Francisco, said: “You want a sense of balance. For any test, you need to ask yourself ‘Why?’ ‘Is this going to help me?’ Parents might also consider simply watching their children and deferring advanced medical imaging studies.” Most importantly, Smith-Bindman said: “Don’t go in thinking you should have your kid go through an advanced imaging study.” Doctors see that expectation and go ahead. Additionally, Smith-Bindman pointed out that the “degree to which extra studies and scans become done, it often becomes a distraction and takes away from care.” If medical imaging is medically necessary, frequently, an ultrasound will give you adequate information without adding radiation risk for your kid.

Parents need to know for starters that “doing a scan just to be safe paradoxically can do more harm,” said editorialist Alan R. Schroeder, MD, from the Department of Pediatrics at Valley Medical Center, San Jose, CA. Dr. Schroeder is also part of an effort in pediatrics to “Safely Do Less.”

“It’s also not just about radiation,” said Dr. Schroeder. “What happens next are downstream interventions.” For example, say, a kid falls and hits his head, explained Schroeder. The next thing you know, the kid has more and more scans. Dr. Schroeder also sees harm in cholesterol screening for kids. “A good proportion of kids screened will go on statins,” he said.

“Nothing less than a paradigm shift will be required if clinical medicine is to succeed in reversing overuse of tests and procedures in children,”  write Schroeder and Rita F. Redberg, MD, in the editorial, adding that our culture needs to “become more tolerant of clinical diagnoses without confirmatory imaging, more accepting of ‘watch and wait’ approaches and less accepting of the ‘another test can’t hurt’ mentality. Uncertainty can be unsettling, but it is a small price to pay for protecting ourselves and our children from thousands of preventable cancers.”

Next on Patient POV: Numerous programs and resources are available for parents and doctors, including everything from counting the radiation exposure your child is getting to questions to ask. I will put up a second post later this week that you can use for reference.

If you like what you read here, or share this with others, please consider making a small donation, to keep this work going. It takes hours to interview, research, and write these pieces, and I receive no funds for this work. Paypal donations can be made in the upper right column.

 

 

 

Posted in cancer, medical imaging, overuse, pediatrics | Tagged , , , , | 4 Comments

Making Gender Justice, Birth Control,
And Abortion Access Health Priorities

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Women’s health and life are under fire in the United States and around the world. Here are  issues that health policymakers need to incorporate into health quality. It’s time to stop marginalizing them.

Last week, women’s groups coordinated by the Women’s Media Center and Everyday Sexism, successfully organized a campaign against Facebook rape #fbrape to get advertisers to pull ads off the site unless it pledged to monitor and remove content condoning violence against women. It was successful: the campaign led to an editorial in the New York Times,  and papers and social media nationally and internationally. The campaign’s success suggests organizing other campaigns around gender justice and reproductive rights may pick up steam and make the world friendlier to women.

Delaying “Beatriz” Access to Abortion Unconscionable

Broad international outrage over the forced continuation of one woman’s pregnancy with an anencephalic fetus, i.e. a fetus missing most higher brain structures, in El Salvador, led to an international court ruling that a woman’s pregnancy must be terminated.

Another issue in this case concerns detection of an anencephalic fetus. A routine fetal ultrasound will clearly show a fetus lacking parts of the brain. Because anencephalic fetuses have never lived more than a few hours after they are born, women who learn that their fetus lacks higher brain structures, choose to have an abortion as soon as it is detected. This option was not open to “Beatriz” because abortion for any reason is illegal in El Salvador. In states that block women from speedy abortion access, women will also have to prolong a useless pregnancy like this.

“Beatriz” also had her own health risks, namely lupus and kidney failure, which made her continued pregnancy hazardous. But that carried no weight in El Salvador, nor does it carry much weight with far too many legislators in the United States and elsewhere. That’s worrisome.

“Beatriz” had a cesarean section under general anesthesia at 26 weeks of gestation. The fetus died shortly after the procedure. Broad consensus exists in the ob/gyn and public health community that cesarean section abortions (hysterotomies) are hazardous and that an induced abortion would have been far safer. In fact, in the United States, these procedures are rarely done.

Frances Kissling, President of the Center for Health, Ethics and Social Policy, and past-president of Catholics for a Free Choice, had this to say: “ I totally agree that an early abortion should have been performed and the case is an example of extremist anti-abortion medicine…We have every right to condemn the delay, the decision to incur greater risk by performing a hysterotomy rather than use the best technique for abortion in her case. We also should reject the noting of trying to save both woman and fetus, especially when the fetus has no chance of more than minutes of survival. This way of constructing cause and effect is hooey, which results in women’s death and/or suffering.”

The Vast Scope of Reproductive Control Practices

El Salvador and several other countries in Central and Latin America have some of the most regressive policies internationally on abortion. A Foreign Policy post this week points this out. As shown repeatedly, in countries that block access to abortion and contraception, maternal and child health outcomes suffer.

You don’t have to look very far to see that access to birth control and abortion are getting blocked. Legislation on the books and proposed, puts discriminatory hurdles up to women getting contraceptives and abortion. Sadly, federal programs and religious organizations are controlling access. Unscientific, biased regulations, including waiting periods, mandatory fetal ultrasounds that pregnant women must view, and onerous abortion facility construction requirements are just some of the barriers. Efforts to pressure women to continue unplanned pregnancies must be stopped.

The so-called “pro-life” fanatics will stop at nothing to state their case. Just like edited ACORN tapes by James O’Keefe and Hannah Giles on Andrew Breitbart’s website that went viral at first uncritically,  Live Action anti-abortion fanatics have gone to abortion clinics using secret microphones and cameras, photoshopping and editing alarmist videos for their cause. As Carol Joffee, MD, notes in this article: “I fear that a possible consequence of these Live Action videos may be a chilling effect on the free and open conversation between clinic staff and patients that is such an important part of abortion care.”

Honoring and Organizing for Quality Women’s Health

In the past week, we remembered the four-year assassination anniversary of George Tiller, abortion provider who was murdered by anti-abortion fanatics, as well as the death of Henry Morgentaler, Canadian doctor who helped spearhead legalized abortion. Conscientious providers who provide quality reproductive care merit thanks from us too.

We must continue to organize to protect access to contraception and reproductive care. As Robin Marty and Jessica Mason Pieklo note in their new book, Crow After Roe: How Separate But Equal Has Become the New Standard in Women’s Health and How We Can Change That, a separate, discriminatory standard of health care for pregnant women is expanding rapidly across the United States. Our elected officials must be held accountable.

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10 Ways Healthcare Reform Might Help People with Disabilities

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Healthcare reform discussions frequently center on the changes anticipated for the general population. But people with disabilities — about 56 million in the United States — are generally left out of the healthcare reform picture.

That absence is not unusual. According to Lisa Iezzoni, MD, Professor of Medicine and Director of the Institute for Health Policy at Harvard Medical School, discrimination against people with disabilities stretches back thousands of years in human history. They “have been discriminated against, stigmatized, institutionalized, and hidden behind closed doors,” she says. The disability rights movement, which began in the 1970s with deinstitutionalization, made progress through the passing of the Americans with Disabilities Act in 1990. Now, says Iezzoni, new health reform measures will offer people with disabilities important additional protections.

Healthcare reform has a variety of names, including the Affordable Care Act (ACA), the Patient Protection and Affordable Care Act (PPACA), and Obamacare. All of the terms refer to the same federal statute that President Obama signed into law on March 23, 2010.

The diversity of disability

Disability can occur in any body system or several systems at once. Sometimes, a disability is clear, but other disabilities can be “invisible.” The two most common types of disability center on mental health or musculoskeletal disturbances, according to the Social Security Administration. But disability covers a huge spectrum from developmental and congenital conditions to sensory, cognitive, and emotional differences. With the aging baby boomer population and the link between disability and age, the number of disabled persons is expected to grow considerably in the coming years. Many of them will be women, who tend to experience higher rates of disability than men.

Data on the healthcare experiences of people with disabilities are limited, says Iezzoni. Much of it comes from national surveys. What researchers do know is that people in the disabled community experience relatively increased rates of poverty, low education, unemployment, domestic violence (including against disabled men), and physical and attitudinal barriers to a good quality of life.

Barriers to care

 Barriers to care might be the most important obstacles, literally and figuratively, that a person with disabilities encounters.  These barriers are among the issues that the new healthcare reform can address. In comparison with the nondisabled in the United States, people with disabilities receive fewer screening and preventive services. For example, women with disabilities have much lower rates of Pap testing and breast cancer screening and are less likely to be asked about reproductive health and contraception. “Part of this is attitudinal,” said Iezzoni, noting that doctors often behave as if sex and reproduction are just not part of the lives of people with disabilities.

Physical barriers also hinder access to care, and even medical equipment itself is often not adaptable for people with disabilities. For example, medical examination tables are very high, and women with disabilities may have difficulties getting onto one or maintaining the typical position for a pelvic exam. The same might also be true for mammography equipment.

“Women with disabilities are far less likely to get standard of care procedures for breast cancer and their outcomes are worse,” Iezzoni explains, referring to her own research. Among the disparities that health reform is intended to address are higher rates of mastectomy (complete breast removal), rather than lumpectomy (limited to removal of the tumor) for women with disabilities, lower rates of radiation therapy needed to produce disease-free survival, and higher death rates from breast cancer. Providing people with disabilities a chance to be more independent is also a pivotal issue for healthcare reform.

Trying to build in measures to improve access for people with disabilities is uncharted terrain, however, according to Iezzoni. That in itself might serve as an intangible reflection of what people with disabilities can encounter every day in a world without appropriate accommodations. It is also, though, terrain that the new healthcare reform might smooth out for the population with disabilities (see sidebar), lowering barriers and improving access … and quality of life.

10 Ways Healthcare Reform Might Help Individuals with Disabilities

1. Insurance can no longer be denied to individuals with pre-existing conditions, including disabilities and chronic medical conditions.

2. Ends the practice of rescissions, which allowed insurers to drop coverage for individuals who develop a serious health condition.

3. No more lifetime or yearly dollar caps on coverage will be allowed.

4. Beginning this year, health plans must cover basic preventive care, annual checkups, and health screening at no charge to anyone.

5. Encourages more accountable, coordinated care through development of patient-centered medical homes. However, one key problem is that many of the contracted organizations have had no experience providing care for individuals with disabilities.

6. New minimum technical criteria for medical diagnostic equipment that are accessible to people with disabilities must be specified within 24 months of passage of health reform, potentially helping improve access to care. However, the standard falls short in that installation requirements in physician offices or clinics are not specified.

7. All federally conducted or supported health care programs, activities, and surveys must add six specific questions reflecting functional areas pertinent to individuals with disabilities—seeing, hearing, cognition, mobility, self care, and performing errands into all health survey data. This data has not been collected previously.

8. The Centers for Medicare and Medicaid Services are testing a new Independence at Home Demonstration Program at 18 sites across the country. It will offer primary care services at home to people with multiple chronic conditions. The goal is to improve health outcomes and lower Medicare costs. If this program proves successful, it could permit broad changes in supporting independence at home across the nation.

9. Long-term care services and supports for people in their home or the community are ratcheted up through a variety of enhancements.

10. Aging and Disability Resource Centers are funded through ACA grants to states. These centers are meant to offer people visible and trusted information on long-term services and support through Medicare.  

 Note: Iezzoni’s remarks are from a presentation she made at a Rising Women’s Voices teleconference on the impact of health reform for women with disabilities. Story written by Laura Newman. This story first appeared on DoubleXSci.org with a slide show (not posted here), but viewable on DoubleXSci. Shout out to Emily J. Willingham and Jeanne Garbarino for hosting it, invaluable editing, and images added to original post.

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Personalized Medicine: Read the Chart!

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This is a guest post by Ricki Lewis, PhD, who blogs at DNAScience, part of the PLOS blog network. Ricki is a science writer with a PhD in genetics. The author of several textbooks and thousands of articles in scientific, medical, and consumer publications, Ricki’s first narrative nonfiction book, “The Forever Fix: Gene Therapy and the Boy Who Saved It,” was published by St. Martin’s Press in March 2012. In addition to writing, Ricki provides genetic counseling for parents-to-be at CareNet Medical Group in Schenectady, NY and teaches “Genethics” an online course for master’s degree students at the Alden March Bioethics Institute of Albany Medical Center.

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stethoscope on med chartWhile we’re busy debating the pros and cons of clinical genome sequencing and tossing around buzzwords like “personalized” and “translational” medicine, I’ve recently caught some health care providers ignoring the archaic skills of communication and common sense. So while we await genome analysis apps on our smartphones and DNA sequence annotators in our doctors’ offices, here are 3 suggestions on how to provide personalized medicine right now:

1. Read the patient’s chart (paper or digital)

2. Listen to the patient

3. Look at the patient

Disclaimer: Today’s blog is anecdotal and non-scientific, but may identify a trend.

MY MISSING THYROID
A few weeks ago, I had a long-overdue check-up, with a nurse practitioner. It was my first visit to the practice, which had provided excellent urgent care.

On the medical history form, I described my circa 1993 thyroid cancer in intimate histological detail: papillary in left lobe, follicular in the right.

The NP spent an impressive 45 minutes asking questions and listening to me – or so I thought. During the brief physical exam, I told her all about my thyroid cancer, my daily Synthroid dose, and even brought her hand to my throat, having noticed that dentists get very excited at my lack of a thyroid gland. No thyroid tests needed, said I. My endocrinologist had recently done them.

So I was surprised when, early the next morning, a Saturday, my cell phone quacked.

“Ricki? This is the nurse practitioner. I’m afraid something very alarming has turned up in your bloodwork.”

I braced myself.

“Your thyroid hormone is very low.”

Imagine that!

“Could that possibly be because I take a pill every morning to account for the fact that my thyroid gland has not been part of me for 20 years?” Had she read the chart, where she herself had typed in the cancer info and I’d written it? Did she recall palpating my glandless neck? And why didn’t my health insurer note the duplicated blood test?

“OK. Let’s move on to your LDL. It’s too high.”

Genetic counselors are experts in listening, documenting, recalling, and making important clinical connections. (NHGRI)

Actually, it wasn’t, considering the family history of zero cardiovascular disease that she had neglected to inquire about.

Happily, my HDL was just fine, but she didn’t appreciate my pointing out that HDL is no longer considered a valid biomarker for everyone — geneticists noticed years ago that quite a few families with perfectly good tickers have low (supposedly high-risk) HDL. I’m not going to link to it because the news is pervasive on the Internet. I’ve already altered my textbooks.

Still, she wanted me on a statin, stat, perturbed at my refusal to sign up for a lifetime on a drug that I didn’t need. (Within a few seconds of ending the call, I found a blog by an MD, from 2007, warning of the dangers of statins and providing cases of exactly who shouldn’t be on them. Minus a few years, the “60 year-old woman who is trim, exercises daily, does not smoke, and has no family history of heart disease = no cholesterol-lowering medication” was me.)

Time to switch gears.

“You should begin an exercise program,” the NP helpfully suggested.

“Is the 60 to 90 minutes a day I told you about not enough?”

“Hmmm. Well, you need a low-fat diet to lower your cholesterol.”

I nicely reminded her that she might require a refresher on basic biochemistry if she thought eating less cholesterol lowers cholesterol. It doesn’t work that way. My 10-year low-carb diet made the most sense. The low-fat diet she suggested was exactly what not to do.

I could have chalked up this forgetfulness to a packed schedule, too many patients to recall details, but she spent 45 minutes with me – she probably saw only a handful of patients a day. And she could have at least opened the chart before she called me with potentially upsetting news.

Burying one’s head in a laptop whilst the patient sits there, in the glamorous paper gown, can be a problem too.

Soon after my encounter with the NP, I took my mother-in-law to the cardiologist. After the requisite long wait, we went into an examining room for another wait, and finally the snazzily-dressed doctor rushed into the exam room, pulled up a stool, and proceeded to become one with his laptop. Tapping away, he fired incomprehensible drug and disease names at his elderly patient. He never looked up. And he yammered on about the importance of high HDL, too. I could have sat there with a water buffalo instead of my mother-in-law and he probably wouldn’t have noticed anything amiss until the 2-minute physical exam.

Look at the patient. Engage.

And then there’s the fictional example of young Dr. Gorgeous on the new medical drama “Monday Mornings” who, in the debut episode, let a boy bleed out on the operating table from an inherited clotting disorder, having forgotten to query the single mom about the father’s medical history. Oops.

IGNORED OUT-OF-CONTROL BLOOD SUGAR
The worst example of physician cluelessness happened to a friend I’ll call Karen, who recently had weight loss surgery. This is not a cosmetic procedure. In many people, the surgery ends years of diabetes, polycystic ovarian syndrome, hypertension, even depression.

Karen checked out several offerings. A program at a local hospital seemed so eager to sign her up that it felt like a drive-through. She finally found a bariatric “center of excellence” near her home in a large, midwestern city. She respected the tough requirements: lose 5% of her body weight, and keep her blood sugar down. Specifically, that meant maintaining her A1C level at 7 or below. A1C measures how much blood sugar is carried attached to hemoglobin, the oxygen-carrying proteins packed into red blood cells. Because a red blood cell lives approximately 3 months, the A1C test is repeated every 3 months.

Karen’s A1C rose a bit last August. Too many barbecues, maybe.

“Oh, don’t worry,” chirped the endocrinologist, clutching the chart, unopened, sitting in front of her laptop, also unopened. “If it’s high again, just let me know, I can help. Meanwhile, take two more meds, and up the other one. I’ll email it to your pharmacy.” Tap tap tap.

No one seemed overly concerned with the A1C, because six weeks later, Karen had the all-important appointment with the surgeon, to get “the date.”

First, an intern flounced into the room and pulled up a stool. She sat down, a paper chart on her lap, unopened. A laptop next to her, unopened. The newbie doctor asked a few condescending questions to determine whether Karen was a moron or not and actually knew what the various weight loss surgeries — band, sleeve, bypass — entailed. She did. So the intern launched into a lecture about how sometimes the doc has to remove the gallbladder during the surgery.

Much as I had to remind my NP that I had no thyroid, Karen had to fill the intern in on that fact that her gallbladder had exited her body some 8 years previously. Karen, realizing the doctor was still in training, suggested that perhaps she consider actually reading a patient’s chart beforehand. What a concept!

Deer-in-the-headlights, the flustered intern raced out, without asking the important questions, for her job was to screen the patients to save the surgeon time. How much weight have you lost? What’s your most recent A1C? It was all there in the chart.

Then the surgeon came in. Very serious. He, too, held a chart, unopened. After a brief speech comparing the surgical options, he gave Karen the thumbs-up, and off she happily trooped to pick the date. She assumed he and the nurse with the scheduling calendar knew her A1C. He seemingly assumed the intern, his screener, had no objections to the A1C. She’d passed!

Karen was so excited. The countdown began to the surgery, which would be in December. The diet and exercise continued.

And then Karen had routine bloodwork, her red blood cells having recycled themselves, the hemoglobin within hopefully free of the offending sugar. Shortly after, the bariatric center called. The surgeon had canceled her surgery. Her A1C was too high.

Her A1C was, in fact, just a drop lower than it had been on the day that the surgeon had given her the go-ahead. Had he, or his biliarily-obsessed underling, so much as glanced at the chart, no date would have been bestowed. No apology for the setback.

Karen was devastated, but at first hopeful. “Remember, the endocrinologist said she’d help!” Karen cried to me over the phone.

So she emailed the doc, called, and tried to get her next appointment moved up. She got nowhere. No answers.

Time passed. Finally, the next endocrinology appointment rolled around, which was, in happier times, supposed to be the pre-op check-up.

After the requisite hour-long wait, for no apparent reason and without explanation or apology, the endocrinologist bustled into the room, holding an unopened chart.

“How are you doing?” Big smile. She sat down on the ever-present bewheeled stool, opened her laptop, and then noticed Karen’s uncharacteristic silence.

“How are things?” she tried again.

“Terrible,” said Karen, starting to cry. Her story spilled out. “Why didn’t you answer my email? Return my phone calls?”

The doctor quickly scanned her email and claimed never to have seen any messages. Not true, Karen later deduced. It’s easy enough to check.

“Oh, but look! This is your pre-op visit!”

The doc was still utterly confused, until Karen pointed out, again, that the problem was the A1C. When the doctor launched into the familiar litany of upping the non-insulin meds, with no obvious concern about the potential dangers of taking drugs for many months that didn’t do anything, a strategy that would delay the surgery at least another three months as a new generation of red blood cells formed from reticulocytes extruding their nuclei, Karen had had enough.

“Give. Me. Insulin. NOW.”

The doctor readily agreed, scurried out of the room purportedly to figure out how she had not known of this disaster, and a nice nurse came in to demonstrate insulin injections. Karen learned more in 5 minutes from the nurse/diabetes educator than she had with any physician she’d encountered during her long journey to weight loss surgery.

READ THE CHART!
Theoretically, electronic medical records are a great idea, having a patient’s information instantly available on a laptop or tablet. But as I’ve learned from writing textbooks, you lose something in being restricted to seeing one page at a time – you learn more when pages are compared on real paper, in real space. At the ob/gyn practice where I do genetic counseling, we switched to electronic records a few years ago – but practically, we still use paper charts. Otherwise, you can miss things.

A timeless type of medical chart, the pedigree. (NHGRI)

In those medical charts, electronic or dead tree, the family history is of paramount importance. This is hardly a new concept, and family histories are certainly stressed early on in medical school, as anyone who’s been examined at a teaching hospital can attest. But somewhere along the way, amidst all the new tests and technologies, the biotech bells and whistles, the importance of the history fades.

Maybe the new genomics will bring back both the family history and the pedigree.

Posed Alan Guttmacher, MD, Francis Collins, MD, PhD, and Richard Carmona, MD, MPH, in “The Family History – More Important Than Ever” in The New England Journal of Medicine, “Will the family history eventually become a relic of antiquated medical practice that has been replaced by more ‘modern’ tools? For instance, in a decade or so, when sequencing a patient’s genome may cost less than $1,000, will it still be worth a practitioner’s time to obtain the less precise information contained in a family history? We think so.”

(NHGRI)

That was written in November 2004, so the decade’s almost up. Genome sequencing is here, arriving faster than expected, with cost plummeting. But our genome information will only be actionable in a piecemeal fashion, until we understand all gene-gene and gene-environment interactions, and all the variations therein. Family history will be crucial to the interpretation, for it provides the context without which identifying gene variants may be meaningless. Even tragic.

Reading the chart, especially the family history, can provide valuable clues – as can what the patient says, and how she says it.

Let’s bring common sense and intuition back to the practice of medicine.

Posted in diabetes, Patient stories, weight-loss surgery | Tagged , , | 3 Comments