VIDEO: A troubling pharmaceutical cocktail | Dee Mangin #WalrusTalks

Polypharmacy-smashing superstar Dee Mangin delivered a compelling talk for The Walrus about the problem of too much medicine.

In just over 8 minutes, she beautifully articulates the issue and a vision of how we can address it.

Source: https://www.youtube.com/watch?v=QQkV7yHuQ-...

VIDEO: #ChoosingWisely in Cypress Health Region

Since 2015, The Saskatchewan Health Quality Council has been moving forward the very important agenda of Appropriateness of Care.

 

In partnership with the Saskatchewan Medical Association, they have now launched Choosing Wisely Saskatchewan and are working engaging patients, clinicians, and learners to implement a province-wide strategy to tackle overuse. To start, they are focussing on pre-operative testing and imaging of lower back pain, and some of the health regions are taking on their own projects.

The Cypress Health Region has demonstrated their commitment to Choose Wisely:

Here's hoping many people will see their example and make the same pledge to choose wisely - because more is not always better in healthcare.

Source: https://www.youtube.com/watch?v=gkqKRYpKbQ...

FACTS & MYTHS: Prevent and Treat Cancer with Diet and Lifestyle

Families, doctors, nurses, patients, people all:

Everyone knows someone with cancer. Cancer is unfortunately inevitable unless something else gets you first. It may sound awful to talk that way but because of what cancer is - essentially the unchecked growth of progressively more abnormal cells - and the fact that our cell's replicating machinery gets a little wonky as it wears out over time, the older we are the more likely we are to develop cancers.

Cancer is horrible. It devastates happiness, bodies, minds, families, plans, and dreams. We want to do everything possible to treat it and prevent it. Although I've written a lot about the futility of aggressive care in the end of life, the harms of delaying a palliative approach, and our misplaced trust in screening (which often harms more than it helps: PSAs or mammograms, for example), I also advocate strongly for patient access to the things that do work.

There are things you can do to lower your risks, robustly backed by the evidence: 

  • Avoid smoking
  • Exercise regularly
  • Stay away from environmental/industrial carcinogens like asbestos, radon, and benzene
  • Reduce radiation exposure by avoiding unnecessary medical imaging tests
  • Avoid excesses of alcohol
  • Wear sunscreen
  • Consider a pap test
  • Only take supplemental hormones if medically required
  • Get other 'screening' tests eg. colonscopy if you are a high-risk patient (eg. an immediate relation was diagnosed with colon cancer)

There is a great summary of some specific examples of dietary items in the "Summary of global evidence on cancer prevention" from the World Cancer Research Fund International.

As much as we want them to work, natural supplements, diets, 'miracle' clinics overseas, and homeopathy just don't.

Billions of dollars are made in scaring people into taking 'natural' remedies that are meant to prevent or treat cancer. Let me tell you: if these remedies were effective, they would be patented, put into pill form, and your family physician would be nagging you to take them. Heck, we might even lobby the government to put cancer-preventing agents in the drinking water! And if there was such thing as a miracle clinic, curing cancer constantly, well I would like to work there because that sounds amazingly rewarding.

Sadly, despite our dearest hopes, turmeric and elimination diets, cannabis oil, black fungus like that growing at Chernobyl (Fox News), and a whole host of other things continue to be proven useless at preventing or treating cancer. Most of these 'remedies' are harmless, but some have real side effects and none of them help the wallet.

In fact, while people are wasting their time, money, and hope on these snake oils, they are depriving themselves of the opportunity to focus on what matters:

  • Eating whatever you want
    • to try to slow the process of weight loss from cancer and to enjoy life because food = joy for many
  • Using money to enjoy experiences that are important to you 
    • visiting family, ticking items off the bucket list... one incredible patient I met shocked his family and had an incredible time by skydiving for the first time after age 70 (despite cancer with metastases to bone!)
  • Focusing on treatments that have been shown to be effective through scientific study
    • nothing breaks a caregiver's heart more than seeing someone chose an 'alternative' treatment when there is a validated one that would likely be well tolerated, and is quite likely to lead to cure (eg. death of Makalya Sault, after her family got their hopes ensnared by a quack in Florida
  • Working through the difficult task of coming to terms with having cancer, whether treatable or not
  • Receiving palliative care (which improves quality of life and can actually extend life!)

Optimism is not wrong - optimistic people probably live longer. If you trust that (scientific) statement, then you should also trust that the optimism should be directed towards scientifically-backed things that work.

--

Learn more about Tackling cancer treatment myths, from clean eating to cannabis

Source: https://www.theguardian.com/science/blog/2...

No strong proof that flossing your teeth has medical benefit

This is the third in a series of "no evidence" posts I've made recently, with the first two being "No evidence that N95 respirators are better than surgical masks" and "No benefit to locked mental health wards."

Today's serves as another example of where something seemed like a good idea but... "sURpriSe!!!!" maybe it isn't. 

Certainly, the evidence is lacking to support the bullying that goes on in dental chairs around the world.
"Are you flossing?"
"Yes....."
"Are you sure?"
"Uhhh....." *guilty face*

Personally, as a reluctant flosser, and as a person who questioned the risk/benefit return of having wisdom teeth extracted, I feel a little bit vindicated here. I was always curious 1) if I asked the dentist to guess whether I was flossing or not, could they tell? and 2) Does flossing really do anything useful?

I can't lie to my dentist... how could they do their job if I did? So when asked "have you been flossing?" I usually tell them "no" or "yah but just for 2 months" if I had been doing so, in a phase of thinking I should probably try to stick with flossing. 

Last time I was feeling contemplative in between wafts of chemical smells and *wizzzzzzzes* of the drill in the neighbouring stall, I told my dentist and hygenist that if they could show me solid evidence of benefit of flossing, then I would do it. The hygienist listed a bunch of benefits and I went home to check it out. All the PubMedding in the world didn't find anything to back up her statements. Since they couldn't produce a strong reason for me to do it, so I decided to stop.

Flossing is not fun, it creates waste, and I can think of better things to do with 5 minutes a day. In fact, with those 5 minutes today, I can bring you this article in The Journal of Clinical Peridontology, which found:

The majority of available studies fail to demonstrate that flossing is generally effective in plaque removal. All investigated devices for inter-dental self-care seem to support the management of gingivitis, however, to a varying extent.

The paper did find that  inter-dental brushes (IDBs) are effective in removing plaque. These brushes I have tried and they look like little pipe-cleaners that you shove between your teeth. It feels about as good as it sounds!!! Ow.

I may wait for the randomized controlled trial (RCT) proving that those angry little bristles decrease caries (cavities) before attempting their use again, as "plaque removal" is but a surrogate marker for other things.

Further to the lack of advancement of evidence-based practice in dentistry, one periodontist. Dr Ghilzon, when interviewed by the CBC said:

I would say if you know how to floss I would continue just in case it does make a difference

When the CBC talked to Matthew J. Messina, a dentist and spokesman for the U.S. dental association, they pressed him. He acknowledged weak evidence, but he blamed research participants who didn't floss correctly.

It seems Dentistry is eons behing medicine in terms of evidence gathering let alone application. Whether employing patient-blaming, citing anecdotes, or declining to accept the value of evidence, Dentistry is set to follow Medicine in suffering the same "just in case" approach that dooms patients to overtesting and overtreating and promotes ignorance of the harms of intervention.  

See the original CBC article here.

Source: http://www.cbc.ca/beta/news/health/dental-...

No benefit to locked mental health wards: 15yr study

A once 'sound' idea is now in question.

A 15-year study has concluded that there is no benefit in locking up many mentally ill patients.

Looking at about 350k cases, the researchers selected 145 738 cases, matched for propensity around suicide attempts. In open units, elopement and suicide attempts were less frequent than in locked units.

An open-door policy could be preferable for those with depression, anxiety or psychosis, as it promoted a better therapeutic atmosphere and more positive health outcomes

Even if this large study is imperfect, it gives us a perfect illustration that what seems sensible or logical does not necessarily result in the expected outcome. Although it makes sense that locking people up should not only help them stay put but also keep them safe,, that seems not to be the case.

Counterintuitive? Yes. But brains and bodies often do not conform to the rules of logic. This is in part due to the fact that we have only a superficial understanding of the complexity of our behaviours and physiology. 

How else are we hurting people when we think we are helping them? 

The full article is in Lancet Psychiatry

Source: http://www.radionz.co.nz/national/programm...

MedStopper de-prescribing online app now live!

It is with great pleasure that I introduce: 

MedStopper 
 

Polypharmacy, the state of being on multiple (too many) medications, is an increasingly recognized problem. Though variably defined, everyone agrees that polypharmacy leads to dangerous consequences for patients, particularly in the elderly.

It is so much easier to start than to stop a medication. Now, there is help!

An incredible team, mostly from British Columbia, many of whom I'm had the pleasure of working with, have developed this superb resource. MedStopper is an online tool to help stop medications for patients.

Aimed at clinicians, this deprescribing aid allows you to created a medication list, suggests which medications need to be stopped first, and advises the safest way to go about stopping them. 

Screen Shot 2015-09-19 at 12.50.18 PM.png

Smiley/frowny faces show you the extent to which the medicine: may improve symptoms, may reduce risk for future illness, and may cause harm. If the patient is considered frail, the recommendations are adjusted accordingly.

The tool is a synthesis of many things, so you can view the Beers/STOPP criteria, the NNT or a risk/benefit calculator if available, and print out the plan if you desire.

Not sure if you (or your patients) are on too many medications? Use the Rxisk questionnaire.

Try out MedStopper today and be sure to use the feedback section to let the team know if there are any glitches or errors.

Congratulations to the group on creating this hands-on, easy to use, and practice changing tool. 

Source: http://medstopper.com/

Giving Doctors Grades - The New York Times

Kelly Blair's illustration of health care grades

Kelly Blair's illustration of health care grades

I write a lot about well-intentioned tests and treatments for patients leading to (unintended but very real) negative consequences.

For example: high cholesterol is linked to heart attacks and heart attacks kill. We have a kind of drug that lowers cholesterol (statins). Give the drug, lower the cholesterol, lower the number of heart attacks. So, we put everyone on statin drugs, yay! 

Except, no. Physiology is not logic; lowering cholesterol with statins may NOT lower the number of heart attacks or it may not do so in most people. And statins don't actually save lives in people who don't already have heart disease. But many people (~1/10) given this statin drug will experience unpleasant side effects, like daily muscle cramps. (theNNT.com)

Good intentions, bad results. Surrogate markers are not meaningful.

 

That understood, it should not be surprising to see this thinking error applies not only to physiology but also to the health care system, a system (like the human body) that does not follow the simple rules of logic.

Well-intentioned quality or performence measures can lead to unintended and very negative consequences. This NY Times article, Giving Doctors Grades, illustrates this problem perfectly.

While trying to ensure high quality care, some metrics are set. These metrics are meant to be measured repeatedly to ensure that whatever changes are made result in better and better patient outcomes, lower costs, etc. Unfortunately, the choice of metrics can drive physicians to behave badly, in order to score higher on their report cards. To get the best outcomes, surgeons stop helping the sickest people and surgerize the healthy instead.

Bad things happen to patients that did not need things done to them.

My own provincial medical association, Doctors of BC, and many other organizations in Canada have discussed measuring physician performance. We as physicians want to be accountable to our patients, and the public wants this too. Our common goal: that dangerous, unsafe practices be weeded out and high quality care be supported and applauded.

We must proceed very very carefully when we put measurements in place lest we incentivize the wrong thing and do more harm than good.

Read more in the NY Times.

Source: http://www.nytimes.com/2015/07/22/opinion/...

PODCAST: Questioning Medicine - Statin showdown

When it comes to statin dosing, um, what is the right dose?

Drs Joe Weatherly and Andrew Buelt of Questioning Medicine tackle this question as they review the evidence on statin dosing in their latest podcast. They also do a nice shout out to Less is More Med, but get into dangerous territory by bragging to a Canadian about their hockey team.*

Anyway, they do know a lot more about statins than they know about hockey; this is the fourth in a series of 5 shows devoted to critical appraisal of statin studies. The whole collection is here at Podomatic. 

The pair also run a blog at MedPage Today, Questioning Medicine; though less frequently updated, their posts are great at tackling some of the assumptions we make.

Kayexelate to lower potassium? Maybe not that effective. Pelvic Exams? Probably unnecessary and likely harmful. What Joe and Andrew write always provides a gentle reminder to readers that our thinking "it might not help but it probably doesn't hurt" is off-base; there's plenty of evidence to back a change in practice for the better.

Like their style? You'll also love the other groups that act as Evidence-Based Medicine champions and 'medical mythbusters,' providing sharp (and sometimes hilarious) critical reviews of the latest evidence.

 

* While Tampa Bay did pretty well this NHL Playoff season, these guys will have to be careful about bragging about their success, given that the Lightening's roster is primary comprised of Canadian players. 

Source: http://questioningmed40708.podomatic.com/e...

Doctors' grade: C- on #ChoosingWisely Test Your Knowledge Questions in CMAJ

Fascinating results emerge from a small online poll of Canadian Medical Association Journal (CMAJ) readers. Web polls on the CMAJ site were done over the span of 7 months and the following 12 True or False questions were asked.

Although not scientific, the results tell us that (at least mildly-) engaged physicians (those going to the CMAJ website) like to provide a lot of unnecessary and harmful care, particularly in the area of diagnostic imaging.

Not only do we need more research on why physicians think this way, we also need research on what methods are effective at changing behaviours. We don't know yet if Choosing Wisely-type outreach to patients and providers can improve practice. We think and hope so . . .

See the Choosing Wisely Canada update for more.

EDIT:

*NB: Dr S.P. Landry has a keen eye and noticed an error; for the item pertaining to "All children with head trauma require imaging to rule our fracture and brain injuries" the answer should be FALSE. So, the correct response rate would be 70% on that question, making the overall score of respondents a little less terrible, but still remarkably bad ;)


Source: http://www.choosingwiselycanada.org/news/2...

VIDEO: Good Stewardship / Model conversations with patients about overtesting and overtreatment

The National Physician Alliance (NPA) has done a lot of work in the area of preventing overdiagnosis and empowering patients to find the right amount of care. They are a partner in the Tandem Health project/app, created Top 5 lists (in good stewardship) which served as a model for the Choosing Wisely Campaign, and promote responsible prescribing (by limiting influence of the pharmaceutical industru) through The Unbranded Doctor.

Created in 2011, this video is a timeless tool for Good Stewardship. It gives a simple, 5-step plan of how health care providers can discuss unnecessary tests and treatments with patients.

They suggest:

1. Clarify what the patient’s true concerns are
2. Provide the patient with the information he/she needs to understand the plan
3. Be courteous and respectful
4. Provide clear contingency plan
5. Make sure the patient is satisfied with the plan
Source: https://www.youtube.com/watch?v=kh7EKP9wSg...