BCMJ Book Review: The Patient Paradox: Why sexed-up medicine is bad for your health

At the Preventing Overdiagnosis conference last year in Oxford, I heard Dr Margaret McCartney speak. This is a passionate woman, one who advocates tirelessly for patients and follows the motto "Think critically and demand evidence." She is an outspoken leader, holding the NHS, her patients, her peers, and herself to high standards, eschewing conflict of interest and junk science.

I was lucky to meet her and when we talked further, Margaret handed me a copy of her book, The Patient Paradox: Why sexed-up medicine is bad for your health. Travel and work got in the way of me opening it, but when I did, I devoured it, underlining and folding and marking key points that resonated with me.

I have read many essays and a few books in the area of "too much medicine," and agreed with most of what they had to say. This book was different. It gained my trust by talking about things I already knew and accepted (more is not always better in medicine) and pushed me just outside my comfort zone, to question things I take for granted (eg the importance of pap tests). I admire the bold way in which she can push the already skeptical to challenge assumptions we didn't even know we had. Since I felt the need to share this book with others, I wrote it up.

You can read my piece about the book and its message in the July/August copy of the British Columbia Medical Journal (BCMJ).
 

You can buy the book from the publisher, Pinter and Martin here. If you want to read other reviews or get a copy on Kindle, Amazon.ca can help.* 

If you like the idea of reading more on the subject of "Less is More in Medicine," there are about 20 books in the Read section of the site, ranging in focus from cancer screening or overdiagnosis in psychiatry to patient-centered care, achieving evidence-based medicine, and turning healthy people into sick.

 

 

 

* I don't receive any kickbacks here, just hoping to make it easy to get the book in your hands

Source: http://www.pinterandmartin.com/the-patient...

BCMJ: Measuring and improving quality of care in family practice

With about 400 articles on the subject of "Less is More" overdiagnosis, overtesting, overtreatment, undertreatment, etc. in my Instapaper queue, I figured I should start tackling them again with brief précis or reflective posts so that you can have the benefit of my curating.

I'll probably alternate between older foundational articles and new interesting stuff.

Today: a new article in the British Columbia Medical Journal (BCMJ) by Dr. Martin Dawes, head of Family Practice at UBC, my alma mater.

Quality assurance for family practice should be determined locally and provincially, with a distributed model of quality assurance for the province rather than a centralized model, to increase the likelihood of positive change in response to variations in practice.

Dr Dawes captures it well when he writes of the need for a quality measurement system which takes into account appropriate variations in practice, and that such a system must flex and be  adjusted as we understand more about the meaning of the data we are collecting.

I was glad to see that Dr Dawes, unlike many others, doesn't put all the weight solely on achieving  "targets." It's not that guidelines and clinical measures should be forgotten about, however they are but one part of the larger quality picture and fortunately he spells this out. I worry that governments and health authorities have not yet arrived at this way of thinking.

While I appreciate that things like accessibility are mentioned in the article, I do note the lack of emphasis on (or even mention of) the role of a strong relationship or attachment between doctor and patient in high quality care. Hopefully this is something that decision-makers are well-aware of, and they take it so for granted that they don't explicitly mention it in their articles.  :P

This article is a timely piece as physician organizations, health authorities, and governments in Canada begin the discussion about 'what is good care?', 'how can we measure it?', and 'what can we do to make it better?'

Read more in the BCMJ.

Source: http://bcmj.org/premise/measuring-and-impr...

Coccidiomycosis and other "Zebras" in Medicine; reconciling with Less is More

This is the first time I've had a peer-reviewed article published. Shortly after I wrote an email to the patient, the subject of this case report, to let him know, I was looking through my other emails and realized not only was it published, but that it had become the cover story for this of the British Columbia Medical Journal (BCMJ)!

Read the article here: A textbook case of coccidiomycosis (web version or a PDF version).

Ok, perhaps I shouldn't be so proud as it's not the Lancet or BMJ, but I think the BCMJ is pretty darn good and it was exciting for me to get to share this case in so doing, to make good on a promise to this patient to educate others about his diagnosis. It was also great to work with a friend, the very smart Dr Barlow!

I also liked the reflective exercise of thinking about how a "Less is More" kind of doctor could still diagnose exotic conditions.


The article is about an uncommon fungus (coccidiomycosis) that a patient I saw in on Vancouver Island had acquired. There's an expression in medicine:

"When you hear hoof-beats, think horses, not zebras."


One should never jump to the exotic diagnosis. However,  occasionally, people do have exotic diagnoses.

Even though I had to order some specialized tests to find out for sure what he had, this practice is still consistent with the "Less is More" philosophy. The idea is that in avoiding all the unnecessary stuff, we can use our time and resources wisely to order the RIGHT tests and treatments. It also helps immensely when patients are aware of their own health and can tell us their story clearly.

It all worked out because we had:

- A clear patient, advocating for himself, open-minded & contributing to my assessment and plan
- A doctor with time to hear the patient's story, medical knowledge appropriate for the situation
- Judicious ordering of tests (wrong test for most people, the RIGHT test for him)
- Confirmation of a suspicion gained from the history and reviewing the labs/xray that were already available

This was a highly satisfying case. I'm rarely clever, and rarely have a patient who is as good a historian as he. It's a wonderful illustration of a working acute care system, the benefits of being a patient who takes ownership for his health, and that some obscure knowledge is tucked away in my brain which will sometimes emerge when needed!