If lobsters had doctors...

Comfort with uncertainty is an essential part of medicine, particularly in family practice and other generalist pursuits. There are many labels, lab tests, pills, and therapies, but not everything has an answer.

We must not only tolerate uncertainty, but embrace it.

Dr Rabbi Abraham Twerski, a man who marries psychiatry and spirituality, suggests that discomfort is essential for growth. This applies not just to physicians but to patients as well. Facing adversity can be the key to developing resilience. 

Source: https://www.youtube.com/watch?v=3aDXM5H-Fu...

End of Guidelines (Video parody by James McCormack feat. ZDoggMD + friends)

James McCormack (@medmyths, BS Medicine Podcast) does it again!

Clinical Practice Guidelines must change! This is the end of guidelines as we know them.

Yes that is me and Gilbert Welch on the same screen. For realz!

Yes that is me and Gilbert Welch on the same screen. For realz!

We need patient centred care, including discussion of the values of the patient, the harms of intervention, and alternative options. Right now we have a bunch of arbitrary target numbers for treatment that medicalize normal people. These guidelines are mired in conflict of interest as the majority of guideline-authors having egregious conflicts of interest with industry. 

It's time to fix this! I'm honoured to be a part of this effort and call for action. It was awesome fuel for my imposter syndrome being asked to be in one of James' videos alongside some of my 'preventing overdiagnosis' heroes, not to mention ZDoggMD (whose videos I have followed for ages, probably since Hard Doc Life). The video features such like-minded pals including but not limited to: Gilbert Welch, Tim Caulfield, Iona Heath, Victor Montori, Richard Lehman and yep, yours truly - "it's just common sense!"

See for yourself and share widely:

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

VIDEO: It's just life (not a disease). Así es la vida [subtítulos inglés] - YouTube

"Thisislifix 1 g There is no pill that can solve the reality of not being sick."

"Thisislifix 1 g
There is no pill that can solve the reality of not being sick."

The idea that any normal, bad thing that happens to our bodies is a disease state is called "medicalization." When we label normal aspects of life in this way, it seems to degrade coping mechanisms and increase dependency on the health care system.

Perhaps a bit silly, but certainly on-point, this video reminds people that some things are just a part of life. There is no pill to fix getting a cold, feeling sad after a breakup, or getting older; these are things we have to accept and work through.

Source: https://www.youtube.com/watch?v=mqxuxN5Fw3...

Pre-Osteoarthritis: Do we really need another "Pre-" disease?

This Spring, Dr Annemarie Jutel (RN, BPhEd(hons), PhD) from the Victoria University of Wellington shared with m some of her work on Social Issues in Diagnosis.

Dr Jutel is a social theorist and clinician interested in finding an understanding of just how diagnosis works, whether from the historical, linguistic, social, literary, clinical, or other angle. 

She explained: 

I am most interested in the “diagnostic moment” and the power of the diagnostic utterance; there is nothing that fundamentally changes in your soma from the moment you walk in to the doctor’s rooms, and the moment you get your diagnosis, but at the same time, if the diagnosis is a difficult one, everything has changed. 

I started following her posts on the Facebook Group, Social Issues in Diagnosis, which explores why and how we create these labels and what impact they have on patients and the course of medicine.

The most recent post is about pre-diagnosis, stimulated by this 2015 paper in Cartilage. If we can detect osteoarthritis before it starts, maybe we can stem the epidemic. Or, maybe we can turn a bunch of healthy, naturally aging, well-people into frightened patients?

In response to the article, Jutel asks:

What is a prediagnosis and what are its consequences? 

If pre-diagnosis states are, potentially, windows of opportunity, wherein individuals can adopt healthy, disease-avoidance behaviours, is there an advantage to calling these states "pre-whatever" as opposed to identifying them as healthy states, wherein health can be further improved?

What are the consequences of being given a pre-diagnosis? For some it may be a scary moment which marks their identity forever more. For others, it may be a wake-up call.

What would it be for you?

Take a look on the FB Group to participate or to learn more, see her book, Social Issues in Diagnosis.

Source: http://www.ncbi.nlm.nih.gov/m/pubmed/26175...

RADIO INTERVIEW: Dr Iona Heath: Too much medicine is making us sick

Dr Iona Heath is one of the foremost voices of the movement that confronts overdiagnosis and medicalization. She is in Australia to deliver a Sydney Ideas talk, "Too Much Medicine: Exploiting Fear for the Pursuit of Profit," on August 5th.

Testament to her ability to draw a crowd as she speaks frankly, humanly, and persuasively about this controversial subject, it has been moved to a larger venue!

While the Sydney Ideas talk may not be made available online, she has also given an interview with ABC Radio Conversations in Australia.

In the discussion, she frames the problem of 'too much medicine' and helps to define the difference between illness and disease, explaining how we make well people into patients.

With reference to A Fortunate Man and drawing on experience and connection with patients from her own 30 years in practice, she speaks about the role of the general practitioner and our inability to address the social determinates of health - the real underlying risk factors for poor health. 

Challenge by an interviewer who is not familiar with the science behind risks and outcomes of screening mammography for breast cancer, Iona emphasizes that the key message is not that a test or treatment is wrong for everyone, but that patients must be given informed choice. They must be fully informed of the potential risk and benefits of any intervention, and think about how it may impact them personally.

When the interviewer sticks to the common rhetoric 'prevention is better than cure' and insists that listeners should not run out and cancel their mammogram, Iona answers this bravely and personally. She shares that she, being in a low risk category, has decided that the harms of a mammogram outweigh the benefit for her. The paper she wrote in the BMJ in 2009, It is not wrong to say no, summarizes the arguments fully.

Iona does not state this explicitly, and I'm not sure it is fair to suggest it is implied, but our professional oath guides us such that: where there is risk but no benefit, the medical expert has a duty not to harm and so will encourage avoidance of the unnecessary test or treatment.

I am hopeful the lecture hall tonight is bursting at the seams with contemplative fence-sitters who may be persuaded by her words. Every event like this brings us closer to transforming the culture of care and being able to improve the lives of our patients.

Source: http://www.abc.net.au/local/stories/2015/0...

Doctors warned not to encourage young women to freeze their eggs

Aging is a normal part of human existence.

Screen Shot 2015-04-19 at 11.04.38 AM.png

As we age, parts of our body change the way in which they work - or stop functioning all together. For women, natural aging means a slow down and then a stoppage in our ability to be fertile.

With women increasingly devoting the early part of their lives to establishing a career, many are delaying pregnancy. Some are freezing their eggs for later use. Physicians, employers, and society as a whole are starting to encourage this practice.

This is troubling in a few ways. Drs Petropanagos and colleagues write (in the CMAJ) that it raises some significant social implications, reinforcing that "motherhood is a central aspect of womanhood." 

Egg freezing as a way of preserving women’s reproductive options reinforces the social norms and expectations that construe motherhood as a central aspect of womanhood. Women are encouraged to freeze their eggs as a way to “have it all” (that is, to have both a family and a career), implying that for those women who want both these things, egg freezing makes this possible. Although individual women may benefit from egg freezing to satisfy their reproductive desires, physicians should not assume that having a genetically related child is equally important to all women who ask about social egg freezing.

Our bodies do things for a reason. Delaying pregnancy and then using frozen eggs exposes women (and their new children) to greater and greater risks, due to complications of pregnancy and childbirth. 

Fighting the natural changes makes aging a 'medical problem' rather than a part of our existence that we can embrace and accept. I agree with the authors' suggestion that there are better solutions, like funded child-care, that could enable women to really have a choice when it comes to balancing motherhood and a career.

Read the National post article here, or the original CMAJ article here.

Source: http://news.nationalpost.com/health/doctor...

VIDEO: How To Become Gluten Intolerant: The lighter side of medicalization

You are going to have to watch this genius video to understand. When the human condition becomes a medical condition, it can be very very funny.

JP Sears (@AwakenWithJP) explains that "being gluten intolerant is a fantastic opportunity for you to assert your dominance in the life everyone around you, which helps improve your life."

His video contains amazing tips on how to achieve the gluten intolerant lifestyle, among them:

Give expert medical advice. Once you take your gluten free vows, you'll need to have an automatic understanding that every medical condition in caused by gluten. Depression: it's always caused by gluten. Obesity: that's 100% gluten. Every single case of cancer is caused by gluten. I swear, gluten's what killed Gandhi. . . 

Seclusion makes gluten healthier. Understand that when no one's around, you somehow become less gluten intolerant. How does this happen? Well, based on medical evidence that's yet to be discovered, there's a direct correlation between how many people are around and how gluten intolerant you are."

See for yourself, and become enlightened in the ways of the gluten free: 

Being gluten free used to be a luxury only reserved for those who are intolerant to gluten. With this cutting edge gluten educational video, you can become gluten intolerant too, whether or not you're actually intolerant to gluten.

Source: http://devour.com/video/how-to-become-glut...

Less is More in Healthcare (an evening with Dr Iona Heath)

Speed. Need. Greed.

Dr Iona Heath came to Vancouver, BC to talk about When Less is More in Healthcare, thanks to efforts by many, and particularly Dr Tracy Monk, of British Columbia's Center for Relationship Based Care.

I was humbled by Dr Heath's first slide: A screenshot of my website. That's right. Jaw-dropped, cheeks rosy, I stared at the front page of Less is More Medicine in all its glory on the screen at the front of the room.

And it got much better from there. Dr Heath wove clinical examples with philosophical perspectives to make the case for Less is More in Healthcare. Her essay along similar lines - The Art of Doing Nothing - can be read here.

To us she spoke about the barriers to achieving this kind of care and how or why things wound up as they have. Speed can be a problem in many ways. Rushing to cure and fix everything, we forget the patient and their wishes; an elderly woman goes to the hospital, gets poked and prodded and optimized, and dies two weeks later anyway. How efficient. ?. She would have stayed home and been cared for at home, if given the choice.

In the talk, as in the essay, Dr Heath makes reference to Christopher Rick's book Beckett's Dying Words. His reflections help illustrate the problem of our strange obsession with fighting death at all costs; later, she drew from Beckett himself:

Samuel Beckett understood more about futile doing than most. He is ­de­scribed by the literary critic Christopher Ricks as:

The great writer of an age which has created new possibilities and impossibilities even in the matter of death. Of an age which has dilated longevity, until it is as much a nightmare as a blessing.

In Malone dies, Beckett writes:

And when they cannot swallow any more someone rams a tube down their gullet, or up their rectum, and fills them full of vitaminized pap, so as not to be accused of murder.

(my German is not great but I believe the essay is a transcript from Dr Heath's keynote lecture at The Art & Science of General Practice and Family Medicine)

The most resonating part of the talk for me was the dissection of our persistent and inflated idea of "need."  Dr Heath found many ways to point out the ridiculousness of our quest to create patients, including thoughts from post-war Polish poet Zbigniew Herbert:

I invented a bed with the measurements of a perfect man
I compared the travellers I caught with this bed
It was hard to avoid - I admit - stretching limbs, cutting legs
The patients died, but the more there were who perished
the more I was certain my research was right.
The goal was noble.  Progress requires victims.

However, it was Iona's casual phrases, like "the contemporary distortion of need" that so eloquently stated the issue. By diagnosing "risk," like an increased risk of heart attack or stroke, we inflate the need. We create a responsibility to do something, do anything to prevent a potential thing that hasn't happened yet and might but probably won't.

We have done this in the case of mammography. For years we promoted self-exams and clinician breast exams. Then we realized those were a waste of people's time and encouraged worry about lumps that were nothings. So we said "just mammogram." In 2009 I read the New Zealand guidelines for screening for breast cancer. At that time, they were encouraging against clinician exams and even suggesting that mammography might not be recommended in future. I failed to convince one of my preceptors, a wise and thoughtful guy. For years he had helped women find "the lump" that ultimately was hacked off, irradiated, and chemo'd, and their lives had been saved. Patients, convinced by their doctors for years and years, still feel something must be done. "Early detection is key."

That anecdotal experience is hard to trump, but as the data floods in, we are discovering that less is more. It is the responsibility of physicians and the medical community to undo the messaging that we touted for years.

It never boils down to just randomized controlled trials, NNTs, or confidence intervals. We are caring for humans, and that cannot be reduced to just fighting disease or perceived risk.

Powerful words bear repeating and so we were given some of Annemarie Mol's to chew on.

The Dutch philosopher Annemarie Mol, in her book The Logic of Care, writes about how ‘the logic of choice’ now undermines ‘the logic of care’.  She says:  ‘Even if good care strives after good results, the quality of care cannot be deduced from its results.  Instead, what characterises good care is a calm, persistent but forgiving effort to improve the situation of a patient, or to keep this from deteriorating’.  The richness of that aspiration compared with getting the numbers to the correct point is incredibly important.

Mol goes on:  ‘You do what you can, you try and try again.  You doctor, but you have no control.  And ultimately the result is not glorious:  stories about life with a disease do not end with everybody ‘living happily ever after’.  They end with death.’ Unless we as both a profession and as a society get over the idea of death as medical failure, we are doomed to torture our patients when we should be leaving them alone. (from The International Futures Forums)

Exploring need, the example of the overdiagnosis of ADHD and the medicalization of our children emerged. Dr Heath explained that labeling and medicating children teaches them 'that they are not normal, not responsible for their behaviour, and that answers come in pills.' It might be that our kids are not disordered - they just learn in a different way. See this snippet of Sir Ken Robinson's great Ted Talk on the subject:

Lastly, there is greed. Diseases are invented in order to market drugs. Normal behaviour is medicalized, or deemed pathological as we sterilize the definition of 'normal.' Those who have get more, and just because we can do something expensive and fancy and new doesn't mean we should. Christopher Ricks:

It is now almost impossible to die with dignity in USA unless one is poverty stricken

If you have the means, you'll be poked and prodded beyond your heart's desire. We've got it wrong most of the time. Doing more is not better, and fails to solve the underlying problem. "We seek technical solutions for existential problems" (Overdiagnosis: when good intentions meet vested interests—an essay by Iona Heath) and that leads us down a very slippery slope. Just one more test. Let's try this treatment.

 

Let's stop. Let's think of the patient and what matters to them. Or as the patient, what matters to us? Must we keep our numbers within normal parameters? Shouldn't we just strive to feel good, pursuing a "modified hedonism," in order that we might appreciate more the quality than the quantity of life we are given?

General practitioners would do better to encourage people to lead lives of modified hedonism,so that they may enjoy, in the full, the only life they are likely to have.

(J McCormick, Health promotion: the ethical dimension, Lancet, requires subscription)

 

I admire the strength of Dr Heath. She is an unapologetic champion for the right care, and explained to us with wisdom and compassion the reasons we've wound up in this state of aggressive care, and offered solutions for moving past it. The role of the Family Physician and the connection we share with patients is central to this.

 

 

What’s in a name? Why we need to reconsider the word cancer

doctor: "You have cancer."
our brains: Panic! Cancer! What!? Cancer!
our mouths:  "Oh . . . Uh oh! Well, is it a BAD kind of Cancer?"

It's the "Big C." It's a scary word. And fortunately there is a lot we can do with screening, advanced tools for diagnosis, and treatment in many modalities to combat the Big C.

These days, everyone gets cancer, unless something else gets them first. Cancer is part of the natural process of cells replicating, and it's all explained elegantly by the New York Times Sunday Review: Why Everyone Seems to Have Cancer.

But not all cancers will end our lives. There are "pre-cancers" and there are "early cancers," and these are often not going to hurt us, so they are okay to manage with a 'watch and wait' strategy. People can be scared into seeking aggressive treatment because they lump these "pre-cancers" in with the "very much cancers," which usually warrant a good battle in the right patient.

Sometimes it does matter if we can catch things early and treat them before they progress, like when we see changes of the cervix during pap screening; these can be treated to prevent progression to invasive cancers. That's really important, and it saves lives, but it only applies to a certain population, under certain circumstances.

Sometimes it doesn't much matter when we catch things, as we are learning with most cases of prostate cancer, for example. In recent years we have started to discover that the treatment might be worse than the disease, and maybe we shouldn't be screening for prostate cancer the way we have been.

Perhaps we should be more careful then with what we label "CANCER." That word tends to lead to a cascade of troubled thoughts, and we wind up worried about writing a will, rather than understanding what those dastardly – but potentially harmless – cells in our body are doing.

Alexandra Barratt, Professor in the Department of Public Health at University of Sydney writes:

Early cancers and pre-cancers (abnormal cells that could turn cancerous) found by screening tests, such as mammograms and PSA tests, should be renamed without (scary) words such as carcinoma or neoplasia in their title. They suggested they could be renamed IDLEs – indolent lesions of epithelial origin.

She goes on to explain the risks of overdiagnosis, the fallacy of lead-time-bias, and what we can do about all this as patients and providers, with the guidance of the National Cancer Institute.
 

Read more on The Conversation.

Source: http://theconversation.com/whats-in-a-name...