It's hard for most of us to imagine that our physician(s) may be going against scientifically-drafted guidelines when it comes to screening for diseases and/or their treatment. But, this seems to be the case for cervical cancer screening.
Researchers from the Centers for Disease Control and Prevention (the CDC) recently conducted a survey on whether or not docs would do a Pap smear on 3 different imaginary, yet low risk patients (defined as a woman in a monogamous relationship with one partner having a current negative HPV test or 2 consecutive normal Paps), and 2/3 of them recommended another smear in one year. This goes AGAINST the clinical guidelines that recommend spreading these screenings out for low risk patients. Not only do these extra tests cost us all more health care dollars, but they also increase frequency of pain and anxiety for the women undergoing them. And trust me, that discomfort and anxiety can be significant.
This doesn't mean that 2/3 of doctors are setting out to cause harm to their patients or order needless tests. For the most part, I do not believe that physicians are bad people looking to take vengeance out on their patients. I believe the confusion lies, well...in the confusion of clinical guidelines. Guidelines change constantly. One day, physicians are supposed to teach monthly breast exams to women for breast cancer detection and the next, they are supposed to recommend "breast awareness". One day, vitamin E is good for preventing heart disease and the next it's actually harmful! Etcetera, etcetera. The contradictions are endless.
But such is the nature of the beast. Medicine is dynamic, not static. It changes just as the seasons change, our moods change, our lives change. It is a process. With more and more technology and research, researchers are trying to figure out how to become more efficient and less costly with providing medical care to the aging masses. However, this is not an easy task nor is it simple. For one, it COSTS money to study cost-effectiveness...lots of it and secondly, it takes TIME to conduct a good study and obtain the results. The average randomized clinical trial lasts over 5 years which is often not enough time to make long-term predictions. Funders of studies want results asap, thus putting even more pressure on researchers.
Thirdly, doctors are constantly bombarded with information and often do not have the time or the patience to read the latest, most credible journals and research updates (which, in my opinion, is a product of the system). They then defer to practicing medicine the way the person(s) who trained them did. In doing so, non-evidence-based traditions (and there are MANY) are practiced and taught to future practitioners. As such, tradition has a great influence on the practice of medicine. Until this issue is addressed, costly medicine will persist and not without it's risks.
Potential ways to address this issue are investments in electronic medical records that automatically schedule the next screening according to the most recent guidelines and physician audits during which random chart are extracted from a physicians' caseload and the physician is held accountable and liable for not adhering to current recommendations (although I would not be a fan of either of these options if I were in private practice as the former is very expensive and time-consuming to implement and the latter is very regulatory).
Changing the pay structure for docs would also help. Instead of the current fee-for-service structure in place now where payments are made for procedures, not necessarily for quality time spent with a patient, physicians are financially inclined to do more procedures (including Pap smears). This flies in the face of ethical medicine - no matter how ethical a person is, finances rule all and we, despite what some of our own think, are only human.
So, my proposal to my readers is - be an astute patient and question your physician (in a nice way) as to whether or not you really need that cat scan or the annual Pap smear. After all, it most likely will not extend your life but it may make it less enjoyable (think anxiety, discomfort, etc). And if you question them and end up changing their practice, you can claim the cost-savings with pride!
As many of my close friends and family know, I had the pleasure to work with Dr. David Katz of Griffin Hospital in Derby, CT this past year. The rotation was fabulous as I got to see true Integrative and Preventive Medicine in action. For those new to Dr. Katz, he is rock star in the Integrative and Preventive Medicine world.
Here's a quick bio (skip this paragraph if you want to get to the meat of the article): "Dr. Katz is the director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, CT; founder and president of the non-profit Turn the Tide Foundation. Know internationally for expertise in nutrition and chronic disease prevention, as well as integrative care models, Katz has secured roughly $30 million in research funding, and has published over 120 scientific papers, numerous textbook chapters, nearly a thousand newspaper columns, and 12 books to date. He is the principal inventor of the Overall Nutritional Quality Index utilized in the NuVal™ nutrition guidance program (www.nuval.com), currently offered in approximately 1,000 supermarkets throughout the United States. He has been recognized three times by the Consumers Research Council of America as one of the nation’s top physicians in Preventive Medicine; was a nominee for the position of US Surgeon General in 2009; and was the 2011 recipient of the Katharine Boucot Sturgis award from the American College of Preventive Medicine, the most prestigious award the College confers – awarded for illustrious career contributions to the field. Dr. Katz is a health editor for the Huffington Post, and Editor-in-Chief of the peer-reviewed journal, Childhood Obesity."
So needless to say, I was thrilled to work with him for 5 weeks. He publishes a weekly column in the Huffington Post and in his most recent column, he discusses the differences between irradiation (medical procedures that require radiation) and illumination (knowing whether or not the test is the best one for diagnosing and/or treating your medical conditions). Here's what he writes:
"My colleagues at the Huffington Post recently did a fine job characterizing the trade-offs that bedevil decisions about the use of modern medical imaging. On the one hand, sophisticated imaging with CT scanners can inform treatment choices, and save lives. On the other, rates of imaging have sky-rocketed over recent years, raising concerns about radiation exposure for patients and for doctors, that invention may be acting as the mother of necessity!
The challenge, of course, is finding the sweet spot between damned if you do, damned if you don't. Being overly cautious about medical testing -- imaging or otherwise -- could mean missing out on the very test you need to answer a critical question, or guide a crucial therapy. Being overly accepting of every application of modern medical technology might well mean it does you more harm than good -- making you glow in the dark, rather than illuminating the source of your troubles.
Up to a point, getting such decisions right requires trust in your doctor -- because they are decisions your doctor has been trained to make. Often that trust will be warranted -- and ideally it is in your case. Ideally, your doctor is not only highly educated, but equally intelligent and genuinely caring. With my many colleagues in mind, I can certainly say this is true much of the time. I can also say it isn't invariably true, and even the best of us have bad days. So I invoke my favorite Reaganism: Trust, but verify.
Verify you are getting the tests you need, and only the tests you need. Challenging such decisions is not an insult to your doctor. Simply, it is an affirmation of the fact that you, literally, have skin in the game: It's your body and your health on the line. Take nothing for granted.
In her Huffington Post column about diagnostic imaging, Emma Gray makes the following, reasonable suggestions. Before getting any type of scan, ask: How will this improve my care? Are there any alternative imaging exams that don't use radiation?
I like these tips, but I would like to go further and generalize them. Radiation is not the only hazard of medical testing -- any test can do harm of some kind. That's acceptable if, and only if, potential harm is much outweighed by potential benefit. To ensure that, always ask these questions before any test:Wwill the results of this test directly affect your decisions, or my options? Will this test provide a definitive answer, or is it preliminary to more tests? Is this test the safest way to get the information we need? Would you have this test if you were me?
If you can bring yourself to ask these questions about medical testing as a matter of routine, they should serve as a fairly good filter, letting only genuinely useful testing through. But with a little help from your inner statistician (yes, s/he's really in there!) you can do even better.
The goal of medical testing is to figure out what is going on (and then, what to do about it). That, in turn, is really dependent on establishing two things: What does this patient have and what doesn't this patient have? Testing is about confirming a diagnosis (ruling it in) and excluding all the rest (ruling them out). Ideally, it leads to ruling out everything so you can get that proverbial clean bill of health.
There are two, simple statistical concepts you should (and can!) master so that you can help guide testing toward ruling in what it is and ruling out what it isn't. The concepts are sensitivity and specificity.
In life, sensitivity is noticing and reacting to every little thing. It's not much different in medicine: It's the capacity of a test to detect a condition when it is really there. In the two-by-two table below, it is [a/(a+c)]. (Imagine a 2x2 table described as below, it would not copy into this post)
The table summarizes the universe of diagnostic possibilities into four quadrants: disease is present and the test finds it (cell a); disease is absent, but the test says it's present (false positive, cell b); disease is present and the test fails to find it (false negative, cell c); disease is absent and the test says it is absent (cell d). Sensitivity is, in essence, the percentage of the time that disease is present (cell a plus cell c) that the test finds it (cell a); thus, [a/(a + c)].
Here's the surprise: Although sensitivity is the measure of how reliably a test finds a condition that's actually there, it's the property a test needs to rule disease out! Here's why:
If a test is highly sensitive, it will almost always be positive when disease is truly there. Therefore, if a test is highly sensitive, it will almost never be negative when disease is truly there. A highly sensitive test will almost never be negative unless disease truly isn't there. And thus, a negative result on a highly sensitive test reliably rules out disease. The corollary, of course, is that a negative result from a test that is not highly sensitive -- whether or not it is highly specific -- does not reliably rule out disease!
Imagine the stunned expression on your doctor's face when s/he says: Llet's get this test just to make sure you don't have X ..." And you reply: "I trust, then, that this is a highly sensitive test for X?" I would love to be there when it happens!
On the flip side, specificity is the capacity of a test to exclude what truly isn't there. In the two-by-two table, that's [d/(b+d)]. The explanation is much as before, so I won't belabor.
Again, it is somewhat counterintuitive, but it's a test that is good at ruling out what isn't there that is needed to make a diagnosis! The logic is much as before:
A highly specific test is almost always negative when disease is truly absent. A highly specific test will almost never be positive when disease is truly absent. A highly specific test will almost only be positive when disease is actually present. And thus, a positive result on a highly specific test reliably rules a diagnosis in. Again, we have the logical corollary: A positive result from a test that is not highly sensitive does not rule a diagnosis in -- it merely suggests it. So before being treated for a particular condition, particularly if the treatment is apt to be unpleasant or dangerous, you would be well within your rights to ask: Was the testing this diagnosis is based on highly specific?
You are, I am confident, more than capable of mastering and using these simple, statistical principles. But I also recognize that some of you break into a cold sweat at the mere sight of anything that recalls high school algebra! For those in that group, here's your shortcut: SPin/SNout. Specificity to rule in, sensitivity to rule out.
There are more useful, simple statistical principles where these came from -- but they can wait for another day, and another column.
For now, we should recognize that medical testing used well should be illuminating. Used badly, it might simply be ... irradiating. Trust your doctor -- but on behalf of your skin, verify! Bring a few good questions -- and your inner statistician -- to your next doctor's visit to help ensure you stay in the sweet spot."
Hope this helps explain one of the ways doctors assess the risks and benefits of certain medical tests/procedures/exams. Remeber, an illuminated patient is the safest one.
Have a great week!
Happy Friday to all!
We've all read the research showing that happier people live longer, have a better quality of life, are more successful, etc. So, why not improve our lives with a Happiness Project?? What is a Happiness Project , you may ask??
Thanks to Gretchen Rubin, a lawyer and best-selling author in NYC, I am finding out!
As an aside to studying for my Internal Medicine Board exam, I just started reading Rubin's book, “The Happiness Project” and am feeling quite inspired! In the book, Rubin discusses the need to improve our lives by setting goals that help us achieve happiness. While thoroughly researching the topic, she discovered that happiness is a long sought-after, yet attainable value. She quotes Aristotle and Socrates during their pursuits of happiness and bases her project on Benjamin Franklin’s own version of the same during which he sought to improve his life in multiple areas, including servitude, temperance, solitude, etc. He even made a calendar with checkmarks and goals to help him achieve this! Pretty modern thinking Mr. Franklin!. The experts (including Mr. Franklin) argue that goals are more attainable when written down and posted in front of you.
In Rubin’s project, she created a list of specific areas in which she would like to improve her life (ie, family, friends, mind, body, finances, etc) and set about creating goals that worked to improve them (ie, spend more time with husband, organize bills and financial papers, etc). Using her analytical skills from law school, Rubin systematically broke down the areas into concrete, attainable monthly goals. Each month she would work towards completing that month’s goals and ultimately end up a happier person by the end of the year. (Disclaimer: I have no idea if the plan actually worked as I’ve just begun the book, but I can take an educated guess that she wouldn’t be writing about it if it didn’t...?)
So, here is an attempt at my own Happiness Project and I’d like for you all to join me. I aim to meditate for 5-15 minutes every day, no matter the circumstances (unless I’m traveling). By meditation, I mean focusing on breathing in a quiet room without interruptions. I know that meditation makes me feel good; it decreases my stress and anxiety levels, issues I have struggled with my entire life, by relaxing my often pathologically tight muscles and allowing me to center my focus on my breathing. In taking these five minutes a day to “breathe”, I hope to achieve a better outlook on life and more energy to help others. We all know the world could use more happiness!
Here's a link to Gretchen's website - http://www.happiness-project.com/
This is my first goal. What’s yours?
"Happiness is neither a virtue nor pleasure nor this thing nor that, but simply growth. We are happy when we are growing." -- William Butler Yeats, poet, playwright and Nobel Laureate
It's Wednesday, aka "Hump Day". Your boss is breathing down your back, the stock market is a mess and all of your nerves are frazzeled. What to do?? MEDITATE! Not only will it decrease your stress relief, but it decreases your blood pressure, risk of heart attack, stroke and other catastrophic health conditions. And we could all use a little security these days.
Here's a fantastic 4-minute guided meditation (it's literally 4 minutes!) by James Gordon, MD, a Harvard-trained psychiatrist and founder of the Center for Mind-Body Medicine in Washington, D.C. Dr. Gordon is an expert in using mind-body techniques to treat anxiety, depression, addiction, post-traumatic stress disorders, etc. He's even bridging gaps between people in war-torn areas (Israelis and Palestinians to name one). To sum it up, he's INCREDIBLE!
So take 5 minutes of your day, EVERY DAY, to smell the roses, be it with Dr. Gordon or on your own. Here's a link to his organization's website - http://www.cmbm.org/. Enjoy!
Thanks to Yahoo Health for compiling these EXCELLENT calorie-saving tips! Try one today and another tomorrow and pretty soon you'll hopefully be cutting significant amounts of calories without even trying. : ) Remember, what goes in must come out (calories in = calories out). So, if you're not so in to slaving it out at the gym, aim for about 1200-1500 calories a day depending on your metabolism. If you're an exercise addict, you definitely need more calories (usually 2000-2200, again, based on metabolism). The more muscle you have, the more calories you burn. It's all simple math.
But today, Yahoo Health helps us all by illustrating 26 practical tips to cut unwanted calories out. Think: cook at home where you know what you're putting in your food. Salud and have a fabulous & safe weekend!!!!
Adding fresh herbs and dried spices can boost the flavor and antioxidant content of your summer meals. The ORAC value, or Oxygen Radical Absorbance Capacity, is a measurement of a food’s antioxidant power, which has been ranked by the USDA. It provides a measurement of a food’s ability to neutralize free radicals in the body that are linked to the development of many chronic diseases, such as cancer, heart disease, Alzheimer’s and Parkinson’s disease. According to the USDA, fruits, nuts, and vegetables are great food sources of antioxidants, in addition to herbs and spices.
What are free radicals? When cells die, they release reactive oxygen molecules also known as free radicals, which can build up in our bodies and harm healthy cells (think of how an apple browns on the surface when exposed to oxygen). Exposure to certain environmental factors, such as tobacco smoke, can also lead to free radical formation. In addition to the color-producing compounds mentioned above, other examples of antioxidants include vitamins A, C, and E.
Herbs and spices are also a no-fuss way to ramp up the flavor of meals without adding a lot of salt or sugar. For a few seasonal starters, try tossing basil into a summer tomato salad, add chopped cilantro to salsa or guacamole, or top your iced coffee with ground cinnamon.
ORAC Values of Seasonal Fresh Herbs:
Herb Serving ORAC Value (the higher, the better)
Sage 2 tsp 500
Peppermint 2 Tbsp 400
Oregano 2 tsp 400
Cilantro ¼ cup 200
Thyme 1 tsp 200
Parsley 1 Tbsp 100
Dill 5 sprigs 100
Basil 1 Tbsp 100
Source: The O2 Diet by Keri Glassman, MS, RD
Dr. Maltz earned a Medical Degree and Master in Public Health from the University of Texas Medical Branch (UTMB) in Galveston, TX. She completed a combined Internal and Preventive Medicine Residency at UTMB in June, 2011. She then completed a 2-year Integrative Medicine Fellowship at Stamford Hospital in Stamford, CT, during which she simultaneously underwent an intensive 1000-hour curriculum created by The University of Arizona Integrative Medicine Program founded by Dr. Andrew Weil.