Caught in the Crossfire | Where is Frodo When You Need Him?


I wrote the title to this post and now have the Stevie Ray Vaughan song with that name running through my head (which is a whole lot better than last week, when some of my office staff were talking about Michael Bolton, and I got one of his songs - that shall not be named - running through my head).  So, if you are like me, hum along with Stevie while you read this post.

What's up with medicine?

Zithromax Kills....But maybe it could prevent heart attacks!

You should take calcium for its many benefits....But isn't calcium intake is associated with an increased risk of heart attacks?

PSA testing doesn't make a man live any longer....That's not what the urologists say!!

Take aspirin to prevent cancer...wait, maybe you shouldn't.

The list goes on.  It seems that everything either saves your life or kills you, and my patients are coming to me for recommendations.  I have to confess, I have greatly curtailed my use of Zithromax (despite the fact that I don't even believe the risk is at all significant) but just don't want to get into a long conversation about retrospective studies in what should be a 5-minute visit.  I am truly caught in the crossfire.

The problem PCP's face is that we are dealing with single human beings, not populations.  The practice of medicine is not science, it uses science.  There is a very big difference between the two.  I don't want my patients to have heart attacks or get cancer, and will do what is best for them to prevent these diseases.  The problem is that every other week there seems to be a new study debunking the study done a few weeks before, and despite the fact that I may not believe all of these studies, my patients hear them and are trying to do what's best for themselves.

A good example is the use of "Statin" drugs in the prevention of heart attacks.  Should a person take Lipitor to prevent heart attacks?  It depends on who the person is: if it is a 25 year-old athlete with an LDL of 150, I would not let the word "Lipitor" come through my lips.  On the other hand, if it is a 55-year old male diabetic smoker with a history of previous heart attack and an LDL of 150, I would be tempted slip a statin into his food if he didn't want treatment.  The hard part comes when the water is not quite so clear.  What about the 48 year-old male who has no history of heart disease in his family but has a high LDL cholesterol?  That was me a couple of years back, and I had to decide which demographic in a primary prevention trial (one which prevents the first heart attack, rather than preventing additional ones) I fit into.  What about the 55 year-old woman whose father had a heart attack at 45, but was obese and a heavy smoker, while the woman runs 50 miles per week and is a vegan?

The problem with any scientific study is in the generalization of the results.  Is the study relevant to the general public, or is it specific for the small population in the study?  It's a question which unfortunately is not asked by the struggling newspaper trying to have good enough headlines to stay in business.  "Aspirin Fights Cancer" is a much better headline than, "A study shows that aspirin use in caucasian men age 40-65 reduces the risk of melanoma."  "Zithromax Kills" gets a lot more hits on the web than, "Retrospective studies suggest Zithromax increases the all-cause mortality in people of certain demographic groups."

Add to that the drive for drug companies to sell their medications, not really caring if the person in the exam room really needs the Lipitor as long as they pay for it.  Then there are the hospitals and specialty physicians who would lose huge sources of income if some of these interventions (removal of a prostate using a robotic surgery thingy, for example) were not needed.  They raise their voices in protest (some with good intent, others not) when their jobs are threatened.  I would be tempted to do the same if I were in there shoes.

Yet as the need for explaining these contradictory headlines grows, the time I have to do this with each patient shrinks.  I have to take time to document my encounter properly so as to meet coding standards and be paid properly while avoiding fraud.  I have to get the right handouts given and data entered so that I can achieve "meaningful use" and perhaps (ironically) become a "patient-centered medical home."  I have to fill out the increasing deluge of forms, attesting to the preventive care I have given, the reason a person should avoid jury duty, or the reason I want to change them from regular formula to soy.  I have to answer questions about patients about the cost of medicines and the reason the last office visit cost what it did.  I have to wait while my increasingly antiquated EMR product loads on the computer we bought 8 years ago.

Sigh. Sometimes I feel like the armies led by Aragorn surrounded by the hoards of Mordor...Except in my case, there is no Frodo.

So what's a patient and doctor to do?  The key to this problem is to figure out what a person's biggest health risks are.  Interventions work best when the risk is highest.  It's not wise to earthquake proof your home if you live in Florida; you should probably instead focus on hurricanes.  The higher the hurricane risk, the more the benefit from strengthening your home.  So, if we knew who was very high risk for prostate cancer, then maybe PSA testing could be of benefit to that sub-population, while giving a pass to those who were low risk and saving a bunch of money.  If I found out that I was really, really low risk for colon cancer, I would probably be fine with neglecting my impending night on the toilet and not feel guilty OK doing so.

I think the key will be genetic testing.  If we can get by the hurdle of health profiling (insurers not insuring high-risk people or employers not hiring them) based on genetic testing, we could do a lot better job at preventing disease.  We could screen only the high-risk populations, saving money and reducing unnecessary procedures.

Maybe then I'll be able to watch the evening news without screaming.  Maybe then I can sit and talk to my patients about their problems, not interpreting the headlines.  Come on, Frodo.  You can make it.

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