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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.




Compliance - noun 1 compliance with international law: obedience to, observance of,adherence to, conformity to, respect for. ANTONYMS violation.

he mistook her silence for compliance: acquiescence, agreement, assent,consent, acceptance; docility, complaisance, pliability, meekness,submission. ANTONYMS defiance.

(New Oxford American Dictionary 3rd edition © 2010 by Oxford University Press, Inc.)

"Why aren't you taking your cholesterol medication?"  I asked the woman.  With the coronary disease I diagnosed a year ago, my discovery that she had not taken her medication was very troubling.

"It made me tired," she replied matter-of-factly.  "And besides, the cardiologist said the stress test was negative, so my heart is fine!"

I ordered the stress test after her heart calcium score was significantly elevated, revealing significant atherosclerosis.  She totally misunderstood the results, and I needed to fix that problem.  So I pulled out my secret weapon: a good analogy.

"The purpose of the calcium score test was to see if you had termites in your home"  I explained.  "I found them.  The negative stress test just said that the termites hadn't eaten through your walls.  It's good news that your walls aren't falling down, but they will if we don't stop the termites."

Her eyes opened wide comprehension: the termites were eating her walls.  She was living on borrowed time.

"Would you take a medication if it didn't have side effects?" I asked.

She quickly nodded.  Of course she would.  From now on she would be a compliant patient.

Compliance is good.  Noncompliance is bad.  It's something I learned very early in my training: patients who do what their doctors say are compliant (good), and those who don't follow instructions are noncompliant (bad).  If you are lucky as a doctor, you have compliant patients.  They are the best kind.   They obey their doctors.  They are submissive.  Noncompliant patients are bad; they are a bunch of deadbeats.

Please hold your nasty comments; I don't really believe my patients should obey or submit to me.*

Sadly, however, many doctors wouldn't flinch at that description of noncompliance, heaping all the blame of noncompliance on the patient's shoulders. But this woman's story (true, albeit changed for anonymity) illustrates one of the most common cause of noncompliance: misunderstanding. She was thrilled when her stress test was negative, grasping at the opportunity to be out from under the diagnosis of heart disease.  The cardiologist told her that her "heart was fine," and that was all she needed to hear to be excused from taking her cholesterol medication.  She didn't understand, and the blame of that misunderstanding can be shared between me, who didn't adequately explain the test before sending her to it, the cardiologist, who gave her "good news" that didn't tell the whole story, and the patient herself, who didn't ask questions when she should have.  It wasn't until I gave the termite analogy that she really understood.


I love good analogies.

In the "good old days" of medicine, doctors were not obligated to explain things like they are today.  Patients didn't have access to medical information and so would have to take the doctors at their word about what they should do.  Today, however, patients have far more knowledge at their disposal than the doctor has in his/her head.  Contrary to what some doctors think, this is (usually) a good thing.  The doctor is forced to defend and explain medical decisions, making truly bad decisions less likely.  True, some questions come from untrustworthy medical sources (websites selling "miracle" cures, those relying on anecdotal data, conspiracy theorists, and Dr. Oz), but if I can't give a convincing enough argument to counter these foes, one of two things is true:

  1. I am not on solid scientific ground.
  2. The patient doesn't trust me.

Either one of these is valuable for me to know.

So I have come to see compliance not as a monicker of disdain, but as a challenge to overcome.  I will never get  near 100% compliance, but I don't get this from my kids, my car, or my dog, so why should I expect it from my patients?  Besides, I get paid the same amount if the people ignore what I say; my job is simply to give them the best advice I have.

Once I get that taken care of I can turn my attention to more important things: compliance with "meaningful use," "medical home," and other fun stuff.  I need to make sure I am obeying and submitting to those wonderful Washington bureaucrats.  I never question them because they know what's best for me.


*I'm using the crazy language tool called hyperbole.  It's good clean fun.  You should try it some time.



Buckle Up

Lipitor can destroy your liver.

Back surgery can leave you paralyzed.

People who take Chantix might kill themselves.

You may never wake up from a simple surgery.

These statements are all true.  They also are very confusing to many of my patients when I am prescribing drugs or recommending surgery.  What should they do when they hear such bad things about drugs, surgeries, or procedures?  How much do they risk when they follow my advice?

It's a hard world out there, with the attorneys advertising on TV about drugs my patients have taken, with the websites devoted to the harms brought on by a drug or an immunization, with Dr. Oz and other seemingly smart people telling them things that are contrary to my advice, and with friends and neighbors who give dire warnings about the dangers of following my advice.  There are so many voices out there competing with mine, that I sometimes spend more time reassuring than I do anything else.  A doctor in our practice believes that Dr. Oz ought to issue a statement to doctors whenever he voices another controversial opinion as gospel fact so that we can be ready with our counter-arguments.

What can doctors do?  We can't quiet the other voices that speak against us.  In truth, those voices have an important role in preventing us from becoming comfortable and dogmatic in our beliefs.  So how do I combat such a heavy current against our advice?

By talking about seat belts.

Seat belts can kill you, you know.  You can be trapped inside your car by your seat belt and not be able to get out before your car explodes.  It's not a fable; it can really happen.  You may be sealing your fate to die terribly every time you buckle your seat belt.

When I say this to my patients they instantly get what I am saying.  Sure, there is risk putting on a seat belt, but that is overwhelmed with the risk of not wearing it.  EMT's will tell you that they rarely unbuckle a dead person.

I love using illustrations like this.  I can, with a good illustration, explain a highly complex subject in very little time.  They give the patient something they understand as a basis on which to consider their options.  In the case of the seat belt, the analogy gives them perspective.  It shows them that the people who talk about the bad stuff aren't lying (seat belts really can kill), but they aren't considering the risk of not having the surgery, taking the medicine, or getting the procedure done (seat belts save lives).

There is the risk of over-simplifying something, or leading patients to believe something is lower risk than it really is.  That's why I always follow this by talking about how I feel the risk of taking the medicine compares with that of not taking it.  I don't argue against those who say Lipitor can destroy your liver, doing so would undermine my credibility because Lipitor can kill your liver; I just simply put that risk in perspective.  Analogies alone don't explain things, but they do take difficult to understand concepts and bring them into a world the patient understands.  From that point on, the explanation is much easier.

I used the analogy this morning explaining to a mother who was worried about the risk of ear tubes in her baby.  I explained that the risk of surgery (wearing the seat belt) was much less than the risk of antibiotic over-use (not wearing the seat belt).  She visibly relaxed when I said this.  I am not belittling her fear, I am just putting it in perspective.

I use seat belt analogies in other ways too.  Today someone told me that they never get flu shots and haven't ever gotten sick.  I told them that I could have never worn a seat belt in my life (which is almost 50 years) and I would still be alive talking to them.  I've never gotten into a serious accident, so seat belts have been a complete waste of time, right?  The patient smiled when I said this.  No, I told him, I think it was a good idea to wear them and will continue to do so.  People who wear seat belts are more likely to be alive in a year than those who don't.  The exact same thing is true for high-risk people and flu shots.

He still didn't get one.

I also talk about the warning labels that seat belts would have if they had to list all of the ways you could be harmed by them.  Imagine a seat belt commercial done like a pharmaceutical ad: "Seat belts could choke young children, could trap you in the car and kill you, could cause bruising to the shoulder, pinching to the fingers, lacerations, and abrasions.  Seat belts also could be used maliciously by older brothers to torture their younger sister.  Call your mechanic if you cannot unfasten your seat belt for more than four hours."

You get the picture.  So do my patients.

Buckle up.