Monday, April 23, 2012

Survival of the un-fittest

I'm glad that I happen to be alive at this particular time in the earth's history.  Check out the dramatic improvement in life expectancy over the past 12,000 years.  

This is really amazing.  If I were alive during any other time period, odds are I would probably be dead by now.  And even more than the improvement in quantity of life, I'm most pleased about the  dramatic improvement of quality of life.  I love all of my first world pleasures.

But this story isn't all roses!  As a realist, I understand that the dramatic improvements we've made over the past couple of centuries surely cannot continue at such a rapid rate.  Just like a booming economy cannot continue forever, the increase in life expectancy has to level off sometime.  And like economic recessions, I wouldn't be surprised if we experience a recession in life expectancy at some point in our future.  Maybe we'll even see a major depression.  It's just the way nature works.  You can't expect to disrupt a system that has been stable for millions or billions of years and expect it to continue forever.  

Sometimes at work I actually reflect on serious issues (shocker, I know).  The key word there is sometimes.  I have to keep it to a minimum because it makes my brain hurt if I think too much.  

But I've often wondered if we're doing humanity as a whole a big disservice by keeping everyone alive at all costs.  

Think about it.  Before we learned to thwart nature and keep people alive for so long, it was all about 'survival of the fittest.'  Only the strongest, fastest, and smartest people survived into adulthood.  

If you happened to be weak, slow, and dumb, this kind of system obviously didn't work well for you.  But for mankind as a whole, the system worked very well.  In fact this whole concept was what has kept the entire human and animal kingdom in check for billions of years.  It has provided a beautiful natural balance that has worked so well for hundreds of millions of years.  

What modern medicine has done is to allow the weak, slow, and dumb to live much longer lives.  It helps the strong, fast, and weak as well, but too a much lesser degree than it helps the weak, slow, and dumb. 

Nowadays most people live long enough to reproduce, which is a big change compared to previous millenia.  Not just the strong, fast, and smart get to have all of the fun anymore - for better or worse, now anyone can procreate!  

And most take advantage of that opportunity.  This means that more of the weak, slow, and dumb genes are being passed on, essentially diluting the human gene pool more and more with each successive generation.  Eventually we'll hit a steady state, but overall the gene pool will not be as strong, fast, and smart as it has been for tens of thousands of years.  

So I naturally wonder if, 1000 years from now, our progeny will be really pissed off at us.  As a whole, they will be weaker, slower, and dumber than ever before!  And this is not a cheap problem to have.  Medically speaking, the strong, fast, and smart are cheap - these are the ones that will live to 100 years old without much help from the medical establishment.   

But the weak, dumb, and slow are terribly expensive to keep alive.  They consume much more healthcare resources than their genetically superior peers.  And if the healthcare debate in the US has taught us one thing about Americans in the past few years, it's that the healthy don't like paying to keep the unhealthy alive.  This could be a real problem.

Furthermore, by keeping people alive for so long, there will be many more old people than young people.  The population distribution will be skewed unfavorably - much like we are seeing today in Japan.  There simply won't be enough young people to support the old.   

What will this all mean?  If there aren't enough resources to care for an aging, unhealthy population, then they will just start dying off.  Life expectancy will start to decrease.  And like we are seeing today, it will cost so much that it may be economically devastating.

Keep in mind that all of the great dynasties of the past have all failed.  The Roman, Byzantine, and Egyptian empires all failed for different reasons.  Could it be that the great American dynasty could crumble as a result of the econimic burden of caring for an old, unhealthy nation?  

It's probably not as far-fetched as you think it is.  We're already in debt up to our eyeballs in this country, and healthcare spending is a large part of our financial woes.  Read my first blog post for a more detailed explaination of this problem.

Now don't get the wrong impression of me.  I'm not arguing for the creation of a genetically superior race of humans (please nobody try that horrible experiment again).  But I just can't help but wonder about the unintended consequences of the era of modern medicine.

I'm all for modern medicine because it benefits not only me, but most those in my life.  I guess we're not as "fit" as we would like to think we are!  We probably would have been weeded out long ago. 

But at what point should we give up our individual desires for the benefit of the human race?  By putting the indivudual above the species, we may be doing the species a huge disservice.  But by putting the species above the individual, we're not doing the individual any favors.  So which is better, improving the life of the individual or sacrificing the individual for the betterment of the species? 

Tought question, and I don't have an answer.  All I have is a freaking headache from thinking about it too much.  Why do I get sucked into this stuff?

Look, here's my take on the whole thing.  Nature had a pretty good system going before we started mucking with it and making people live so long.  But I kinda like my life the way it is, and I really don't want to go back to the prehistoric way of living. 

Am I a selfish bastard for thinking like this?  Of course I am.  And so are you!  We all are, because we have it pretty easy.  I'm not sure any of us would give up our first world pleasures for a loin cloth and club (actually that doesn't sound half bad - hmmmm I'll have to reconsider).  

I guess I figure that things will even out with time.  Mother Nature always seems to win.  As long as we don't accidentally screw up the human genome beyond repair or completely destory our environment (both real possibilities), I think we'll be ok.  I don't think the future will be a rosy as we think it might be, but the species will continue on.  And who knows, maybe once we've come full circle we'll actually enjoy being out in nature, running around naked and living off the fat of the land.

Saturday, April 14, 2012

Crazy people

I've noticed that there are a number of specific diagnoses that seem to be irresistible to crazy people.  They just can't seem to stay away from them.  Just like fat people lust after the double greaseburger with extra mayo and supersized fries with a side of garlic butter, crazy people absolutely adore certain conditions.  Instinct drives them to be diagnosed with something - it truly gives them a sense of purpose in life.  Life without a medical condition is a life that hasn't met it's full potential.  Whereas normal people find worth in career, family, philanthropy, etc, crazy people find joy in their illnesses.

I use the word crazy very loosely.  It's hard for me to come up with a concise definition of who I consider crazy. The way I see it there are normal people, and there are crazy people.  And every now and again there are really freaking crazy people.  You all know what I'm talking about. A good chunk of crazy people probably have some underlying psychiatric illness.  But there are also those who don't necessarily fit DSM criteria for phyciatric illness, but whom I still consider crazy.  So I guess I use the words mentally ill, weird, and crazy interchangeably.  I know that the term crazy isn't politically correct, which is probably why I like it so much.  If you are offended by it, then I might consider you to be crazy too!

The best test I have found to screen for craziness is to simply add up the total number medication allergies and cats that patients have.  The higher the number, the higher the likelihood that you are crazy.  Less than three is usually normal, and anything greater than five is nearly 100% accurate for a diagnosis of crazy.  Having allergies to cats is usually a good negative predictor unless you have four or more other allergies, in which case you meet criteria for crazy.

When a normal person is diagnosed a condition, he finds out how to compensate so he can maintain a normal life, hold down a normal job, and enjoy normal activities.  He tries not to let it affect his life and wishes that he didn't have it.   A crazy person, on the other hand, looooooves his disease.  It will change his life for the better!  Obtaining that elusive diagnosis is like winning the crazy person lottery!  He will mold his life around his diagnosis.  It becomes his identity.  Deep down he is secretly happy that he was lucky enough to get it.  He will frequently mention it in casual conversation.  Everyone around him knows that he has it.  It becomes an excuse for everything from which he wants to be excused.  And if he can get disability for it, even better!  That way it even feels like a job!  Talk about convenient!  The diagnosis is so powerful that it magically liberates them from all responsibility that life demands.

I'm amazed that the crazies gravitate to many of the same diagnoses.  It's almost like there is an underground convention of crazy people that decreed that all their crazy little followers must go at once to the medical establishment and seek out specific, authorized diagnoses to prove their loyalty and be considered part of the group. They don't like the diseases that actually kill people, but the ones that garner the most attention while allowing them to live semi-normal lives.  They adore conditions with extremely vague, subjective symptoms.   These folks are typically found in highest concentrations in one of a few different clinics.  Of course they all start at their PCP's office but quickly get referred out to a subspecialist because the PCP doesn't have time to deal with their vague, crazy complaints.  From my experience, the highest ratio of crazies are found in one of the following specialties:


They end up in these clinics because these are the specialties where subjectivity is common.  The physician has to take your word for the symptoms you are having.  Specialties such as cardiology, pulmonology, nephrology, endocrine, and orthopedics don't have as many crazies because you can objectively test for stuff.  If you can do scans or blood tests and rule out any problems, you politely tell them that nothing is wrong and they don't need to come back.  This infuriates the crazy patient because he feels that the doctor doesn't believe him.  So what do they do?  They pester their PCP to send them to someone else.  Thus all roads traversed by the crazies eventually end at one of the three specialties noted above.

When they visit these clinics, they have a constellation of symptoms sooooo broad and nonspecific that they could reasonably fit into a number of diagnoses.  The doctor listening to the rambling complaints does his best to make sure nothing real is going on, because crazy people occasionally do have real problems.  The looming threat of a potential lawsuit compells even the most skeptical of physicians to at least do some sort of workup.  And once the workup commences, it's only a matter of time before some of the crazies get a diagnosis that will change their lives forever!  Some of them are diagnosed appropriately, while others are the victims of over-diagnosis.  Crazy patients don't really care if the diagnosis is accurate or not - all they care about is that they got one. 

Let me detail a few of these incredibly powerful diagnoses.  For those of you that have been diagnosed with any of these conditions, this may be the first insight into your potential craziness!  You can thank me later.

At the top of the list of crazy people diagnoses is the dreaded fibromyalgia.  It's a condition in which patients have tenderpoints in their muscles all over their bodies.  There is no objective sign of any dysfunction of the musculoskeletal system.  If you were to biopsy these areas, they would be totally normal.  These patients also have a constellation of symptoms that usually includes depression or anxiety, poor family relationships, physical inactivity, poor sleep habits, obesity, and just flat out being weird.  They are predominantly women, but men are afflicted as well.  These are the people who love to tell you stories about how their bodies don't react like other peoples' bodies do.  There isn't much you can do to treat it.  Nothing works for these people.  About everything in the book has been tried, but they just have pain no matter what.  Eventually someone makes the terrible mistake of giving them a narcotic in attempt to control their pain, which does nothing but make them addicted to opiates.  It rarely helps their pain, yet they won't give them up.

Normal people don't get fibromyalgia.  As a physician, you cringe when you see fibromyalgia on someone's problem list.  You might as well just cross it out and write "crazy" in it's place.  Physicians love to tell stories about their fibromyalgia patients.  "So the other day I had this fibro patient in clinic" is a common way to start a good story.  Heads will turn and attention will be keen, because this story is gonna be good! 

The worst part is that fibro patients see this as a real disorder.  They are completely oblivious to the fact that many physicians use this term synonymously with "crazy".  They love to tell people that they have it.  It's always the number one problem that they list on medical forms.  Forget the diabetes, previous six heart attacks, major stroke, and hypertension - they always list fibromyalgia as number one! 

I once heard a colleague say that he wished fibromyalgia would be renamed "Nobody Loves Me Syndrome."  So much more accurate!  I think I'm gonna start doing that.  

Next most popular diagnosis for crazy people is allergies.  You pick the allergy - it doesn't really matter.  Animals, drugs, foods, chemicals - it doesn't matter.  For some reason they love allergies.  When confronted with negative allergy testing, they refuse to believe it.   Surely the test was wrong!  And none of their so-called allergies react in the typical IgE-mediated fashion - they always have some bizarre type of reaction like "my pinky finger ached for an hour and then it felt all gooey like pudding" or something else ridiculous.  Yesterday I had a patient that was totally convinced that the cortisone injection in her wrist caused her to have pus drain from her eye.  Ummmmm ok. 

I remember a lady complaining of headaches, throat pain, burning in the fingers, abdominal discomfort, and dry skin who was convinced it was due to a food allergy.  Where do they get this stuff?  Is there a crazy people manual out there that I've never seen?

The good thing about allergies is that there aren't many harmful treatments for it, so even if you are mistakenly diagnosed, you don't have to worry about killing a patient with the medication you prescribed. 

How about lupus?  As House MD famously says, "It's not lupus."  Whenever a new patient comes to me with a diagnosis of lupus, I don't believe it until I have reviewed all pertinent records and come to that conclusion myself.  I can't tell you how many people are erroneously diagnosed with it.  And once they are, it sticks with them for life.  Even if you look at their chart and tell them they don't and actually never have met criteria to have lupus, they refuse to believe you.  It's like taking their child away - they won't let you do it!  They'd rather die than lose the precious diagnosis of lupus. 

Seizures are another common complaint.  They like this one because they don't actually have to prove it.  All you need to do is say that you've had them, and no one can disprove it!  Brilliant!  Even a normal EEG and MRI don't rule out epilepsy.  So they really like this one.  One thing they can't do, however, is to perform a proper seizure.  They will occasionally try to seal the diagnosis by seizing in your presence.  It's not easy to do and requires a high level of fitness to contract your muscles intensely for a number of minutes, so most peter out after a few seconds of pathetically flailing around.

Speaking of neurology, multiple sclerosis is also a favorite.  This is another one I doubt by default until I see proof of it.  Like seizures, it's sometimes very difficult to prove, so you can weasel your way into a diagnosis without objective proof of the disease.

Occasionally you get a new feigner of illness who doesn't quite know the ropes who just happens to pick the wrong disease.  I had a guy last week who wanted to be excused from work for 3 weeks because, in his own words, "Doc, I've been spraying blood out of my rectum."  Shockingly, his hemoglobin level was normal.  I never call people out on their lies, because I'm a conflict avoidant person.  Plus, you never get anywhere arguing with the crazies.  But I do enjoy presenting them with the facts and then letting them come to their own conclusions, which always amuse me.  "Wow, I made a remarkable recovery," he told me, suggesting that his uber productive bone marrow had cranked out enough red blood cells in the past 24 hours to replace the gallons of blood he had lost out of his rectum.  Ok dude, whatever.  Go back to work.

These are just a few of the gems that I deal with on a daily basis.  Some days they provide great entertainment.  Other days, however, they make my day a living hell.  But for the most part I've gotten so used to the crazies that I see them as just another patient.  If nothing else, they provide me with highly entertaining story material.   And who knows, if they stopped showing up, life might just be too damn boring.  See you next visit, Mr. Crazy, but don't come back too often!

Thursday, April 5, 2012

The truth about cancer screening

Cancer sucks.

Unfortunately, we suck equally bad at detecting cancers in their early, curable stages.

Cancer is the second leading cause of death in the United states.  In 2009 it killed roughly 560,000 people.  There are an astonishing 200+ types of cancer.  The table below is a rough estimate of the number of deaths caused by the leading killers.

Let's pick the low-hanging fruit first - check out lung cancer.  Can you believe how bad it is compared with the others?  Few people survive it.  Thank you, big tobacco, for all the pain and suffering you've caused.  

So with all of the deaths from lung cancer, you'd think we would screen for it pretty aggressively, right?  After all, it's potentially curable if found early.  So we probably screen smokers starting at a young age so we don't miss any, right?  

Wrong.  Truth is that we don't even screen for it at all.  No joke.  Shocking, right?  Most people will find that appalling and even unacceptable.  Before you get your undies all in a bunch, read on.  It's not because we don't want to cure lung cancer - it's because we just don't have a good way to screen for it, safely diagnose it, and effectively treat it.  Lung cancer is a bitch.  It's tricky.  And that's why it's the number one killer among cancers.    

And what about breast cancer?  There was national outrage last year when the US Preventive Task Force changed recommendations for the age at which breast cancer screenings should begin.  For those that are unaware, the recommended age for routine mammography was bumped up from 40 to 50.  Public outcry ensued.  It's still a very controversial issue. 

Much of the outrage stems from a misunderstanding of screening tests.  Health screenings are, in general, a very misunderstood science.  The misunderstanding stems from the two major fallacies of healthcare.  See my previous blog post for a detailed explanation.   In short, people like to be screened for different things because they assume that 1) screening tests are accurate, and 2) there are beneficial treatments for the whatever is being screened for.  I'm not sure when these fallacies became popular belief, but they certainly are out there and they are deeply ingrained into the American psyche.  

There's an old adage in medicine - you better be careful what you order, because you might find something you don't want to.  The public will hear this and be outraged - how can they not want to find something?  They want to know everything that is wrong.  Doctors, on the other hand, understand that most of the time the "something" that you incidentally find is rarely anything serious, but it will take you on a long, wild goose chase that leads to more and more tests, some of them being potentially harmful.

Of all the 200+ cancers out there, the US Preventive Task Force only provides strong recommendations to screen for three of them.  Three!  Colon, breast, and cervical cancer are the ones that we routinely screen for.  They are the only cancers that we 1) have good, accurate tests for, and 2) we have good treatments for.  For all of the other cancers out there, we either suck at detecting them early, or we suck at treating them.  If you can't reliably detect or treat cancer, there's no sense even screening for it.

Let me break down the four reasons why cancer screening is not as simple as you would think it is.  If you understand these principles, you will understand why we do things the way we do.

1) We don't have many good cancer screening tests

Recall the first great fallacy of healthcare - not all tests are accurate.  It would be nice if we could just take a simple blood sample and tell with near 100% certainty that you do or don't have a certain cancer, but unfortunately such tests just don't exist.  Maybe someday they will.  But for now, we don't have them.  And the few blood tests that we do have (e.g. prostate cancer screening test - PSA or prostate specific antigen) are not very accurate.  They are notorious for providing either false positive or false negative results.  The few exceptions to this rule are the tests we do for colon, cervical, and breast cancer.  Colonoscopy, pap smear, and mammography are all very accurate tests.  That is one of the primary reasons that we only test for these cancers - because we have good tests for them.

2) Screening may cause more harm than good

Sounds blasphemous, right?  Recall that no test is without potential harm.  Let's look at esophageal cancer.  The only way to reliably diagnose it is by doing an EGD (small scope that goes into the esophagus).  EGD has the potential to cause perforation, or a tear in the esophagus.  It's a serious complication that can lead to death.  The Mayo Clinic put out a study in 2010 showing that their EGD perforation rate over an 8 year period was 0.033%.  Doesn't sound like a lot, but if every male in America over age 50 (roughly 50 million) was screened on a yearly basis for esophageal cancer, it doesn't take long before you have caused more perforations (0.00033 x 50,000,000 = 16,500) than have died from the disease (0.04 x 292,540 = 11,701)!  If you are going to do an invasive screening test, it has to do more good than harm - and by a significant amount.  Colon cancer screening is done primarily by doing a colonoscopy (done with a scope just like an EGD), but the prevalence of colon cancer is so much higher that we help many more people than we harm.   We know that a small portion of people will die from the screening procedure, but we save many more people from colon cancer than we kill doing the test, so the benefit outweighs the risk.  Kinda weird to think about it that way, but that's the way it is.

3) There isn't proof that screening for cancer leads to less deaths

This is also difficult to believe, but for some cancers it's true.  Recall that not all treatments are beneficial.  We've learned a difficult lesson over the past 20 years with prostate cancer.  Back in the 1990's there was a push to screen for it more regularly.  Guess what happened?  A lot more cases of prostate cancer were diagnosed (duh).  The real kicker, however, is that despite the increase in diagnosis, the rate of prostate cancer related deaths has not declined.  If you are going to screen for a cancer, it makes sense that the treatment for it should do some good.  But as strange as it sounds, detecting prostate cancer doesn't equal a higher cure rate.  So if you're going to test for cancer, you need to make sure you can treat it well enough to make a difference. 

4) It doesn't make financial sense

This one might be the most controversial.  Some of you will advocate that financial concerns shouldn't even be part of the equation - testing and treatment for cancer should be done regardless of the cost.  Remember the term TINSAFL you learned in high school economics (There Is No Such Thing As a Free Lunch)?  It applies to medicine as well.  If we were to screen every person in America for brain cancer with an MRI every year of their life from age 20 - 80, the cost would be staggering.  That test alone would probably bankrupt Medicare.  The truth is that we just don't have the money to do expensive screening tests on a mass scale.  You can hate it and disagree with it, but it's just the way things are. 

So for a screening test to be worth anything, it has to be cheap, accurate, cause minimal harm, and lead to a good outcome.  It's amazing that we have any tests that fit this criteria.  New tests are constantly being developed, and hopefully someday we'll have the technology we need to cut down on the number of cancer-related deaths.  But for now, all we have is all we have, and it's the best we've got.

I wish that things were different, and someday perhaps they will be.  Maybe 200 years from now people will look back at the year 2012 and call it the dark ages of cancer screening.  Maybe by then we'll have simple blood tests to accurately pick up all cancers - or perhaps even we'll be able to screen DNA and accurately predict what kind of cancer you will be susceptible to.  And hopefully we'll be much better at treating it.  But for the time being we'll do the best we can - even if it means only screening you for three types of cancer.

In summary, there is a whole science behind cancer screening that most people really don't understand very well.  It't much more complex than I've outlined here.  There are very smart people that look at this stuff for a living, and we have to trust that they are making the right decisions.  Next time you hear about a change in cancer screening recommendations, hopefully you'll wait a bit before jumping to any critical conclusions because now you understand the science behind it all.  

This post turned out to be more of a downer than I thought it would.  I'm really not a pessimist.  A realist, yes, but not a pessimist.  In order to try to add at least a bit of humor, I've added an amazingly funny, entertaining music video that was created by a fellow internist on cancer screening.  Enjoy, and stay tuned!