Archive for the 'News & Reviews' Category

The Concept of Risk

In the old days, doctors treated patients who sought medical care because they had symptoms they wanted to get rid of. Then came medical treatment of easily measured physical parameters, like high blood pressure, even when not associated with splitting headaches and red cheeks. A normal blood pressure is essentially the same number for everyone. Recently, we have spent a lot of time and energy treating risk factors, like elevated cholesterol.

I find a lot of my patients have trouble thinking about risk; many still think of what we do as treating disease. For example, the National Cholesterol Education Program has set target values for the bad LDL-cholesterol. According to NCEP, a low risk person, for example a twenty-five year old non-smoking woman with ideal weight and blood pressure, has little reason to worry about a mildly “elevated” LDL, whereas a sixty-five year old diabetic chain-smoking man with a history of poor circulation in his legs with the same LDL number would be an obvious candidate for aggressive lipid lowering efforts.

As I counsel patients about cardiovascular risk, I usually first calculate their risk according to the Framingham Heart Study data, then I show how the presence or absence of inflammation, as measured by Highly Sensitive C-Reactive Protein (CRP), can tip the scales. My last step has been to look at the NCEP guidelines with the patient. I have found that not all my colleagues do the same – some seem to look at elevated cholesterol with less attention to individual risk.

Today the author of the original CRP study has published a study showing upwards of 50% reduction in heart attacks and strokes among people with normal cholesterol but with elevated CRP levels, when taking the cholesterol-lowering drug rosuvastatin (Crestor).

This is essentially the same risk reduction we have seen in traditional high risk (high LDL-cholesterol) patients. But bear with me here: Half of all heart attacks occur among a “relatively small” number of people with high cholesterol, and the remainder of all heart attacks occur among the much larger group of people with fairly normal cholesterol. Reducing heart attack risk by half does mean more for someone with a 25% risk of heart disease than for someone with a 5% risk.

My first read of the JUPITER study is that you have to provide as many as 300 patient-years of medication to high-CRP patients with normal LDL-cholesterol to prevent one heart attack. The JUPITER study saw 142 heart “events” (including not only heart attacks, but also strokes, hospital admissions for angina and elective coronary stenting) among 8,000 Crestor-treated patients and 251 heart events among 8,000 placebo treated individuals. That means the untreated group had a 3% risk of having an “event” during the study period of two years.

Any time you prescribe medication to someone who isn’t terribly ill, you have to stop and consider whether you might be trading one problem for another. A person with pneumonia or cancer will clearly tolerate all kinds of medication risks and even side effects in order to save their life, but a person who is more likely to live out their life free from heart disease should be more concerned about the long term safety of medications prescribed to lower their already low risk of having a heart attack.

One of my professors in medical school once gave a talk about blood pressure medications I still refer to today when talking to patients. He said that a good blood pressure medication should be effective, inexpensive, and side effect free, because high blood pressure is dangerous, common, and generally asymptomatic. Said differently, the treatment must really work, it must be easily available to all who need it, and you cannot ask people who feel well to take a medication that makes them feel bad.

The statin drugs were first developed in the 1970’s and it took many years before they became widely used. There are still enough unanswered questions about their very-long-term safety to make us think hard about when they are worth using and when they are not.

The night I suffered my vitreous detachment during my visit to Sweden a couple of months ago, I noticed the spider web visual distortions as I looked out my aunt’s living room window and saw he Astra-Zeneca pharmaceutical plant in the distance. It had come up in our conversation as they had laid off many workers shortly before my visit.

Maybe Astra-Zeneca will do better now – Comments I read suggest that it may cost up to half a million dollars worth of Crestor at $3.50 per pill to save one life in the lower risk group in the JUPITER study. Yes, we’re talking health care in a way. Health care is really big business these days, but still delivered one patient at a time.

Orthorexia Nervosa – Too Much of a Good Thing

In Swedish, there is a word that just can’t be translated succinctly into English. “Lagom” means “just enough” or “adequate”, but it is saturated with overtones of moderation, contentedness and political, even social, correctness. “Lagom” is a way of life – moderation in everything. It is no surprise that Swedish newspapers seem to be on the lookout for stories about people who stray from that middle-of-the-road way of life. One story in Dagens Nyheter caught my eye (for interested/concerned readers, my right eye is almost back to normal) during the flight back to the States this morning. It sent me out on the Internet once I landed and got connected to the airport wireless network: “Exaggerated Healthfulness Can Lead to Serious Disease” is a feature about a 30-year old woman, who after eating a lot of junk food while living in the US started on a journey filled with strict diets and rigorous exercise. She never thought she was too fat, which is the defining feature of Anorexia Nervosa, but she somehow felt she had to eat extremely healthfully to compensate for her prior indiscretions. Her condition, Orthorexia Nervosa (obsession with healthy eating), described by Steven Bratman in 1997, although not officially recognized, is getting increasing attention. Its complications are not dissimilar from those of Anorexia Nervosa, as it can lead to malnutrition with all its consequences. I had not run into the term before – figures I would run into it in Sweden, the Mecca of Moderation. I can see that this is a culture-dependent variety of Anorexia Nervosa, which was first described in the late 1800’s as Fasting Girls. The culture was not focused on healthfulness the same way then as it is today. In Victorian times, fasting was of body image and spiritual interest, and Fasting Girls were said to have mystical powers. Our current DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) classification of Anorexia Nervosa doesn’t mention restricting foods based on their healthfulness, and Orthorexia Nervosa isn’t recognized in it at all. I looked around for blogs on the topic, and found some, including “There’s no such thing as orthorexia nervosa, it’s only a fancy term for a health food junkie“. I like that title, because I think that whenever there is a “new” disease or when an “old” disease gets more attention, patients tend to over-report the symptoms of it and doctors have a tendency to over-diagnose it. While the DSM-IV has weight criteria that help keep the diagnosis of Anorexia Nervosa more objective, most psychiatric diagnoses hinge on value-laden words like often, intense or undue, which are all subjective to some degree. I have said before that there is a tendency (at least in the US) to medicalize the human experience. The last thing we want to do is start calling “health food junkies” sick; let’s not forget that “junk food junkies” have been well proven to get very bad complications from their food choices, too! I have made the observation a few times that the spectrum of what we call the human experience can be defined by what lies at the extremes or by the nuances within the range where most people find themselves. People say “I’m depressed” even if they know they are only experiencing a temporary sadness. They say “I have OCD”, even if they don’t meet the DSM-IV criteria. Going too far with our words isn’t always the most effective way to communicate. Now that there is a new medical term with no DSM-IV definition behind it yet, we all need to be careful how we use it. Let “health food junkies” be just that as long as they don’t suffer medical or social consequences. Let’s restrict use of the new medical term for people who, as Steven Bratman originally suggested, suffer negative consequences of their behavior. It is ironic that we now have a new disease for people who do everything they can think of to be healthy. This is where the concept of “lagom” comes in: Instead of holding perfect eating and maximum exercise as an ideal, we should all do as the Swedes, and aim for pretty good eating and pretty adequate exercise. I guess it’s always hard to see for yourself when you cross the line to extremism. As the old Swedish saying goes: “Lagom är bäst!”

New Doctors: Too Few, Too Many or Too Late?

There are too many doctors in the U.S according to Dartmouth’s Goodman and Fishers commentary of the Association of American Medical Colleges’ Center for Workforce Studies report. The AAMC recently made the proud announcement that 85% of medical schools have or are in the process of increasing first year medical school student enrollment by a total of 30% by 2015. In my view, the real issue here isn’t quantity at all.

This country already has just about the world’s highest ratio of doctors per capita. As a group, U.S. physicians deliver more expensive care with no better outcomes than our colleagues in other countries. American patients are not going overseas for elective surgery because they don’t have access to surgeons here – they fly halfway around the world at their insurance companies’ expense to save money. Now, if the strategy behind increasing physician supply is to drive health care costs (read: doctor salaries) down, it might make more sense, but I believe that even if physician reimbursement is ratcheted down even more, prices will have a way of staying up there anyway because of the tremendous overhead in health care.

There are enough studies showing that greater physician supply, particularly at the specialist level, correlates more with increased cost than improved quality. And where do most medical school graduates today end up? They choose specialties with higher incomes and better  life styles than Primary Care offers in today’s climate. Right now our little community is trying to recruit one or two new Family Physicians, so I know first hand how few new graduates want my kind of job. At the same time, I read advertisements in the City paper, where Family Doctors are offering laser skin jobs (for cash) instead of accepting new Primary Care patients – and they certainly don’t do house calls. Yes, house calls are good medicine and they can save health care dollars! We have plenty of examples in our community of elderly, homebound people we have kept out of the hospital with the help of weekly or biweekly home visits. One Emergency Room visit via ambulance costs more than a dozen house calls!

One of the hot topics in medicine, Primary Care and Health Care Policy these days is “The (Advanced) Medical Home”, which basically means having a technologically astute old-fashioned Family Doctor, who keeps track of your whole medical situation, actually reads your different specialists’ reports, and makes everything happen. If all of us working in primary care don’t claim the authority that goes with this concept, health care will continue to fragment and become more and more inefficient. In my practice I see patients every week who have been discharged after a very brief hospitalization, with lots of loose ends that I have to pull together in order to keep the patient safe. Only if I have the time and resources to do this well will the hospitalization have been worth the time and money it cost.

What will the first year medical students of 2015 have to look forward to when they graduate from their residencies in 2022 or 2023, especially if nothing is done to strengthen Primary Care? They may have hopped on the band wagon too late to find the destination they expected, particularly in the shortage area of Primary care. By then we may have a lot more clinics within drug stores staffed by Nurse Practitioners and Physician Assistants, pharmacists may be prescribing for common ailments, psychologists will be doling out Prozac®, and RN’s will deliver telemedicine services backed by off-shore corporations with Medical Directors in other time zones.

We must learn from the Europeans and not prioritize specialty care over primary care so heavily. Only then can we provide enough preventive and basic health care to affect the ultimate cost of treating the chronic diseases that now drain so many of our healthcare dollars.

So, don’t give us more specialists! Give us well trained generalists, and pay them enough to make it worth their effort to work in the small towns and Community Health Centers where the underserved patients can get their health care needs met!

Cholesterol Guidelines and the Bachelor with Platform Shoes


I have read that tall bachelors have more dates than short ones, and until recently it seemed obvious that men with low LDL cholesterol would have fewer heart attacks than men with higher levels. So what happens when a vertically challenged young man dons a pair of ABBA style platform shoes? And what does this really have to do with cholesterol?

Let me start from the beginning.

In medicine today, there are two mantras, even buzzwords: Evidence Based Medicine and Clinical Guidelines.

To practice Evidence Based Medicine is to do precisely those things that are proven by rigorous research to help the patient. Examples include giving heart attack survivors certain medications (Beta Blockers) or to give aspirin to patients with TIA’s (often called “Ministrokes”).

Clinical Guidelines often involve reaching numerical targets, and this is the first tip-off that we’re on much shakier ground. Keeping a diabetic’s blood pressure under 130/80 may be a good thing to do, but not if the person has a history of fainting from low blood pressure when standing up too quickly.

A dramatic example of failed guidelines came with the recent publication of the ENHANCE study (New England Journal of Medicine, April 3, 2008). The National Cholesterol Education Program has long recommended keeping the bad LDL Cholesterol under 70 in high risk patients, like those who have had a heart attack or a bypass procedure. The problem with this guideline was that it created a situation where doctors faced with an LDL slightly above “target” would abandon high doses of, for example the proven drug Lipitor, and switch patients to moderate doses of Vytorin, which contains a less powerful “statin” drug and an until now unproven new drug, called ezetimibe (Zetia).

The new drug, introduced in 2002, lowers cholesterol by blocking intestinal recycling of old cholesterol from the body’s different cholesterol-based hormones etc. In the beginning, there was no proof that ezetimibe lowered heart attack rates or limited cholesterol buildup in our arteries, but there was something very promising about the drug; it not only helped lower cholesterol, but it also reduced levels of CRP, or C-reactive protein, an inflammation marker that closely follows heart attack risk.

So the number crunchers started to put pressure on doctors to reach numerical targets, and television ads promoted the dual action of Vytorin.

Fast forward to a couple of months ago when, after a billion dollars in sales, the new drug looks no better than platform shoes; better measurements, but same number of dates (in this case meeting our maker…), so to speak. The ENHANCE study didn’t count deaths or heart attacks, but it did measure thickness of cholesterol buildup in arteries, and there was no difference between plain Zocor (simvastatin) and the combination drug (Vytorin). Factor in that you can buy simvastatin for $4/month at some supermarket pharmacies, while Vytorin costs 2,500% more (yes, do the math; $100 divided by $4 times 100%!).

The lesson here is that the guideline writers failed to think about what evidence we had about how patients achieved their goal numbers, just like the guy in the ridiculous shoes only thought he was closer to eye level with the girl he was trying to impress.

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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