A Country Doctor Writes:

Last week’s New England Journal of Medicine reports on a study of 162 people with one parent affected by Alzheimer’s disease. Half the study participants were told the results of genetics testing that indicates a person’s risk of developing Alzheimer’s disease, and the other half were not told the results. People with depression or intellectual difficulties were excluded from the study. 

After one year of follow-up there was no difference in anxiety or depression scores between the two groups. One interpretation of this study is that it doesn’t hurt people to know they are at risk for developing Alzheimer’s disease.

That may or may not be the case – only the most solid citizens were allowed to remain in the study – but I still don’t see the point in looking for potential Alzheimer victims before any symptoms develop.

Both doctors and patients in this country seem to have an insatiable thirst for information, even when there is not yet an understanding of how to use it.

One of my professors in medical school proclaimed something that has echoed in my head through my years of practice: “Don’t order the test if the result won’t change your treatment.”

Until we have an effective treatment for early Alzheimer’s disease, testing asymptomatic individuals just doesn’t make any sense to me. It clutters our minds with unnecessary worries and may prevent us from taking full advantage of the remaining days of our lives.

Who wants to know that a dreadful and unrelentingly progressive disease will rob them of their faculties? The New England Journal study may have proven that some of us can handle that kind of information, but why should we have to? What should we do with it?

I am reminded of a story about a man, who tries to escape his destiny, as told by W. Somerset Maugham and John O’Hara – “Appointment in Samarra”, quoted here from another blog:

A rich man sends a servant to the marketplace to buy provisions, but instead, he returns pale and trembling. “Master,” he says, “I saw Death in the marketplace, and he looked at me a long time, with a strange expression on his face. I am so afraid. Please, can I take a horse and go visit my relatives in Samarra?”
The master lets him go—he has been a good servant, and now he is so shaken that he wouldn’t be able to do much anyway. Off the servant gallops toward Samarra.
Then the rich man goes to the marketplace to see if there is any truth to what his servant said. Sure enough, there is Death, waiting in the shadows and watching.
The rich man comes to him and says, “O Death, my servant says that when he came here, you looked at him very strangely, for a long time. Is this true?
 “Yes,” says Death, “but only because he was here. I have an appointment with him tomorrow in Samarra.”

Doctors in other specialties treat their patients with exotic and expensive instruments to peer inside their bodies or rearrange minute and delicate body parts. Not so Family Practitioners. When I think about it, I am convinced that my most expensive, or, shall we say costly, instrument is my pen. Not the Montblanc my wife gave me for Christmas one year, but the disposable rollerball pen I buy by the box and use when I order tests and prescribe medications.

How often does a doctor reach for the prescription pad as a quick solution to a problem that really should be dealt with in a meeting of the minds between healer and patient? How often does a doctor order a test to document what is already evident through the history and physical exam?

I often hear patients ask for an MRI “just to know what’s going on in there”, and unless they have managed care that requires “prior authorization” for expensive tests, how much faster isn’t it to order the test than it is to explain to the patient that the test serves little purpose in a case of low back pain, for example, since science still hasn’t sorted out what causes most cases of that particular ailment.

We are constantly bombarded with advertisements and promotions for expensive medications that offer theoretical advantages over older, less expensive, drugs. And all the studies backing up the effectiveness claims of these new wonder drugs are double blind comparisons with placebos. How polite, not to compare them with the well established treatments they are hoping to replace.

We as physicians have an obligation to our patients to watch over their health, but also to help them get reasonable value for their health care dollars (or Francs, kronor, Pounds or Marks). One of our duties is to test and prescribe responsibly, and to strive for achieving a fair balance between protecting the individual patient’s interest and the collective interest of all our patients.

I often find myself comparing physicians’ work with that of other professionals, particularly lawyers. I imagine a lawyer, hired by one client to protect that client’s interests, can devote just about any amount of time that the client is willing to pay for, and that ultimately someone else within the legal system, be that a jury or a judge, will balance, arbitrate or adjudicate the claims of the opposing parties. As physicians, we usually can’t give a disproportionate amount of attention to a single patient, at least if we expect the insurance companies to pay us for our work. We also cannot usually practice with complete disregard for the greater common good. We need to be the ones to say “If I did this for all of my patients, what would happen?”

If I prescribe broad spectrum, expensive antibiotics for one patient who doesn’t need them, I need to ask myself what would happen if I did that for most of my patients. This is why we have multidrug resistance today. If I order unnecessary tests “just to be sure” in a few cases, what would the impact be if I extended that behavior to most similar situations?

Doctors in the United States often think that ordering more tests is a way of avoiding criticism or even malpractice litigation. Time and time again, we see that the biggest danger of such events is practicing in a hurried fashion without really stopping to listen to our patients.

Sometimes I reflect on the irony that even one month’s worth of any one of the new maintenance drugs I am asked to prescribe for restless legs, overactive bladder, migraine prevention or prostate trouble costs more and is less regulated than my fee for the time, effort and expertise required in choosing, prescribing and monitoring the treatment.

Unfortunately, my simple rollerball pen is a more expensive instrument than the diagnostic and therapeutic acumen I have developed over the years, at least in this economy.

Patients often chuckle when I tell them I am a recovering vegetarian. As a child I was pretty squeamish about things like chicken drumsticks, spare ribs and other anatomically identifiable foods. In my teens I decided the only rational way to handle my qualms was to be a vegetarian.

Decades later, and somewhat overweight, I decided to go back to being a picky eater instead of a strict vegetarian. Thus I increased the protein content of my diet and lost fifteen pounds. Reading Barry Sears’ “The Zone” and Atkins helped me understand what had happened to me.

All along I have been nervous of artificial ingredients and unnecessary additives. My wife has the same dietary background as I have, and shares my concerns.

Today, we have a one-year-old German shepherd puppy raised on organic human grade food. He has a coat unlike any other dog of his breed that I have ever seen.

This weekend two things made me think again about food. The first one was a woman who is cooking for her dog and had read a book we also have, called “See Spot Live Longer”, which tells stories and provides facts about how bad commercial dog food is for your dog, both because of the low protein content and because of the inferiority of its ingredients.

The second thing I ran into this weekend was the September 25 issue of The New England Journal of Medicine – yes, I am behind on my reading – with an interesting article entitled “Storm over Statins – The Controversy Surrounding Pharmacologic Treatment of Children”.

This article quotes the American Academy of Pediatrics 2008 recommendation of doing cholesterol testing on two-year-olds and prescribing “statin” drugs like Lipitor to 8-year-olds(!). This makes me think of my puppy: Why don’t we just feed them right in the first place?

I have enjoyed reading Family Practice Management for several years. Even though I work at a Federally Qualified Health Center (FQHC), which operates by different rules than private offices, somewhat like the Socialized Medicine of Sweden, I like reading management/business books and magazines.

The issue I received a few days ago had a sheet glued to its front page stating in bold letters: “This is your last issue – unless you act NOW!”

These are my options: I can get the digital (online) version for free, starting in November, if I give them an e-mail address to send it to, or I can continue to get the print version for an undisclosed fee; I have to log on to their website to find out what it would cost me. Hmmm… where does that leave unconnected physicians?

Don’t get me wrong – I’m not against the Internet; I own six domain names, six blogs and even more e-mail accounts. I just don’t prefer to read journals and magazines online; it seems cozier to fall asleep with a magazine than with a laptop. I also feel forced to switch e-mail accounts every several months due to the sheer volume of junk mail I get. I just can’t trust that I’ll receive important communications through e-mail.

A while ago the American Board of Family Medicine sent me a newsletter that stated that the next notification of my upcoming Board Certification would ONLY be sent via e-mail.

I called them up to protest; the best they could do for me was to give me the e-mail address of their President. Hah! I know a trap when I see one.

There is a religious bestselling book series called “Left Behind”, about those left behind after the Apocalypse. In a sense, this is what’s happening now with the Internet as the predominant and sometimes only way of communication.