The Great Bone Density Myth

There’s very little evidence that “preventive” actions make a difference, especially in those over 65.

Bone density scans also are highly recommended but other measures (e.g., muscle tone, ability to rise from a chair) predict fractures more and bone density doesn’t predict hip fractures, as discussed here. I’d like to see references to articles showing that people on meds for cholesterol, high blood pressure, etc., actually experience different end points than those who are not screened. Often when you actually read those articles you find the relative differences are huge but the actual differences are barely noticeable. When you start quoting journal articles to doctors the conversation changes.

Worried unwell (or potentially unwell)

Responding to Abigail Zuger’s column in the New York Times. Zuger notes that today doctors spend most time prescribing for pre-illness, which means they try to predict the future.

I am amused by, “For people who feel fine… It is the patient … firmly planted in the here and now, while medical personnel spin wild tales of coming catastrophe…”

and

“In fact, our future of treating pre-illness will simply catapult us right back to a priestly past, as we offer up misty visions of the future and encourage the masses to see with us and act accordingly.”

Zuger’s image – emotional doctors versus patients demanding evidence – captures my experience perfectly. When I declined a mammogram, citing research in top journals, the doctor responded emotionally, literally throwing up her hands: “It must be better than nothing.”

Urging a bone density scan, she cited relative risk (50%) rather than absolute risk (3%). Outpatient surgical clinics require pre-op tests for despite published research consistently showing no difference in outcomes. Most doctors don’t know the Society for General Internal Medicine’s guidelines limit testing for asymptomatic adults.

Doctors eagerly embrace studies questioning the value of herbal or alternative options, but shrug off equally credible reports showing the low value of mainstream “preventive” medicine. In fact “preventive” really means “risk reduction” and often the reduction is so low as to be meaningless. Thus the line between science and magic become blurred, educated skeptics resist medical advice, and most doctors hate patients who know how to read statistics in the medical journals.

“Too young to die, too old to worry”

An article with that title appeared in the New York Times. The premise is that, after a certain age, you should be able to do whatever you want. Why forego cigarettes? Leonard Cohen announces he is taking up smoking at age 81.

The truth is that there isn’t a lot of research about people who begin to let go after, say, age 65. From what I could find, late-onset diabetes doesn’t kill you.

I couldn’t find anything about resuming smoking in the last part of life. A doctor told me at most I’d get a lung infection that’s easily cured just by quitting for a few weeks.

The article suggested that one might avoid smoking because of potential harm to others due to secondhand smoke. A reader presented this article from a Forbes blog, showing that the dangers of second-hand smoke have been exaggerated.

It’s heartening to read the comments: so many of us are more concerned with living well than living long. And more people fear nursing homes than death.

I’d always planned to take up smoking again when I turned 50 or 60. I’d start now, except there’s no place left to enjoy smoking, even in your own home.

Lung cancer screenings in Medicare population? WSJ gets it wrong

“Nearly 70% of lung cancer occurs in the Medicare population.”  That’s the scare statistic the authors of this article use to incite fear and indignation: “Oh no, they’re killing Granny.”

The statistic is probably accurate. But some of these people are in their 80s and 90s. Lung cancer screening makes sense, at best, till age 74. Some elderly folks have other medical conditions that would preclude treatment, regardless of screening outcomes. And when you’re in your 80s and 90s, you could be treated for lung cancer only to end up with some form of cognitive impairment and/or incarceration (I use that word advisedly) in a nursing home with a loss of dignity and independence.

The article reports, “From 2002 to 2010, the NLST evaluated the impact of low-dose computed tomography—or CT—scans in more than 53,000 individuals and demonstrated a 20% reduction in lung-cancer mortality.”

That number is meaningless. We need to know the number of survivors in the screened group vs the number in the non-screened group. If these groups are self-selected the results will be muddled even further because there are differences in people who successfully seek screening vs. those who don’t seek screening or don’t have access.

It’s hard to trust any screening recommendations from radiologists and cancer centers, who stand to profit from screening and from investigating false positive. Here are links to published research studies showing far less impressive results. If newer research is available, let’s see the links.

“Cumulative lung cancer incidence rates through 13 years of follow-up were 20.1 per 10,000 person-years in the intervention group and 19.2 per 10,000 person-years in the usual care group (rate ratio [RR] …” In other words, intervention – presumably this screening – saved less than one person-year.

http://www.ncbi.nlm.nih.gov/pubmed/22031728

“Overdiagnosis is of particular concern in lung cancer screening because newer screening modalities can identify small nodules of unknown clinical significance. Previously published analyses of data from the Mayo Lung Project, a large randomized controlled trial conducted among 9211 male cigarette smokers in the 1970s and early 1980s indicated that overdiagnosis might exist in lung cancer screening…”

http://www.ncbi.nlm.nih.gov/pubmed/16757699

 

Let’s forget about lung cancer screening and use the money for massage.

Doctors are sick of their profession … and we’re sick of arrogant doctors.

Today’s Wall Street Journal had yet another story by a disillusioned doctor: Why doctors are sick of their profession

Jauhar actually offers a balanced view. He points out that doctors were warned they would kill the goose that laid the golden eggs; many doctors still perform unnecessary surgery. I am healthy and rarely see doctors, yet when I had a small ovarian cyst, a doctor tried to persuade me to undergo a complete hysterectomy! I switched doctors and had an outpatient procedure in just a few hours.

The irony is that managed care often doesn’t prevent unnecessary or wasteful treatment. The term “preventive care” should be replaced with “risk reduction medicine.” Much of a primary care doctor’s work involves screenings of perfectly healthy, asymptomatic people that cannot be justified by research findings.

Doctors are still trained to memorize molecular structures but they need courses in statistics and decision making. Recently the WSJ published a review by a cardiologist who insisted that deaths from heart disease were down by 60%. I looked up the numbers: the reduction was 172/100,000 and that doesn’t account for things like errors in coding causes of death.

And while doctors complain bitterly about lack of respect, many of them persist in making elderly patients (and those close to end of life) suffer with unnecessary treatment. Just read any list of comments in a NYT article. I’ve heard first-hand accounts of 90-year-olds given colonoscopies, paid by Medicare; a doctor writes about aging Alzheimer’s patients getting painful needle tests for diabetes, ordered by a doctor, who can’t be stopped. yet few insurance companies give them what they need – massage, good food and privacy. I’ve heard even more horror stories of doctors who disregard DNR orders and who think they’re doing a service by keeping someone alive for a meaningless, drugged-up existence in a nursing home.

Finally, doctors have limited accountability. It is very, very hard to sue a doctor. Doctors make claims on their websites (and in practice) without disclaimers and disclosures of conflict of interest. Eye doctors actually place ads in their office magazines (“Want great vision? Talk to us about …”) without warning that these procedures do not always turn out well and sometimes make vision worse.

Is your health care ageist?

Mark Lachs is one of the few doctors to acknowledge that doctors are ageist. As he says, who gets more attention: a 22-year-old model or a 52-year-old executive?

As he says, there’s a huge variance in age groups.

“We geriatricians have a saying: ‘If you’ve seen one 80-year-old, then you’ve seen one 80-year-old.’ That’s also true of us at 50, 60 and 70. I have 60-year-old patients who are home-bound and others who can whip me in a set of tennis. Why would I assume they would all want or need the same type of care?”

Original article here.