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Scope of Practice: Advantage of Seeing a Family Doctor First

February 20, 2012 Dr. Pullen

Early in my fourth year of med school, when I was trying to decide what type of residency to apply for, I realized that I enjoyed the breadth of the scope of practice a family physician embraces. I tell my patients that I specialize in what they walk through the door with. As a family physician I have to be comfortable and competent at seeing nearly any patient for any problem and helping them access the care that they need for the problem they present asking for help with. In addition I have to try to recognize problems or health risks that they may not recognize, and have to find a way to let my patients accept what I feel is appropriate preventative care and disease management.

I often am asked by patients if they should come see me or if they should just go directly to the specialist they feel is going to be able to definitively address their concern. I don’t mean to sound pompous here, but often patients are way off base in choosing the specialist best suited to their problem. Seeing a specialist in an arena of healthcare different from your problem has several risks. These include significant delay in receiving appropriate care, incurring the expense of extensive testing in their area of interest prior to reaching the specialist appropriate to your circumstances, overdiagnosis, and missing related or unrelated problems that a family physician may recognize but a sub-specialist may not notice. Let’s go through these in more detail:

Delay in Receiving Appropriate Care: This can be the result of various causes. The one most concerning to me is when a patient makes a self-diagnosis and sees a specialist in that field. Often symptoms that seem related to one area expertise are caused by a disorder not apparent to the patient. Epigastric pain and nausea may be the result of heartburn and a gastroenterologist may be suited to evaluate and treat the pain. On the other hand it may be related to coronary ischemia and need urgent intervention. Seeing a gastroenterologist is not only not going to help, but may delay care, either because of a longer time to get an appointment for evaluation or because specialists often extensively evaluate issues in their area of concern prior to referral to another specialist. The time to have a trial of a medication for acid reflux and have an endoscopic exam of the esophagus and stomach may be detrimental to the care of a patient with coronary disease.
Incurring Expensive Testing: When a patient sees a family physician they are likely evaluated for the most serious or most likely problems causing their symptoms. The list of potential concerns often extends across several areas of sub-specialty interest. By looking at the most serious and most likely issues first a family physician is more likely to avoid expensive tests for very unlikely problems. An example might be a patient with groin pain. If this patient sees a family doctor, they will probably be evaluated by history and physical exam for things like inguinal hernia, urologic causes like kidney stone and infection, hip pathology, in women ovarian-gynecologic issues including ectopic pregnancy, gastrointestinal causes and neurologic causes. If they see a urologist they are likely to have extensive evaluation for urologic problems, and may get a correct diagnosis of a kidney stone or UTI. If their problem very likely a gynecologic problem, they are still likely to have extensive evaluation for the urologic issues because no specialist wants to miss a diagnosis in their field of expertise no matter how low the likelihood may be. This holds true for most specialists. If you see a sub-specialist you are very likely to have an extensive evaluation for problems in their scope of practice whether or not they think you likely have a problem in their realm. A family physician is more likely to go through a process of looking for problems they consider important and likely, and put off extensive evaluation for very unlikely diagnoses. The cost savings of the latter approach can be huge.
Overdiagnosis: I’ll be brief here, but if you have imaging like an MRI, CT scan, ultrasound or even many lab tests abnormalities are often noted that can lead to extensive testing which has its own risks, or diagnosis of a problem that does not now nor will ever bother you. The latter is called overdiagnosis. See a prior post on overdiagnosis for more information on this topic.
Missing related or unrelated Problems: A specialist while highly trained in their scope of practice may not be focused on related or unrelated important health care issues. If you see a cardiologist it is unlikely that they are going to recognize that you are due for a mammogram and urge you to get a preventative care visit for this and other preventative services you are due. If you see a dermatologist it is unlikely you will bring up your “Oh doctor, by the way I am having these odd numbness and weakness symptoms,” that may lead your family physician to consider a TIA and make interventions to prevent stroke. The list of similar situations is nearly endless.

I feel pretty strongly that the first point of care for most health concerns should be either your family physician or the emergency department for life threatening emergencies. The scope of practice of your family physician gives you the best chance of efficient, timely and effective care.

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Meaningful (Ab)use

February 16, 2012 Dr. Pullen

January 1, 2012 brought another layer of documentation mandates to every office visit progress note. Meaningful use regulations added to chronic pain regulations in Washington have changed the context of many patient visits. As of Jan 1 of this year I feel like I’ve crossed over the edge and now have to spend more time as a clerk than as a physician interacting with my patients. I’ve succumbed to well-intended, government-imposed veiled threats and financial incentives, you could say fear mongering and bribery by our governments. This has led me to agree to yet more documentation in every visit to show that in the case of pain management that I am complying with many abuse prevention practices, and in the case of Medicare my use of an electronic medical record shows meaningful use. I guess this is as opposed to meaningless use.

In the meaningful use arena the problem is in how the regulators define meaningful use. At our office we have had an EMR since 1997, and take expend considerable effort to make very meaningful use of the information. We have a virtual disease management registry so that we can improve our efforts to assure our diabetic, hypertensive and hyperlipidemic patients stay on track to maintain good control of their health. We make attempts to get patients in for preventative care visits. We use printed prescriptions to reduce errors with hand written prescriptions. Unfortunately in order to demonstrate the government definition of meaningful use, and qualify for a financial reward for meaningful use from Medicare, I need to do some other things with the EMR. These involve taking time during patient visits to generate documents to pass out to patients at the end of the visit. To a bureaucrat these may seem important, and maybe they are, but to me they mean I have to spend 2-3 minutes of each visit assuring that the patient’s gets a printed medication list and problem list, and then typing a visit summary and directions to give the patient. This means that the note for the patient encounter has to be complete or nearly complete while they are in the exam room. On a busy day I in the past have chosen to complete these at the end of the half-day so that later patients do not need to wait as long for me to get to their visit. For some visits I agree that these are important. For other visits they are just extra work that either takes time away from direct patient – physician interaction or puts me behind in my schedule and late for the next appointment and every subsequent appointment that half day.

In the case of pain management I have done the mandatory 4 hours of additional education on the use of pain medications. That was the easy part. Now I need to document at each visit that I am abiding by the state regulations. The concept of these is right on target, but the details of the regulations is onerous. Now for every office visit with patients on chronic opioid pain management we need to use specific tools to assess the individual patient for depression, opioid abuse risk, degree of pain control, level of functionality and be sure that every 6 months we have a new 20 point pain medication agreement explained, signed and documented in the chart. After this if there is any time left we can actually assess the problem causing the pain and see if there is anything to do to help with that.

These new regulations are on top of the complicated set of rules for what we need to document in order to show to the insurance company that they should pay me and what I need to document to give our lawyers enough information to defend me if I am sued. Oh, I also want to make a note that serves to help me or anyone else provide good continuity of care.

If I sound cynical it is not accidental. I feel like the newest regulations have gone over the top, and now every day I spend more time documenting care than I do providing care. It’s silly, and I predict that these efforts will turn out to be counterproductive. Patient satisfaction and actual quality of care will be lower as a direct result of government regulations designed to improve quality of care. There you have it, my experiences from my first 6 weeks of daily work under the 2012 Washington state chronic pain management regulations and the Medicare meaningful use incentive program.

As president Reagan famously said, “The most terrifying nine words in the English language are: ‘I’m from the government and I’m here to help .’ ”

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Belly Fat Is Bad For Our Health

February 13, 2012 Dr. Pullen

Is I took my shower this morning and once again looked down at my post-middle age belly, I am reminded that belly fat is bad. This is not news. We have known for years that belly fat is not just a problem because it hangs over the belt and many of us dislike the way it looks, but because it is an indicator of intraabdominal fat that is a risk factor for atherosclerotic heart disease. Having a big derriere or big thighs seems to be less of a health concern.

Look at both the subcutaneous fat and the fat inside the abdominal cavity in this overweight patient at laparotomy.

My cadaver for dissection in medical school was an old man, who was quite thin and had very minimal visceral fat, and when I saw my first few general surgical abdominal cases I was impressed by the amount of fat in the epiploical fat in the omentum and around the mesentery of many patients. I somehow had thought that most of our belly fat was just between the skin and the abdominal cavity, i.e. subcutaneous fat. In obesity a part of out abdominal girth is made up of intraperitoneal (inside the abdominal cavity) fat.

A Nov. 2008 NEJM article reported on a very large study of biometric measurements and showed that the rates of death were clearly related to “abdominal adiposity.” The study showed that increasing abdominal circumference and an increased ratio of abdominal circumference to hip circumference were both significantly related for a higher death rate. This correlation held up even when controlled for BMI, a general measure of height for weight. In other words if you have more belly fat that is a bigger health risk factor than if you carry your weight in your thighs, buttocks or breasts. Those of us with belly fat as opposed to having a fat in other places have long been known to be at higher risk of heart attacks, and recent research suggests correlation of belly fat with diabetes, and possibly some cancers.

So why does increased intra-abdominal fat, also called visceral fat, correlate with heart disease. Animal studies in mice show that increased visceral fat leads to higher rates of inflammation. There is considerable evidence that measures of low-grade inflammation, like highly sensitive C-reactive protein (h-CRP) are indicators of higher risk of coronary heart disease. A condition called metabolic syndrome is defined by having increased belly fat, an abdominal circumference of more than 40 inches (measure the smallest abdominal circumference, usually just above the umbilicus while standing at rest) along with borderline or high blood pressure, low HDL cholesterol and borderline or slightly high fasting blood sugar. Metabolic syndrome is felt to be a pre-diabetic condition and is a risk factor for the same types of cardiovascular conditions as diabetes.

Unfortunately we don’t really get to choose where we become obese. Don’t believe the headlines or web sites promising a secret fix to lose your belly fat, or any other particular fat you dislike. There is no believable evidence to support specific exercises to lose weight in specific areas. We can get stronger muscles in areas we exercise, but cannot specifically lose our belly fat, or any other fat by any means other than overall reduction of body fat, i.e. weight loss. Weight loss is not easy, and maintaining weight loss is arguably even harder than losing weight. I have patients who truthfully assure me that they have lost hundreds of pounds, they have just gained it all back and more. Still reduction of total body fat is the only way to reduce belly fat, so I know I need to keep up my exercise and my efforts to eat better to lose my belly fat. Wish me success in my ongoing fight to lose my belly fat.

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Grief Reaction on a Death Anniversary

February 9, 2012 Dr. Pullen

This week I was struggling a bit with melancholy, just feeling somewhat sad, and it took me a while to figure out why. My Mom died a year ago today, and although it was not in the forefront of my consciousness, I know that this anniversary grief reaction is real and normal. For me it helped to just figure it out. I remember for the first few years of my current marriage Kay would expect me to be a bit depressed in early May of each year, the anniversary of my first marriage, and the birthday of my first wife as well as the anniversary of her death. It’s now 28 years later and May is not so tough anymore, but this early February has been a bit rough. I miss my Mom. At the time of her death felt very mixed feelings. Sadness of course, but some degree of relief that she had died fairly quickly and without much suffering after a many years struggle with MS and then throat cancer. Now my feelings are less confusion, but no less real.

Grief about previous losses of loved ones when something reminds us of them is very common. Anniversary times are typical triggers of this type of grief. So how can we best deal with our feelings at times like this? Here are a few suggestions based on personal experience and on a brief review of expert opinions available online:

Recognize what’s happening. The anniversary of a loss is predictable, and knowing that you are at risk for sadness, depression, and intensification of your feelings is helpful.
Share your situation. Just letting your loved ones, family, or appropriate friends know how you are doing and why you are feeling down can be helpful. Let them know that you appreciate their prayers and support, but that they don’t need to do anything more is fine.
Distract yourself. Planning something fun, especially with others, can help. Find current issues, activities or other distractions to occupy your mind.
Call others in the same situation to talk. Reminisce about your loved one.
Write a love letter to the one you lost and tell them you miss them, love them and are praying for them.
Pray to your God for strength and grace.
If your feelings become too intense or overwhelming seek professional help.

Another question that may come up is how to be a helpful friend/spouse in these situations. The key is to just acknowledge the feelings as valid and be supportive. Helping to plan activities as a distraction may be helpful. Mostly just be present and accept these feelings a real in the person affected.

I’m feeling better just having recognized why I was melancholy. Writing this helped even more. Anniversary grief is real and taking active steps to manage it can be helpful.

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Pradaxa Bleeding Side Effects

February 6, 2012 Dr. Pullen

Pradaxa Bleeding Side Effects:: Hard to Put in Perspective

Since my post on Pradaxa in July, Pradaxa side effects especially bleeding complications have dominated the news on this new anticoagulant. The use of Pradaxa has been quite popular in the treatment of patients with atrial fibrillation for the treatment of stroke. In the initial study of approximately 18,000 patients that led to the FDA approval of Pradaxa the incidence of bleeding complications was fairly similar to the incidence of bleeding on warfarin therapy. Between the FDA approval of Pradaxa in October 2010 through August 2011 the FDA reports approximately 1.1 million Pradaxa prescriptions dispensed in the US and over 3 to 70,000 individual patients treated with Pradaxa from outpatient retail pharmacies. This is a lot of patients and with the known bleeding complication rates of both warfarin and Pradaxa significant number of major bleeding side effects would’ve been expected. This is been the case and the FDA is currently reviewing aftermarket use of Pradaxa using a process called The Mini-Sentinal surveillance program to see if the bleeding complication rate in newly started patients on Pradaxa is comparable to warfarin or maybe better or worse. Certainly the Pradaxa side effects of major bleeding are dramatic and can be life-threatening, just as the same as these complications with warfarin use can be. Still the benefit of stroke prevention in atrial fibrillation patients is generally felt to be enough higher than the risk of bleeding complications that anticoagulation therapy with either warfarin, Pradaxa, apixaban or one of the other anticoagulants on the market is felt to be indicated for many patients.

I’ve heard from patients and red in the news about the fact that Pradaxa cannot be reversed with vitamin K like warfarin can. I think this is a seriously flawed argument. The Pradaxa half-life is short enough that requires twice daily dosing (12-17 hours) and within about 36 hours after the last dose of Pradaxa it’s anticoagulation effect should be largely gone in patients with normal renal function. When using vitamin K as an antidote warfarin it takes a day or two for significant hepatic metabolism of the coagulation factors inhibited by warfarin and I seriously doubt if use of vitamin K leads to a reversal of the anti-coagulation in warfarin patients any faster than or even as fast as simply discontinuation of Pradaxa therapy. It’s true that in major emergencies either fresh frozen plasma or other coagulation factor products can be used as an infusion to reverse the quite neuropathy in warfarin use. Pradaxa works directly as an inhibitor of coagulation, so its anticoagulation effect should be less responsive to this type of therapy. Still I suspect that the argument that there’s no antidote for Pradaxa is less important clinically than it sounds in newsprint.

It will be interesting to see how the aftermarket evaluation of Pradaxa and the other newer anticoagulants bears out. Patients taking Pradaxa seem to certainly appreciate not needing to have frequent coagulation clinic visits to monitor their quite elation status necessary with warfarin use, and so far thankfully I’m not aware of any of my patients who have had bleeding complications from Pradaxa. I seem to see the current local cardiologists still prescribing Pradaxa fairly frequently and my expectations are that as more data comes to bear on the situation Pradaxa will be found to have a bleeding complication rate fairly similar to warfarin. Stay tuned for more updates regarding Pradaxa side effects and efficacy as they become available.

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Kalydeco: Science at Its Best

February 1, 2012 Dr. Pullen

I read with a personal interest the approval of Kalydeco (ivacaftor) this week for treatment of the 4% of cystic fibrosis patients carrying the G551D mutation. My first wife Lenore had cystic fibrosis and died at age 26. At that time in 1983 we knew a great deal less about CF than we know now. The introduction of Kalydeco this week brings several key issues in health care to the forefront. Development of drugs to treat disorders with a limited number of patients to use the drug can make the cost to each individual seem crazy expensive. The specific direct targeting of Kalydeco at a specific gene mutation is possibly an indicator of personalized treatments for more common disorders in the future. The whole fast-track process used by the FDA in approval of Kalydeco is an example of their faster approval of some drugs working as promised.

In the years since Lenore’s death CF has been found to be caused by a mutation in the cystic fibrosis trans-membrane conductance regulator (CFTR) gene that regulates ion transportation (ions like chloride hence the traditional sweat chloride test for CF) and therefore fluid flow within cells. One specific mutation is the G551D mutation (substitution of aspartic acid for glygine at position 551), and the new drug Kalydeco specifically targets the abnormal protein in these specific CF patients. Kalydeco helps the defective protein work more normally, and so reduces the abnormalities in CF patients with this specific mutation.

Unfortunately only about 1 in 25 CF patients have this specific mutation in the CFTR genetic code. The rest have some combination of the other at least 1000 known mutations. The most common CFTR mutation is called F508del (a 3 nucleotide deletion at location 508 leading to a missing phenylalanine amino acid “F”) and about 1 in 30 Caucasians have this specific mutation in the CFTR gene. Kalydeco is not effective in patients who are homozygous for the F508del mutation. This homozygous F508del mutation is the most common genetic code in CF patients. IN the 4% of CF patients with at least one copy of the G551D mutation Kalydeco has been shown to be effective in reducing CF symptoms, and is an exciting breakthrough.

Patients with the G155D mutation produce a protein that is able to make it to the cell membrane, where Kalydeco allows it to function much more normally. In patients with the F508del mutation the protein fails to fold in a way that allows it to move to the cell membrane, and so a drug like Kalydeco cannot function. Scientists are working on possible medications that could allow the migration of the other defective genes to the cell membrane where use in combination with Kalydeco could potentially be effective.

It is exciting not just for the 1200 U.S. patients with this specific type of CF, but also because it is an example of how genetic research, gene analysis in genetic disorders, and great basic science can lead to novel therapy for genetic disorders.

The rapid approval of Kalydeco is a great example of the new expedited FDA approval process for drugs that have the potential to be novel or breakthrough products where there is currently no effective therapy, or the drug is a major advance in therapy. It took only 3 months for Kalydeco to get FDA approval, even faster than the promised fast-track approval promised for special circumstance drugs.

The catch in this whole process is the incredible anticipated cost of Kalydeco. In a Wall Street Journal article the estimated annual cost of Kalydeco is reported to be $294,000. Since the anticipated number of patients eligible to receive this orphan drug is so small, and because of the novel and documented improvements demonstrated in patients using Kalydeco it is expected that insurers will pay for the cost of the medication. If all 1200 eligible patients take Kalydeco the annual cost at this price would be $353 million annually. Still this price is not Guinness world record. Two more expensive drugs are Soliris for a rare condition parosysmal nocturnal hemoglobinuria at $409K annually and Elaprase for the rare genetic disorder Hunter Syndrome , a polysaccharide storage disorder, at $375K annually. These are examples of orphan drugs with very limited markets where the cost of development is shared by very few patients.

I look forward to seeing more examples of genetic research leading to personalized medications for individuals.

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Rebound Headache

January 30, 2012 Dr. Pullen

Rebound headache is a well documented phenomenon that results from overuse of headache medications. I think I’ll use rebound headaches as the first of a series of posts on rebound phenomena in medicine. Our body seems to respond to the use of certain medications for treatment of problems by having the condition recur even more dramatically after discontinuation of the medication.

Rebound headaches can occur after the use of almost all headache medications although medications containing barbiturates, opioids, caffeine, aspirin and Tylenol seem to be the primary culprits. When I’m faced with a refractory headache patient and refer them to a headache specialty center almost always after thorough evaluation they leave the headache center with instructions to stop all of their headache medications for month. On returning to headache center up to 50% of the patients are much improved by simply stopping the use of the headache medicine.

In the bad old days of medicine when the standard headache medications were called APC (aspirin-for phenacetin-caffeine) products rebound headache was extremely common. Phenacetin has been removed from the market in the US since 1983 due to its association with kidney failure and possibly its carcinogenic properties, and medications like Excedrin and Anacin which contain caffeine are among the more commonly overused the off-the-shelf headache medications that lead to rebound headaches, although acetaminophen alone is another common culprit. Rebound headaches are also much more common in patients with migraine. If a migraine patient uses headache medication on a daily basis they stand a high chance of developing a condition called chronic daily headache, a rebound headache phenomenon related to medication overuse.

The big problem with rebound headaches is dealing with the interim situation where the headaches persist and patients need to abstain from using their headache medicines. This can be very challenging as headaches do resolve for a few hours if they take the headache pills. Unfortunately as long as patienst with rebound headaches continue to take their offending drug they’re doomed to continue to have frequent rebound headaches.

Strategies to help patients get through the period of time off the headache medications before the headaches improve include use of corticosteroids, sometimes use of an alternative medication like ibuprofen which is less prone to cause migraine headaches, and sometimes use of tryptans in migraine patients. The tryptan medications, including Imitrex and others, have also been implicated in rebound headache the phenomenon but seem to be a lot less commonly implicated than most other headache medications.

Medications like Fioricet (butalbital/acetaminophen/caffeine) are among the worst currently available headache medications that cause rebound headache. Although I still have a few patients using Fioricet I really try to avoid starting patients on this type of drug for headache because I know that rebound headaches can be such a problem.

As a rule of thumb avoiding use of headache medications more than one or two days a week is a good idea. If you need to use headache medications almost daily you should see your physician to come up with some sort of prophylactic strategy to avoid the headaches. This may involve the use of prophylactic medication or some other behavioral approach. Sometimes in cases of migraine headache offending foods or activities can be discovered to prevent headaches.

Stay tuned for discussions of rebound hyperacidity, rhinitis medicamentosa which is the type of rebound nasal congestion from overuse of faith constricting nose sprays, rebound increase in the frequency of herpes simplex outbreaks after stopping prophylactic daily antiviral therapy, and rebound of certain dermatologic conditions after use of potent corticosteroid therapy. Rebound phenomena in medicine seem to be common and are something to be aware of in the treatment of numerous conditions.

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Risks of Defensive Medicine

January 25, 2012 Dr. Pullen

There has been a lot of criticism of defensive medicine as a major contributor to the rapidly rising high cost of medical care in the United States. Although the real financial cost of defensive medicine is one issue, it is not the only problem with defensive medicine. Defensive medicine also has the risks of incidental findings on tests that are unnecessarily ordered, the risks patients encounter due to evaluation and treatment of these findings, and overdiagnosis.

Screening for prostate cancer has been all over the news recently, with the USPSTF proposed recommendation against routine PSA screening, and is a classic example of the risks of screening tests. The strongest argument against PSA screening is overdiagnosis and exposure of men to invasive prostate biopsies, and potentially dangerous therapy for prostate cancers that will never become clinically significant in some unknown but likely high percentage of cases. One of the primary reasons I don’t anticipate a dramatic reduction in PSA testing in primary care is because it is perceived by physicians that they are much less likely to be sued for complications of care caused by overdiagnosis of prostate cancer than if a patient is diagnosed with advanced prostate cancer and who has not been offered PSA screening. I suspect at least some physicians are going to be afraid to do the right thing even if they are convinced that the evidence supports not doing PSA screening.

Far less emotional and dramatic are consequences of defensive medicine precipitated by the ordering of imaging tests. It is commonplace for a physician to order an MRI of a patient’s knee early in the course of management of a knee injury. In an NEJM study of randomly chosen men without a complaint of knee pain the incidence of finding a meniscus tear on knee MRI was 31%. A finding of adrenal masses on abdominal CT scan is very common. In one study the incidence of an adrenal mass finding on abdominal CT in patients without a known malignancy was 5%. In this same study of 973 consecutive patients of the 973 zero were found to be malignant. This is exactly my experience, i.e. I’ve never had one of these turn out to be a cancer. Yet once an adrenal mass is found it is almost always recommended as a part of the radiologists report to have it reevaluated at least one, often twice or more to assure “stability.” It is unusual for a primary care physician not to order these follow up tests, more defensive medicine. The risk of radiation exposure from abdominal CT scanning is not insignificant.

Treatment of sore throat, acute short-duration sinusitis, otitis media and acute bronchitis with antibiotics is very common. It may be defensive medicine or just taking the path of least resistance, but there are very real risks of antibiotic therapy and almost all the evidence and expert opinion argues against the use of antibiotics in these conditions. With the increasing incidence of Clostridium difficiele infections, and increasingly virulent and antibiotic resistant C. diff as well as the other risks of side effects of specific antibiotics their use is far from risk free.

Nearly every new highly sensitive imaging technique is also very good at finding incidental variations of normal and abnormalities for which radiologists are reluctant to recommend no further evaluation, This is defensive medicine on the part of radiologists, as well as good business on their part in our fee-for-service environment. What business person of sound mind is going to put themselves at legal risk and at the same time recommend against a test that is in their financial interest. The risk to patients is more than just the risk of further radiation. Often the tests also lead to invasive tests or treatments, all of which have their own risks.

Many blood tests have the same risks, including tests like CA-125 for ovarian cancer, of course PSA, but also things as simple as a CBC. A CBC with a low white blood cell count is usually either normal or the result of a recent viral illness. Still it usually leads to a follow up test to assure a return to normal. If it persists low it may lead to referral to a hematologist who often orders a bone marrow evaluation. These are not only moderately painful but can have uncommon serious complications.

Essentially every test or procedure we do entails some risk. Ordering tests for defensive medicine reasons when the chances of finding clinically important and helpful results is fairly low makes the chances of finding false positives or overdiagnosis and leading to complications that would never have happened if the testing had not been done relatively higher. The cost of defensive medicine is not just in dollars.

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Doctors Die Too, but Maybe Differently

January 23, 2012 Dr. Pullen

I stumbled across this terrific article titled:

How Doctors Die by Ken Murray a FP at USC.

It is largely anecdotal, but is a really an interesting perspective on how at least some physicians choose to forgo futile end-of-life treatments because they know the limits of modern medicine first hand.

Also Enjoy:

Octogenerian’s Letter to Santa

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Robotic Surgery Today

January 20, 2012 Dr. Pullen

I’ve known for some time but have recently become focused on robotic surgery since my wife is having a robotic surgery today. The idea of robotic surgery makes it seem like a robot is somehow doing surgery better than a surgeon could. In fact that’s not the case at all; rather the robot allows the surgeon doing laparoscopic surgery to have an advantage over using traditional open surgery or manual laparoscopic surgery to accomplish difficult surgeries. As many surgeons have become more experienced with robotic surgery the hope of superior results with less collateral tissue damage and reduced recovery time makes robotic surgery an exciting new tool in the surgical management of many diseases. Robotic surgery has become commonplace in surgery for prostate cancer and several gynecologic procedures, but also for conditions as complex and diverse as cardiac valve replacement to rectal cancer.

The Da Vinci robot is a machine that allows the surgeon to use stereoscopic cameras letting the surgeon get closer looks at the tissues they are operating on, and to use joy-stick like controls to maneuver surgical instruments to accomplish the dissection, ligation of vessels, and suturing necessary to accomplish the surgery. This can in the hands of skilled operators give the ability to use a laparoscopic approach with superior equipment, visibility and using the robot can avoid human tremor to achieve better results than with laparoscopy using surgeon’s hands to control the instruments directly.

There is a moderate amount of evidence that robotic surgery causes less tissue trauma and faster recoveries. Like all procedures there is a learning curve with robotic surgery. In the early days of robotic surgery a major problem was the increased duration of procedures subjecting patients to prolonged anesthesia, and the expected mistakes and misadventures of learning a new technique. Now that many surgeons, including ours, have done hundreds and even thousands of robotic surgery procedures the duration of procedures approaches the duration of open and traditional laparoscopic surgeries.

Let’s pray that Kay’s surgery today will be one more successful example of robotic surgery.

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