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Category Archives: Opinion/Editorial

Giving Thanks for Uncertainty

November 24, 2011 Dr. Pullen

For most of my career as a family physician I have told patients and firmly believed that the hardest part of being a good family doctor is uncertainty. Almost every time I see a patient there is some uncertainty in the diagnosis, choice of treatment and in what to expect from the recommended treatment. Making decisions as to how much uncertainty to accept, when to seek a higher level of certainty, and how to present this all to my patients in a way that is both reassuring and truthful is the crux of the art of the practice of medicine.

When I see a patient with a typical fatty lump I’m confident is a lipoma, or a firm well circumscribed dermal level skin lesion I’m certain is a dermatofibroma, the level of uncertainty is very low. In these cases I feel very good about telling my patients their diagnosis and that no further diagnostic evaluation is needed, with the proviso that if the behavior of the lesion changes to let me look at it again. Certainly we could have a higher level of certainty if I excised all of these lesions and sent them for microscopic pathology evaluation, but the known risks of this option, i.e. scarring, pain, cost and risk of complications seem to clearly outweigh accepting a very low degree of uncertainty. This same balancing act plays out with nearly every office visit. Is the chest pain cardiac, reflux esophagitis or chest wall musculoskeletal pain? Is the headache a tension headache or something more serious like an aneurysm or a brain tumor? Making decisions about when to live with some level of uncertainty is the real decision.

Just today I was struck with the flip side of uncertainty. The beauty of our human existence is by its very nature filled with uncertainty. We all certainly will die, but when, how, and where are all uncertain. The exact prognosis for most disease processes is quite uncertain. My wife has ovarian cancer, and although she has accepted chemotherapy exceptionally well, has had very limited complications of the initial course of therapy and the second course after her first relapse, she is now in a time of waiting to decide when to treat the gradually increasing tumor marker that haunts us and tells us the cancer is not gone, it’s just lurking and trying to come back. After an all-too-brief three month hiatus of no CA-125 testing we anticipated a fairly high number, and were pleased yesterday when the marker came back only modestly higher than prior to the level three months ago. This was a reminder that nothing about this cancer is certain. The long term prognosis is poor, but what does that mean? Nothing is certain. Kay may live many months or even a year or two (or more?) before needing more treatment. The next treatment, whatever that turns out to be may be highly effective, totally ineffective, or anywhere in between. A poor prognosis maybe, but the uncertainty in times like this gives room for hope. Will a breakthrough in ovarian cancer happen in time for us? More uncertainty.

For some patients living with uncertainty is difficult, anxiety provoking, and hard to accept. In our situation I give thanks for the uncertainty. It is far easier to remain upbeat, positive and hopeful when a future that could be looked upon as filled with negatives has some uncertainty.

When you really think about life nearly everything is uncertain. As a Christian I feel confident that salvation is a certainty, but that is faith based. When I look at objective expectations nearly everything has some degree of uncertainty. Uncertainty is so much a part of our lives that we take great care to plan for the uncertainty. Insurance, be it health insurance, homeowner’s insurance, life insurance or auto insurance we are paying for insurance against uncertainty. Actuaries mathematically calculate the premiums of our insurance based on multiple sets of data and assumptions, but all of their calculations come with calculated degrees of confidence. On each of our medical study conclusions you will see a p-value. The lower the p-value the less likely the conclusion is wrong by random chance. You will never see a p-value of zero.

So this Thanksgiving I am giving thanks to my God for the uncertainties our lives. May we come to cherish this uncertainty, live each day and each minute with the certainty that there is some uncertainty about what the next minute, hour, day, week … will bring. May I continue to strive to achieve the optimal achievable levels of uncertainty in my management of my patient’s health care decisions, and may the uncertainties in my own and my family’s lives be a blessing so that we live each minute with only the certainty that we have the this minute to enjoy and cherish.

Another article you may enjoy is Citalopram HBr: Don’t Be Confused by the Name on the Bottle.

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Why Quit Smoking?

November 17, 2011 Dr. Pullen

This post is in appreciation of the 35th anniversary of the first “Smokeout”, actually the November 18, 1976 “Don’t Smoke Day” (D-Day) in San Francisco sponsored by the California Division of the American Cancer Society which received national (all 3 major national networks at the time ) and became a national event thereafter. The third Thursday of November each year, just one week prior to Thanksgiving is the Great American Smokeout. About 45.8 million Americans still smoke and most studies show more American smokers would like to quit smoking than those who don’t want to quit. Here are some great reasons to quit:
1. Retire Early(or take a nice vacation every year) on the Savings: If you smoke 1 pack of cigarettes a day for a year, at an average cost in Washington State where I live and work at the average cost in WA of $9.89/ pack you spend $3609.85 a year on cigarettes alone. If saved the 3609.85 annually and invested it at only 4% you would have $111,794.17 in 20 years. It would be more if you invested daily or monthly. Quit smoking now and you can be a long way towards a retirement fund. You may also live to retire. (I admit Washington is the second most expensive state to buy cigarettes in the U.S.)
2. It Stinks: Any non-smoker can tell you that they can smell the odor of cigarettes on your clothing, hair and body from several feet away. By quitting smoking you will avoid smelling repulsive to the majority of others in society.
3. Live Longer and Better: The average smoker dies 7 years earlier than the average non-smoker, and estimates of the time lost per cigarette smoked is 7-10 minutes per cigarette. The whole issue is really much more complex that this, but without doubt quitting smoking can add significant time to the average person’s lifespan.
4. Better Sex for Longer: Smokers have a much higher incidence of peripheral vascular disease, and erectile dysfunction is often the result of vascular disease. Quitting smoking can lead to a better sex life for many smokers.
5. Dying of COPD is Among the Worst Ways to Die: This is my personal opinion, but I’ve taken care of people who have died nearly every common cause of death. Respiratory failure has to be among the least desirable way to die. Being essentially immobile, gasping for air while on oxygen for months or years, and finally dying of a respiratory infection that leads to inability to breath is not among the ways I hope to die.
6. Get Your Kids/Grandkids/Spouse/…. Off Your Case: Nearly every smoker I see in the office comments that their loved ones are hoping the get them to quit, and often annoying them with encouragement and pestering. Why not change all that to congratulations and positive reinforcement after you quit?
7. Feel Proud that You Quit: Most smokers would like to quit smoking. Most who do tell me that they are happy and proud that they were able to quit. Join the ranks of proud ex-smokers.
Please leave comment with more and better reasons to quit. I’d love to have this post be a place for smokers to find the right reason for them and quit themselves. There is no time like today!

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The Real Costs of Defensive Medicine

November 15, 2011 Dr. Pullen

by Brittany Lyons

With estimates ranging from $35 billion to a whopping $850 billion, the true costs of “defensive medicine” are difficult to pinpoint. A variety of government reports, physician surveys and studies have attempted to pinpoint exactly how much of U.S. healthcare costs are generated by defensive medicine, but the varied definitions of “defensive medicine” make the real number hard to determine.

Defensive medicine refers to the costs associated with doctors protecting themselves from medical malpractice lawsuits. These costs include liability insurance premiums, malpractice judgments and settlements, and sometimes extend to unnecessary testing or other physician services provided to patients solely to avoid malpractice claims. Indirect costs associated with defensive medicine can also include “assurance behaviors,” such as ordering tests or delivering additional services that have only marginal medical value, or no value at all, to discourage malpractice lawsuits—which can cost more than even earning PhDs. A 2005 study published in the Journal of the American Medical Association discovered that doctors may perform these unnecessary services in the hopes that if a malpractice claim were to arise, the court would be satisfied that the physician met the standard of care.

A Look Behind the Numbers

The Congressional Budget Office estimated that defensive medicine accounted for $35 billion—or 0.2 percent—of the total U.S. healthcare expenditures for 2009. This figure is significantly lower than the estimated $650 to $850 billion in annual expenditures attributed to defensive medicine by Gallup and Jackson Healthcare surveys of physicians. The Jackson Healthcare survey gathered data from thousands of physicians across the United States on the indirect and direct costs generated by defensive medicine, concluding that physicians considered defensive medicine the primary driving force behind rising healthcare costs—the result of an overly litigious healthcare environment.

Nine out of ten surveyed physicians said they practice defensive medicine, and general estimates predicted an average of 34 percent of overall healthcare costs arise from defensive medicine. A subsequent Gallup poll of physicians found that approximately 73 percent of surveyed physicians admitted to practicing defensive medicine within the past year, but estimated overall costs at only 26 percent. The 2005 JAMA study by researchers from Columbia and Harvard Universities also revealed that for physicians practicing in “high-risk” specialties, these monetary figures may be much higher; 59 percent of the physicians surveyed admitted to ordering more diagnostic tests than medically necessary to prevent malpractice litigation. Plus, the physicians avoided caring for high-risk patients, referred patients to other specialists, prescribed more medications than medically necessary and suggested unneeded invasive procedures—all to avoid malpractice lawsuits. Another study by the American Academy of Orthopedic Surgeons discovered that defensive medicine accounts for a startling 20 percent of all imaging orders, and half of these imaging orders were for expensive MRIs.

Why the Disparities?

So why is the Budget Office’s number so low when the Jackson Healthcare survey is so high? Because physicians aren’t regularly logging every single expenditure arising from defensive medicine, and no one is entirely sure what even qualifies as “defensive,” quantifying the costs with exact accuracy is nearly impossible. The great differences in estimated costs, however, is likely due to the particular expenditures included in the figures for defensive medicine. For instance, the CBO’s low estimate of $35 billion includes “malpractice insurance premiums together with settlements, awards and administrative costs not covered by insurance,” but does not include unnecessary procedures, medications and other services, so long as they are covered by insurance. This difference in accounting is more than enough to explain the disparity.

The Jackson Healthcare survey adds a myriad of other direct and indirect costs to the CBO’s numbers, including all the excessive diagnostic testing and medical services provided in the spirit of defensive medicine. The survey results then translate the percentages into dollar amounts using the calculations of estimated overall U.S. healthcare spending released by the Centers for Medicare and Medicaid Services. Thus, this number includes more items than the CBO’s report, and bases its numbers on another estimate.

With healthcare costs rising rapidly in the United States, combined with increasing tort reform and malpractice fears, defensive medicine is becoming a more and more expensive slice of the healthcare-cost pie. Regardless of the actual monetary amount, defensive medicine practices strain not only Medicare and Medicaid, but also the insured and uninsured healthcare consumer alike, contributing to increasing prices for medical services and greater costs to insurance companies. Unless something is done to relieve the legal pressures placed on physicians, defensive medicine will continue to generate billions of dollars in healthcare expenditures every year.

Brittany is a blogger-in-residence at PhDs.org

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Remember all the Drugs With a Narrow Therapeutic Window?

November 7, 2011 Dr. Pullen

The concept of the therapeutic window, the dose of a medication where the serum level is high enough to be effective but not so high as to be toxic, is much less of an issue today than it was in my days as a younger physician. I am sure I’m not alone in being delighted and relieved by this welcome change. I thought it would be fun to muse about the drugs we used to use routinely whose narrow therapeutic window was often a dilemma.

We still commonly use a relatively few medications with a narrow therapeutic window, notably warfarin, digoxin, and lithium, but many others have fallen out of favor because safer effective treatments have become available. For fun and historical perspective let’s look at some of the drugs with troublesomely narrow therapeutic windows.

Thoephylline: Prior to the widespread use of inhaled corticosteroids, long acting inhaled beta agonists, more aggressive use of short burst courses of oral corticosteroids, and new medications like spireva, Singular, and others the mainstay of asthma and COPD management was theophylline. With a non-linear metabolism (the serum levels do not gradually and steadily increase with increased dose, but rather jump quickly at times with minor dose changes), severe toxic side effects at only slightly supra-therapeutic serum levels, and many drug interactions, theophylline toxicity was a common cause of ICU admission for many years.

Digoxin: Digoxin is still used for many patients, but not nearly as often, and usually at considerably lower doses than when it was considered a key part of management of most patients with CHF and tachyarrythmias of many types. We have learned a great deal about CHF treatment in the last 20 years, and digoxin plays at most an ancillary role in cardiology today for most heart conditions. This is nice as often life threatening arrhythmias were commonplace in years past, and digoxin toxicity was extremely common.

Tricyclic Antidepressants: These are a prefect example of a narrow therapeutic window. At a daily dose of 300 mg daily, amitripylene ingestion of as little as 4-5 days of dosing could be lethal. In contrast ingestion of a full month prescription of most SSRIs is unlikely to be life-threatening. Amitriptylene, imipramine, nortriptylene, desipramine and later some tetracyclics like trazodone were the only effective antidepressants available prior to Prozac, and the SSRIs have been popular not just because of their lack of bothersome side effects. The fact that lethal overdose of an SSRI is extremely uncommon, whereas ICU admissions and deaths from tricyclic intentional and unintentional overdose were daily occurrences 30 years ago. We rarely use the tricyclic antidepressants in doses needed for depression today.

Warfarin: We still use warfarin plenty, but new directly acting drugs like Pradaxa, Xarelto and apixaban are becoming available for prevention of stroke in atrial fibrillation, and are likely to be used in the future for DVT therapy. It remains to be seen whether bleeding complications will be significantly less problematic, but it is clear that the therapeutic window with warfarin is about as narrow as they get. A patient therapeutic on 5 mg daily, may be significantly over-anticoagulated at a dose of 6 mg daily, and with many drug interactions, dietary variation of vitamin K ingestion, and patient compliance issues with frequent INR monitoring this is a major factor in patient care.

Aminoglycoside antibiotics: These remain a very effective therapy for many gram negative bacterial infections, but have in large part been replaced with much less toxic drugs. Use of these antibiotics requires close monitoring of serum levels and renal function to assure both therapeutic serum levels and non-toxic levels.

Lithium: Lithium remains an effective therapy for the mania associated with bipolar disorder, but the narrow therapeutic window where serum levels below 0.5 usually not effective, but levels much above 1.0 leading to toxicity, drugs with a much wider therapeutic window are often preferred by patients and physicians alike. (Visit this Lithium side effects resource)

Aspirin: No not 81-325 mg daily for their anti-platelet effect, but three Ecotrin or Bufferin 325 mg tablets four times daily. Prior to the huge list of NSAIDs beginning with ibuprofen and naproxen, high dose aspirin was the standard of therapy for rheumatoid arthritis, osteoarthritis and most inflammatory disorders. Who remembers checking salicylate levels, watching for tinnitis and bleeding ulcers or hemorrhagic gastritis from aspirin toxicity. I don’t miss those days.

Other drugs like many of our chemotherapy agents still remain in widespread use despite the need to push dosing to levels where toxicity is expected, but overall the development of safer and improved drugs has made consideration of the therapeutic window much less of a day-to-day concern than it was just a couple of decades ago.

Please leave your stories about use of drugs with narrow therapeutic window issues for readers to enjoy. Leave your e-mail in the subscribe area on the right side bar to be notified of future DrPullen.com posts, and follow on Twitter @DoctorPullen to get additional thoughts and health care commentary.

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Pfizer Strategy to Get You to Buy Lipitor not Generic Atrovastatin

November 3, 2011 Dr. Pullen

The patent on Lipitor expires this month, and inexpensive generic atorvastatin should be available within months. I cannot think of any good reason that generic atorvastatin prices should be higher than the prices of the other generic statins once true competition comes to the marketplace. Pfizer has in place a strategy to try to keep patients buying and physicians prescribing brand name Lipitor and maintaining their market share to some degree. Here is how they hope to retain sales as outlined in the Wall Street Journal in an article by Peter Loftus:

Discount Drug Coupons: In every state except Massachusetts the use of manufacturer coupons to reduce the copay for brand name drugs is legal. Federal insurance plans Medicare and Medicaid disallow these coupons, as their real effect is to negate the intent of the payer (the U.S. government and its taxpayers in the case of Medicare and Medicaid) to force the individual patient to pay a premium in the form of higher copayments in order to use higher price brand name drugs. The effect is to give incentive to patients to use cheaper generics, save money themselves and save money for the health care system. Discount drug coupons take the incentive away from the individual patient and end up raising the cost of health care. Pfizer hopes that physicians and patients will make use of these coupons and help them retain market share instead of using less expensive generic atorvastatin.
Making deals with the pharmacy benefits managers that insurance companies use to give rebates or market share incentive deals that in essence give larger profits to these companies if patients use Lipitor instead of generic atorvastatin. These pharmacy benefits managers have considerable power in the choices patients have and drugs they are dispensed.

If Pfizer is successful in their attempts to retain significant market share of the $11 billion in annual sales of Lipitor, the #1 grossing U.S. drug for the last several years we can be sure other pharmaceutical companies will follow suit as their drugs lose their patent. Don’t be fooled by drug discount coupons. They may save you dollars in select situations where an expensive drug is clearly the best alternative, but in my opinion are rarely good choices, and certainly not in the case where their sole purpose is to convince us to use a more expensive brand name of a drug where a generic alternative is available. Everyone wants to reign in the cost of medical care, and discount drug coupons are trying to circumvent incentives to lower the cost of health care.

I’d be in support of either the federal government or each of the states following the MA lead and make drug discount coupons illegal.

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Sequenom™ brings MaterniT21™ and a Whole New Set of Difficult Choices

October 22, 2011 Dr. Pullen

Coming to 20 major U.S. metropolitan areas this week will be a test called MaterniT21™ from Sequenom™. Over the past 25 years we’ve gone from alpha-fetoprotein testing, to adding 2, 3 and more recently 4 tests as “penta” screen to try to improve the estimation of a woman’s risk for having a trisomy-21, or Down’s syndrome pregnancy without actually obtaining fetal cells, but all they have really done is improve statistical prediction capability. Up to this point in order to tell if a woman is carrying a Down’s Syndrome baby required amniocentesis to obtain amniotic fluid at about 16-18 weeks gestation, or the arguably higher risk chorioamniotic villous sampling at 10-12 weeks gestation. Both of these tests ran low (estimated 1/350) but real risks of fetal injury and miscarriage. Now from a company named Sequenom™ comes a test on fetal cells obtained by a venous blood sample of the pregnant women’s blood as early as 10 weeks gestation that can do genetic screening for Down’s Syndrome without more invasive ways to obtain fetal cells. The initial study of 212 women showed a >99% accuracy rate. (1 false positive, 2 false negatives in 212 women tested).

This is both exciting and frightening. It raises huge questions including who if anyone should get this testing. Here is a list of some of the issues that come to my mind as we start the process of figuring out the role of this new technology:

Increased Abortions and Earlier Abortions of Down’s Syndrome Pregnancies: One consequence of a more accurate test for Down ’s syndrome if it leads to more widespread testing or women for this condition is that more women will face the decision of abortion or not. Now women first face the question, “Would I abort my pregnancy if I knew I had Down’s syndrome, and if so am I willing to undergo a test that could cause miscarriage to get that information.” With the Sequenom™ MaterniT21™ test women will be able to get much more definitive information without a test that puts their fetus at risk from the test itself. This may lead to more women choosing to be tested. Putting aside the whole “pro-life vs. pro-choice” debate, the opportunity for earlier diagnosis will make technically easier and less physically traumatic abortions possible in women who have a Down’s Syndrome pregnancy.
Who should be Eligible for the Test?: Although the risk of Down ’s syndrome rises with increasing maternal age many Down’s Syndrome babies have young Moms. With a more accurate and less dangerous test available should all or more women be offered the test?
Who should pay for the testing?: This is a very complicated question. This test is not going to be inexpensive. On the Sequenom™ press release they suggest that the cost will approximate the cost of amniocentesis testing. They do not make it clear if this means the cost of the amniocentesis test itself, the cost of the genetic testing of the cells obtained, or both. If the test is done it will lead to higher costs for prenatal care as the test itself will significantly increase the overall cost of prenatal care. On the other hand the cost of having a Down ’s syndrome baby is not inconsequential. Down ’s syndrome children sometimes have major other congenital deformities, and the long term cost of education, support as adults, and associated family and societal costs are real and significant. A comprehensive cost-benefit analysis of this process will be interesting to see when it becomes available. These issues themselves will lead to ethical and moral choices.
Lower Incidence of Down’s Syndrome: If this tests becomes widely used, and if more women choose to abort pregnancies with Down’s Syndrome fetuses, the incidence of Down’s Syndrome could significantly decline. While many may consider this the desired outcome, some Down’s Syndrome supporters fear that this may lead to reduced support and reduced research into drugs and other techniques to help Down’s children.

I’m sure I’ve only touched the surface of the ethical, emotional, medical, moral and financial issues this new MaterniT21™ test from Sequenom™ and likely others to follow will bring. It seems a near certainty that with the ability to sample fetal cells from maternal blood other genetic tests like tests for cystic fibrosis, sickle cell disease, and many others will follow.

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What Vitamins Should I Take?

October 20, 2011 Dr. Pullen

I’ve been asked “What vitamins should I take?” by many patients over the years. I’ve usually answered that a store brand multiple vitamin is a good choice for most people, but recent evidence suggests that maybe the best answer to the question is that most people who have a reasonably healthy diet are best taking no vitamins at all. I know that answering the question, “What vitamin should I take?” with the answer that most vitamin supplements may cause more harm than good is not likely to be the answer patients want to hear, but as more evidence becomes available it is more clear that we just cannot get the healthy nutrients of a balanced diet in a pill, and that attempts to do so may actually be detrimental to our health.

In the nearly 30 years I’ve been practicing medicine there has been one miracle vitamin/mineral/supplement after another in vogue, and almost none of them have stood the test of time. The only way to get the full benefit of nutritious foods is to eat them. Bummer. It’s so much easier to just buy vitamins or supplements and eat junk. Sorry but that just doesn’t give the benefits of a nutritious diet.

In the last couple of weeks two new studies show that there may be more harm that good from taking several vitamins. A large study published in the Archives of Internal Medicine where 38,000 women were followed for 17 years showed slightly higher death rates in women taking multiple vitamins than in women not taking them. Specifically taking multiple vitamins, vitamin B6, iron, copper, zinc and magnesium were all associated with statistically significantly higher death rates. Only calcium seemed to be associated with slightly lower death rates in this study of older women.

An NIH study released recently showed that Vitamin E is associated with higher rates of prostate cancer. Over the years Vitamin C, Vitamin E, beta carotene, saw palmetto, multiple antioxidant regimens, and nearly every vitamin with a letter or number has been in fashion for reduction of one health condition or another. One by one they have almost all been shown to be useless or worse.

Who else remembers the theory that the whole trick to avoiding atherosclerosis was to ingest the right ratio of saturated to polyunsaturated oils. I remember a resident physician in Boston when I was a student who urged everyone to drink corn oil every day so that we could eat all the meat we want because our ratios of fat consumption would be in balance and that would make eating animal fat OK. Most of us laughed at him, but that theory had lots of followers 30 years ago. Beta carotene and vitamin E as antioxidants have been clearly shown to be more harmful than good.

So what’s a person to do? Here are my suggestions:

First and most important try to eat a healthy diet. Avoid fad diets, eat more fruits and vegetables, less meat, and exercise more. Don’t think you can rely on vitamins, mineral supplements, or gimmicks to substitute for healthy eating. See previous posts on Anti-inflammatory Foods, Foods High in Fiber , and Anti-aging Diet.
Be skeptical of whatever vitamin or supplement craze is in fashion at any given time.
Don’t think that more is better regarding vitamins. It has long been known that high doses of vitamins A, E and B6 can be toxic. There is little evidence to support high doses of any of the other vitamins either.
Keep in mind special conditions where supplementation with specific vitamins is important. Examples of these include many causes of malabsorption like gastric bypass surgery, some medication use, and celiac disease.
Understand that this is a long term issue. Eating well this month is good, but eating well for a lifetime is the key.
Avoid vitamin regimens that have been clearly shown to do more harm than good. These would include:
1. Beta-carotene supplements
2. Vitamin E supplements in most people
3. Iron supplements in men and post menopausal women
4. High dose supplements with nearly every vitamin. Currently Vitamin D is in vogue, and currently most of the data looks positive. Time will tell whether this works out or not.
5. I’d avoid even a multiple vitamin daily at this time if you eat a reasonably healthy diet and have no specific reasons to take the vitamin.

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Keeping Perspective: A Key Role for the Family Physician

October 13, 2011 Dr. Pullen

I believe that one of the most important things I can offer to my patients is help in keeping perspective when making medical decisions. I have a fund of knowledge and experience that adds a layer of perspective to the patient’s own beliefs, situation and overall health scenario. Hopefully I can get enough of a feel for the patient’s own personal, psychological and interpersonal situation to add my own perspective to theirs to help advocate for them in keeping perspective on the issues they are facing.

By a physician’s balanced perspective I mean the ability to look at the whole clinical, personal and psychological situation in which a medical decision is being made and help their patient make choices that are aligned with both the medical facts and reality as well as the their own beliefs, values and desires. Often the emotional issues or prior anecdotal experiences of a patient can prevent them from keeping perspective in making important decisions. My role at times is to help them see the broader picture and make the best decisions.

Sometimes this is simple, but sometimes not simple at all. Let’s look at one simple and one complex example, and then summarize by looking at examples of times keeping perspective helps with making the best choices.

Simple: A 45 year old male with a blood pressure of 195/125 who has no symptoms but is a smoker, has a poor lipid profile and whose Dad had coronary bypass surgery at age 50 is reluctant to take blood pressure medication because he “just hates to take pills.” The physician has a simple task. Find out the real reasons for being reluctant to take medication, present the facts- this fellow has a >30% chance of a coronary event in the next 10 years, and find a way to convince him to use medications to control his blood pressure. In this case the evidence that treatment of this patient’s hypertension along with his cholesterol can reduce his risk of an event to 11% (if systolic BP goal of <130 and Total cholesterol goal of <180 are met, and if he can quit smoking to about 3%). Presenting this evidence to the patient, along with finding out the reasons for disliking taking medications is likely to persuade him to comply with therapy, and be hugely to his benefit.

Complicated: A 39 year old mother of two who is divorced but involved in a new relationship with a childless man is found to have an enlarged uterus on routine annual exam. Ultrasound shows a thickened endometrial lining at 1.7 cm, and endometrial biopsy shows endometrial hyperplasia with atypia. Her family physician refers her to a gynecologist for further evaluation, and she is presented with several options. She can have a laparoscopic assisted vaginal hysterectomy to remove the uterus and assure no progression to endometrial cancer. She can have a D&C, which will further assess the endometrial pathology and likely but not absolutely get rid of the atypical cells. She can take hormonal medications to get a “medical D&C” to bring on a heavy menses and try to rid her uterus of the hyperplastic lining. Keeping perspective of her wishes, future plans and feelings about the options is very important in helping this woman make the best decision for her individual situation.

In the former situation with family doctor trying to convince the patient to treat their hypertension is straight forward. Hopefully the physician can help the patient in keeping perspective of the whole picture and will lead the patient to comply and take the drugs to reduce their risk of serious long and short term cardiovascular problems. In the latter case the physician will hopefully discuss the needs of the woman involved and help her in keeping perspective of both the medical facts and risks as well as her feelings and needs in making her choice. Does she want further children? How does she feel about a hysterectomy? Is she willing to submit to long term careful follow up of the condition if she chooses a less aggressive therapy? Keeping perspective involves figuring out the needs of the patient involved.

Examples of when keeping perspective in mind rises to the top of the physician roles include:

prostate cancer treatment, especially in the older man
treatment of moderately elevated LDL cholesterol
whether to take estrogen for moderately severe hot flashes and night sweats around the time of menopause
whether to use oral contraceptives, an IUD, or barrier contraception at various times of your life
whether to take Accutane for moderately severe acne
whether to start insulin for poorly controlled type 2 diabetes

The list could take up pages, as it really comes up to some degree with every physician visit. Sometimes the issues are so simple as to be obvious to both the patient and the physician, and go almost without overt comment. Other times as the physician we can help by labeling our role as helping the patient at keeping perspective, and assisting in their decision making by adding our perspective while trying to understand theirs.

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Moral Responsibility to Get Your Flu Shot

October 10, 2011 Dr. Pullen

Moral Responsibility to Get Your Flu Shot

I Got Mine

This topic comes to mind again this year as we have plenty of influenza vaccine, on time this year and ready for distribution. A prior version of this post was posted in 2010. I have strong enough feelings on the subject to repost an updated version. If anything good came of the Swine Flu epidemic on 2009 it was that more Americans get immunized not than ever before.

This year as every previous year Dr. Pullen was first in line at our office for my influenza vaccination. I take seriously the mantra primum non nocere, first do no harm. It’s hard to imagine doing more harm than seeing a patient with influenza on Monday, and on Wednesday, the day before I get sick, sneezing and passing the influenza germ to one of my vulnerable older patients, or a pregnant woman, or a young baby who then dies from influenza. This scenario is just inexcusable given that I could have avoided harming the patient if I had received the recommended and easily available influenza vaccination. It would be immoral and irresponsible to put my patients at that type of risk unnecessarily. I encourage, coax, tease, and everything short of intimidate my employees and fellow physicians to get their influenza vaccination also. School teachers, emergency workers, and others in close contact with the public should similarly feel morally compelled to get influenza vaccination. It is our moral responsibility.

I also got a Tdap vaccination last year also, even though was several years until I was due a tetanus shot. See Dr. Pullen Gets His Tetanus Booster Shot Years Early! My thinking was the same, try to avoid a pertussis infection, and not put my patients at risk.

It’s a small step from discussing health care workers and influenza and pertussis vaccination, to talking about parents and childhood vaccinations. The parent who chooses not to vaccinate their children against measles and pertussis puts not only their own child, but other children in the community and the school who may be at particular risk for complications from these infections in danger. These children at high risk may catch these infections from these unimmunized children. As a parent I’d feel terrible if my child died or became brain injured from measles, but I’d also feel horrible if my child passed Pertussis or measles on to a child with leukemia, or HIV because I chose to not immunize my child. I appreciate that this is a free society, and we can make our own personal choices about health care including immunizations. It’s not illegal to decline recommended immunizations, but in many cases it is irresponsible and not living up to our community moral responsibility. Parents who choose not to immunize their children and take advantage of the herd immunity of the majority of children whose parents responsibly immunize their kids are just ignorantly selfish. They think they are protecting their children from risks of immunizations, though a great mass of evidence refutes this point of view. In fact they are putting both their own child, and other children who lack immunity through no choice of their own or their parents at risk.

I’m anticipating a rash of angry comments calling me a mouthpiece of the brainwashed physicians of organized medicine. Don’t believe them.

See these references on the safety of childhood immunizations.

Prenatal and Infant Exposure to Thimerosal From Vaccines and Immunoglobulins and Risk of Autism (there is none).

Data Fail to Support Thimerosal-Autism Link

The end of the autism/vaccine debate?

Book Is Rallying Resistance to the Antivaccine Crusade

Also see the great video at the top of the Musical Docs page Immunize: The Vaccine Anthem.

You may also enjoy:

Dr. Pullen Got His Tetanus Booster Years Early!

Polio Eradication

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PSA Controversy Continues

October 5, 2011 Dr. Pullen

The controversy over PSA testing is tough. Nobody wants to hear that although prostate cancer is the second leading cause of cancer death in men behind lung cancer that there is no good reason to believe that PSA testing leads to either longer or better lives. It is a tough dilemma. Death from prostate cancer is not good. Men sometimes die after long, painful illness with metastatic bone cancer and a wasting painful death. Everyone including me wants to believe that early diagnosis must be good. Unfortunately the evidence just does not lead you to that conclusion. You may have enjoyed my last post on Prostate Cancer Screening, “Don’t Do Something: Just Stand There” and in todays New York Times is a very thourough historical and analytical article outlining the controversy of PSA screening. It is full of emotional quotes by advocates and skeptics. Also is a link to Dr. Kenny Lin’s latest article on the subject also. These make a good read for anyone considering PSA screening.

Can Cancer Ever Be Ignored? by Shannon Brownlee and Jeannie Lenzer

I especially like the article’s visual. It raises the seldom stated but often considered axiom that every good primary physician knows: If you don’t want to know the answer, don’t ask the question.

Dr. Kenny Lin, a key player in the PSA debate as the ex-USPSTF point investigator on the PSA screening dilema who resigned in protest of political pressure to withhold new recommendations to make PSA screening a grade D (as in don’t do it) for PSA screening in healthy males that was based on the best available evidence but was politically unacceptable writes another excellent discussion of the topic:

The Meeting that Wasn’t Revisited by Kenny Lin MD.

Stay tuned for the latest on this controversy. Subscribe to DrPullen.com to not miss a post. You can choose to subscribe to all posts, or just by category. Just enter your e-mail address in the subscribe area at the right.

NOTE THAT SINCE THIS WAS POSTED THE USPSTF HAS POSTED A PROPOSED UPDATE TO THEIR RECOMMENDATIONS FOR PSA TESTING FOR MED AS A “D” RECOMMENDATION, i.e. RECOMMENDING AGAINST USE OF PSA AS A PROSTATE CANCER SCREENING TOOL.

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