Feeds:
Posts
Comments

Archive for the ‘Medical opinions by a physician’ Category

Documenting a deteriorating healthcare system.

Posted in Blogfinger Presents, Medical opinions by a physician, Medical topics by Paul Goldfinger, tagged on October 6, 2015| 3 Comments »

Internet graphic

Internet graphic

Paul Goldfinger, MD, FACC.   Editor @Blogfinger.

Some of you have berated me for having a negative attitude regarding Obamacare. The truth is that many good things will come out of our new healthcare, but I am alarmed by the negatives which continue to slowly drip out the cracks and insinuate themselves seemingly overnight and unannounced into our experiences with doctors, hospitals, drug companies, etc.   I am concerned that the negatives will outweigh the positives and cause damage to our loved ones as they seek care.

So I will have an ongoing project to report on pluses and minuses as they occur. Here are two that appeared on my radar screen this week. Since I am no longer practicing medicine, I go by the experiences of family, friends and myself. Yes it is anecdotal but I also keep watch on the media, especially when clinical trials look at these matters, when doctors speak about the situation, and by watching the AMA reports which I receive regularly.  Hopefully some of you will share your observations.

Here are my recent findings.   It may not seem like much, but cumulatively, there may  be substance, and I do believe that smoke might indicate a fire.

#1. A man approached the front desk at a surgeon’s office. He asked that the surgeon’s report be sent to his doctor. He was told that he would have to pay $15.00 for that service.

Whenever a specialist sees a patient, it is his obligation to send a consultation report to the primary doctor. Ideally he should also call the referring physician. I believe that communication of this type is deteriorating because of the expectation that electronic medical records will fill that void, but they won’t because they are lacking in specificity, and when our society allows time-honored individualized medical practices to fall by the wayside in the interest of time and money, quality will suffer.

Patients should request copies of their consultation notes and they should read those notes carefully.   They should find a history, physical exam, test results, a diagnosis and a narrative discussion/analysis, with an individualized plan, regarding the problem;  and no one should be charged for those reports.

#2. A doctor orders a blood test for a patient. He orders it, not on a whim, but because it is needed for proper patient care. The patient goes to the lab and is informed that the insurance company may not pay for the test. He is required to sign a form to indicate that he may have to pay personally.

Subsequently he receives a bill for $115.00 from LabCorps for that routine test. Evidently the diagnostic codes supplied by the doctor did not justify the test.   The patient complained to the doctor’s office and asked that the bill be resubmitted by the doctor for consideration, using “better” codes. The office tells the patient that this is not the doctor’s problem. Ouch!

Sorry, but this is the doctor’s problem, and he should help so the patient doesn’t get stuck with the bill. This is an example of interference in the practice of medicine by insurance companies  and indifference on the part of the doctor.

Read Full Post »

Advisory panel considers changing recommendations on cholesterol

Posted in Blogfinger Medical Reports, Blogfinger Presents, Medical opinions by a physician, Medical topics, Medical topics by Paul Goldfinger, tagged on February 16, 2015| Leave a Comment »

AMA new bannerACC

The Blond Pharmacist

The Blond Pharmacist

Scott Pelley reported in the CBS Evening News (2/10) that according to the Dietary Guidelines Advisory Committee, a government advisory panel, “we don’t have to worry so much after all about cholesterol in our diets.”

 

Dr. Jon Lapook noted that while “the amount of cholesterol in your blood is still important,” the panel found that “the amount of cholesterol in your food doesn’t necessarily translate to a higher level of cholesterol in your blood.”

 

While the current recommendations “say people should have less than 300 milligrams of cholesterol in their diet a day,” that number is “likely to change when the recommendations come out later this year.” Linsey Davis noted on ABC World News (2/10, ) that while the panel said that “eating some foods that are high in cholesterol like eggs and seafood may not be so bad after all,” foods like “meats and cheeses, because they contain saturated fats, are still on the list.”

 

The Washington Post (2/11)  reported in its “Wonkblog” blog that this “does not reverse warnings about high levels of ‘bad’ cholesterol in the blood, which have been linked to heart disease,” adding that “some experts warned that people with particular health problems, such as diabetes, should continue to avoid cholesterol-rich diets.”

 

The blog stated that “a group from the American Heart Association and the American College of Cardiology who looked at the issue in 2013 said there is simply not enough evidence of danger to call for limiting cholesterol in diets.”
USA Today (2/11, ) reports that “the committee will send its final recommendations to the Department of Health and Human Services and the U.S. Department of Agriculture, which issue the dietary advice.” HHS and the USDA “are expected to issue Dietary Guidelines for Americans, 2015 later this year.”

 

The AP (2/11, Jalonick) reports, however, that “it’s unclear if the recommendation will make it into the final guidelines.”

 

Blogfinger Medical Commentary by Paul Goldfinger, MD, FACC

The cholesterol story began in the 1960’s when it was found that high blood cholesterol levels were associated with heart disease. But we also found out that dietary cholesterol does not increase blood levels of “bad” cholesterol, unlike lab models where heavy intake of cholesterol leads to plaque formation.

When it came to dietary advice, early on in the cholesterol era, most experts favored diets low in saturated fats without stressing cholesterol so much.  In our book, in the chapter called “Concepts: Cholesterol Risks and Treatment,” we did not even mention dietary cholesterol. As it turns out, many foods that are high in fats, such as red meats, are also high in cholesterol. But eggs, rich in yolk cholesterol, contain no fats and do not raise blood cholesterol.

What hasn’t changed is the fact that lowering bad blood cholesterol levels does save lives, but restricting dietary cholesterol is not the way to do it.

As time went by, we learned that even severe dietary fat restriction often doesn’t lower bad cholesterol levels enough to produce a clinical benefit, and that has led the prevention community to stress Mediterranean style diets which we discuss in depth in Prevention Does Work: A Guide to a Healthy Heart by Eileen and myself.

If the guidelines change, as described above, I don’t think it will make much of a difference in what people do or doctors advise. Maybe there will be a loosening of restrictions on eggs, lobsters or shrimp, but otherwise, not much change.

Read Full Post »

CDC says flu activity has reached epidemic threshold.

Posted in Blogfinger Presents, Medical opinions by a physician, Medical topics, tagged on January 3, 2015| Leave a Comment »

 

 

Unknown-9

AMA new banner

 

“Following earlier warnings from the CDC that this year’s flu season could be more aggressive than other years, the agency announced that flu incidence has crossed the epidemic threshold. An emailed statement from the CDC’s flu division said that influenza “reaches an epidemic level when the proportion of deaths attributed to pneumonia and influenza reaches a certain threshold: 6.8 percent.” Most major national outlets covered the story, focusing on both the characteristics of this year’s strain and the efficacy of the vaccines currently available. Local media have focused on the flu as it has affected local hospitals and school systems.

“The Washington Post (12/30, Ohlheiser) reports that the CDC’s announcement that this year’s flu activity has reached “epidemic levels” comes as “the number of states reporting a ‘high’ level of influenza activity jumped from 13 to 22 in one week.” The dominant strain of the flu this year is H3N2, and in early December CDC Director Tom Frieden warned that “H3N2 predominant seasons tend to have more hospitalizations and more deaths.”

“Similarly, ABC News (12/31) chief health and medical editor Dr. Richard Besser said that “while this year’s strain of the virus is especially severe,” the flu “can always be deadly for children, the elderly and anyone with a compromised immune system.”

“USA Today (12/31, Grisham) reports that according to Michael Smith, a doctor and chief medical editor for WebMD, the H3N2 strain of the flu “isn’t uncommon; it’s just not what was predicted when the flu vaccine was created.” What ultimately gets included in the vaccine is decided each year by the FDA “based on recommendations from the World Health Organization” and “takes about six months to produce.”

“Reporting on the available treatments, Bloomberg News (12/31, Cortez, Edney) adds that some areas of the US “are experiencing spot shortages of Tamiflu (oseltamivir),” one of the mainline flu treatments for this year.”

Blogfinger Medical Commentary:  By Paul Goldfinger, MD, FACC

Influenza can result in a “superinfection” with pneumonia.   Such lung infections can cause death in about 8% of cases, and the combination can cause a patient to get very ill and wind up in the hospital.    

If you are over 50, ask your doctor about a new vaccine to prevent pneumonia called Prevnar13.  It is not 100% protective, but it can offer good results in some people. It is a single shot treatment, and it doesn’t matter if you had a pneumovax shot in the past  (except less than one year ago.)

If you haven’t had a flu vaccine, you can still get one.   This new pneumonia vaccine can cost about $135.00, but Medicare may pay for it.

Read Full Post »

Preventing Stroke by Extended Heart Monitoring Looking for Atrial Fibrillation (AF)

Posted in Blogfinger Presents, Medical opinions by a physician, Medical topics, tagged on July 22, 2014| 2 Comments »

AMA_masthead_728

The New York Times (6/26, O’Connor) “Well” blog reports that “two major studies suggest that many strokes of unknown origin (i.e. cryptogenic strokes) — up to a third — may stem from atrial fibrillation.”   Atrial fibrillation  (AF) is a cardiac rhythm disturbance which causes the heart to beat erratically.   “These findings are likely to encourage physicians to look more aggressively for signs of atrial fibrillation in patients who suffer strokes of unknown cause.”

Hooman Kamel, MD, Weill Cornell Medical College, New York, says that most patients with cryptogenic stroke or transient ischemic attack should undergo at least several weeks of rhythm monitoring.

 

Blogfinger Medical  Commentary.  By Paul Goldfinger, MD, FACC

When considering the cause of stroke, the heart is usually not directly involved.   But if that occurs,  it is usually due to a clot  (an embolism,)  originating in the heart,  traveling  to the brain . This condition  is called an “embolic stroke”  and may be due to atrial fibrillation.  Atrial fibrillation  (AF) can be chronic  (i.e. present all the time) or intermittent (paroxysmal—-  PAF)

Stroke patients receive a workup in the hospital to look for a specific cause of the stroke.   After that  initial evaluation, including heart monitoring,  up to 1/3 of stroke cases are found to  have no obvious cause—i.e. they are “cryptogenic strokes.”   But the absence of AF in the hospital does not rule out PAF as the cause of the stroke.

In the past, if we found AF in the hospital, we would soon start anticoagulation (blood thinners) to prevent clot formation. If there was no AF in the hospital,  many doctors would also get an outpatient  24 hour Holter monitor recording done.   But thanks to new extended heart monitoring technology, we now know that AF may  commonly occur intermittently, including very infrequent episodes,  last for short periods of time, produce no warning symptoms, and  can cause embolic  strokes.  So now we have the challenge of finding out if a stroke victim has undetected paroxysmal AF  (PAF,)  and that involves extended ECG monitoring of the heart’s rhythm.  Just a few days of monitoring is not enough.

This fairly new observation about PAF has awakened the cardiology community, and on June 26, 2014, two new clinical trials, one from Canada and the other from Italy, appearing in the New England Journal of Medicine, have confirmed that embolic strokes due to PAF are more common than ever thought before, and that finding those patients  with new monitoring methods may save lives by getting those individuals on anticoagulation treatment and possibly treatment aimed directly at the AF itself.

That is why the American Heart Association now  suggests that doctors order heart monitors for up to 30 days to look for evidence of “silent” PAF  (i.e. the arrhythmia occurs, but there are no symptoms such as palpitations.)  

And now, thanks to long term monitoring (for months or years) using small implantable devices that are on constant alert (Medtronic “Reveal XT”), one of those new studies  reveals that up to one third of those cryptogenic strokes are, in fact, due to parosysmal atrial fibrillation.

Medtronic implantable heart rhythm monitor. Medtronic graphic.

Medtronic implantable heart rhythm monitor. It is placed under the skin on the chest . Medtronic graphic.

The NY Times article  linked above speaks in lay terms  about these amazing monitors, and as a cardiologist interested in heart rhythm problems, this is very exciting.  As with all new medical discoveries, new answers generate new questions, and  related issues need to be investigated to identify how to best use the new technologies while keeping costs down.

Some insurance companies may not pay for the expensive implantable monitor.  In my opinion, anybody who is found to have a stroke or TIA due to AF,  should undergo an evaluation by an electrophysiologist—-a cardiologist who specializes in heart rhythm disturbances.

 

 

 

Read Full Post »

New study of dietary fats finds that saturated fat intake is not linked to heart disease.

Posted in Medical opinions by a physician, tagged on March 30, 2014| Leave a Comment »

By Paul Goldfinger, MD, FACC.  Chief Investigator of the Blogfinger Off-shore School of Medicine   (that would be off the shores of Wesley Lake.)

In Woody Allen’s 1973 movie Sleepers , he wondered if we might discover that dietary fats would eventually be found to be healthy.  In the last 40 years, the public has been encouraged to reduce fats in their diets in order to prevent heart disease. Many research trials confirmed that saturated fats, such as are found in red meats, ice cream, butter and cheese are a major factor in causing clogged arteries. Along with that, we were told to reduce trans-fats and foods rich in cholesterol, and to have more polyunsaturated fats such as canola and olive oil.   Our book Prevention Does Work: A Guide to a Healthy Heart stresses such dietary efforts but acknowledges the complexity of the situation.  We wound up recommending a Mediterranean diet which allows increased “good fats”–a recognition that not all fats are bad.

images

Americans responded by reducing their fat intakes, but obesity has continued to be a problem along with hypertension, diabetes and smoking. In addition, other dietary factors contribute to risk including refined sugars, salt, excess calories,  processed foods, and inadequate fiber intake.

Some of you may have heard about a British (U. of Cambridge)   study published last week in the Annals of Internal Medicine which said that they could find no relationship between dietary saturated fats and heart disease.  Many media outlets jumped up and down over this report, and many of you said, “Yes!! Let’s buy real butter and steaks.”

Unknown-1

The trial was a meta-analysis of about 70 studies from 18 countries that encompassed over 600,000 people. But the usual  gold standards for definitive research are  controlled randomized trials. Instead this analysis is an amalgam of many prior observational studies which looked at groups of people  and checked what kinds of fats they were eating and whether they got heart trouble or not. The meta-analysis took all  those studies, ran them through their computers, and came up with generalized conclusions.    This sort of  homogenized information  proves very little that is new;  it just sorts it out differently and raises some new questions.

What the study does is to suggest that the dietary advice which the public receives from official agencies be reassessed and that more research  be done for clarification.   Dr. Chowdhury of the U. of Cambridge, the lead author in the study said,  “These are interesting results that potentially stimulate new lines of scientific inquiry and encourage careful reappraisal of our current nutritional guidelines.

Although the British study did surprise some experts, it probably will not change the dietary recommendations of the National Institutes of Health or the American Heart Association. At most they may change the wording or the emphasis somewhat. But this trial just came out last week, so after the medical community digests the results, we can expect to hear more controversy about it.

What the trial  points out is that we need to look at the foods people are eating along with the specific kinds of fatty acids and other nutrients they are consuming.  We already have reported here on the need to adopt a diet  such as the Mediterranean style diets  which emphasize plant based foods and fish and which emphasize more natural heart-healthy nutrients as are found in  fruits and vegetables. The idea of avoiding processed foods is important because so many new such products appear every day.  The mantra now is not to eat anything which your grandmother wouldn’t recognize as food.

Yes you can have some saturated fat in your diet but it should be minimized and carefully selected.   Trans-fats are still toxic, even in this study, and carbs  (other than fiber rich kinds)  can make you fat even if you eat very little fat.

The British Heart Foundation said that the findings did not change the advice that eating too much fat is harmful for the heart.  Prof. Jeremy Pearson the charity’s associate medical director said ,” This research is not saying that you can eat as much fat as you like.”

So, sorry Woody, but too much saturated fat in the diet is still not good for you.

 

Here is a link for supplemental reading:     Saturated fats link

Read Full Post »

Healthcare Vocabulary: Collaboration and Communication

Posted in Medical opinions by a physician, tagged on March 21, 2014| Leave a Comment »

Internet photo

Internet photo

By Paul Goldfinger, MD, FACC.  Medical Director of the Blogfinger School of Health Sciences, based in beautiful Ocean Grove, NJ.

Recently I posted a piece about how electronic medical records might compromise quality patient care:

EMR interfering with quality care

In that piece the emphasis was on how a physician, wound up entering data into a computer, might not be engaged effectively in the traditional doctor-patient interaction in the office setting, the clinic, or the hospital. We have been told that EMR’s will improve quality and lower costs, but the technology is not yet mature, and it is causing a degree of chaos in the medical setting along with huge increases in the cost of practice having to do with the turnover from traditional medical records to a new and incomplete system.  It is a promise not yet kept.  Obamacare, through Medicare, is pushing hard to make this happen, but it is difficult to feel confident about the administration’s current  grasp of complex computer systems.

Yesterday I spoke to a physician friend who is one of the leading oncologists in the state of New Jersey.  I asked him how things were going, and he said that about 125 cancer specialists in New Jersey had formed a group in order to continue the private practice of medicine and to avoid being taken over and turned into employees  by corporate hospital systems. Other oncologists from other states might join the group as well, as these doctors struggle to maintain their independence.

I have heard about efforts like this, and it seems as if the old ways are dissolving and that, like Sisyphus, traditional doctors are trying to push a boulder up a hill.

But he also had something  to say about EMR’s as they are currently being used.   He said that they were reducing the quality of care by reducing communication between doctors.  He said that collaboration between doctors has always been important for patient care, but now, he says, doctors simply type into their computers and “they don’t talk to each other any more.”

In the past, a consulting physician would often pick up the phone and discuss the situation with the referring doctor.  He would also send a detailed consultation note.  But now, I have a suspicion that formal opinion notes and conversations are on the decline.

Next time you see a consultant, ask your primary doctor if he has heard from the consultant and can you have a copy of the consultation report.  I’m not sure how that collaboration and communication is working now, but test it out. You deserve to know.

Read Full Post »

Are Electronic Medical Records Interfering with Care Quality?

Posted in Medical opinions by a physician, Medical topics, tagged on March 10, 2014| 4 Comments »

images

AMA_masthead_728

Forbes contributors say EHRs leaving physicians with less time for real patient care.

In a Forbes (3/4) op-ed titled “Technology Is Interfering With Your Doctor’s Visit,” contributors Louis Goodman, PhD, president of The Physicians Foundation and the executive vice president and CEO of the Texas Medical Association, and Tim Norbeck, CEO of the Foundation, discuss “a recent Rand study commissioned by the American Medical Association” in which physicians “said being able to provide high quality healthcare is the primary driver of their satisfaction.” That study “also found the number of factors contributing to dissatisfaction is becoming almost insurmountable.” Goodman and Norbeck also point out that EHRs are not saving as much money as it was once believed that they would. According to Goodman and Norbeck, “Couple the burden and disappointment of inadequate EHRs with the added obligation of entering data to a patient record at the rate of 30-40 keystrokes per patient, and physicians are left with much less time for real patient care.”

Here’s a quote from that Forbes article:     “Washington appears to be convinced that technology is the answer to better care, even when physicians will tell you that better care depends on listening to and examining the patient through their history and physical – albeit technology has a role in diagnosis and confirmation of findings.”

BLOGFINGER MEDICAL COMMENTARY  by Paul Goldfinger, MD, FACC

The implementation of electronic medical records is a recent development, and I have had no personal actual experience with it, but I have spoken to practicing doctors and I am aware of the theoretical benefits.

But let’s go back to basics.  The medical record (file)  is a key care component—a vital tool in the practice of medicine.  It is the best way to contain all the pieces of a medical history  It needs to be thorough, legible and organized.  The doctor is the main player because he must make notes that describe what the patient said, what he found, what the assessment (i.e. diagnosis)  is, and what the plans are.  But also the record must contain test reports, nurses’  notes, consultation reports and any other relevant data.

In my practice we used to have a full time person who kept the files in good condition, properly filed,  and who used to drive the charts all over Morris and Warren counties to catch up with the patient and his doctor, whether it meant taking charts to the ER, the hospital  or to one of our satellite offices. It was very difficult, but we needed the chart to properly evaluate the patient.  Inadequate documentation made the chart less valuable, and some doctors did a lousy job of that while others were meticulous.  As for legibility, we had 3 full-time typists completing our dictated notes and pasting them into the medical record. Of course, if one of our patients wound up in a South Dakota ER, there would be no “old chart,”only the chance that the ER doc could speak by phone to the NJ doc, and that often did occur, but you can see the potential problems.

EMR’s should eventually make the medical record component of care much better.  But, at this time, the technology is not as good as it will become. Your doctor may be able to access your labs from the local hospital, but that South Dakota doctor may still be out of luck because most EMR systems are locally based—eg Meridian’s EMR system may be available only  to doctors on their staffs.  And then, or course, the EMR’s are only as good as the data inputted by various sources.

The EHR is a necessary piece of the pie, but most important is the traditional role of the physician.  In this brief but very provocative Forbes article  (click the link above ,) you can see that some doctors believe that EMR’s are compromising their goal of providing the best care to their patients.

I was seen by a local ER doc last year who took my history while having his nose buried in his computer–and with his back to me.  I could have been an egg plant with no arms or legs for all he knew. There was no doubt in my mind that the damn computer was an obstacle to my getting proper care.  This all may get sorted out, but for now, don’t be too enamored by high tech EMR’s—in medicine the doctor-patient relationship is paramount, and it is a very old, tried and true concept which should not be sacrificed in the name of technology.

Read Full Post »

AMA: “Little evidence multivitamins prevent heart disease, cancer.”

Posted in Medical opinions by a physician, Medical topics, tagged on February 25, 2014| 6 Comments »

AMA logo_1_1

images-1

According to USA Today (2/25, Painter), “Most vitamin and mineral supplements, alone or in combination, have not been proved to help or hurt when it comes to preventing cancer or heart disease, says a new report from the…US Preventive Services Task Force.” In the majority of “cases, more research is needed, but there are two exceptions, the panel says: Consumers should not take beta-carotene or vitamin E to prevent heart disease or cancer because vitamin E doesn’t work and beta-carotene increases the risk for lung cancer in people at high risk for the disease.”

Blogfinger Medical Commentary:  By Paul Goldfinger, MD, FACC

In 2011 when we finalized the current edition of our book “Prevention Does Work–A Guide to a Healthy Heart” we reviewed all the current data on vitamins and came up with this summary, “Vitamins used to be recommended as preventive therapy due to their anti-oxidant actions. In recent years, however, large trials have shown no benefit with vitamins, so these supplements can no longer be considered part of a prevention regimen. This conclusion does not apply to vitamins found in fruits and vegetables “

The AMA summary above brings us to 2014 on the subject of vitamin supplements.  There was a 2012 trial of Centrum Silver which suggested that daily multivitamin use in men might reduce the risk of cancer, but the proof was iffy.  The article below from Forbes is a brief and excellent review of the whole topic.

A huge number of people take vitamins regularly, but unless they have a vitamin deficiency, they are just engaging in wishful thinking.  As a practicing doctor, some patients did confess that they took vitamin supplements.   My reaction was to say that there was no good evidence as to benefit, and I reminded them that supplements are not always safe.

Do I take daily vitamins?  No.  But after the 2012 study, I hopefully bought a bottle of Centrum Silver, however,  it still is sitting in a closet, with about 14 tabs missing—my personal two week trial.

Good vitamin review at Forbes

EDITOR’S NOTE:  I call your attention to the comment below where David Seres, MD, a genuine expert in nutrition and Associate Professor of Medicine at NY Presbyterian Hospital in NYC, has offered us a superb and erudite discussion of the roll of vitamin supplements in preventing disease.

David is also a Grover, one of many highly accomplished individuals who call Ocean Grove home. So, you see, you never know who might be in line with you at Days.   —PG

Read Full Post »

The Mammography Mess: A controversy with conflicting information

Posted in Blogfinger Presents, Medical opinions by a physician, Medical topics, Medical topics by Paul Goldfinger, tagged on February 2, 2014| 7 Comments »

AMA logo_1_1

Mammogram

Mammogram

“A 25 year Canadian study just published in the British Medical Journal  questions the value of mammography. Research suggesting that mammography may not be beneficial was covered by some of the nation’s most widely-read newspapers as well as on several medical websites.  

“In a  front-page story, the New York Times (2/12, Kolata) reports that research published in the BMJ, “one of the largest and most meticulous studies of mammography ever done, involving 90,000 women and lasting a quarter-century, has added powerful new doubts about the value of the screening test for women of any age.”

“The findings may “lead to an even deeper polarization between those who believe that regular mammography saves lives, including many breast cancer patients and advocates for them, and a growing number of researchers who say the evidence is lacking or, at the very least, murky.”

“The  Los Angeles Times (2/12, Morin) reports that investigators “examined the medical records of 89,835 women in six Canadian provinces between the ages of 40 and 59. All of the trial participants received annual physical breast examinations, while half of them also had yearly mammogram screenings for five years, beginning in 1980.” During “the next 25 years, 3,250 of the 44,925 women in the mammography arm of the study were diagnosed with breast cancer, along with 3,133 of the 44,910 women in the control group.” Meanwhile, a nearly identical number of patients from each group died of breast cancer.

“In a separate story, the New York Times (2/12, Rabin) reports that the new findings will add to the controversy surrounding the value of mammograms. Further complicating the issue is the fact that different medical groups have different recommendations regarding mammography.

“USA Today (2/11, Szabo) reports that ‘Barbara Monsees, a radiologist with the American College of Radiology, says the…study is fundamentally flawed and useless for drawing conclusions.’ “

Blogfinger Medical Commentary by Paul Goldfinger MD, FACC:

If you walk on Main Avenue in Ocean Grove, if the snow has been cleared, you will see remnants of a pink stripe that was put down during a one month breast cancer fundraiser in October. The pink symbols were everywhere, and the theme was to promote mammograms for women who hadn’t had them.  I thought that the pervasive drumbeat was overdone, given that it was all about pushing mammograms. I couldn’t recall another comparable  fundraiser that focused on a diagnostic test rather than basic  or clinical research into prevention and cures, so this month- long effort seemed to me to be out of proportion.

In 2009, the US Preventive Services Task Force recommended cutting back on mammograms for all women, and especially avoiding them altogether for those in their 40’s.  They suggested that women age 50-74 have the test every other year.  The American Cancer Society disagreed and suggested mammograms yearly from age 40 and up.

A controversy ensued which is still simmering and has now been exacerbated by this massive Canadian trial on nearly 90,000 women over 25 years.  The study concluded that annual screening mammograms do not reduce death rates when compared to skilled manual examinations by specially trained nurses.  They say that too many mammograms are being done and that mammograms can cause “harm.”

Last week, on NPR.org  radio, there was a one hour discussion with Diane Rehm interviewing  two of the world’s experts in mammography as they debated the results of the Canadian trial. They had practically opposite opinions and they were attacking each other over facts and even  issues such as conflicts of interest and flawed conclusions.

So there is no way that I can do this subject justice except to summarize the facts and the  issues, especially as put forth by the Canadian trial.  I suggest that women do some reading on their own to avoid being swayed by experts with agendas:

1. Mammography is an imperfect test for the diagnosis of breast cancer and is over-rated as a life-saving procedure. The idea that early detection saves lives is being seriously questioned.

It is true that in recent years, the survival rates of breast cancer have improved significantly, especially in the 40-49 year old group, but the benefit seems to be due to newer treatment options, such as the drug tamoxifen, and not due to screening mammograms.

2. This huge Canadian trial is being criticized by some, such as a leading professor of radiology from Harvard, on the grounds that the study design was flawed, the quality of the mammograms was awful, and too many small tumors were missed due to antiquated  machines.  He also had other highly technical criticisms as well.

3. Even current mammography machines sometimes miss small cancers. The test also often raises questions about abnormalities that are not cancer  (i.e. false positive results.)  30% of the time patients are brought back for more films causing great stress and extra radiation.    In addition, the test may detect cancers that either are too small and slow growing to cause harm or are pre-cancerous conditions which will not endanger lives.  One in five cancers found by mammography are the kind that pose no lethal threat, so those patients currently get unnecessary treatment.

4. The problem with such “over diagnosis” is that some women get subjected to  harmful aggressive approaches including biopsies, drugs and mastectomies which are not necessary. The harms include drug toxicity, surgical mutilation and risks, and mental distress.  The researchers in Canada say that sometimes mammograms cause more harm than good.

The clinical challenge is to decide which cancers can be left alone or just treated medically. The ability of oncologists to make these differentiations are currently inadequate.

5.  Some fund raising organizations have been accused of over stressing the importance of mammography and distorting the statistics of success attributed to the test.   (see the Time article below).

6. This new trial of 90,000 will cause all doctors who treat breast cancer to re-evaluate their use of mammography and will result in a new assessment of the criteria for ordering screening mammograms. These new guidelines should be available in 2015, but as with the PSA controversy, different expert panels will offer different recommendations.

7. At this time, most women will probably plan to continue with the same yearly regimen from age 40-59  (which is the age range of the new study,)  but they may be surprised to find a more nuanced individualized approach when they see their doctors. And they may discover that their doctor offers them an option of skipping mammography altogether.

One potential concern is whether the new Obamacare insurance policies will cover all mammograms that are requested. This Canadian study will likely provoke women’s advocacy groups to object strenuously because most American women have been sold on the life-saving benefits of early diagnosis with mammography.

8.   There will be many women who have not had mammography  or who have been skeptical of the test.  They will use the controversy as a reason not to have mammograms.  But if a woman makes that choice, she must do self examinations and have a manual exam by an expert examiner yearly.  (The same is true also for women who do have mammograms.)  She also should discuss her decision with a doctor, because some individuals have higher risks than others.

9.  New imaging methods are in the works including 3-D mammography.

Time magazine article on Komen ad

10.  Here’s a link to a  NY Times article on self examination of breasts:

self exam link

Read Full Post »

Higher alcohol consumption in middle-aged men tied to memory decline.

Posted in Medical opinions by a physician, Medical topics, tagged on January 26, 2014| 3 Comments »

AMA_masthead_728

Source: LA Times

Source: LA Times

One national news broadcast, several major newspapers, one wire source, and numerous consumer online medical sources report a study suggesting that mental decline is associated with heavy drinking in middle-aged men.

ABC World News (1/15, story 8, 1:40, Sawyer) reported that a study (1/16) published online Jan. 15 in the journal Neurology “shows that beer and wine speeds up memory loss, but it seems only if you drink a certain amount.”

The Los Angeles Times (1/15, Healy) reports, “Middle-aged men who consume an average of more than 2½ alcoholic drinks per day accelerate the rate at which their memories decline by almost six years over a 10-year span,” the study found. What’s more, “while a higher consumption of spirits such as vodka, gin, whiskey or scotch was linked to the fastest rates of mental decline in men, researchers saw little difference between the cognitive loss seen in heavy beer drinkers (who drank more than 2½ 12-ounce beers per day) and that seen in men who quaffed a half-bottle of wine or more per day.”

USA Today (1/15, Painter) reports that the study, which also “looked at women…found no clear results for them.” The research suggests that “lighter drinking does not contribute to cognitive decline.” The study’s lead author said, “The findings are in agreement with previous studies and suggest that moderate alcohol consumption is probably not deleterious for cognitive outcomes.”

BLOGFINGER MEDICAL COMMENTARY:  By Paul Goldfinger, MD, FACC

I don’t suppose too many of you would be surprised by this study since most of us have experienced the effects of alcohol on our brains. Most of us also understand that as we get on past middle age, a certain amount of mental  (i.e. cognitive) function deterioration might occur due to aging.  But this trial from England of 7,000 government workers  ages 44-69  (mean age 56)  shows that fairly heavy drinking will accelerate the progress of cognitive decline. The study was published on January 15 in the journal Neurology.  You can read the definitions by clicking on the links above.  Note that there weren’t enough women in the trial to come to any credible conclusions about them.

The USA Today article mentions adverse effects of alcohol drinking which include “increased car crashes.”   I’m sure you all are shocked by that disclosure.

As a cardiologist, I have the peculiar task of advocating mild alcohol use , especially red wine, for prevention of coronary disease, while preaching against heavy drinking because of risk of some forms of heart failure.   But that advice is consistent with the results of this trial which showed no cognitive impairment for those who are light or moderate drinkers. Only the heavy drinkers had brain problems.

Other serious disorders which can be increased by alcohol  include breast cancer, brain damage, and liver disease.

Read Full Post »

Confessions of a High Blood Pressure Doctor, Part III: New Treatment Guidelines from the JNC 8.

Posted in Blogfinger Presents, Medical opinions by a physician, Medical topics, tagged , , on December 30, 2013| Leave a Comment »

images-2

By Paul Goldfinger, MD, FACC

You should understand that these JNC 8  (Joint National Commission) guidelines were first published in 1972, and “since then the incidence of strokes has fallen by 70%, and heart failure rates have fallen more than 50%”  (Source: NY Times, Gina Kolata 12/18/13)

Most doctors will follow these recommendations, but the JNC stresses the importance of making individualized decisions when treating patients. Such flexibility is essential for excellent quality care.

There are two central issues at play in the field of hypertension.  The first is, “What is the definition of hypertension?”  The second is, “What is the correct way to treat hypertension?”

There has been no fundamental change in the definition of hypertension in 30 years including the current guidelines.   Anyone who has a persistent BP reading of over 140/90 is diagnosed as being hypertensive. Sometimes a patient may only have high systolic (the top number) readings or just high diastolic (bottom number) readings, but in such instances, those patients are also considered to have hypertension.

The diagnosis of hypertension should not be made from just a few BP measurements. Especially unreliable are isolated readings in a doctor’s office.  In my practice, I would insist on multiple home readings taken at various times of the day, in various circumstances, and with written documentation.  A very good test for diagnosis is a 24-hour ambulatory BP monitor, but insurance companies often will not reimburse for that expense.  (about $225.00 )  Sometimes it’s good to get a test anyhow and pay for it yourself.

The JNC 8 report represents the first change in ten years regarding guidelines for physicians as to when and how to treat high blood pressure.   This group has its origins at the National Institutes of Health, and it uses evidence derived from RCT’s (randomized clinical trials.) This commission, comprised of experts, took five years of study before coming up with this result.

The actual document is quite complicated. But the most important point is that treatment should be started for anyone over age 60 who has a blood pressure exceeding 150/90.  The cutoff used to be 140/90, but the commission decided to be less strict on the systolic number based on the studies.

For those under age 60, 140/90 is still the cutoff number, although the evidence regarding how to treat young hypertensives is less compelling.  Unlike the prior recommendations, lower goals for diabetics and with chronic kidney diseases are no longer recommended.

Some of you may have heard from your doctors that your BP should be 120/80 in order to maximize risk reduction, but that concept has been rejected by JNC 8 because it is unproven.

Your doctor may choose to treat your hypertension with non-pharmacologic  “life style treatments” that include diet (including salt restriction*,) weight control and exercise.  Those treatments should be adopted by anyone with high blood pressure, but there is no strong evidence that they alone can reduce the risk of complications.  In addition, life style approaches can be tried without drugs, but only in the mildest cases. If someone has moderate or high readings, there should be no delay in initiating drugs.

The guidelines are very specific regarding which drugs are used, and it is common for patients to require multiple medications in order to keep doses and side effects down.

In our part IV installment, I will share some of the insights and ideas that I have followed after 30 years in practice and which pretty much fall in to the realm of “the art of medicine.”  Patients need to know that many decisions which doctors face  must be made using sound judgment, experience, collaboration with colleagues, and clinical studies which do not rise to the lofty category of  RCT’s.

* Blogfinger article earlier this year about saving lives with salt restriction:

Blogfinger salt article

Read Full Post »

The Conversation on Obamacare Moves to the Next Step: Understanding why you should hate your existing health insurance

Posted in Blogfinger Presents, Healthcare Topics @Blogfinger, Medical opinions by a physician, Medical topics, tagged , on November 11, 2013| 14 Comments »

news.yale.edu

news.yale.edu

By Paul Goldfinger, MD, FACC

I have been skeptical about Obamacare since the law was passed.  I have tried to stay clear of the politics. My concern from the start has been, “What the heck is inside that law?  How will it actually work in terms of the practice of medicine?” Hardly any details were released, and it now seems that some legislators may not have read it, as indicated by all the surprised lawmakers who are currently upset about cancelled pre-existing health insurance policies.

So now that  the controversy is looking past the incompetent roll-out, and assuming that insurance plans will soon be available to purchase on the exchanges, the conversation is moving to the details about the insurance policies themselves.

Naturally, if one is worried about the practice of medicine, paying attention to health insurance is essential.  The President promised that we could keep our existing plans and doctors if we want, giving the impression that the ACA was essentially about the non-insured.

He also gave the impression that the insurance exchanges would give private insurance companies the chance to compete in a free enterprise marketplace.  But now we see that no company can get their policies into the exchanges unless those policies are designed just the way the government demands they be.  As a result, millions of people are losing their existing plans.

 Evidently this aspect of the ACA is hidden somewhere inside the huge pile of papers that make up the bill. It’s just that it was kept under wraps until now when so many Americans are getting those surprise letters.

So now that people are being dropped  (including nearly 1 million in New Jersey) from their existing plans, the administration defends what’s going on by saying that those pre-existing plans are “crummy” and not worth keeping in the first place.  Why are we hearing this news for the first time now?

So we get to the crux of the problem:  The public is too stupid to understand what one needs in an insurance policy to  get quality care.  But history shows us, including what happened in the ’80’s and ’90’s regarding “managed care/HMO’s,” that people do know what they need.  They just have to be educated about the particulars, and the bureaucrats who are running Obamacare, have assiduously avoided telling us the truth until now, and more hidden truths will keep oozing out of the ACA as the  smoke screen continues to fade.

Read Full Post »