Demystifying Medicine One Month at a Time

Tag: medical skepticism

Healthy Skepticism

"Just a little pressure."

“Just a little pressure.”

GlassHospital readers know that I am skeptical of medical practices that defy logic, or as we say in the business, evidence. Among the most controversial issues that beguile all of us (patients and docs) is this business about the PSA test.

A loyal reader sent me a doctor-written column with the provocative headline “My Patient, Killed by The New York Times.”

First, keep in mind that the website that posted this, Mediaite, is all about the media covering (really fawning and dishing) itself. The purpose of this story, with its provocative headline, sad outcome, and mea culpa tone, is to generate “buzz.”

Then understand that this is a story of one patient who made an informed decision to forego PSA testing, based on the fact that he was an intelligent person without symptoms who’d read the literature (or at least responsible press coverage of said evidence). He did not want to open the Pandora’s Box (literally: crapshoot) that is PSA screening.

Yes, he wound up with advanced prostate cancer and subsequently died. Had he had his prostate removed or radiation to ablate his cancer, and wound up with horrible side effects (impotence, incontinence) would he value the trade-off?

I offer you the counter-anecdote of Ted, who in a discussion with me, insisted that he get a PSA test because his heroes Joe Torre and Norman Schwarzkopf told him to. When it came back at 4.10 ng/dL (threshold 4.00), he went for biopsy (what else to do?) which showed low grade, gland-confined prostate cancer. Fearful of the “C” word, he couldn’t live with the idea of doing nothing (“watchful waiting”) about his cancer. So he chose external beam radiation, with the hope that it would be less damaging than radical surgery.

What is radiation proctitis? Is that when your rectum is severely burned as collateral damage by the radiation beam that’s targeting the prostate, and you wind up with rectal pain and bleeding for years? Why yes, it is. That’s in addition to the impotence and loss of bladder control that Ted experienced and had hoped to avoid by foregoing the surgical knife.

Or George, who dutifully came yearly for his digital rectal exam, got his PSA, and when his biopsy showed low grade prostate cancer, opted for surgery. At 64, he told me he’d have rather be dead than live wearing adult diapers his incontinence now thrust upon him.

PSA is a contentious issue. There will always be anecdotes showing that one approach or another is WRONG. The “retrospectoscope” is always 20/20.

But when an entire industry has evolved to profit off of “advanced” treatment for prostate cancer and innocent people are harmed in the process, I get angry.

I took an oath to do no harm. Treatment that causes more harm than the disease it’s designed to cure is tragic.

People will read this post and be outraged. So let me be clear: I’m not saying that NO ONE should get a PSA to screen for prostate cancer. That genie has left the bottle decades ago. I’m saying that the medical and disease-mongering industries owe it to men to be more forthcoming about the risks, benefits, and alternatives to screening.

I try my hardest–and I’m countering years of ‘public awareness’ campaigns. Just ask my Dad, who at not-quite 75 keeps getting the darn PSA year after year despite my advice to stop. “How can a test that detects cancer be harmful?” he always asks me.

Helmet, Helmet, Helmet…NOT!

Here’s a great article questioning some wisdom that has become quite conventional.

As the French say, “sans casque.” (photo: WBUR, Boston)

[As you may know, I rather like that kind of thing.]

Like a lot of preventive health ideas, we have beaten the importance of bike helmets into (onto?) everyone’s head. Overall, this is probably a good thing.

I was lucky in my previous job to be able to walk or ride my bike to work. On the few occasions I failed to wear a helmet, I was castigated by my children, my wife, and even passers-by on the street. When you’re a doctor, there’s higher pressure to practice what you preach. [Hey, nobody ever said role modeling is easy.]

Like seat belts before them, helmets have become so routine that riding a bike without one makes me feel naked.

But what is the cost?

We can calculate real and theoretical costs of head injuries due to bike accidents. There are sobering stats: 91% of those killed while biking in 2009 were not wearing helmets. So the danger is real. But what about people choosing not to ride a bike because of mandatory helmet laws?

The article compares cities that have bike sharing programs, where people pay very little (or nothing) to borrow city-maintained bicycles and use them as a healthy, non-polluting transportation source.

Author Elizabeth Rosenthal, anticipating New York City’s inauguration of a bike sharing program, compared cities that required helmets with those that didn’t. Perhaps unsurprisingly, cities requiring helmets had much less ‘uptake’ of bikes than cities that don’t. Example:

  • Melbourne: Climate:Temperate/  Helmets:Required/ Uptake: 150 rides/day
  • Dublin: Climate:Rainy/    Helmets:Not required/   Uptake: 5000 rides/day
  • [editor’s conclusion]:  Happiness: Dublin

An expert that Rosenthal interviewed summed up the thinking this way (with some U.S. counterpoint):

“Pushing helmets really kills cycling and bike-sharing in particular because it promotes a sense of danger that just isn’t justified — in fact, cycling has many health benefits,” says Piet de Jong, a professor in the department of applied finance and actuarial studies at Macquarie University in Sydney. He studied the issue with mathematical modeling, and concludes that the benefits may outweigh the risks by 20 to 1.

He adds: “Statistically, if we wear helmets for cycling, maybe we should wear helmets when we climb ladders or get into a bath, because there are lots more injuries during those activities.” The European Cyclists’ Federation says that bicyclists in its domain have the same risk of serious injury as pedestrians per mile traveled.

Yet the United States National Highway Traffic Safety Administration recommends that “all cyclists wear helmets, no matter where they ride,” said…an agency official.

There’s an ironic (but happy-ending) twist to this story: Three days after the article ran, former Boston Red Sox manager Bobby Valentine was riding his bike in New York’s Central Park. He made the unwise choice of reading a text while biking, then flipped over his handlebars, injuring his knees and hips.

Said Valentine (per the LA Times story): “I shouldn’t have been reading a text while I was riding. That’s the wrong thing to do. But at least I was wearing my helmet.”

[Two days after that, Red Sox management fired Valentine for leading the team to their worst record in 47 years. Unclear if helmets were involved.]

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