What do Patients Want?

What do Patients Want?

I looked at the question and thought. Well that is simple. Isn't it?

Patients have acquired a disease or illness. So the first thing they want from their doctor is:

1. Understanding of their malady: They want to know what the doctor understands about their signs and symptoms and what will he/she do about it. They want the doctor to listen to their relevant complaints before he/she decrees a treatment. If it satisfies the patient then all is well. But herein lies a problem. Even if the patient is agreeable to that interpretation, is that the right one? And that is where modern medical care gets hung up. Trying to define “interpretation” is a subject du jour  of great debate. So in the academic and political world of medicine, where medicine is not practiced, a physician’s judgment must be exact, correct and to the point. But, but… There is a thousand page reference book of “Differential Diagnosis,” which seems to suggest that what is manifest does not have an exact answer, but is merely an algorithm to get to a fragment of the truth. Therefore outlining issues for the patients by the doctor, in tabulated form, is a good measure of prioritizing time and helping the patient understand the nuances of their medical care and the disease itself. It is in this vein that the facts about the disease, its curability or lack thereof must be discussed. Humans are not robots and even with all the advances of science and knowledge of genetics and cellular function, life remains a terminal disease!

2. Time: The patients want to spend time with their physicians so they too can understand the process of their disease, its treatment and the potential benefits of therapy for their malady. Here is the biggest bugaboo in the land of medicine. Time is in short supply for both the patient and the doctor. A patient desires less time in the waiting room and more time with the doctor - a worthy reasoned argument. The question that arises is does extra time equate to better care? Most doctors don’t think so, and data on this subject is equivocal at best, while most patients think so. This conflict appears to be a perceptual issue, doesn’t it? If the doctor who understands the malady is able to communicate the entirety of the case in short form and render good care for all his/her patients in the long run, isn’t that a better outcome for all? In the United Kingdom where universal healthcare exists and money is removed from the equation, the preferences for 1000 patients scaled from “thoroughness of visit,” “doctor who knows and treats them with warm and friendly manner” with “less waiting time and flexibility of appointment scheduling,” are the main desires. (Jennifer Warner, @WebMD 2008) Different strokes for different folks. But one must not forget where the patient most wants to spend time is with his or her family and not in the bowels of an inner city or outer rural hospital, or in a stranger's office (even though it is a physician). So lengthen that time the patient can spend with their loved ones is a consummation devoutly to be wished by the physician.

3. Communication: Patients want their doctor to treat them as one of their own. Through the years, I have heard this question asked many times, “What would you do, if this was one of your own family members?” A valid question that has a simple answer. The best possible therapy that is available. This satisfies most of the patients, because it is the truth. But unfortunately it does not satisfy the industry, which is at odds due to expenses involved. So the best possible treatment is neither going to be the best nor is it possible in today terms. And that has both the patient and the doctor frustrated. One thing that physicians must not do is to wear their harried-existence patience thin to the detriment of communications. Take the time to listen and explain. Take the time to be human. After all, we have all suffered the whips and scorns of time.

4. Costs: Depending on the medical insurer, the patient wants to be oblivious to all discussions related to costs. If discussions regarding costs are brought up by the physician, this implies to the patient that the doctor cares about money more than the patient. Media constantly states that doctors should work for the goodness of humanity and society takes that as gospel. Some have come to believe that medical care is a right. Others do not think so. The battle continues at least in the US. This discussion will occupy more patient care time in future. Those with limited insurance usually go to doctors that will accept their limited insurance claims and there the patients find less time, less communication and less thought. The times, they are a-changing. But in the realm of “costs” is a pesky minimally uttered cry from the patient that the doctors need to listen for; the cry to understand, how the disease will impact their lives. Not I used that in plural and that signifies that disease impacts more than the patient, it effects the whole family. It affects their dreams and desires, their vacations planned or soon to be, their mortgage payments, their daily living. The physician needs to be cognizant of these unexpressed wailings in the voice of his or her patient. There is always more to "it" then a “hello” and “goodbye.”

5. Decision Making: Do patients actually want to share in the decision making process of their care? That is akin to asking of a passenger in a commercial aircraft, which flight-level he would prefer to fly at. The pilot like the doctor has the key information and knowledge, not the patient. However discussions regarding the quality of care are an important discussion to have. The pilot shares his by saying, “We will descend to a lower altitude to prevent further turbulence,” and the doctor says, “We will avoid that therapy due to the risks of complications inherent in the treatment.” Those are information-sharing decisions rendered for the knowledge, comfort and safety of the individual/patient. These communications are necessary where marginal survival benefit relating to the coincident complications from a certain treatment exist. The act of making a decision between Treatment A and Treatment B should be shouldered by the physician and communicated to the patient in simple terms and be based on good, solid and verifiable clinical evidence. The “Shared decision making” is not to my knowledge a patient deciding therapy based on his or her understanding of what the internet/or their research has yielded but the richness of conversation between him/her and their physician regarding the fully understood choices available and what would suit that patient.

6. Comfort: Some physicians have the ability to provide comfort with their words and others not so. Not all physicians are alike. It is in that comfort level that a patient has a choice to stay with, or make a change from their physician. Should a physician strive to be a comfort giver and sacrifice the mandate that he has undertaken to cure the disease? The answer is a simple, No. Is comfort rendering a teachable process? Only by example and a desire to learn.  Rendering “false-hope” is not the answer either to garner that emotion from a patient, it is the care to listen to the patient complaint in building the road to healing. I have known many a patient say, “He (the physician) has terrible bed-side manners but he is an excellent doctor.” And “I would go to him in a heartbeat.” Yet the best honor a physician can elicit from a patient is, “he is a good doctor and a decent man.” This dichotomy is worthy of another discussion at a later time. Since the three-pound flesh housed behind the pale thick walls of the cranium controls the remainder of that which lies beneath it, must give pause to the physician to make sure that he or she  gingerly handles the input to this most extravagant and auspicious of all nature-made living things, so that the output from the patient's brain is always a positive defiance to disease.

Aside from a warm “hello,” an “empathic conversation” displaying “concerns through eye contact,” and “sitting down” that ease some issues, do they address the “compassionate concerns” that are much bandied about these days, what is it other than that, that patients want doctors to deliver? The answer might be a simple; maybe the media-impressed society demands everything, including immortality and cannot find satisfaction from anything short of it! And that is sad. It is “madness most discreet.” 

The Best of the Best

This caught my eye. I remembered seeing it before, but this time the words whacked me in the face. A quite disconcerting discourse, to say the least, took place between my unimaginative self as it wrestled with its true opposite. What? My mind cried out in despair and disbelief. What can come of this?

For those still in limbo and distracted by the mental image of my minds utter chaos, let me lay the scene.

It was a quiet Sunday afternoon covered by a canopy of cloudy skies heralding a most inopportune thunderstorm -on the moisture indulged earth, brewing nearby.

Metaphorically it seemed appropriate for what was to come.

A liar begins with making falsehood appear like truth, and ends with making truth itself appear like falsehood. ~William Shakespeare

The headline simply read, “93,000 medical error related deaths.” There were many exclamation marks in that article. They were provocative and suggestive of a mishandled, mistreated population suffering from the inadequacy; inefficiency, malpractice and sloppiness of the medical care provided in these the United States. Really? I thought are we that bad? Do we lack the scientific rigor and knowledge? Do we lack empathy? Do we lack the “substance” that makes this noble profession, noble? Are we slackers worried about enrichment, as the article seemed to imply, with no care for the patients? Are we callous? Are we the epitome of irrational, inconsiderate and selfish human beings?  Well if you read that article you would be vaccinated too against the real facts that I am about to explore.

The answers that arrived via the slow methodical train from reality were: No! We are none of these. As physicians and nurses we are the best of the best. We are the paragon of humanity, immersing ourselves in the service of humanity. We, the physicians, dentists, nurses, psychologists, pharmacists, clinical researchers and others that deal with providing health care in the United States, have warded off more diseases and rendered more scourges and plagues to the isolated cells of “once what was,” then any other in the human race. We continue to kick the rouge expressed, human body related, sentiments of nature’s fury into the casket of oblivion. We help people survive longer and slowly –albeit agonizingly slow, we are forcing the learning of the art of healthy living, although that still only addresses one side of the equation.

So what was this 93,000 number floating in front of my eyes?

Let me take this slowly and one by one. This is not meant to be paternalistic nor derogatory by any means. It is meant to educate those “media journalists” who learn slowly but yield a broad demonic vilifying brush of ignorance to paint their, innocent or otherwise, version of the reality. There is simplicity and a great argument to be found in the numbers that this very elite group of “know-it-all” seems to not want to adhere to. Just so they can sell their news wares!

In the United States, there are approximately 956,000,000 (956 million!) visits to the physician offices and a total of 1,200,000,000 (1.2 Billion) ambulatory care visits to the physician offices, emergency room and ambulatory care centers within and out of the hospitals per year. Now let us grapple with the enormity of this statement, provided by the CDC. One can parse this information in many different ways, but what remains constant is the absolute number of health-visits. This data is based on insurance claims filed.

Of these 1.2 billion visits 132,000,000 (132 million) visits were to the Emergency Department of a hospital. 42,400,000 (42.4 million) visits were injury-relief seeking related. Additional data gleaned from the sources indicate that there were 3,200,000,000 (3.2 Billion) prescriptions written during that time and a total of 7,000 errors related to “handwriting skills” which by the way remains constant even with the electronic prescription filings (recent published annual data).

The total number of physicians in the United Sates is around 550,000, (0.5 million) serving a population of 308 million, both in the rural and urban areas. Majority of them however are located in the urban, suburban and near-reaches of the large towns where hospitals exist and large populace reside.

Having those facts at hand, let us dissect the error rates for those easily convinced with what is broadcast on television and by the provocateurs in the news media.

Based on the total healthcare visits, the error rate of 93,000 medical errors translates to a 0.00775% error rate per visit!

And to tackle the error related to handwritten or electronically transmitted prescriptions. Of 3.2 Billion prescriptions per year and 7,000 errors translates to 0.000021%. The magic of hard numbers is, that you cannot hide from their truth.

Now if you will indulge in some comparisons, as the media is wont to comparing medicine and Airline Transportation: The fatality rate for Airline Transport is 0.43/100,000 hours of flying. In General Aviation the fatality rate is 2.3/100,000 hours of fight time. Now let us compare that with driving where the fatality rate is 35-40/100,000 hours of driving. (NTSB Data) So car wrecks are almost 20 to 1 compared to plane wrecks, yet an occasional plane wreck wreaks havoc on the news circuits. They seem to flash the photo of twisted metal on the screen ad-nauseum. Why is that? Why not bring the gory, grimy, bloody and heart-wrenching detail of every car accident to the forefront? The answer is simple; because the element of fatigue would set in and that is not “sexy” or another way to put it is, it is not “newsworthy.” Similarly on a slow media day when no guns are going off and the markets are not crashing, the media decides to pull out from its hat something derogatory related to medicine and parade it before the eager eyes. Let us not be fooled by such insipid and irrational comparisons made by “well-meaning” pundits. Know the facts!

Based on just the numbers quoted above, those that try to equate aviation accidents or anything to medical errors are surely misinformed, uneducated or both! But they do!

What is not mentioned here and which, is very telling: Of the 202,400 patients diagnosed with Breast Cancer each year  (2010), 160,000 survive the disease from therapy! So we are comparing "apples and oranges" as one would say in kindergarten between a "naturally acquired" disease entity treated successfully with a 80% success rate and a 0.00775% error rate when treating a large population with multiple encounters!

Let me offer another opinion as to why this, the media blitz, happens? Maybe I have grown cynical over time, but there is always a benefit to someone or some organization when such peddling of unrelated facts are brought to the fore in our consciousness with pseudo-statistical fiat. It might be a company advocating a new piece of software for the electronic prescription transmittal? It might be the desire of the legal industry to legislate and thus by virtue of that regulate and mandate, failing which criminalize the innocent offender.  It might be an industry marketing a competitive product. Or it might be a politician wanting some much needed time before the camera to garner attention. Whatever it is, there is disservice to the many.

There is another little inconvenient fact about malpractice not well advertised: More than 80% of the Malpractice Claims are settled in the medical community’s favor. As one lawyer put it, “That’s because the doctors have good lawyers defending them.” Really? Or may be it is that the litigation machine enriches the legal side and puts an inordinate and unnecessary stress on the medical side. May be that is why tort reform and capped rewards are so angrily prosecuted by the attorneys and the politicians. Or maybe as I have been told many times, “You just don’t see the big picture!” I guess, I don’t.

Is it no wonder that 400 physicians commit suicide because they are under extreme stress, working long hours, spending less time to decompress from the vicissitudes of disease, having less time with their family, which ultimately leads to depression and faced with a constant microscopic scrutiny it turns their world upside down. They are after all humans! Or did we forget that? Physician suicide rate is twice that of the lay population and metes both males and females equally. Related to physician suicides rate, several psychological undertakings have emerged; finding faults with the persona of the physician, the environment where they work and even the families and heritage they were born to. All are conjectures of idle minds mostly trying to hide behind the “compassionate euphemisms” of the day. Only those in the trenches of this modern medical warfare know what it is to face the music.

Case in point (And I bring this in for the simple act of understanding), a legislation proposed in Sacramento, California mandates the use of “fitted-sheets” to be used in all hotel beddings through out the state. (SPF432) Now any logical individual would ask the question, “Why?” No one knows except the legislator. But carrying this thought experiment further indicates that now a State engulfed with over $140 billion in debt, when adding such legislation is seeking to be punitive with the “gotcha” factor and trying to recover money from private enterprise. Stupid! And wildly idiotic, but that is the compulsion of a mind-set steeped deep in “Gotcha!” So of necessity a common-sense question would be what would this piece of legislation do to the small hotels and motels in that state. Answer is simple, run them out of business with the added expense. Shooting oneself in the foot is a mark of supreme something! Some might label it as “bravery” but only in a fool’s paradise. The sinister encroachment in the name of “doing good” can bite an entire industry in the rear and lay waste overall societal benefit. The regulatory burden on medical care has increased significantly making it impossible for private practitioners to render care. More and more physicians cowed by the fears and the burdens of today are resorting to belong to a hospital under the umbrella of “safety.” The chapter of individual thought is rapidly coming to an end. Maybe it is for the better, or then again maybe it is not. Time will tell.

Have we made progress in medicine? Yes, certainly! That is an undisputed fact. Will we make further progress in the medical field; ridding cancer, heart disease, lung disease, kidney disease, diabetes etc.? That remains to be seen on how we as a nation approach freedom of thought and action.

So, is my premise that these medical errors are acceptable? No definitely not! We must try to limit harm to any and all patients as much as humanly possible. That is the Hippocratic oath. But to demonize the entire medical industry of physicians, nurses and pharmacists alike, is akin to pointing fingers at mirages. There are simple solutions that are in effect at the hospitals and pharmacies for diminishing medication errors, but they do inspire into play the patient’s own sense of safety and cognizance. Several well-constructed algorithms are already in place in hospitals to limit any oversight that might endanger the patient. These constructs did not arise from the media induced fervor, but through the thoughtful reconstruction of the facts and a constructive methodology to prevent furtherance of the previous errors. Unfortunately, whatever new method is undertaken to rectify previous error, the searchlights are focused upon the errors and not on the new-found religion of safety. Physicians by and large reflect on their own methods and that of their peers to cajole and mold the process of helping patients achieve health and better life through rigors of science and facts. And it is the managing physician who sleeps on a wink and rides the rollercoaster of his life, constantly harangued with images and dreams of preserving the life of another human being. We must remember the frailty of human survival, the limits of human intelligence and the infinite and rapidly expanding horizons of the misinformed “word,” that shape our world. I offer no excuses only that baked into these facts but not visible, one must not forget that “to err is human.”

References:

http://www.cdc.gov/nchs/fastats/docvisit.htm

http://www.cdc.gov/nchs/fastats/ervisits.htm

http://www.time.com/time/health/article/0,8599,1578074,00.html

http://www.bts.gov/publications/national_transportation_statistics/2002/html/table_02_01.html

http://articles.latimes.com/2011/aug/14/local/la-me-bed-sheets-20110814

http://www.webmd.com/a-to-z-guides/hospital-medication-errors-reducing-your-risk

http://emedicine.medscape.com/article/806779-overview

http://www.nejm.org/doi/full/10.1056/NEJMsa1012370

Green Tea Frappaccino

Recipe for

Green Tea Frappaccino:

1. Two cups of ice
2. A cup of Skim Milk
3. Three teaspoons of Island Tea Matcha Green Tea Powder
4. ½ to 2/3 scoop of Nature’s Plus’ Spiru-tein Tangerine Dream
5. Blend in blender till no ice chunks remain.

Island Tea Matcha Green Tea Powder 1 pound bag = $24@ Island Tea (Good for about 33 Servings)

Each serving = Venti (Largest) style Starbuck’s product

Nature’s Plus Spiru-tein Tangerine Dream = $15 @Amazon (Good for about 30 servings)

Estimated cost per serving is around $0.90-$1.70 depends on actual costs incurred.

Source of EGC (Antioxidant)

Source of Protein

Source of complex Carbohydrate

Source of caffeine (<100 mg)

Calories estimated around 250-280

And if you like it you will be in a delicious healthy haven.

By the way this is not to be construed as a promotional announcement. I do not receive any income from this recipe and/or for promoting products linked to this recipe. It is a mere function of sharing with my Tweepies and Blog readers my new-found interest. Enjoy!

Let Food be your Medicine and Medicine be your Food. ~Hippocrates

Mammograms: Benefits and Controversies

Mammograms

The mammogram controversy is due to multiple competing issues: The desire to test and diagnose early, the excessive insults to the tissues from testing and surgical probing and the potential benefits overall. Lets look at the facts:

Breast Cancer Diagnostic Process (courtesy: Images.com)

Mammograms benefit by detecting breast cancer at an early stage! The data clearly shows that 60-70% of all breast cancers are detected at DCIS or Stage I level. This imparts a significant survival advantage. However and there is a however in every story. The following “however” is a representation of all the known and validated information.

Mammograms below 40 years of Age:

Mammogram Images

Mammograms in younger women age less than 40 years have higher “false positives,’ and therefore are subjected to un-needed needle biopsies and further diagnostic radiation exposures for confirmation and re-testing. The NCI projects this false positive reading at 20% (2 in 10). This anomalous reading is primarily due to the increased breast density as a result of the milk ducts and fat ratio. But here in lies the additional dilemma whereby dense breasts are subject to a higher risk of malignancy and scrutiny.

("In a theoretical population of 10,000 women aged 35 to 39 years, 1,266 women who are screened will receive further workup, with 16 cancers detected and 1,250 women receiving a false-positive result.") (The researchers examined the medical records of more than 117,000 U.S. women who got their first mammograms between the ages of 18 and 39. In the ensuing year, not a single woman under the age of 25 was diagnosed with breast cancer. For women between 35 and 39, 12.7 percent were called back for further tests but only 0.16 percent actually had cancer). – NCI.

Recent NCI data suggests that 29% of women in their 30s undergo mammography which exposes them to many false positive results and unnecessary retesting and biopsies.

Radiation Exposure:

Mammograms initiated at an early age also expose the breast tissue (localized, specific and focused) to increased cumulative lifetime radiation. With a risk of 1 Rad (mSv) causing a 2% (2 in 100)/ year risk would necessarily cause the risk to increase to 20% (2 in 10) in 10 years or 40% (2 in 20) in 20 years of annual mammography. The peak effect from a single intense source of radiation (Hiroshima and Nagasaki data) occurs between 10-15 years, the cumulative effects of annual mammography would account for similar peak/plateau to occur.

Solid tumor risks with a linear dose-dependence 

“Tumor registries were initiated in 1957 in Hiroshima and 1958 in Nagasaki. During the period from 1958 to 1998, 7,851 malignancies (first primary) were observed among 44,635 LSS survivors with estimated doses of >0.005 Gy. The excess number of solid cancers is estimated as 848 (10.7%) (Table). The dose-response relationship appears to be linear”

Age, radiation exposure and malignancy

Additional views of the breast to delineate “abnormal” tissues would add to that risk. A known but fortunately rare complication of post radiation therapy following breast-conserving surgery is malignant angiosarcoma. This radiation induced malignancy occurs in elderly individuals with a mean age of 68 years and has an incidence of 0.05-0.2% over a 12.5 year period. Radiation induced angiosarcomas or RIA start as bluish-purple spots on the irradiated breast skin, are detectable by physical examinations and not by mammograms. Median survival in RIA is reported from1.5 to 2.5 years Recurrence rates approach 70 % and 2-year disease free survival ranges from 0–35 % in various series.

NCI (National Cancer Institute) states the following: “Mammograms require very small doses of radiation. The risk of harm from this radiation exposure is low, but repeated x-rays have the potential to cause cancer. The benefits, however, nearly always outweigh the risk..”

Radiation from an X-Ray machine is a low-energy source focused-radiation as is in Computer Tomography scans. (The initial data on CT scans suggests a "probable" risk of cancer in 15,000 amongst 73 million patients who received CT scan procedures).

DNA annealing process

The energetic from the machine cause dislocation of the electrons within the cells that can disrupt the DNA molecule by changing one of the four Nucleotides: Adenine - Thymine, and Guanine - Cytosine that form the backbone of the DNA helix and the genomic structure. This alteration can lead to disrupted DNA by shutting down a tumor suppressor gene or accelerating a tumor promoter gene or both by changing the down-stream signal transduction into the cell via protein and subsequent cell propagation (growth). These data are not meant to create fearfulness, it merely underscores that persistent continuous exposure is cumulative and methods to mitigate must be considered in future strategies especially for detection.

Digital Mammograms:

Digital Mammograms are no different than the Conventional Mammograms except in the mode of recording. The amount of radiation remains the same as does the light source in a digital camera, only the recording method differs; instead of a photographic film, the information is recorded on a CMOS chip. Having said, in digital mammography, due to the ability to modulate contrast, Singh et al. state,“Full-field digital mammography optimizes the lesion-background contrast and gives better sensitivity, and it is possible to see through the dense tissues by altering computer windows; this may be particularly useful in younger women with dense breasts. The need for repeat imaging is reduced, with the added advantage of reduced radiation dose to patients. MRI has a role in screening women at high risk for breast cancer.” This modality also has cost saving benefits built in,  since it limits the use of special photographic film; its production, delivery and storage.

MRI

Physics of Mammograms:

On an average the human body receives radiation from natural sources, for example the cosmic rays deliver to the tune of  2.4 mSv per year to the human body. Other sources include; the soil that contains various radioactive elements (Potassium 40, Carbon 14 and Radium 226 found in the soil) within and impregnates the foods (Vegetables/fruits) grown in it and transfer the substances into the  humans and animals that consume the food. Humans additionally consume the meats from the animals that have consumed the same grown vegetables thus imparting the radioactive elements into the humans again. Fortunately for us humans we have the DNA mismatch repair mechanisms built into us to thwart such daily attacks. It is the cumulation of such events that can over burden the mismatch repair mechanism and diseases then ensue.

Mammograms use low-energy radiation to a total value per test at -20KeV (1 eV or electron volt = 1.602×10^−19 J and 20 KeV = 20 * 1 kiloelectron volt = 20 * 1.60217646 × 10^-16 joules) The absorbed dose is recorded as 0.56% mSv (millisievert (1 mSv = 10^−3 Sv)

The IAEA states, “The biological effects of ionizing radiation vary with the type and energy. A measure of the risk of biological harm is the dose of radiation that the tissues receive. The unit of absorbed radiation dose is the sievert (Sv)”

Increased cancer risk to humans is in 1 in 1000 at 1250 millirem or 8% per Sv (BioPhysics of Radiation)

False Positive:

Taking into account all Mammograms, 9 in 10 abnormal mammograms when subjected to a biopsy are proven negative or said in another way; the yield is 10% (1 in 10) true positivity which means 10% of all abnormal mammograms actually reveal cancer the rest (90%) are proven negative! And speaking of False Negative, which means that the cancer that is present, is not detected by the mammography is an additional conundrum faced by the screening method. Some 10-30% false negative reports are reported. This means that of 1000 women with verified cancer 100-300 will be missed by the diagnostic mammography. This happens due to reader inexperience, oversight, tumor hidden in dense breast or small cancer without telltale signatures. Thus to recapitulate simply: 1 in 10 abnormal mammograms are truly representative of cancer,  2 in 10 mammograms are misread as cancer when there is no evidence of it and 2 in 10 mammograms are misread as normal when cancer exists in the breasts.

Risks and Risk Mitigation:

In younger women the risk of developing breast cancer is dependent upon genetics being the major factor. The family history is extremely important and therefore the directive for extra vigilance. An individual who’s mother or sister with a history of breast cancer especially at a younger age is high risk.

BRCA gene

(As are with known BRCA1 and/or BRCA2 gene mutation are considered high risks). BRCA1 and 2 mutation increase the risk by 60% (6 in 10) up to the age of 90 and simultaneously increase the risk of Ovarian cancer by 55% or (55 in100). Thus these younger women at high risk should be subjected to extra vigilance and scrutiny to protect them against the potential diagnosis. Other factors such as menstrual history, breast feeding (protective?), alcohol (lobular breast cancer) radiation therapy, HRT (hormone replacement therapy), and diet/obesity are surrogates of environmental risks and therefore not taken into account for early age related cancer since the damage is limited and risks projected over time.

NCI data of risks of breast cancer diagnosis increase with age:

At age 30 the risk is 0.43 in 10 years

At age 40 the risk is 1.45 in 10 years or 1 in 233

At age 50 the risk is 2.38 in 10 years or 1 in 69

At age 60 the risk is 3.45 in 10 years or 1 in 38

At age 70 the risk is 3.74 in 10 years or 1 in 27

At age 80 the risk is 3.02 in 10 years

False Negatives;

So in younger women a family history dictates the need for a diagnostic test. If such a test is needed then a MRI (Magnetic Resonance Imaging) may be the test of choice. Albeit the cost is high but the yield is identical to Mammography! The false negative or missing a diagnosis of cancer, is roughly 20% (2 in 10) with all known testing procedures available today, including the MRI, however the radiation risks are mitigated with the latter.

Feig et al. from Jefferson Medical Center states, “Report of the National Academy of Sciences and a mean breast glandular dose of 4 mGy from a two-view per breast bilateral mammogram, one can estimate that annual mammography of 100,000 women for 10 consecutive years beginning at age 40 will result in at most eight breast cancer deaths during their lifetime. On the other hand, researchers have shown a 24% mortality reduction from biennial screening of women in this age group; this will result in a benefit-to-risk ratio of 48.5 lives saved per life lost.” So although the risks remain, the benefits seem to outweigh in favor for screening women over the age of 40.

Elderly and the Mammogram:

In older women who do not have dense breasts a competent breast examination leads to an extremely high yield of discovery of malignancy 78–83% a close equivalence to mammography. The biologic reason for this is, that in majority of the elderly individuals the disease is more indolent, slow growing and localized. However, screening mammographic examinations yield earlier stage of the disease and therefore potential for curability. In spite of all the screening performed, a recent British Medical Journal Study*(ref) refuted benefits in survival (reduced mortality) amongst women who received mammograms versus those that did not. Further research needs to be done to corroborate this new data.

BI-RADS:

Reporting of Mammograms via the BI-RADS(Breast Imaging Reporting and Database System) method is graded from 0 to 6: 0-2 considered benign. 3, Probably benign, 4 Suspicious, 5 Highly probably cancerous, 6 Malignant

Incidence of Breast Cancer:

The Incidence of late stage Breast Cancer is decreasing both due to diagnostic tests (caused or just discovery?) although a recent downward trend is due to cessation of the HRT and the death rate is also falling due to early diagnosis of DCIS (which carries an excellent 98% 10-year survival) and better management of the disease. The question being, whether the diagnostic testing and disease discovery are just a self-fulfilling prophecy? (Annual mammography, with its inherent radiation effects, over time creates the disease that the test ultimately detects is the plague of thought that pricks the conscience?) More data and research definitely needs to be done to address this issue.

Other Methods of Detection:

Developing non-ionized methods of detection are important for the future. Thermography and Infrared imaging have yet to prove themselves. Unfortunately BSGI (Breast-specific gamma imaging approved recently by the FDA by 23 times) and PEM (Positron Emission Mammography by 20 times more) expose individuals to a higher radiation exposure than mammogram. 

MRI as a Diagnostic Tool:

However a portable MRI dedicated for the breast evaluation can easily be developed (One is on the way as you read, this waiting implementation, following more corroborative data). The volume testing would lead to lower costs and limit the annual radiation exposure giving the benefit of 85-87% detection rate currently known and equivalent to mammography. The benefits are that MRI does not lend to cumulative radiation risks.

Medicine is fraught with risks on either side of the diagnostic testing. Too little and the disease runs rampant and too much exposes a patient to unnecessary procedures and the risks mentioned. The straight and narrow path is rarely straight and narrow. Medicine is constantly competing within its own boundaries to help solve the riddle of human disease. It has for millennia from the days of Paracelsus and will into the foreseeable future. In the mean time we seek knowledge to tip the scales in our favor.

References:

Feig S, Hendrick R (1997). "Radiation risk from screening mammography of women aged 40–49 years". J Natl Cancer Inst Monogr (22): 119–24.

Mandelblatt JS, Cronin KA, Bailey S, et al. Effects of mammography screening under different screening schedules: Model estimates of potential benefits and harms. Annals of Internal Medicine 2009; 151(10):738–747

National Cancer Institute: Breast Cancer Screening (PDQ®)―Health Professional. Date last modified 09/03/2010. Available at: http://www.cancer.gov/cancertopics/pdq/screening/breast/HealthProfessional.

Pisano ED, Gatsonis C, Hendrick E, et al. Diagnostic performance of digital versus film mammography for breast cancer screening. New England Journal of Medicine 2005; 353(17):1773–1783.

Singh V, Saunders C, Wylie L, Bourke A., New diagnostic techniques for breast cancer detection. Future Oncol. 2008 Aug;4(4): 501-13.

Miller AB, To T, Baines CJ, et al.. Annual screening with mammography and breast examination did not reduce breast cancer mortality in women 40–49 years of age.

The Canadian National Breast Screening Study-1: breast cancer mortality after 11 to 16 years of follow-up. A randomized screening trial of mammography in women age 40 to 49 years. (2002) Ann Intern Med 137, 305

*Phillipe A, Mathieu B, Anna G, Lars V,. Breast cancer mortality in neighbouring European countries with different levels of screening but similar access to treatment: trend analysis of WHO mortality database. BMJ 2011; 343:d4411

Preston DL, Ron E, et al.: Solid cancer incidence in atomic bomb survivors: 1958-1998. Radiation Research 2007; 168:1-64

Givens SS, Ellerbrock NA, et al. Angiosarcoma arising in an irradiated breast. A case review of the literature. Cancer. 1989;64:2214–16.

e Pluribus Unum (From the many One)

      Once I was a student of medicine. That was such a long time ago. It was filled with anticipation. Lots of stuff happening. There were things to learn; knots to tie, dressings to change and patients to please. I cannot forget of course the books. Oh yes the books. And there were many. And I loved them. They were big, no maybe the word huge would qualify them better. They were filled with diagrams and photos but mostly words. Some of the more strange sounding words that seemed to filter into my ears and stay, did so without much ado. It was like I was born to know them. The words were definite. They spoke of finality. They spoke about facts. They spoke about the known truth. They spoke about the human body as it existed then. 

What a wonderful love affair this was. From the embryo to this vast adulthood landscape, it was a journey of immense understanding worth undertaking! From a tiny germ cell to the trillions of cells joined up in perfect union and harmony to format us all. “E Unum Pluribus” would describe that better. Anyway life was great as the pages of the books got dog-eared and dirty and my mind filled up gradually with this and that.

And then came the internship, residency and fellowship years and the tomes disappeared while the thin weekly journals took over. The facts became thinly disguised, like the shifting desert sands; the landscape changed every time you looked at it.  This too was gratifying in its own right. Plumb with the nuance of progress was the slight itch and restlessness of understanding. I wanted to gain an advantage over disease. And how best to do it would be to cull through the thin journals and use that information to gather experience in real life, essentially to see if the data that I was reading fit the scales in real life. 

There were disappointments along the way but mostly the illustrated events seem to have a fairly robust tit-for-tat relationship. Life was fine now that the bandage dressing and suturing was a thing of the past and I could delegate that to the younger crowd, which kept filtering in.  And they in turn happily jumped at the opportunity. It is a strange case of leadership quality that is so pervasive in medicine that most fail to see it. Essentially you learn a process and then you teach it to the one willing to learn next to you. The process never stops. The teaching continued through part of academic life and through it though lesser and lesser time was spent in caring for patients

So life transformed once again into clinical practice. But here is where it got interesting. The diseases started to morph into the ugly and the strange and the bizarre. The pathologies became grotesque. The manifestations did not seem like the cookie-cutter factoids that I was used to, secluded behind the great halls of learning. Now the disparities in the kind of patients that were showing up at the doorsteps were strangely unique and not the ones that I had cared for in my past. The paradigm did not fit with my former mental landscape. It was back to the books again. This time however the journals were thicker and many, many more then what I had skimmed and read before. Each and every one of them appeared to have landmark studies. The data in these journals was chock full of graphs, numbers and details. Everything I read made some sense. Yet the very next month another study would refute the data from the previous one that had been rendered a gospel a month before. My natural cranial suture lines hurt from the exploding controversies within. This went on for a while, until one day, I decided it was time to look at the wonders of statistics.

That is when I learned the subtle nature of the world of probabilities. I discovered that everything could be an inference based on a simulated process derived from a part of the whole. Or to put it simply, one could use small numbers and through the “gizmatological” use of number crunching come up, expressing the premise one set out to prove. So everyone can prove their own premise by mathematical means and thus give credence to their study. Oh these became heady times. The splitting headaches, the conundrum of contrarian viewpoints seemed charged with deception yet imbued with legitimacy. “Oh what a web we weave in an effort to deceive,” is all I could think. And yet there were kernels of truth too in there. Now this became a time where, I had to do my own work to extrapolate real information. No more could I depend on the authors. And just when I was about to get comfortable with this thought, a rash of very bright and driven individuals decided to up the ante to gain fame and become the "Best of the Best." They decided to create data from “thin-air” and publish it. It all appeared legitimate. It appeared fool-proof and as all such behavior is wont to come to light, this did. Authors, found fabricating in an effort to “publish,” perished by their own sword. Legitimacy once again became an issue.

Back to the drawing board once again, I went. The once bright portrait of reality now faded appears smudged, in need of restoration. The art of the craft has yielded to the temptation. It is time for some of the journals to fold and the readers to realize that quality is definitely better than quantity. Instead of publishing every nuance and hiccup of the wayward cell, the basic framework needs to be understood. 

With the Social Media in full bloom there are many “doctor” experts touting scientific data that they don’t even comprehend much less understand. Maybe we should arm ourselves with enough knowledge to be able to decipher between those that know and those that pretend to know.

So here I am, back with the books and the journals trying to find the wonder and delight of the yesteryear. Some days it is there for the taking and other days it is wanting. Interesting as all things in life are; the pathology of disease starts in one cell or multiples of a single cell. 

And here in lies the “e Pluribus Unum,” from many, one; that the behavior of the many can be learned from the behavior of a single entity. 

The peaks of knowledge stand out from the valleys of ignorance. We need to see them both at a single glance. I am, become, the student of medicine again. The wonderful journey begins anew.

Medicine, Oedipus and the Theban Sphinx

Theban Sphinx

It was past midnight, the moon still shy of its blemishes, hid part of its face. The trees were silent in prayer and the eerie darkness that lay heavy like a blanket, compressed all living beings into dream-like state. It was then that I noticed this creature. Beguiling deep-set eyes that seem to enshroud my thoughts. They were surrounded by a beautiful face, which commanded my total attention. She, or it, had wings for flight that were wide-spanned, light brown in color, with specks of iridescence and were imbued with power and might. The body lithe with the rhythm, grace and the strength of a lion perched on its metallic looking talons. What was this creature that did surprise but not scare my senses? It did not appear threatening nor did it appear evil. It was a transmogrified creature bearing the armament of a predator yet serenely and oddly also displayed the distinction of a human. In my eyes it seemed to have found a particular place in life's tragedy, unable to lift the burden and yet equally unable to displace it. 

The face held my gaze as the beautifully crafted wings unfolded and spread. With just a whiff of air, it took flight and gathered its claws underneath. Majestic, complete, complex, foreboding, petulant in its arrogance and self-assured in its gaze, it commanded my attention as it hovered with its powerful beating wings, demanding lift from the still air.

Sphinx of Giza

I woke up startled as my dream abruptly ended. What was it? The question haunted me for a while. What creature has those characteristics and what was it doing in my dream. Sneering? No definitely not. Reprimanding me? For what purpose? Defining a course? To where and for what reason? Those first waking moments were infused with confusion.

Slowly as the sun rises and darkness recedes, the confusion was laid to rest. The extraordinary grip of this reality cleared the sinus of my senses and I could relate the creature to what, I feel, medical science is all about.

The irresistible eyes adorning the beautiful and radiant female face is a metaphor for the capture of our senses by the nobility, dignity and grace of medical science. The nobility that lies in the care rendered to someone in need. The dignity that is ever-important to the patient’s self worth and that, of his or her physician and the grace of inspiring health and infusing a sense of well-being in the patient was the representative nuance of that haunting face, that was all angelic and all purposeful.

"What a piece of work is man! how noble in reason! how infinite in faculty! in form and moving how express and admirable! in action how like an angel! in apprehension how like a god! the beauty of the world, the paragon of animals! " Hamlet quote (Act II, Sc. II) William Shakespeare

Theban Sphinx and Oedipus

The gorgeous wings that magically unfolded and inspired an almost hypnotic flight represented the ideas and thoughts, which translate into discovery and innovation. The questions Why? And How? And When? All arise from the same seed, the same essence of desire and the same thirst for knowledge. The iridescent specks are the virtues of an inspired creative and accomplished thought. Those wings support us into newer discoveries and newer paths to follow, to help nurture life and expand the healthier horizons for humanity. The slow rhythmic motion of the wings represents a methodical effort-full but effort-less-appearing venture of validation, set in motion by the rigor of thesis and experimentation. The largesse of the wings implied the ample minds grappling with the basic science and clinical medicine to help a fellow-person in need. The still air represent; limited or no outside help, interference or resistance to the exploration of an inspired thought.

The powerful muscular physique represent the strength of the human body, its genetic diversity and its hearty immune system that tackles and wins against many a predator; It runs fast, jumps at a movement, turns to a direction and speeds through a trend to capture it’s prize. All motion is controlled, smooth and directed. All focus is narrowed to a purpose. All action is methodical and thoughtful.

And those claws that glistened in the darkness of night have a strangle hold on its purpose. Like medicine, it grasps and grabs an idea and sees it to its fulfillment. Like medicine it is replete with some bias of thought and action and like medicine if the result that springs from such action fails to bear fruit, it is discarded, sometime quickly and other times reluctantly. But it always is.

This then is the shape of the metaphorical creature. It is the mythical Theban Sphinx! It is today’s Medicine! Roiled and mauled, it helps and sometime hinders. It inspires greatness and equally subservient disdain. It transforms humanity as humans transform it. It is riddled with rancor as well as unity. It is the epitome of nobleness and also the reason for despair. It feeds on principles while principles sometime abandon it. It lies awake while humanity sleeps. It manifests its virtues while the vices are being explored. It never surrenders to the status quo. Always in flight, it explores new vistas. It explores. It divides. It changes and then is changed. The grudging gulf between humanity and medicine lies within the heart and soul of humans. It is the paradoxical strife between the beautiful face and the powerful unsheathed talons. There are no real answers that answer all the questions of life, thus there are no Oedipal heroes that will slay this beguiling beast for in it rests the vile and virtuous apothecary of human existence.

Thebes Sphinx asked the question, "Which creature in the morning goes on four legs, at mid-day on two, and in the evening upon three, and the more legs it has, the weaker it be?" She strangled and devoured anyone unable to answer. Oedipus solved the riddle by answering: Man—who crawls on all fours as a baby, then walks on two feet as an adult, and then walks with a cane in old age.”

Oedipus and the Theban Sphinx

Those Baby Blues

The other day, I looked into a pair of deep pool of dark blue eyes. I thought I saw heaven. There might have been a momentary cognition of my presence in those eyes. But then I might have misjudged. I could see that this 5 hour-old baby held the strings to the world. She would make it dance; make it play the harmonics to her melody, make others smile. She would fill the void where ignorance exists and create, innovate and accentuate the good that seems to have filtered beneath the surface. Ah! She will govern the next 100 years of life.

The eyes followed my face as I moved. Or was it my imagination? It did. It was remarkable. It was a spectacular feat for a new life. We all rejoiced at the bursting intellect! Why not? It made for a celebration. There are billions of neurons (brain cells) that are bubbling into existence, calling for connections with their fellow journeymen, to share in their exploits into this new frontier. What a riot of pure and abject disregard of limits!

With each passing hour there was more: First the opening of the eyelids to reveal the beautiful blue irises, followed by the wandering gaze and now the whimper of contentment. Such a remarkable feat all wound up in a small package of 25,000-30,000 genes that click on and off at a predestined time and space to create, cajole and modify. If heaven has a reflection, it is inside those baby-blues.

So what happens as she grows? Oh, she learns to understand self and non-self. She grasps objects and then concepts and then finally understands the world for what it is. The hopes of her future and her progeny reside on her shoulders, a heavy weight to carry, but those determined eyes don’t see any relenting in that cause.

As the synaptic (neuronal connections) begin to form and the light from the non-self begins to filter in, the self will arm itself, but the journey has begun!

Those tiny hands and fingers all curled up quietly are imagining the molded transformation of the society and the world around. The fingers will delicately tease out the bad and there she will lay the foundation of a harmonious peace.

I can feel her heart beat through the tiny chest and it shows strength. It will be filled with love, protection of others but will remain vigilant. It will beat to the march of a different drum. Her own!

And those tiny little feet that I can cover with my right hand will pitter-patter over the floors of her house, walk the gardens and climb on transports to distant places in search of fulfillment of her quests. Oh she will be a force to reckon and this is just the beginning! The maze will unwind itself in her sight, the overgrowth of despair will dissipate and an under whelmed intellectual phoenix will rise again.

Her eyes are open once again and “life,” demurred, stands with hands behind her back, awaits her instructions!