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Overtreated July 1, 2009

Posted by drolarn in Medical musings, Rants.
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One question that is being asked frequently about Michael Jackson’s death is: did he die because he took too many prescription drugs?

I believe that many people have died, or suffered ill health, from being over-medicated. Some because the drugs are addictive, or induce psychological or physical dependency. Sleeping pills and painkillers are common and well know examples of these. But many suffer simply because they are taking too many medicines which are not addictive, and are prescribed to treat symptoms and conditions that the patient is suffering from or complaining of.

There are many reasons why patients may be prescribed too many medicines, to the point where the medicines make them sicker. Firstly the patient himself may be fond of taking pills, and doctors who are willing to indulge are not uncommon. Secondly many doctors feel that if they more drugs, especially the newest strongest drugs, that makes them more proactive in their treatment than others who judiciously use tried and tested therapies. Thirdly, and I have seen this happen many times and in conjunction with the other two scenarios, the doctor and patient get in to a vicious cycle of drugs and symptoms. This is how it happens:

Imagine a patient comes in with a rash that itches and irritates but otherwise not serious. A doctor gives him steroids which he finds is effective in controlling the rash. Long term steroid use cause him to be hypertensive, so the patient goes to see a cardiologist who gives him blood pressure medicine. This controls his blood pressure but causes him to have insomnia so he goes to see a neurologist who gives him sleeping pills. This helps him sleeps but causes him to be anxious, so he goes to see a psychiatrist who gives him anxiolytic drugs, which gives him nausea and heartburn, the treatment of which gives him diarrhoea, and meanwhile the steroid is giving him diabetes and so on and so forth.

All drugs have undesirable side-effects. Treating the side effects with more drugs lead to more side effects. If one doctor was in overall control of one patient’s treatment, things may not get out of hand but in situations where the patient has a free choice of doctors and doctors fail to communicate with each other, patients could be receiving drugs that work against each other, or duplicate each others effects and side effects, or otherwise interact adversely. In countries where the government provides universal health coverage and drug consumptions are kept under control, this situation is less likely to arise. But in a situation where the patient can freely shop for health care and doctors compete for business, it is common place. In (good) medical schools prospective doctors are taught to limit drug treatment to a minimum. The elderly particularly, are rarely able to cope with more than 4 different drugs in a day. In private hospital it is common place for patients to be on 12-15 different drugs at the same time, prescribed by up to half a dozen different doctors, and costing the monthly wage of the average man in the street.

If you are taking more than four different drugs everyday, chances are you are overtreated. Ask yourself are  you really feeling better ,overall, on these drugs than before you were started on them.

If you are consulting with more than one doctor, and your doctors are not seen to be communicating and cooperating, no matter how disparate their specialties, you are running a high risk of overtreatment. Find a doctor who is happier giving you explanations rather than pills, with luck he will help you stop the vicious cycle.


Circumcision June 28, 2009

Posted by drolarn in Medical musings, Rants, Uncategorized.
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Of all the things new parents request from me, the most irritating is  circumcision for their son.

The practice of surgical removal of the foreskin without medical indication is widespread in the world. It is of course the norm in Muslim societies. In America it is widespread enough to be the rule rather than the exception. The practice has spread into other countries and societies. Here in Thailand, at least in Bangkok, it is common, even among non-Muslims.

OK look, I don’t want to offend Muslims and Jews, I am proud to say I count many Muslims and Jews among my friends past and present, but this aspect of jewish and islamic practice impresses me not at all. I don’t know why your God mandate circumcision for all male faithfulls, but it seems to me if He feels males should not have foreskin, he would not have created it in the first place. The fact that the Judeo-Christian-Islam God created men with foreskin logically should mean He has a purpose in mind for it. Could God’s only purpose for the foreskin be for it to be cut off as a mark of the faithfull?  Seems to me He might prefer other kinds of marks, such forms of dress, prescribed rituals, any number of other things. As proof of faith, having to get one’s dick out in the open for demonstration, is frankly ludicrous.

But all right, it’s not my place to tell muslim or jewish parents not to practice their religion as their traditions dictate, and indeed when parents request circumcision for religious reasons, I always make the arrangements without demur. What makes me mad though is when non-muslims and non-jewish parents make this request.

Most likely, ritual male circumcision arose as a practice from the middle east, as the cradle of the judeo-christian-islamic faith. It probably originated from a jewish tribe, spread around the world with the diaspora, and into the related islamic faith. Why has it become almost normal, routine practice in America? I really don’t know. Could it be because jews in America, especially jewish doctors, extolled the benefits of this practice (in all sincerity and in all good faith I’m sure), and convinced the gentiles of America that it is the smart thing to do?

Certainly in America, medical practitioners and researchers list many health benefits of circumcision. Better hygiene, lower risk of urinary tract infection, lower risk of penile cancer (an exceedingly rare cancer), lower risk of transmission of genital wart virus (HPV) which causes cervical cancer in women and lower risk of HIV-AIDS transmission are among the most frequent health benefit claims. Research papers are cited to support these claims enthusiastically. Meanwhile in Europe, Australasia, and other areas where the practice has not taken hold, equally eminent physicians, surgeons and researchers deny that there is good evidence to justify removal of the normal foreskin. Again research papers are brandished, tables are thumped and beards are muttered into.

So what is the truth, are there health benefits of male circumcision that would justify routine use? Why can’t researchers agree?

The problem with medical research into circumcision is that it cannot be conducted in such a way as to eliminate all researcher bias, and the effects of other factors on the analysis of data cannot be totally excluded. In a good drug trial, to test the efficacy of a new drug, research conducted using the double blind technique (whereby neither the drug prescriber nor the recipient know if the drug given is the new research drug on an older established drug against which comparison is saught, or placebo). If properly done the result of such a trial can be totally compelling. Obviously this kind of research technique cannot be applied to circumcision and doctors (at least the smarter ones) are aware of the pitfalls and limitations of non-blinded medical research.

The world concensus seems to be that yes, circumcision can help reduce the spread of HIV-AIDS, at least in Africa, and there has been moves to increase the practice in Africa for this reason. There is no world concensus on the balance of risks/benefits of circumcision in relation to any other health claims.

And so the status quo in American and Europe looks set to continue, Americans will continue to circumcise most newborn boys, and Europeans will continue to circumcise only jews, muslims, and the few boys who have problems with their foreskins.

Let’s talk a bit about female circumcision. This ritual practice is common in parts of Africa. There are strong tribal beliefs that uncircumcised females will die prematurely, or suffer diseases, or are impious and unfit for marriage. Not all circumcised African females are forced to it against their will. Strong tribal beliefs means many have it done quite voluntarily. The exact methodology of female circumcision varies from tribe to tribe, particularly as to which parts and how much of the female genitalia should be removed.

The western world regards female circumcision as a barbaric act. In many (perhaps all?) western countries the practice is banned, that is doctors cannot perform it on any girl regardless of parental request or background. To me this really begs the obvious question: if female circumcision is barbaric, senseless and despicable, why is male circumcision ever wise, commendable, and acceptable? In both male and female circumcision, the genitalia is mutilated by removal of varying amounts of skin. In both the precedure is commonly performed without anaesthetics. In both the disfigurement is permanent and may affect sexual function thoughout life. Is there really any difference between male and female circumcision in terms of logic and reasoning other than religious beliefs? What about the benefits of female circumcision? If male circumcision provides health benefits as some research shows, could not female circumsion also have health benefits? Just because no research is (or can) be done does not mean female circumcision can’t possibly have any health benefit. And if those African tribes that practice it are barbaric and cruel, why, by the same yardstick, are not the middle eastern tribes that first practiced male circumcision?

Here in Thailand I have come across, all too frequently, parents (mostly fathers) who have no religious or cultural justification for circumcision who are almost desperate to have their newborn son’s genital mutilated at the earliest opportunity. For some of them the first two questions they ask the paediatrician when their son is born are 1) how much does he weigh? and 2) when can he be circumcised?

I have had arguments with parents like this. Sometimes I manage to persuaded them out of it (mothers are often much less keen on the idea) and other times the parents never want to see or speak to me again (and good riddance to them to, the despicable excuses for parents). I also not infrequently alienate the surgeons who perform the procedure who stood to benefit financially.

But here is where I stand: if parents have been deluded into thinking that circumcision is good and necessary but not for religious reason, I will patiently explain the pros and cons. If they see reason, wonderful! I shall be happy to care for their son through out his childhood. If they are unreasonable, and will subject their baby boy to a barbaric, painful, and cruel procedure to permanently mutilate is penis, and all this without the boy himself ever having a chance to chose what is done to him, well then I won’t be a party to it. I took an oath not to deliberately harm my patients, and I don’t care for parents who won’t listen to reasons. There are many other doctors out there eager and willing (for a fee of course) to help torture and scar innocent baby boys so go to one of them and may you all one day weep for the errors of your way.