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Choosing Wisely

Posted March 4, 2013

It may be a paradigm shift and for many, that would be welcome. For years many, if not most of us, have been culturally customed to think of medical decisions through the prism of “What did the doctor tell you to do?” Regarding not only medicine but legal issues and financial matters were also viewed as areas where we turned to the “experts”. We looked for experts in tax law, experts in investment, experts in joints, experts in gynecology, and the like when faced with decision making for ourselves. We all wanted the best cancer doctor, for example, when it came to the cancer of someone in our family or even ourselves.

Looking for experts does have its benefits. Think of going to a heart surgeon who only does 4 procedures a month versus a heart surgeon who does 40 procedures a month when contemplating a doctor to perform your heart procedure has obvious benefits. However, that must be weighed by the fact there is no one right way. Every field of medical expertise (and we have many, imagine we even have experts in heart rhythms) is practiced with standard of care guidelines.

That is, say, your mother has an irregular heartbeat. It is the standard of care for her family practitioner to refer her to a cardiologist who will prescribe certain blood tests and diagnostic procedures  Then, the medication which she will be prescribed is scrutinized not only by the insurance company that insures your mother but also by the state licensing board that has granted the medical license. Nowhere in this medical process is a discussion of do the risks of the medication outweigh the benefits for your mother? What is your mother’s age? What other medical conditions affect your mother and what other medications is she taking? Has anyone considered your mother’s lifestyle? For example, if she is alone and likely not to eat lots of fruits and vegetables she is at risk of magnesium deficiency that affects a large percentage of Americans. Magnesium deficiency alone may set the stage for an irregular heartbeat. Her cardiologist is likely to prescribe a blood thinner with the risks of bleeding never considering she falls frequently. The blood thinner may interact with other medications she has been prescribed. When she reaches 10 medications (keep in mind the average American senior takes over 20 medications during the course of a year),her risk of side effects due solely to the interaction of the medications is 100%. Her physicians are dutifully practicing the standard of care but it may not be the best care for her.

Physicians often practice medicine looking over their shoulder at whether a medical malpractice attorney may scrutinize their patients’ medical records. Studies have shown over 90%of medical procedures are unnecessary used solely to insure the physician will not be sued. The procedures may never affect the patient’s diagnosis or treatment but they are used in case a hostile attorney asks “why wasn’t this done or why wasn’t this prescribed?” We all know those procedures and prescriptions are not without side effects of their own.

All of these factors and more make a new campaign launched by 9 medical groups who are now joined by 16 medical societies a welcome step. It is called Choose Wisely. Courageous guidelines including lists of over-used tests and procedures to question or avoid have been released. It deserves national attention and a nation-wide effort to educate both patients and practitioners alike.

Consider, for example, the use of CT scans in children. There are more CT scanners in Pittsburgh, PA than all of Canada. Radiological procedures like CT scans generate large amounts of money for the medical system. But how do you choose wisely? CT scans come with the risk of radiation that can increase our risk of cancer over time. The Choose Wisely campaign notes that 50% of all childhood head injuries result in CT head scans. Over a lifetime, that radiation from medical procedures has a cumulative effect on our DNA causing possible breaks and increasing our risk of cancer. If that child has dental x-rays, several minor head injuries requiring CT scans of the head, a broken limb or two requiring x-rays the cumulative effect of the medical radiation could increase that child’s risk of cancer and heart disease. Click to read the research of the late John Gofman,MD, professor emeritus of University of CA San Francisco that correlated the use of medical radiation with an increased risk of cancer and heart disease. Choose Wisely aims to educate parents and practitioners that minor head injuries do not require the use of CT scans of the head. Money can be saved and the risk of further cancers as well as heart disease reduced without comprising the child’s health. That is a win-win for all.

It may be scary. We are used to the if a little is good, more is better, and a lot is best of all. We are slowly embracing more medicine is not necessarily better care. More medicine comes with more risks. Everything comes with a risk-to-benefit ratio. Choosing wisely is assessing when the risks outweigh the benefits for you. Each of us has a unique genetic map. It is both empowering and sobering that our lifestyle choices including the amount of medical radiation to which we are exposed can affect the expression of our genes. Expose your genes to an excess of radiation and you may be genetically susceptible to develop cancer or heart disease in later years. This is one reason medical doctors like Dr. John Gofman teach us to ask questions including “What is the lowest dose of radiation needed for this CT scanner to diagnose a possible concussion without adversely affecting the quality of the scan?” Interesting case studies have found the radiologist parents of children with head injuries recognized that often the dose of radiation could be lowered without negatively impacting the quality of the CT scan. As radiologists, they well knew less radiation is better for their children and ours, too. .

Obstetrics guidelines have also been issued by the Choosing Wisely medical campaign. American medicine now acknowledges giving birth with more medical intervention has not resulted in reducing the risk of low birth weight babies, reducing the risk of repeat Caesarean sections, and the risk of dangerous births. Studies dating back to 1932 have found that the use of midwives not hospital-based births could have dramatic positive effects on the rates of low birth weight babies and babies born via C-sections. Even simple steps to choose wisely by not inducing labor before 39 weeks of pregnancy and before the cervix is ready for labor induction have resulted in less babies born with low birth weight and born via C=section. Both situations can result in a lifetime of medical challenges for that child. Many obstetricians have been strongly criticized by their colleagues for misconceptions including but not limited to:
Any baby born after 5pm or before 8 am is to be done via C-section.  Once a C-section, always a C-section.

The way we have always done it sometimes does not stand up to scientific scrutiny nor the question what is the way that is best for me? Click (web site URL) to learn more about this important step by practitioners in order to choose wisely. Urge everyone you know to learn the questions to ask in order to make wise decisions for their own healthcare needs. They may include:

*           How is this procedure going to change the diagnose or treatment of my condition? Note: if the answer is not all all, the risks of the procedure outweigh any benefit for you.

*           What are the risks as well as the benefits of this prescription as well as this procedure? Note: if your genes put you at risk, for example, for cancer and this procedure could    increase your risk of cancer, the risks could outweigh the benefits for you.

*           How does nutrients does this medication impact? Educate yourself and your physician, perhaps, about drug-induced nutrient depletions. Many side effects are the results of      nutrients affected by the prescription.

*           What are the long-term effects of this procedure and/or medication? A new drug is not necessarily the best drug but it is the drug for which the long-term side effects are not    known. You don’t want to be the experiment.

Cultivate a team of health care practitioners who are not offended by asking questions. Often asking your practitioner “If I were your mother, is this the approach you feel in your professional opinion is the best for me?” may elicit an answer completely different than what your practitioner has recommended to you. You are in charge. No one knows your body and how it reacts better than you. No one but you can know what is best for you.

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