Gyroscopic Investing

Benko wrote: Perhaps pt expectations/ requests have something to do with this (and perhaps it is more common in docs not as up on the current literature).    Oh and sinus infections can make one quite miserable, so I understand the desire for an intervention.

I was the medical director of an ED for a few years.  I have had to defend a physician's decision NOT to give abx to sinusitis a number of times in different venus, to both patients, other physicians, and administrators.  It's always a pain in the ass.

I've noticed recently that my docs seems afraid to stray from "guidelines" even though they seem skeptical about them. This leaves the decision making in the hands of the patient without the guidance of the doctor's opinion and experience. If going to a PCP or specialist will become a simple session of him/her following a set decision chart, the future of medicine is bleak.

Mdraf wrote: I've noticed recently that my docs seems afraid to stray from "guidelines" even though they seem skeptical about them. This leaves the decision making in the hands of the patient without the guidance of the doctor's opinion and experience. If going to a PCP or specialist will become a simple session of him/her following a set decision chart, the future of medicine is bleak.

I agree...

The thing is, this is kind of how doctors are trained...to memorize stuff.  In medical school if you memorize what you're supposed to memorize, you get an A.

In practice, you memorize the guidelines and sound smart and trustworthy regurgitating them.

I'm not saying all docs do this.  A lot of this stuff is hotly contested by some very smart physicians.  Still, a lot of the "trench" doctors do fall into the trap of adhering rigidly to guidelines.

One thing that has helped me is to try to understand the rationale behind some of these recommendations, and explain them to patients, especially when I think the patient would benefit from some deviation.

A lot of times, people don't really seem to want to hear it, but when they do it makes me happy.

WiseOne wrote:

MediumTex wrote: I would love to be able to look inside the mind of a typical GP and observe the decision making process used to determine which medications to prescribe.  Something tells me that the drug reps who frequent his office have a huge influence on these decisions.

The whole doctor/drug rep thing is a really peculiar arrangement.  It's sort of the medical equivalent of the relationship between male football fans and the chicks in beer commercials.

MediumTex you are second to none with your literary analogies!!!  Can I borrow that one???  Of course you are spot on with this.  It should be outlawed, along with TV ads for drugs (don't you love the one where the voice-over mutters something about a 4 hour erection being a side effect at the end of the commercial?)

OTOH, I'm sure the beer companies would love for their commercials to give you a 4 hour erection, and the only known cure for this condition would be to drink a lot of their beer.

***

It's ironic that one of the premises behind beer commercials is that drinking a certain type of beer will make you more attractive to the opposite sex, more confident in yourself and more potent should the mating ritual progress to completion.

The truth, of course, is almost exactly the opposite--consuming a lot of alcohol rarely makes you more attractive to the opposite sex, the confidence created by being drunk is more of the reckless and stupid type, and should the mating ritual continue to the final stage, heavy alcohol consumption often renders one or both parties incapable of copulation.

***

WAIT A SECOND!!!  I have a great idea.

The boner medicine companies and the beer companies should do commercials combining their products. 

The guy would be in the bar getting drunk and he would see some woman through the distorted lens of his beer goggles (since beauty is, after all, in the eye of the beerholder), and when he succeeded in persuading her to join him for an ill-advised tryst, he would be shown taking the erectile dysfunction drug. 

The commercials would show a "party pack" consisting of a 12 pack of beer with a side pocket containing individual Levitra tablets.  It would be like the drinking equivalent of those old Reese's Peanut Butter Cup commercials.

MediumTex wrote:
WAIT A SECOND!!!  I have a great idea.

The boner medicine companies and the beer companies should do commercials combining their products. 

They could also put some antibiotics and anti-retroviral medications in the beverage to try to minimize the chance of getting a sexually transmitted disease...maybe some antidepressants to help avoid any shameful feelings that may result from such an encounter. 

MediumTex wrote: It would be like the drinking equivalent of those old Reese's Peanut Butter Cup commercials.

"You got your Viagra in my Wild Turkey!"

http://www.youtube.com/watch?v=DJLDF6qZUX0

(35 second trip down memory lane...who walks down the street eating peanut butter out of a giant container anyway?).

AdamA wrote:

"You got your Viagra in my Wild Turkey!"

http://www.youtube.com/watch?v=DJLDF6qZUX0

(35 second trip down memory lane).

Maybe my mind is just in the gutter, but when they bumped into each other in my mind I heard the woman saying "You got your penis in my vagina!"

I love the way the woman was supposed to be just walking down the street with her headphones on eating peanut butter out of the jar with her hands "Winnie the Pooh-style."

MediumTex wrote:
Maybe my mind is just in the gutter, but when they bumped into each other in my mind I heard the woman saying "You got your penis in my vagina!"

That's understandable.  The commercial kinda had that 1980's VCR-porno vibe.

AdamA wrote: A good example is TPA ("clotbuster") for stroke.  There's no good evidence to support it, but b/c of industry funded studies (with conclusions that contradict the actual data supplied), this dangerous treatment, which can cause a patient to develop a brain hemorrhage and die, is now recommended by supposedly authoritative sources.

I beg to differ on this one.  There is indeed good evidence in both American and European studies that tPA works, and just anecdotally I've seen many cases where it was effective in cases that couldn't have just resolved spontaneously.  I trained at a major center during an intra-arterial tPA trial, so there was documentation of a clot blocking a major cerebral artery before the tPA was given.

Yes, there is a risk of hemorrhage.  We used to joke about it in residency ("...left MCA stroke, $10,000.  Basal ganglia hemorrhage...priceless."), but a treatment that leaves you either cured or dead is preferable (IMHO) to the near certainty of permanent aphasia and paralysis, i.e. nursing home, bedbound, fed through stomach tube, unable to communicate forever.  Personally I'd take tPA without hesitating.

But I do agree with your main point...doctors unfortunately are trained above all to be sheep.  Endless exams and online "training courses", MOC requirements, CME requirements, absurd license renewal fees, and on and on.  And now, Obamacare has started introducing the vibe of "depart from guidelines and we will SMACK you."

WiseOne wrote: I beg to differ on this one.  There is indeed good evidence in both American and European studies that tPA works, and just anecdotally I've seen many cases where it was effective in cases that couldn't have just resolved spontaneously. 

Yeah...I figured someone would. 

But I do agree with your main point...doctors unfortunately are trained above all to be sheep.  Endless exams and online "training courses", MOC requirements, CME requirements, absurd license renewal fees, and on and on.  And now, Obamacare has started introducing the vibe of "depart from guidelines and we will SMACK you."

Do you agree that conflicts of interest are a problem when it comes to medical literature?

WiseOne, Adam, or whoever wants to comment,

What do you think the maximum human life expectancy would be for someone who had an optimal diet for life, exercised regularly in some kind of optimal program of aerobic, strength, flexibility, and endurance training, took all the right supplements, tweaked their hormone balances to maintain early life levels, didn't get cancer, didn't have heart disease, and avoided accidents?

I always seem to see these really old but otherwise very fit people dying of respiratory infections.  What is it about these types of infections that would kill an otherwise healthy and strong (but very old) person?

One thing I seem to see in virtually all old people is a loss of muscle mass.  To what extent would you say that maintenance of muscle mass is a good proxy for overall health--i.e., if a person focused solely on maintaining muscle mass into old age how healthy would you expect that person to be overall, assuming no bad habits/conditions like smoking, obesity, etc.?

I seem to remember reading somewhere that one of the best way to maintain bone density into old age is to maintain muscle mass.

MediumTex wrote: tweaked their hormone balances to maintain early life levels,

Tread carefully with this one.

Benko wrote:

MediumTex wrote: tweaked their hormone balances to maintain early life levels,

Tread carefully with this one.

I will, but I'm just including that in the variables that we might consider because some believe that hormone changes as one ages trigger processes that culminate in death at more or less the range of "expiration dates" for the typical human body.

What is your concern with this item?  That it may set in motion other health problems that are not currently well-understood?  I assume that's your concern, but if it's something different can you elaborate?

MediumTex wrote: WiseOne, Adam, or whoever wants to comment,

What do you think the maximum human life expectancy would be for someone who had an optimal diet for life, exercised regularly in some kind of optimal program of aerobic, strength, flexibility, and endurance training, took all the right supplements, tweaked their hormone balances to maintain early life levels, didn't get cancer, didn't have heart disease, and avoided accidents?

I always seem to see these really old but otherwise very fit people dying of respiratory infections.  What is it about these types of infections that would kill an otherwise healthy and strong (but very old) person?

In all honesty, your guess is probably as good as mine on this...I'm just a lowly ED doc (we are not exactly thought of as the geniuses of the medical community).

However, I do remember a lecture I once attended about lung physiology.  The lecturer seemed to feel that if you could keep all of your other organs healthy, your lungs would become an issue somewhere between 110-120 years old.

The reason he gave had to do with something called "vital capacity," which is basically the volume of air you can forcefully exhale after taking a deep breath.

The formula for vital capacity is something like:  Vital Capacity = [25 - 10% of age (in years)] x height (this is not exact--it's different for men and women, but you get the idea).

I'm not sure how all of the units work out, but the final value is usually given in liters.  For a healthy person it's from 3-6 liters.  You can see that by the time you're 100 years old, you're substracting 10 from the initial 25.   

So, if you're 40 and 170 cm, your vital capacity is around 3.5 liters, and if you're 120 and 170cm your vital capacity is around 2.2 liters.

Vital capacity is sort of a way to measure your respiratory reserves.  Another formula:  Vital Capacity = Tidal Volume (the volume you breath regularly) + Reserves. 

Less vital capacity means less reserve, so after a certain point/age, any active that increases your tidal volume is going to get you into trouble b/c you don't have much left in the way of reserves.
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One thing I seem to see in virtually all old people is a loss of muscle mass.  To what extent would you say that maintenance of muscle mass is a good proxy for overall health--i.e., if a person focused solely on maintaining muscle mass into old age how healthy would you expect that person to be overall, assuming no bad habits/conditions like smoking, obesity, etc.?

Another one I'm not sure about...

It's a causation/correlation question. 

Are muscular people muscular because they're healthy or are they healthy because they're muscular?  In other words, does the muscle keep them healthy, or are they able to stay muscular b/c they're already healthy?  Or...is there something else they do that makes them muscular that also makes them healthy?

I think that there are a lot of good physiological arguments for staying muscular.  The thing is, very often in medicine something that makes physiologic sense, doesn't turn out to be true when it's studied. 

Do you know who Dr. Life is?

http://www.cenegenics.com/?uid=PT1_MS1_CEN_TM_RAIS 

(I am skepical).

I seem to remember reading somewhere that one of the best way to maintain bone density into old age is to maintain muscle mass.

I think this is true (although I am speaking just as a layperson here...way beyond my area of expertise). 

I don't think it's necessarily the muscle mass that maintains the bone density.  I think it's the exercise you do to develop the muscle mass...at least in part. 

When you do weight-bearing exercise, you put stress on your bones that initiates some kind of hormonal positive feedback loop.  Your body recognizes that your bones are being stressed, so it sends hormonal reinforcements that help maintain bone density.

I think the main benefit is to those who exercise regularly throughout life, b/c there is a use/lose component to this feedback mechanism. 

Again...I'm far from an expert on any of this stuff.  This is just what's gotten into my head over the years. 

MediumTex wrote: What do you think the maximum human life expectancy would be for someone who had an optimal diet for life, exercised regularly in some kind of optimal program of aerobic, strength, flexibility, and endurance training, took all the right supplements, tweaked their hormone balances to maintain early life levels, didn't get cancer, didn't have heart disease, and avoided accidents?

I always seem to see these really old but otherwise very fit people dying of respiratory infections.  What is it about these types of infections that would kill an otherwise healthy and strong (but very old) person?

The answer to your question depends mostly on genetics.  Somewhere in the 80-90 range for most people.  The brutal fact is that stuff starts breaking down as a natural part of aging.  Muscle mass and brain volume both begin to decrease around age 40, renal function begins to decline noticeably around age 60, and immune function declines as well.  Exercise, good diet with emphasis on local, small-farm products, a multivitamin to replace nutrients that are no longer in the produce we eat, and a good social network are probably the best guarantee of a comfortable old age.  I second AdamA's concern about supplements beyond this.

About the respiratory infections...well, you gotta die of something.  An infectious disease doc from my intern year used to call strep pneumo "the friend of the elderly", because it's not a bad way to go.  It's not lung deficiencies, it's the immune breakdown and antibiotic resistance.

Re conflicts of interest in the medical literature, I guess it depends on what you consider a conflict.  There's a natural inclination in all of us to report the result we wanted to see, for whatever reason we wanted to see it (personal pride, pet theory, financial reward, etc).  The peer review system is also flawed:  usually the people best qualified to critique a study or grant proposal are exactly the ones who have to be excluded because of perceived conflict of interest.  But with all these issues, the system works pretty well.