Doctors and Your Health

[VH-MLE]

In recent years I have become a little disillusioned at the role of the medical profession in being proactive in healthcare. Yes we get warned on the dangers of smoking, obesity and heart disease, however preventative healthcare should go a lot further than that in my opinion.

Having said that I think my GP is quite good at diagnosing medical conditions that I and my family have presented with but feel his role and other doctors my family has dealt with (and there have been plenty of them unfortunately) is more reactive than proactive. I will now tell you why.

Approximately 6 years ago my brother in law (at age 44) was diagnosed with bowel cancer, with a secondry tumour on his liver. He passed away 16 months later. During this period I went to my GP and asked for a colonoscopy just as a precautionary measure. He said that the health guidelines were that unless there were symptoms or family history then 50 was the recommended age for a colonoscopy. I was told to wait until 50 unless things changed ( I was 44 at the time). Approximatey two and half years ago my wife was diagnosed with cervical cancer and after her treatment was complete I went back to my GP and once again requested a colonoscopy because of my wifes condition. He begrudgingly agreed and 2 years ago (at age 46) I had my first colonoscopy and it turned out I had a moderately sized adenoma polyp (the type that can turn nasty) and the gastroenterologist remarked that it was good that I came along when I did. If it wasn't for me taking control of my own health I'm not sure what that polyp may have done in the next 4 years. As an aside I had a follow up colonoscopy on Monday and had 2 very small polyps removed.

My wife had a routine pap smear that came back normal however 17 months later (in May 2005) she was diagnosed with cervical cancer. Due to a lack of experience in dealing with such a disease and the medical profession I/we foolishly put our trust in our various doctors and were badly let down by a couple of them. Initially the cure rate for her disease was in the vicinity of 85%-90% and her primary doctor kept stating at each of her 3 monthly checkups that he would order a CT scan and chest X-ray "next time". By the time she eventually had a scan (at our GP's request she had multiple secondaries in her lymph nodes and that was the beginning of the end for her. Even when the nodes showed up her surgeon wanted to wait 3 months and have another scan because he wasn't convinced the radiologists report was accurate (this was after a PET scan also revealed multiple cancerous nodes as well NOTE: the PET scanner is a new and more accurate cancer diagnosis tool). By then I had learnt enough that we wanted those nodes out ASAP and of course they were all malignant.

At the end of the day we were having to largely take control of my wife's treatment however, in the end it was all to no avail.

In recent times I have asked my friends of similar or slightly older age what tests does their GP recommend for them. None have been recommended for colonoscopies, very few have had prostate checks (PSA and the physical examination), very few have had blood tests for cholesterol, liver, kidney function etc so I ask what benefit is your GP if he cannot make some attempt to monitor your overall health?

To me it is largely up to the patient to take control of his own destiny. The problem is many people don't know what tests they should or shouldn't be having.

Any comments welcome.

Regards.

VH-MLE

[gingernut]

I think the first thing to say is that it sounds like you've had an awful time, and you are quite rightly questionning the events and procedures which brought about the suffering you and your family have endured.

I think it would be innapropiate to respond to the individual cases you have highlighted, but perhaps it may be useful to bring some insight to the situation generally.

Incidentally, a simillar thread is also currently running. http://www.pprune.org/forums/showthread.php?t=299823

I'll deal with 2 issues you've raised.

Firstly screening: your quack is as good as his toolkit. Unfortunately the tools he's got to hand are generally pretty limited, and unfortunately do not always give the result we desire. Screening tools have to be acceptable to the population they are used on. They have to be accurate, and the result has to make a difference to the eventual outcome. Otherwise, they are not useful as a screening tool. Unfortunately, as the science is at present, 2 of the 3 tools you mention, do not fit these criteria.

Secondly, access to investigations. Here's how it works. The patient presents with a set of symptoms, the GP has access to the specialists, tools, scanners etc.

If he's worth his salt, the Gp will be taking into account all the factors in your case, the story of the symptoms, pre-existing illness, family history, results of his examination etc. IHe will then be making some sort of risk assessment, how serious, or how potentially serious is this situation. The results of this assessment will then guide his management of your situation.

Sometimes, your problems fit into a neat little "guideline," and the next step is quite clear. For example, you were 60, and you told me that you had lost 3 stone, had heartburn, and your food stuck when you swallowed, I'd be wanting to get you investigated, (a camera in the tum), pretty much straight away. (In the UK, the "journey" between you presenting to your GP, and being seen by a hospital quack should take no less than 2 weeks).

If you told me that you were 20 years old, drank 8 pints of Stella prior to your chicken Jalfreizi, and woke up with heartburn this morniong, I'd be a little reluctant to send you off for further investigating. (In that case, the chances of you having something nasty, are about one in 250,000, the chances of the camera in the tum causing harm are about 1in 1000, of serious harm, 1 in 10,000.)

Unfortunately, most patients seem to fit somewhere in the middle, which is probably why a machine will never completely take over from your quack.

I wish I could tell you it was more magical than that, it isn't I'm afraid. :)


(Although others may have a different perspective.)

Cheers, ginge.:)

[obgraham]

VH, I recall some discussion with you a year or two ago about your Missus. I'm sorry to hear of the ultimate outcome. You have some very valid points to raise.

I don't know the answer to our health "system" failures these days. Your UK system is perhaps overly bureaucratised. But our US system has so many impediments to getting proper care, that it seems only flinging loads of cash around seems to get results.

We have to keep in mind the old "macro- versus micro-" issue. We need planners and academics who can look at the overall situation and say, for example "we'll advise screening for Disease X because the testing and overall outcome results justify the cost. We won't screen for Disease Y because we don't have an effective screening plan that is effective and affordable". Example: Cervical cancer is X, ovarian cancer is Y.

However, at the micro- level, we have to evaluate and treat the individual. So sometimes that plan for Disease X lets us down and does not work, and sometimes we need to look at screening for Disease Y in a particular person because they have individual differences in their case.

How to balance these is the great unknown in health care today. And it is true in every country's systems.

Best wishes to you and your family, VH.
_________
Graham MD

[VH-MLE]

Gingernut and obgraham,

Thankyou for your informative responses.

The main purpose of my post was to basically draw it to peoples attention that at the end of the day you have to take control of your own health and request/arrange for screening for those diseases that commonly take people out.

My wife's radiation oncologist (who was her best oncologist by far) made a couple of general comments that have always stuck with me. The first was that a colonoscopy is the best 50th birthday present you can get. The second related to the the "big 4" types of cancer that generally take out males (in Australia at least) - these were (i) lung cancer; (ii) bowel cancer; (iii) prostate cancer; and (iv) melanoma. Lung cancer is one you don't generally get checked for but the other 3 should be incorporated into your overall health management and are relatively easy to screen in my opinion.

The point I am trying to make is that your GP, as your primary doctor, should be ensuring that (ii), (iii) and (iv) are checked at appropriate intervals but generally this doesn't happen.

I don't think you should have to present with rectal bleeding and find out you have bowel cancer at age 55. If your GP is doing his job he would have recommended you have a colonoscopy at 50 (although I believe 45 is better personally although I'm not a doctor) and hopefully any precursors to bowel cancer can be nipped in the bud much sooner.

This as you can probably see is an important issue to me.

Regards.

VH-MLE

[gingernut]

If your GP is doing his job he would have recommended you have a colonoscopy at 50

I'm not entirely sure this is true VH.

Remember, they have to balance the risk the procedure carries, (albeit very low- complication rate 0.14-2%), with the benefit it derives. (In a "low risk" patient.)

I'm certainly not an expert on the subject, and perhaps one of my more learned friends could shed some light, but as far as I'm aware, colonoscopy in an asymptomatic patient aged 50 is probably not recommended.

Of course, the great thing about this job, is that things do change on a day to day basis, so perhaps one day your prediction may be correct, but as far as I'm aware, there is no evidence for such practice at this present time.

If you are interested in the subject, a starting point maybe http://www.sign.ac.uk/guidelines/fulltext/67/section4.html

or have a scout round the British Society of Gastroenterology website.

Sending regular poo samples off for hidden blood analysis may be of more benefit for the asympomatic population.

As regards PSA testing, check my comments in an earlier thread regarding it's limitations as a screening tool per se.

Cheers, ginge.:)

[gingernut]

Found a better link http://www.sign.ac.uk/guidelines/fulltext/67/section2.html


look at 2.7.1, it does mention that a study on the subject is due to be released in 2007.

Or look at Colorectal cancer screening in the UK: Joint Position Statement by the British Society of Gastroenterology, the Royal College of Physicians, and the Association of Coloproctology of Great Britain and Ireland

(In google scholar)

[VH-MLE]

Thankyou Gingernut,

I acknowledge absolutely that your level of knowledge on this issue far exceeds mine - I tend to see it not so much from a statistical point of view but more from real life experience.

As an aside, I was talking to an anesthetist friend who assists a gastroenterologist with sedation during endoscopies and colonoscopies. He decided - in his 40's, to also have a colonoscopy because of the number of people in their 40's who had tumours identified during this procedure.

However, I'm probably getting away from my original point in that I am not referring to just colonoscopies - I also refer to skin cancer screening, prostate cancer checks (the physical check and the PSA), cholesterol, ECG, kidney and liver function as well as a general blood count which don't appear to be routinely conducted by the average GP. Ladies, of course, require slightly different checks.

The average person does not know what screening he/she should be having and that to me is an important role of the GP. Maybe I have it all wrong but that is the way I respectfully see it.

I look forward to further comment on this topic and have also been closely monitoring the thread instigated by Loose rivets, which was one of the driving forces behind this one.

Best regards.

VH-MLE