Category Archives: Mainstream Medicine

Meet the doctor big pharma can’t shut up

Posted on by

Dr David Healy does not consider himself a radical. He prescribes antidepressants and other prescription drugs to his patients. He runs a national university school of psychological medicine. “I’m fairly conservative. I’m a very mainstream doctor, really,” he said. But as New York Times reporter Benedict Carey pointed out in a 2005 story, the Irishman living on an island off the coast of Wales “has achieved a rare kind of scientific celebrity: he is internationally known as a scholar and pariah.”

Do you remember the reports that the pilot who crashed the German Wings plane into the Alps, killing all 150 people on board, was on anti depressant drugs?

[David] Healy’s status as an outcast arises from his grave concern that blockbuster drugs like Prozac and other antidepressants can lead to suicide, murder and unforeseen mental health problems. In the 1990s, he began to publish academic journal papers providing evidence that antidepressants could increase the risk of suicide. Although many colleagues denied the link, by 2004 American and British drug regulators issued strong warnings supporting Healy’s and other’s claims.

http://www.alternet.org/meet-doctor-big-pharma-cant-shut

 

 

Treating thyroid patients like children – Dr Malcolm Kendrick

Posted on by

This is a very refreshing article by a well known UK doctor.  Such were the truths it revealed that many of the (at the time of writing) 264 replies came within the first two days after it was posted on his blog. Patients were virtually screaming (forgive the pun) with joy that at last somebody had recognised how they feel.

We do have some doctors in Singapore who recognise how we feel when T3 is missing but it seems that their hands are becoming increasingly tied with regard to helping us deal with it.

Some extracts from the article are posted here with permission but please read the whole article – Dr Kendrick speaks for so many of us. If only he could speak to the Ministry of Health!

Dr Kendrick admits:

To be honest, until about a year ago I had no real idea what T3 was either, but I have learned quite a lot since.

He certainly has. This paragraph really caught our attention (bolding by HCS):

The lab tests, especially for TSH, are far from 100% reliable, to say the very least. In fact the man who developed the test in the UK, at Amersham International in Wales, has told me that the test is virtually worthless in many cases (especially continuous testing when patients are taking thyroid hormone replacement).

And yet more good sense, which echoes what many of us at Hormone Choice Singapore have experienced (bolding by HCS):

Far more telling, from my point of view, is the fact that hundreds, indeed thousands of patients report that, although their blood tests were normal, they felt terrible, and that they have felt so much better when they have been given ‘excess’ T4 and/T3, or NDT (natural desiccated thyroid). Whilst there is no doubt that some of them are, to quote a medical colleague, ‘not tightly wrapped.’ I have spoken to many, many, people who are calm, rational and reasonable, and their stories are compelling. A hellish existence that was ‘cured’ by Dr Skinner and his like. I refuse to believe that all of these patients are ‘somatising’ fruitcakes.

Read the whole article at:

http://drmalcolmkendrick.org/2015/05/01/treating-thyroid-patients-like-children/

And comments at:

http://drmalcolmkendrick.org/2015/05/01/treating-thyroid-patients-like-children/#comments

 

 

Revising guidelines for testosterone testing could more accurately diagnose deficiency

Posted on by

One of the issues under discussion among patients and doctors in Singapore is how to determine when there is a need to treat men with supplemental testosterone therapy.  This new study shows that levels of free testosterone are more informative than total testosterone levels

European Society of Endocrinology     16 May 2015

A new study presented at the European Congress of Endocrinology in Dublin suggests that some men suffering from testosterone deficiency may be missed under current clinical guidelines while others are misdiagnosed with testosterone deficiency. The researchers call for a revision of the clinical guidelines to ensure that men are receiving the best possible care.

Testosterone deficiency, also known as male hypogonadism, can lead to decreased libido and infertility, but it has also been associated with a higher risk of developing metabolic syndrome, diabetes and osteoporosis. In men, testosterone levels gradually decline with age. In recent years, an increasing number of ageing men are presenting with symptoms suggestive of hypogonadism and testosterone levels that are around or below the lower limit for young men. To date, the diagnosis of hypogonadism in these middle-aged and elderly men and their management remains controversial.

Researchers at the University of Manchester, UK and the University of Leuven, Belgium (represented by Dr Leen Antonio) used data from the European Male Aging Study (EMAS) to determine the relative importance of total and free testosterone measurements in diagnosing testosterone deficiency in aging men.

Testosterone exists in the body in two states; bound to proteins (98 % of total testosterone) and non-protein bound or free (2% of total testosterone), the latter being the biologically active fraction. Current clinical guidelines suggest that testosterone deficiency is diagnosed by measuring total testosterone levels. However Dr Antonio’s study shows that levels of free testosterone are more informative.

Only free testosterone can enter cells and is responsible for testosterone action. When men get older, total testosterone levels decrease while the levels of the protein that binds it increases. This means that the level of free testosterone decreases more than the total testosterone with age.

Dr Antonio, “We show that middle-aged and elderly men with normal total testosterone levels but low free testosterone levels have more symptoms of hypogonadism compared to normal men than those with normal free but low total testosterone – these men currently miss out on treatment because they are not diagnosed with testosterone deficiency.”

“On the other hand, men with low total testosterone but normal levels of free testosterone do not suffer from testosterone deficiency, yet are misdiagnosed with the condition and can be treated with testosterone inappropriately.”

Dr Antonio and colleagues propose that new guidelines should recommend measuring free testosterone, in addition to total testosterone, in the evaluation of men with hypogonadal symptoms.

http://www.alphagalileo.org/ViewItem.aspx?ItemId=152794&CultureCode=en

 

Real evidence based medicine

Posted on by

Trish Greenhalgh and Neal Maskrey

Trish Greenhalg is Professor of Primary Care Health Sciences and Fellow of Green Templeton College at the University of Oxford. She has twice won the Royal College of General Practitioners Research Paper of the Year Award and in 2001 received an OBE for services to Evidence Based Medicine.

Neal Maskrey is an Honorary Professor of Evidence-informed decision making at Keele University and consultant clinical adviser in the Medicines and Prescribing Centre, National Institute for Health and  Care Excellence, UK.

In this video, these experts explain the concept of real evidence based medicine (EBM) as it should be applied to real patients.

Note particularly 6.30 to 7.47

. . . if you look at the research literature on expert judgement you will find  that experts . . . don’t mechanically follow rules. They do something much more intuitive and much more rapid and what they then do is they come to a rapid decision and then they go back and unpack why they got to that decision and they justify it by using the evidence  . . . one of the things that clinicians say again and again is “I don’t want to be tyrannised by these guidelines. I don’t want my patients to be tyrannised by these guidelines.” And it seems that their clinical judgement is being challenged by these guidelines and what we want is for the clinical judgement to be supported by the guidelines so EBM will be delivered in a much more nuanced and granular way than people sometimes assume it should be.

Also 7.57 to 8.30

There are, of course, in every consultation two people involved in making the decision. The clinician has their own expertise and the patient has their own expertise.

How sad that, while the rest of the world is reassessing the concept of Evidence Based Medicine, Singapore is taking the backwards step of applying the guidelines in exactly the mechanical way that these experts feel should be avoided!

 

The evidence must come not from tests but from a thorough observation of the patient

Posted on by

Emeritus Prof Sir Gordon Arthur Ransome (1910-1978)

Today one of the four colleges at the Duke-NUS Graduate Medical School is named after Emeritus Prof Sir Gordon Arthur Ransome, remembered by many as the founder of modern medicine in Singapore and admired as an outstanding and brilliant clinician. His contributions to medicine in Singapore went back to 1938, when he was made Associate Professor of Medicine at the then King Edward VII College of Medicine. He also founded the Singapore Academy of Medicine and was its first Master.

The following is taken from an oration to mark Prof Ransome’s retirement in 1971: The life and times of Gordon Arthur Ransome by Seah Cheng Siang in Annals of the Academy of Medicine, January 1972, Vol. 1 (Bolding by HCS)

http://ams.edu.sg/view-pdf.aspx?file=media%5C591_fi_219.pdf&ofile=gar+01.pdf  

Foremostly, Professor Ransome taught by example. Himself a well-trained clinician, he has handed down to hundreds of doctors, clinical methods which were learnt from his teachers and also those innovated by his own increasing experiences.

In taking a meaningful medical history, he has on many occasions, and still does so now, sit by the bedside, eliciting point by point the story of the patient’s illness, with students watching on. From the history and adopting Lord Horder’s methods, a list of possible diagnoses to account for the presenting symptoms, is then compiled.

In front of the students, Professor Ransome will then examine the patient meticulously. A very careful inspection from head to foot is followed by an examination in minutia of the different systems. . .

From the signs culled, and with the results of some laboratory tests, he has nearly in every instance been able to arrive at a definitive diagnosis. A firm diagnosis by this method and not by intuition, is always teachable. He converted many a doctor from practising intuitive diagnosis into exercising a perceptive scientific method.

Another interesting insight into his powers of diagnosis comes from Sir Gordon Arthur Ransome  by Beng Yeong Ng and Jin Seng Cheah in Annals Academy of Medicine May 2008, Vol. 37 No. 5 (Bolding by HCS)

http://ams.edu.sg/view-pdf.aspx?file=media%5C614_fi_929.pdf&ofile=V37N5p426.pdf

 He taught from first principles and emphasised the importance of the use of the 5 senses in the practice of medicine. He placed importance on the art of listening, the essence of the artistry of bedside medicine. Effective listening involves all the senses, not merely the ears. To succeed in healing, a doctor must be trained, above all else, to listen. His skills as a diagnostician were renowned. He believed that X-rays findings tended to lag behind the physical signs. Without any laboratory tests, he was able to arrive at an accurate diagnosis just by taking a comprehensive history and examining the patient skilfully. He was nicknamed “kosong” (meaning “zero” in Malay) as he would give a student zero marks for poor performance in clinical examination. 

This letter from Dr Quek Koh Choon, one of Prof Ransome’s former students, appeared in the Sunday Times on 26 April 2015 and again highlights the importance Prof Ransome attached to observation – note “Tests and investigations were needed only to confirm the diagnosis. (Bolding by HCS)

http://www.pharmacychoice.com/News/article.cfm?Article_ID=1366630 

If Professor Gordon Arthur Ransome were alive today, he would be pleased to see how Singapore has become a great medical centre (“Prof hopes S’pore becomes medical hub”; last Sunday). 

I was privileged to have been taught by him, and to also have had the opportunity to work with him.

He taught me that the practice of medicine is not just a science, but also an art. He emphasised the need to observe the patient as he came into the consultation room – to watch his gait and facial expressions – and also advocated listening to the patient well.

These days, many patients say that many doctors are not listening enough to their complaints, and that they are quickly dismissed to undergo a battery of tests and investigations.

Prof Ransome did not think it wise to resort quickly to investigations. He believed that a great deal could be learnt from a patient’s history, and that astute observation and a thorough examination were key in clinching the diagnosis. Tests and investigations were needed only to confirm the diagnosis.

I used to accompany Prof Ransome on his ward rounds, and he surprised me when, at the end, he invited me to sit down with him and asked for my opinion of the various cases.

I was the most junior doctor then, and the experience certainly jolted me and taught me to value mutual respect among fellow colleagues and to be open to consider an opinion, even from a novice.

Prof Ransome treated all patients with respect and kindness, and did his best for them no matter what their status and background were. Once, he was called to attend to a VIP while examining a patient in a C ward. He said that the VIP had to wait as he was still attending to his patient.

He was a doctor devoted to the practice of medicine. He did not care much for accolades and prestige. Patients were his priority.

He was truly one of the great founders of modern medicine in Singapore. His inspirational values should be remembered by all who follow in the tradition of good doctors and healers.

Quek Koh Choon (Dr) 

We can only guess at what Prof Ransome would have thought of today’s Ministry Of Health insisting that all diagnosis be based only on test results and supposedly evidence based medicine. One can sense his disappointment and hear him cry, “What about the patient? The patient will tell you what’s wrong if you just listen! Just listen – with all your senses! I am giving you zero!”

 

Our Holy Miracle of the Infallible TSH Test

Posted on by

A beautiful video which sums up the ‘approved’ approach to thyroid treatment.

The Ministry Of Health insists that the Thyroid Stimulating Hormone (TSH) test is the be all and end all and punishes those doctors who question it. Meanwhile, many patients with normal TSH levels continue to feel unwell.

 

Is evidence-based medicine broken?

Posted on by

This article by Trish Greenhalgh, Professor of Primary Health Care and Dean for Research Impact at Barts and the London School of Medicine and Dentistry, looks at the controversy surrounding evidence based medicine.

She finds that (bolding by HCS)

. . . the attempted solution – hard-wiring the guidelines into computerized “decision support tools” – has been largely a flop, given computer models’ inability to accommodate messy, real-world clinical practice. For example, generations of medical students have memorized the textbook features of celiac disease for their examinations. But your Aunt Nora’s celiac disease has not read the textbook.

Indeed, only Aunt Nora can tell you how her celiac disease behaves. She also happens to be opposed to taking blue-colored pills. And she insists that, years ago, when she took drug x, it made her feel like a new woman – despite the fact that, in 1,000 patients, drug x has demonstrated, on average, no effect. The computer model’s treatment recommendations would probably not work for Aunt Nora.

But this does not mean that evidence-based medicine is broken; it simply lacks the needed maturity. High-quality randomized trials are as important now as they were at the time of the evidence-based movement’s founding. But the system must be shaped by the doctor’s judgment and the patient’s individual experience.
She later states:
. . . research-derived facts about the average patient must not outweigh individual patients’ observations of their own bodies and illnesses. New processes for capturing and accommodating patients’ personal experiences – which are typically idiosyncratic, subjective, and impossible to standardize – would go a long way toward ensuring that each patient receives the right treatment.

Read the whole article at:

http://www.project-syndicate.org/commentary/is-evidence-based-medicine-broken-by-trish-greenhalgh-2014-10