When Doing Nothing Is the Best Medicine

OCTOBER 20, 2011

When Doing Nothing Is the Best Medicine

By DANIELLE OFRI, M.D.
“Don’t just do something; stand there!”

It’s one of those phrases that attending physicians will spout off to their medical students while on rounds, trying to sound both sagacious and clever at the same time. It sometimes grates, but it does make a valid point, because so much of medicine is about “doing something.”

Sore throat? Prescribe an antibiotic.

New headache? Get a CT scan.

P.S.A. at the upper limit of normal? Get a biopsy.

Blood pressure still high? Add on another medication.

Doctors tend to want to “do something” whenever they note something amiss. And patients, by and large, want something done when they have a symptom. Few people like being told just to watch and wait.

Of course, every “thing” a doctor does also has side effects — rampant bacterial resistance from antibiotic overuse; major increases in radiation exposure from unnecessary CT scans; incontinence or impotence from prostate cancer treatments that may do nothing to prolong life; toxic drug interactions from multiple medications, particularly in the elderly.

The admonishment “Don’t just do something; stand there!” reminds us that we should stop and think before we act, that there are many instances in which doing nothing is greatly preferable to doing something.

In fact, there are some doctors for whom “doing nothing” is the dominant way of thinking, who are not reflex “do-ers.” They tend to lean toward the status quo: If the patient is doing fine right now, why rock the boat?

There’s a term for this in the medical literature — clinical inertia — a term with a distinctly negative connotation. It describes the doctor who, for instance, sees a patient with cholesterol levels that are not optimum but who does not prescribe a statin. Or the doctor who notices that a diabetic patient’s blood sugar levels are still not normal but refrains from increasing the patient’s medication.

Of course, this is not black and white: There is a continuum of practice styles, just as there is a continuum of personalities in general. At one end are doctors who jump on the merest hint of a borderline lab value; at the other are doctors who avoid making changes unless absolutely necessary.

I like to think of myself as perfectly balanced in the precise middle of this spectrum, but if I take a hard look in the mirror I can see that I tend toward the clinical inertia side, always hesitating before I write a prescription or order a test. I tell myself that this arises from the august wisdom of my clinical experience, from having witnessed my fair share of side effects and adverse outcomes due to medical meddling. But I have to be honest and recognize that it reflects my personal tendency to be slow in making major decisions of any sort, to need a strong sense of how things are likely to play out before I act.

Every time I prescribe a medication — or order an invasive test, or refer a patient to a surgeon — it always feels like I’m placing a stone on a balance scale. Intellectually, my goal is to place the stone on the side of the scale that benefits my patient. But in my heart, I fear that it could end up on the other side, the side that harms, and the weight and permanence of the stone give me pause.

Many make the argument that deciding not to act is as momentous as deciding to act. Except that it never feels that way. My hesitation induces guilt; it makes me ask myself if I am harming my patients by not acting as fast or aggressively as some of my colleagues would.

An essay I came across in The Journal of the American Medical Association called “Clinical Inertia as a Clinical Safeguard” offered some food for thought. The authors postulated that doctors who tend toward inertia might actually benefit their patients by protecting them from overzealous medical intervention.

They focused on three common medical conditions — diabetes, elevated cholesterol and hypertension — for which there are established clinical guidelines for doctors to follow and “quality measures” that evaluate medical care. For all three illnesses, “lower is better” is the dominant mantra.

But while “lower is better” is probably true for large populations, that is not always the case for individual patients. In fact, there are some clinical trials in which aggressively lowered blood sugar or blood pressure have been associated with higher rates of dying.

The authors weren’t saying that these medical conditions shouldn’t be actively treated, but they did caution that standard clinical guidelines tend to favor overaggressive treatment in pursuit of “good numbers.” In the stampede toward good numbers, individual patients can be harmed by the side effects of these treatments. Clinical inertia might actually act as a safeguard for such patients.

No one, of course, wants doctors who fail to act when action is necessary. And medical emergencies are a different story altogether. But most chronic illnesses, luckily, are not emergencies, so there is room for deliberation before action. And while insurance companies won’t reimburse for deliberation, and report cards pointedly penalize, it’s interesting to consider that there are many patients who may have been saved by inertia.

Danielle Ofri is an associate professor of medicine at New York University School of Medicine and editor in chief of the Bellevue Literary Review. Her most recent book is “Medicine in Translation: Journeys With My Patients.”

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Oregonian Coverage of Oregon Health Authority Public Meetings

The Oregonian yesterday reported on the Oregon Health Authority’s public meeting held in Portland yesterday (see my note from Sept. 28 below). The story reports that Dr. Dhai Barr (1998 NCNM graduate) wondered where ND care will fall in the new CCO plan—and it ends by noting a patient’s unfortunate health care experience—with a nod for naturopathic medicine. Here’s the story, “Oregon Health Authority meeting on health transformation packs the room in Portland.”

Here is the link to the story: http://www.oregonlive.com/health/index.ssf/2011/10/oregon_health_authority_meetin.html

Surgery Not 'A Magic Pill' For Obese Patients

While bariatric surgery has its place amongst the morbidly obese, this article points to the many reasons to go back to the basics and set the foundation for a healthy lifestyle with adequate nutrition and exercise. A Naturopathic Doctor is a great addition to your team if you struggle with weight loss and chronic health issues.


Original link:
http://www.npr.org/2011/10/01/140803898/surgery-not-a-magic-pill-for-obese-patients

Surgery Not 'A Magic Pill' For Obese Patients
by CARRIE KAHN

Listen to the Story
Weekend Edition Saturday [7 min 29 sec]


October 1, 2011
Part of an ongoing series on obesity in America

Losing weight in America is big business. Americans spend $61 billion a year on everything from diet pills and exercise videos to meal plans, health club memberships and medical treatment. One of the fastest growing and lucrative segments of the weight-loss market is surgery.

And if you want to learn about the risks and benefits of going under the knife to lose weight, there's a great place to go in Los Angeles — and it's not a Beverly Hills doctor's office. Check out Power 106, L.A.'s popular hip-hop station, and its larger-than-life DJ, Big Boy. The DJ — seldom referred to by his given name, Kurt Anderson — used to be really big.


Before getting bariatric surgery, Los Angeles DJ Big Boy posed for a photo promoting his radio station, Power 106. He weighed more than 500 pounds.
"I had gotten up to like an 8X shirt and size 66 pants. My whole life I've always been big. It just went from big to bigger till I got to my biggest," Anderson says.

He reached 520 pounds. At that weight, Anderson posed provocatively for a photo in his underwear. It was plastered on billboards all around L.A. But he says he knew he wouldn't last at that weight.

"I was 33 years of age, I was over 500 pounds, and you start to ask yourself, 'Do you have more years behind you than you have in front of you? Do you see any 66-year-old, 500-pound men?' You don't," he says.

Anderson says that after years of failed dieting, he decided on gastric surgery.

"There's really nothing in the field of medicine that can match what surgery can do for these patients," says Dr. Amir Mehran, the director of bariatric surgery at UCLA. He points out that there are many different types of bariatric surgery, from removing large portions of a patient's stomach to just restricting it so less food can get in. Mehran says each procedure has its risks and benefits.


Eight years after his surgery, Big Boy maintains his weight right around 200 pounds.
"The surgery is not a quick fix. It's not a magic pill at all. It's a very strong tool. And depending on the surgery, some are stronger and some are weaker," Mehran says.

Big Boy had what is known as the duodenal switch surgery. More than 70 percent of his stomach was removed, and his intestines were rerouted. Eight years later, he maintains his weight right around 200 pounds.

But Big Boy wasn't — and isn't — the only overweight personality at Power 106. Three others have had bariatric surgery. Joe Grande chose the Lap-Band. It's a trademarked device that is surgically implanted around the top of the stomach.

It's been four years since Grande, whose real name is Joe Lopez, had the gastric band implanted. When inflated, the gastric band restricts the stomach so only a small amount of food can get in.

"Everybody always said, 'Joe, you carry your weight well.' I always looked like a football player. It wasn't like I carried it in my stomach. My weight was all around me. I looked like Shrek, basically, and people loved Shrek."

But unlike Shrek, Lopez had diabetes, high blood pressure and gout. Both his parents died in their 50s from complications due to diabetes. Lopez says he tried dieting and exercise for years. The lowest he could ever get down to on his own was 285 pounds. Eventually, he would gain it back and more. He had a lot of long-learned bad habits.

"You know, eating that rich Mexican food — 10 carbs for dinner. It's like, 'OK, we are having beans, fideo [pasta] with rice and other rice.' You grow up going, 'My mom was the best cook ever.' Everything was wrapped in bacon," he says. "Thanks for the diabetes! Love you!"

Bariatric Surgery On The Rise

Within three weeks of surgery, Lopez's diabetes and high blood pressure were gone. After taking medication for five years, he threw out all his pills. Lopez lost 125 pounds and became a spokesman for several bariatric surgery centers.

Lap-Band Surgery

But not everyone is happy with the Lap-Band. At the UCLA surgery clinic, doctors won't use it. They say they don't like the idea of leaving a foreign object in the body indefinitely.

And there are objections to the aggressive advertising used by some surgeons.

For example, spots and billboards advertising 1-800-GET-THIN blanket L.A. Critics say the ads focus more on getting thin than getting healthy.

Some surgeons tied to the advertising campaign are being sued by relatives of patients who died after having the Lap-Band implanted. Other patients are suing, claiming false advertising. In the past two years, five Southern California patients have died after having Lap-Band surgery at clinics tied to the ads. The clinics deny any connection.

David Pyott, the CEO of Allergan, which manufactures the Lap-Band, said the company does not condone the ad campaigns.

"We don't always agree with the tone of some of those advertisements by our customer. But we're not the advertising police," Pyott tells NPR.

Pyott says thousands of Lap-Bands have been implanted in patients. It is a safe, simple and successful way for people to lose weight, Pyott says.

"It's a mechanical way of controlling hunger — after a couple of hundred of calories of food intake, to say, 'I am satisfied, I can take a break,' " he says.

Four Common Procedures
When it comes to bariatric surgery, there are four common procedures:

Duodenal Switch: A large portion of the stomach is removed and food is diverted from the small intestine. A smaller stomach means a patient eats less, and some experts see a link between the removal of the hormonally active portion of the stomach and the treatment of health issues like diabetes.

Gastric Bypass: Like the duodenal switch surgery, doctors create a smaller stomach. Food is also diverted from the small intestines. However, nothing is removed and the stomach is smaller than with the switch surgery. Diabetes patients have also been helped by the surgery.

Adjustable Gastric Banding: A doctor implants a silicone ring around the stomach that is connected to tubing that goes to a port that sits above the abdominal wall, underneath skin. Using a needle, fluid can be added through the port to make it tighter (so patients eat less) or removed (so patients can eat more).

Vertical Sleeve Gastrectomy: Roughly two-thirds to three-quarters of the stomach, including hormonally active portions, is removed, but unlike the duodenal switch and gastric bypass surgeries, the intestines are not rerouted. This is the newest of the four methods.

Source: Dr. Amir Mehran, Director of Bariatric Surgery at UCLA

Despite the safety reassurances, the American Society for Metabolic and Bariatric Surgery is also concerned that the message to obese clients overemphasizes cosmetics and appearance. Society President Robin Blackstone performs between 300 to 400 gastric surgeries a year at her Scottsdale, Ariz., clinic. But she says surgery should be the last resort — not something decided after seeing a billboard.

"It causes people to continue to have an image about thinness rather than about health," Blackstone says.

Blackstone says patients should be wary about going to a surgeon who only offers one type of surgical treatment.

Post-Surgery Struggles

For Big Boy, it's been many years of doctors' visits and dealing with side effects after he had most of his stomach removed in the gastric bypass. On the day he was interviewed for this story, he was struggling with edema. His lower legs were swollen.

"I'm still going through medical problems. I'm at the doctor all the time," he says.

And he says he's still tempted by fatty food. He said the big box of doughnuts that is frequently on the table at the radio station calls out to him.

Lopez, who lost 125 pounds with the Lap-Band, says he still has an eating problem, too. Lopez says once he even had the doctor loosen his band. He was going on his honeymoon and wanted to indulge.

"Because I went to an all-inclusive resort and I wanted to eat a little more, so I asked my doctor if I could get it adjusted. And I gained 20 pounds, and it shows that left to my own devices I can gain about 20 pounds in a couple of weeks," Lopez says.

Once back, he had it tightened and dropped the extra weight.

Such success stories have helped boost the number of bariatric surgeries performed every year — more than 200,000 annually, according to the American Society For Metabolic and Bariatric Surgery. And that number could grow higher. Lap-Band maker Allergan recently got FDA approval to market the device to people needing to lose as little as 50 pounds. And the company is waiting for approval for its use in another obese group — teenagers.

If obesity has touched your life, share your story with NPR and the Public Insight Network.