Healthy New Year!!! (and thereafter, as well)
As the new year approaches many people begin to ponder what they might wish to include in their list of resolutions. Most of us, when considering new year’s resolutions, try to think of those actions, alterations or behaviors which will have a positive impact on our lives and or the lives of those about which we care. They often include a focus on facets of our lives such as health, finance or more quality time spent with loved ones. I suspect many folks are focused on some aspect of health, diet or exercise.
It is common knowledge that health club memberships and personal trainers all see a boom in business around January 1st. If you ever wish to see an exercise facility at its capacity, try visiting at the beginning of a new year. However, return to that same facility in February or March and you will likely find that you no longer have a wait to climb on that elliptical trainer or treadmill.
Unfortunately, the same rings true for diet and weight loss aspirations. Food choices are often incarcerated by the latest in “get-thin quick schemes” and fad-diets. Most of these well-intentioned souls never complete the scheme or fad-diet and the small percentage that do usually are disappointed to find three months later that they have regained all the weight and then some.
I would like to make a suggestion that has been of huge benefit to me and is something I often share with my patients. Most people, I believe, when they finally muster the gumption to tackle a weight or food choice issue start with one of the following statements, “I’m going on a diet” or “I am going to get these extra 30 pounds off.” While well intentioned, when this is one’s starting point, I believe we are setting ourselves up for failure. Why? Because these statements and this mind set imply that there exists an end-point to this process. That the choice is a destination instead of a journey.
When one “goes on a diet” or “gets that 30 pounds off” it implies that once the goal weight is achieved, then you have won and you can go back to doing and eating whatever you wish whenever you want. The reality is, at that point, the party has just begun. Party? Yes, party. More on this in a moment.
I will submit to you that if you dive into this endeavor with the following statement, you will be laying the foundation for success, “I am going to choose to live a healthy lifestyle today.” If you say that today and everyday and begin to educate yourself on healthful dietary choices and exercise habits you cannot help but lose weight. Not just today, next week or next month but everyday, there after. There is no end to it. The “diet” never ends and the exercise never ends because that is the reality of it. This is a journey, not a destination.
Enjoy the journey! I said earlier that this is when the party begins. No, I am not crazy. It IS a party because living a healthy lifestyle really is enjoyable. Healthful diet and exercise habits are exactly that, HABITS. The more we do them, not only does it become easier, but you will begin to miss them if you miss a day or have difficulty finding a healthful food choice on the run.
It feels good to exercise. It feels good when you sit down at a meal and KNOW that the food you are placing in your body is healthful and GOOD for you. I love that feeling of knowing the meal or workout I just completed is really good for me. It IS fun and it will make you feel better in general and better about yourself! You will sleep better, look better and feel better.
So, “choose to live a healthy lifestyle today” and everyday and you will reap the rewards.
Healthy New Year!!!!
Hormone Replacement Therapy (Revisited)
So much has changed over the last 10 years in terms of recommendations for Hormone Replacement Therapy (HRT). In the 1990’s and before we routinely recommended HRT for most postmenopausal women touting its multiple benefits from control of hot flashes and night sweats to better bone health and decreased cardiovascular risk and improved sexual function. But the HRT world was turned upside down with the initial and subsequent findings of the study known as the Women’s Health Initiative (WHI).
This study originally was suppose to be the “end-all” of studies, finally confirming, once and for all, the benefits of HRT. However, their results sent things in the opposite direction. The investigators for the WHI reported that HRT actually increased cardiovascular risks and increased breast cancer risks and, perhaps, there were not any benefits at all to taking HRT. Telephones in physicians offices began ringing off the hook with terrified patients, many of whom quit taking their hormones immediately.
I felt at that time, and still do today, that the WHI study perpetrating one of the great injustices to women around the world. There existed significant problems with design of some of the arms of the study, including problems with the patient populations chosen to participate in the study. And, unfortunately, when the WHI results began to be published, funding for other similar studies in other parts of the world, studies with exact opposite results, had their funding discontinued. This was disastrous because, in all likelihood, we will never see these types of studies repeated because they are simply too expensive to conduct.
Over time, even some of the WHI’s most ardent supporters began to back away from some of the study’s conclusions. Many of us believed then and now that there are benefits to taking HRT and many women are not receiving those benefits because of the conclusions of this flawed study.
The reason I chose to report on this topic again this week is because of more results coming from the WHI folks were published this month in the Journal of the American Medical Association. This follow-up reported that women in the study who were taking estrogen-only HRT, as opposed to estrogen and progesterone in combination, actually had a 23% lower risk of breast cancer than patients taking placebo. This report separated the estrogen-only patients from the women who were taking estrogen and progesterone in combination. The estrogen-progesterone group still demonstrated an increased risk of breast cancer.
This report demonstrates the most frustrating aspect of the Women’s Health Initiative study. That is, that immediate and sweeping changes were made based on the results of this flawed study, and its results were generally applied across different segments of the population without regard to potential important differences such as each individual woman’s health status or her age or the type of hormone replacement utilized.
The bottom line really has not changed. The fact is that HRT has, like most things in medicine (or life, for that matter), risks and benefits. There are risks in some women AND there are clearly benefits in some, as well. The point is we cannot practice cookie-cutter medicine. The decision on whether or not to take HRT is a personal choice of each individual patient. With guidance from her physician, she must make the decision that is best for her. If she decides she would like to take HRT she should still strive to take the lowest possible dose that will provide benefits while minimizing the risks.
At the end of the day, the Hormone Replacement Therapy data-base is a work in progress.
Stealthy Infections Catch Cheating Partners
It is a jungle out there. It should surprise no one that if they were to bring a sexually transmitted infection into a relationship, their partner would be none-too-happy. However, many infections will bring symptoms to the cheating male and, if they seek treatment before passing it to their partner, they can escape without being exposed. There are, however, 2 sexually transmitted infections that usually will not afford this escape opportunity for the cheating male. Which two can provide this service? They are the human papilloma virus ( HPV ) and trichomonas.
Many sexually transmitted infections like gonorrhea or chlamydia, for instance, often are accompanied by symptoms in a cheating partner that motivates them to seek treatment. Males will often experience urethral discharge and or painful urination with these infections and seek treatment. If they are able to accomplish this before passing it to their partner, they may escape unscathed. The key here is the symptoms they experience. These symptoms are their friend, warning them to seek treatment. That is the difference. HPV and trichomonas do not usually provide this service to the cheating male. Let us look at the two infections individually to understand why.
First, the human papilloma virus or ( HPV ) is the most common sexually transmitted infection today. It is estimated that a staggering 70-90% of sexually active people will be exposed to some form of this virus. There are many different types of this virus, each identified by their individual number and the list of numbers is long. Additionally, these virae are generally separated into two groups, low risk and high risk. Generally speaking, the low risk forms are responsible for causing genital warts or “condyloma” and the high risk are associated with precancerous and cancerous lesions of the cervix and other parts of the body. For the purpose of this discussion, we will focus on the high risk types.
High risk HPV is considered “high risk” because, following exposure, and if left untreated, it will cause precancer or cancer in some people. It is because of these high risk forms of the virus that we perform pap smears in women. The pap smear is a screening test used to identify women with precancerous changes of the cervix. If the pap smear identifies a woman with cervical cancer then it has failed. The purpose is to screen women, identify those at risk and then treat them BEFORE they develop a malignancy.
There are two basic parts to the pap smear. First is the evaluation of the cervical cells themselves under microscopic magnification, a cytologic evaluation. Cytology is the study of cells. The second part is a screen for the presence of one of the forms of high risk HPV. A woman can have a “normal” pap smear but have a positive screen for high risk HPV. In this case, she has been exposed to the virus, but the virus has not yet caused any precancerous changes in the cervix.
The pap smear has been one of the most important scientific advances in health care for women saving many, many women from a truly devastating diagnosis with miserable consequences. That is just it, though. Pap smears are for women. There is no pap smear for the penis. And an infection with HPV is completely asymptomatic. This is true for men and women, actually. That is, until the virus is allowed to cause the damage that it does and results in a cancerous lesion that will cause vaginal bleeding. The fact that the infection with HPV is asymptomatic is exactly what makes the pap smear so incredibly important. When my patients present for their annual exams and undergo a pap smear, I can inform them of the infection and monitor and or treat them as required. Men do not have this service. They acquire the infection and remain completely asymptomatic. The virus can cause precancerous lesions of the penis known as, Bowenoid papulosis, as well as penile cancer, but this is much less common than cancer of the cervix.
So how are these men caught cheating? The typical scenario plays out something like this. I have a patient who has been coming in for 10 years for her annual exam. Every year her pap smear is normal and her high risk HPV screen is negative. Then suddenly, in her 11th year with me, her pap returns with a positive high risk HPV. I meet with her and inquire as to whether or not she has had a new partner, if she has not, then her partner has. I mentioned before that HPV is the most common STI with 70-90% of sexually active people being exposed. However, if you have 2 uninfected monogamous people in a relationship, HPV will not suddenly appear. If it does, someone has taken a new partner. And please, ladies, do not buy the “toilet seat” defense. Inform your man that is not a means of transmission.
The second stealthy infection is known as trichomoniasis, or”trick” in some circles. Trichomonas is a protozoal infection (as opposed to a bacterial infection). These tricky little fellas cause a horrendous frothy, foul smelling discharge in women but are normally completely asymptomatic in men. So the unsuspecting cheating male believes he has gotten away with something until his partner returns from her doctor visit with a prescription for Flagyl and a lot of questions.
Unlike the HPV infection, whose test must be sent off to the lab for analysis, most of the time the trichomonas infection can be diagnosed in the gynecologist’s office by inspecting a slide of vaginal fluid under the microscope. The protozoae have a distinctive flagylated tail that spins in constant motion. Fortunately, infections with trichomonas are easier to treat and much less dangerous than an infection with one of the high risk HPV strains. The bug’s ability to identify cheaters is no less effective, however.
So cheaters beware and ladies, if you are unlucky enough to find yourself combating one of these infections, you should have a sit-down with your partner. Although unpleasant, to say the least, these infections may provide you with valuable information about a troubled relationship.
Do you need a DEXA bone density test?
The Study of Osteoporotic Fractures Research Group published a nice study in the New England Journal of Medicine providing evidence-based guidelines for the appropriate interval for the testing of women for bone density. This bone density test is often referred to as a “DEXA” or “DXA” scan which is short for dual-energy x-ray absorptiometry.
The recommendations from the study were based upon the amount of time it would take for 10% of the women in each group with either normal bone density or reduced bone density, known as osteopenia, to progress to osteoporosis before a fracture occurred and treatment was begun.
This interval was found to be every 15 years for women with normal bone density or mild osteopenia, 5 years for those with moderate osteopenia and testing at 1 year intervals for those with severe osteopenia.
While every woman may not be comfortable with this recommendation, it is an evidence-based guideline that will be useful for all of us as practitioners as we try to find the right balance between appropriate and excessive testing. This recommendation should provide the reassurance both patients and physicians seek when following these conditions and deciding when and how often to test and treat this condition.
To Mammogram or Not To Mammogram?
Is that really the question? Apparently, so. What are the current recommendations or guidelines for mammography? Who should have a mammogram? When should they have one? How often? At what age should mammographic screening begin? These are all straight-forward questions for which, one would think, we would have simple answers.
We should not have to stand for this, right? Let us simply ask the experts. “They” should know. There in lies the problem. These answers are dependent upon which experts constitute “they”.
Back in the stone age when I was a medical student and later an obstetric and gynecologic resident, the recommendations were simple and it seemed everyone was in agreement. Women should have a screening baseline mammogram between the ages of 35 and 40, mammograms every two years from 40 to 50 years of age and yearly thereafter. Life was so simple then. The recommendations showed a reasonable progression. Obtain that baseline picture-in-time from which all other future films would be compared and increase surveillance over time as a woman’s risk increased. Sounds reasonable, no?
It was reasonable until 2002 when the U.S. Preventive Services Task Force (more on these folks in a moment) decided, after reviewing all of the evidence, that the baseline screening mammogram was not all that useful and should be discarded. They further concluded that screening mammography should begin at age 40 and repeated at 1-2 year intervals. I do not recall many clinicians objecting much to these recommendations. Most reasoned, “OK, do away with the baseline, usually normal, mammogram but effectively increase our vigilance by beginning annual mammography at age 40 rather than 50. No problem.” However, in 2009, things changed AND many “experts” not only took notice, but raised a contrarian eyebrow at this task force.
So who is this, “U.S. Preventive Service Task Force”? By whom are they empowered and what is their purpose? Your good friends in congress established the Task Force and have directed it to review the, “scientific evidence related to the effectiveness, appropriateness and COST-EFFECTIVENESS of clinical preventive services for the purposes of developing recommendations for the health care community.” Although their recommendations are primarily directed at primary care physicians, do not think their recommendations do not influence those making important decisions about your health care benefits. Is there anyone more interested in cost containment (read stock dividends) than your caring insurance professional?
In 2009, those on the U.S. Preventive Service Task Force, changed their recommendation regarding mammography again. These new recommendations were based largely on the results of studies conducted by Heidi D. Nelson, M.D. and colleagues. They recommended AGAINST routine mammographic screening in women ages 40-49. Additionally, they recommended screening for women aged 50 to 74 every 2 years and stated that the evidence was insufficient to assess the benefit or harm of screening women aged 75 and older. They did not stop there, however. They also recommended AGAINST teaching patients self-breast examination and stated that the evidence was insufficient to be able to assess whether one’s physician doing a breast exam was of benefit or harm.
Now does that sound reasonable or even logical? What possibly could have been their reasoning? The task force concluded that despite the fact that women in their 40s experienced equal benefit from routine mammographic screening as women in their 50s, they experienced greater harms from the screening than did the women in their 50s. These increased harms were reported as radiation exposure (a low dose consistently shown to be safe), false-positive and false-negative results, over-diagnosis, pain during procedures, anxiety, distress and other psychological responses. Incredible!
And how about those pesky breast exams? Dr Nelson and the Task Force concluded that breast exams did not decrease breast cancer mortality but resulted in increased imaging and biopsies. Therefore, they recommended against teaching breast exams as they offered no benefit and placed women at risk for harm.
How many of you know someone, a friend or family member who found a lump on a self-breast exam that prompted them to seek evaluation and were found to have breast cancer? My grandmother is still alive today following just such a scenario.
Well, they are the experts, right? We, in the medical community, have all fallen in line with the current recommendations of the Task Force, correct? Not so fast my friends. Not this time. Remember the initial questions? Remember the answers to those questions were dependent upon who the experts were comprising the “they?” Fortunately, other experts outside of the Task Force or Dr. Nelson have a different view.
The American College of Obstetricians and Gynecologists still recommends screening mammography every 1-2 years for women aged 40-49 years, screening mammography yearly for women aged 50 years and older, patient self-breast examination and a clinical breast examination by a physician every year for women aged 19 and older.
Additionally, the American Medical Association, the Society of Breast Imaging, the American College of Radiology and the American Cancer Society all support screening mammography and clinical breast exams beginning at age 40.
So what is a girl to do? The information available and recommendations are varied and sometimes conflicting. Several studies around the world have since provided additional information on the subject including a Swedish study revealing that screening in this population of women in their 40s reduces cancer deaths by as much as 29%.
I believe, especially when faced with conflicting information, it is best to evaluate all of the variables and perhaps the motivation behind the various opinions and make a decision that is most appropriate for you as an individual.
For example, in this case, Dr. Nelson and the Task Force feel that the possibility of some additional anxiety or discomfort from a procedure outweigh the potential benefit one might obtain from a screening mammogram or breast biopsy. If it is me, I will trade a little anxiety or a little discomfort if it will increase my chance of avoiding death at the hands of a malignancy.
In terms of evaluating motivation behind these studies and opinions, one must keep in mind we live in a society where a growing number of individuals view medical care as an entitlement. Unfortunately, a disproportionately large number of those same individuals do not want to participate in funding this “entitlement.” As such, we have an ever-decreasing percentage of the population providing the financial support for a health care system that is, itself, on life support. Therefore, as fewer and fewer are paying in to this system, fewer and fewer dollars are available for services within the system like mammography. This is where cost analysis and cost-effectiveness come into play.
I am sure there would be a significant savings if we eliminated routine screening for women in their forties. And as I heard from one of the physicians involved in the studies and Task Force recommendations say, “We are only going to lose “x” number more women per year if we don’t screen that population.” No problem if you are not one of the women included in “x”. For the record, I believe the number reported by the Task Force is ONLY a savings of 1200 women per year. Yikes!
The American College of Obstetricians and Gynecologists reported that when looking at U.S. Census data in conjunction with epidemiologic data that screening women in their 40s would decrease the number of deaths expected from the 10-year death rate by 6,800 and stated, “The fewer deaths expected with screening compared to the predicted deaths demonstrates the significant benefit of screening on mortality in this age group.”
The question you must ask yourself is, “How much is your life worth?” Not only financially, but other factors, as well. Is it worth some additional anxiety or discomfort from screening or a procedure? Even if these services were not covered, I would still want to have the information and pay out-of-pocket. I am worth it, my family is worth it and my patients are worth it.
Mammogram or Not to Mammogram? MAMMOGRAM!
Yoga: A world of health benefits
Many of you who know me, know that I am prone to do a marathon now and again. Most of you know that I am more than a little fond of exercise. The New York marathon was on a Sunday in November in 2010 and I was scheduled to run it. I had been running 100 or more miles a week leading up to the race but was having difficulty gauging my progress. I feared a number of factors were having an adverse affect on the quality of my training despite the quantity.
On the Wednesday before the race I did an 8 mile treadmill workout which was suppose to consist of roughly a 3 mile warm-up, 2 miles at marathon race pace and a 3 mile cool-down. No problem. I felt great and the workout seemed to go well. Unfortunately, when I awakened on Thursday, both of my hamstrings were toast. I went ahead and traveled to New York and ran the race with bilateral hamstring injuries and a tight left calf, knowing within the first 3 strides of the race that my goal of something in the 2:40’s was not going to happen. I finished the race and crossed this race off my bucket list.
After returning home, my workouts over the weeks following the race were spent in cross-training, cycling and yoga, all to assist in recovery from my injuries. This time also afforded me the opportunity to reflect on where my training program had failed in preparing for New York.
Although there were many contributing factors, I really felt that the biggest problem was not what I had done, but something I did not do. I realized as I was taking part in all of my post-race workouts that I had been doing myself a huge disservice by ramping-up the mileage at the expense of doing less, or worse, NO cross-training.
Of all of the cross-training options, I believe, without a doubt, yoga is the most beneficial. As I attended my yoga classes following the marathon, I was reminded of how quickly it makes you feel better. Its healing and strengthening properties at work simultaneously are miraculous. If I had simply made more time for a little yoga during my marathon training I am quite certain I would have avoided injury altogether.
People have been practicing yoga for 5000 years and more than 10 million Americans have a yoga practice today. There are many different forms or types of yoga practice. And they run the gamut from those which are more focused on the meditative component to the most physically demanding forms practiced in hot rooms flowing from one pose to another. These poses are called asanas. And these asanas will bring you many a health benefit.
Yoga, of course, improves strength and flexibility which results in better posture. But it does so much more. It has been show to reduce stress, possibly by its effect on catecholamines, combat depression and obsessive-compulsive disorder as well as increase GABA levels in the brain, thus possibly slowing the progression of Alzheimer’s disease.
Yoga has been shown to increase one’s self-image and improve one’s self acceptance and has a positive effect on mood, decreases anxiety and promotes a more stable and positive outlook on life.
Other medical conditions where yoga has been shown to have benefit includes decreasing blood pressure, lowering cholesterol levels and providing a boost in immune function. Yoga is a weight bearing exercise and thus helps combat osteoporosis by increasing bone mass and its lowering of cortisol levels may help maintain calcium levels in bones. Yoga increases aerobic capacity, improves asthma, and insomnia and has shown positive effects on multiple sclerosis. Some studies have even shown a possible antioxidant effect.
Additionally, studies have shown a positive effect on learning and memory, improved energy levels and a delay in the aging process. The list truly goes on and on. But the main point I wish to share is that yoga, in all of its forms, feels good, makes you look good and is an enjoyable form of exercise with a seemingly endless number of benefits. And you will begin to see and feel its effects in a short amount of time in your practice.
So if you are looking for a kick in the asana to get you going what better place to start than with a yoga studio near you?
Namaste! – Dr. Grisham
Stay Balanced
The Healthy Living section in the Guide Daily of the Dallas Morning News today supplied a nice one-two punch just in time for the holidays. Two separate articles one entitled, “Wretched excess: If miserable holidays are your aim, here’s what to do” and the other, “With the holidays, simple is better”, Ms. Barker Garcia and Ms. Churnin help us take notice of what is truly important in our lives not only during the holidays but day-to-day, as well.
Often times we lose sight of the importance of balance in our lives and how the sometimes unreasonable expectations we have or aspire to achieve create more problems than we realize. I am often espousing the importance of balance, proper rest, proper diet and proper exercise. These efforts go a long way in making the challenges in our lives easier to confront and overcome. Perspective and balance are so important. The holidays and the opportunity to be with family and friends often help me keep things in perspective and remind me of what is most important in our lives. Family, friends, our health and the relationships which enrich our lives.
Have a wonderful holiday season and take a moment to give thanks for those relationships in your life that mean so much. Stay balanced and keep perspective on what is truly important.
– Dr. Grisham
Three Articles to Share
I have read a few great articles lately that I felt would be of interest to my patients and their families.
The first one is a great read for those who are rearing teens and pre-teens in this fast-paced world. Inside the Teenage Brain
The next one is a fascinating look at our nation’s approach to food and the effect on everything from health care to the economy, and what it says about our culture. Divided We Eat
The final article was about the importance of weight management from the Dallas Morning News. Extra Pounds Carry a Risk of Earlier Death
Enjoy! – Dr. Grisham
Seduction By Robot
Seduction by robot??? Sounds strange does it not? But that is exactly what appears to be happening at a hospital near you. Perhaps you have not yet heard of the da Vinci Surgical System. However, I can assure you, your hospital administrators have, as have the surgeons who practice in your area. What is it? When did it arrive on the scene? And, perhaps, most importantly, why should you care?
Originally launched in January of 1999 by Intuitive Surgical, The da Vinci Surgical System is described by its creators as “a sophisticated robotic platform designed to enable complex surgery using a minimally invasive approach. The da Vinci System consists of an ergonomic surgeon’s console, a patient-side cart with four interactive robotic arms, a high-performance 3D HD vision system and proprietary Endowrist instruments. Powered by state-of-the-art robotic technology, the da Vinci System is designed to scale, filter, and seamlessly translate the surgeon’s hand movements into more precise movements of the Endowrist instruments. The net result is an intuitive interface with breakthrough surgical capabilities.”
Wow! Sounds great, does it not? Sign me up! As a surgeon, I cannot wait to place my hands on one of these things. What patient would not want their surgery to have this technology incorporated into their procedure? “Seamlessly translate the surgeon’s hand movements into more precise movements, state-of-the-art, breakthrough surgical capabilities.” Seems like a no-brainer, right? Hospitals around the nation and the world seem to think so. And they have snatched these robots up in a “We don’t want to be left out” frenzy. Many surgeons have also been eager to jump on board. However, wait a tick. Let us take a closer look.
There exist several potential issues with this device as well as issues with how it has been marketed. Some of these include the cost of the device, monthly maintenance costs, significantly increased operative times, steep learning curve, increased complications and, at least in one area, presentation of the robot as the least invasive approach when a lesser invasive procedure is available. These potential problems deserve a closer look.
Consistently, the cost of the da Vinci Surgical System is reported to be $1-1.2 million. A hospital administrator recently informed me that the monthly maintenance for the system is in the neighborhood of $10,000.00. That is a significant amount of money. Add to that the enormous cost of training in terms of both time and money, and we are talking about an even larger sum. This is something of which any hospital system that acquires one of these robots will be acutely aware. This presents one of the issues I have found most concerning surrounding this device, more specifically, its marketing.
Several times over the last year I have received and read advertisements with invitations for people in neighboring communities to attend a meeting or dinner to learn about a new minimally invasive procedure available for hysterectomy. This, in and of it itself, poses no problem. However, the slant presented appeared to be that this new technology (read robot) was less invasive than “traditional” hysterectomy. This is where the problems arise.
There can be no argument that the LEAST invasive hysterectomy is a vaginal hysterectomy. The vaginal hysterectomy has also consistently proven to be the safest in terms of dangerous complications like ureteral injury. However, the purpose of these meetings is to “inform” people of this less (read, least) invasive option of robotic hysterectomy. A more skeptical assessment might be that these meetings intend on “selling” prospective hysterectomy patients on the idea that this robot offers the least invasive approach to hysterectomy.
Let us not forget, these da Vinci systems are extremely expensive and it appears from these marketing efforts, that these hospital systems are looking to drum-up business to help cover their costs. If, in so doing, they are deliberately misleading patients that the robot offers the LEAST invasive option for hysterectomy, then it is at a minimum wrong, and at worse, potentially assault and battery.
But let us back-up for a moment. Let us examine potential issues with this da Vinci Surgical System craze in more general terms. When news began making its rounds in surgical circles about this device and as most of us watched procedures being performed “robot-assisted”, there was one comment heard time and time again. That comment was that the system seemed to be a “technology looking for an application.” In other words, yes, this is an interesting, fancy machine, but it really had not been able to demonstrate a benefit in any particular area of surgery that could come close to justifying its enormous costs. Keep in mind that these costs consist of much more than the cost of the machine itself and its monthly maintenance costs (which we have seen are substantial), but the enormous costs in terms of increased surgical times, increased anesthesia costs and increased costs of surgical training.
These are some of the costs speaking in financial terms. Potential personal costs to the patient include increased operative times, increased time under anesthesia and the potential for increased operative risks and injury. More on this in a moment.
When I first began learning about robotic assisted surgery, the one area where they felt they could definitively state that there existed a significant proven benefit to the patient when robotic-assisted surgery was employed was in the area of a radical prostatectomy. There existed decreased risk of erectile dysfunction and other morbidity and the surgeons apparently really raved about the benefits of robot-assistance with this procedure. Radical prostatectomy is way out of my area of expertise but it certainly sounded reasonable to me at the time and I was pleased to hear they had a truly beneficial application for the technology. However, recently when speaking to a urology colleague about the incidence of complications in robot-assisted surgery he informed me that his colleagues were beginning to question this benefit and some of their contemporary literature was refuting it, as well.
It was during this conversation that I was discussing another of the potential issues with this robot-assisted surgery, that is of complications and what is more concerning, unrecognized complications. Any surgeon will tell you that if you operate enough, eventually, you will have complications. There is no way around it. It is part of surgical medicine. The best, most gifted surgeons in the world have surgical complications. One strives, as a surgeon, to minimize complications through thorough training, proper preparation, careful surgical technique and vigilance. Even with all of these things sometimes complications will occur. When they do occur, you, as a surgeon, want to recognize that a complication has occurred and address it appropriately and timely thus minimizing the impact it has on the patient.
We have already mentioned that the learning curve for physician training with the da Vinci system is very steep and time-consuming. It is one of the few, if not only, products on the market of which I can think that charges the surgeon a fee to learn how to use its product. The system itself is very hands-on and labor intensive not only for the surgeon but for the operating room personnel, as well. It only makes sense, that depending on where any given surgeon is on that curve, the potential for complications may increase. The discussion I was having with this urologic colleague stemmed from a patient recently referred to me following a robot-assisted gynecologic procedure during which the patient sustained injuries to her bladder and ureter. The ureteral injury was unrecognized at the time of surgery. This colleague discussed with me the increasing number of robot-assisted surgical injuries that he is seeing in his practice, as well.
There are numerous surgical fields that are attempting to incorporate robot-assisted procedures into their practice. I have read some reports from cardiovascular physicians and oncologists who report enjoying using the da Vinci Surgical System and feel it has benefits in their field. You can read many of these posted on the company’s website (perhaps, not the most objective source). As I have no expertise in those fields I am not qualified to opine. Where I can voice concern is in my own area of expertise in how this technology is being employed in gynecology. I recently had a conversation with a gynecologic oncologist who was planning to use the robot in a benign gynecologic case, not because the robot offered any particular benefit to the patient, but simply because he wished to use the robot. Never mind the aforementioned increased cost to the patient and our medical system but also the increased operative and anesthesia times and potential risks. This is concerning.
When discussing increased operative times, we are not talking about 20-30 minutes. Unfortunately, doubling, tripling and even quadrupling of operative times is common. Approximately 3 years ago when returning from a medical conference I was discussing the pros and cons with one of the more experienced “robotic” surgeons in my area. He stated that, at the time, a case that might require 45 minutes for him to complete with traditional laparoscopy might require 2.5 to 3 hours with the robot. He reported that he did not mind the increased operative time because he really enjoyed robotic surgery. And this, he reported, was a significant improvement over the initial increase in operative times. He explained that one could expect even longer times when first learning the system. Is this reasonable? Is this acceptable in the field of gynecology, or in any field for that matter? Does the end justify the means? When is this the best approach? Most cost-effective? Safest? Is it ever any of those things or does it offer all those things and more? The answers to these questions are certainly not clear and require further evaluation, at a minimum.
There are often numerous choices in the approach a surgeon uses to perform a procedure. Some surgeons are trained in multiple approaches to the same procedure, others perhaps only one. Numerous factors go in to deciding on which procedure is most appropriate. Factors include surgeon’s skill, patient factors such as their health, size, or organ size, as in hysterectomies. Never should a more invasive procedure be chosen simply because a physician finds it to be more “fun” or “interesting.” Additionally, a procedure should never be chosen because it is a part of an efficient marketing machine. I was caught a little off-guard the first time I saw a physician advertising themselves as a “robotic surgeon.” Does that sound like a good thing? I know what they are trying to say/advertise. But does anyone truly want a “robotic” surgeon? Not me. I want a skilled surgeon who has the ability, adaptability and fluidity to adjust their approach as the case requires, not plod aimlessly forward in robotic fashion without regard to the circumstances of the specific case. This is clearly not what they mean, but it sounds a little odd.
The most appropriate procedure should always be the least-invasive procedure that can be safely performed in a particular surgeon’s hands at a given surgical facility.
I am not saying that there does not or never will exist a place in medicine for robot-assisted surgery. I personally know many well-respected surgeons who are using the product and believe it offers a benefit in their hands. I am simply saying that in a world with an increasingly scarce healthcare dollar we should tap the brakes a bit and determine if this or any other technology is appropriate for any given medical field. And whether it truly offers a cost-effective benefit to our patients without increasing their risks.
Contraception: You Have Come a Long Way Baby!
Since the early 1900’s, when Ludwig Haberlandt, an Austrian physiologist working out of the University of Innsbruck, was feeding ovarian extracts to mice, we have known that the administration of certain hormones leads to inhibition of fertility thus providing contraception. However, it was not until the 1960’s, coincidentally coinciding with the sexual revolution, that ‘The Pill’ made its rather conspicuous debut.
Decades later this relationship continues to flourish as a third generation of women begin to reap the benefits of reliable contraception. Hormonal contraceptives provide numerous well-documented non-contraceptive benefits also. In fact, in March of this year a study of 46,000 women conducted over a 40 year period found that women on ‘the pill’ are less likely to die prematurely of any cause including cancer and heart disease. Indeed, approximately 100 million women world wide are taking some form of oral contraception.
But this is the United States of America. We love our freedom. We love choice. And we REALLY love freedom of choice. As such, women today have a plethora of options when choosing a contraceptive. With the pill alone you have mono-phasic, multi-phasic, 21 day, 24 day, continuous, progesterone-only, as well as numerous estrogen and progesterone combination options just to name a few. These are just ‘pill’ options.
What makes the choice landscape that much more rich and interesting are the non-pill options. These options are as unique and varied as the individual women they are designed to serve. They include patches, rings, implants and intra-uterine devices. Each of these options have specific advantages and disadvantages to fit the lifestyle and medical needs of different patients.
First, let us consider the patch, Ortho Evra. These patches are structured and work in much the same way as oral contraceptives in that women receive a combination of estrogen and progesterone for the first three weeks of the month with the fourth week hormone free during which time she will experience menses. However, with this method, she will not need to remember to take a pill everyday. Rather, she simply needs to change the patch once a week during the first three weeks and is patch free in the fourth week. Another advantage espoused by this method is that it avoids what is known in the medical field as the ‘first-pass effect’ where by a medication is first processed by the liver.
You like the idea of not having to take a pill daily but are not so sure about wearing a patch on your skin? No problem! The Nuva Ring may be the answer for you. The Nuva Ring is a vaginal ring that is placed vaginally and the hormones are absorbed through the vagina, also avoiding that ‘first-pass effect’ through the liver. Additionally, because the vagina is very vascular, it readily absorbs hormones easily, allowing the makers of Nuva Ring to use a lower dose with less fluctuation in hormone levels that one might have when taking an oral contraceptive. Lower dose with less fluctuation of hormone levels can equal fewer side effects.
To use the ring, you simply place it vaginally, leave in for three weeks, then remove and menses will occur in the fourth week. Then repeat the cycle. Additionally, if you would like to skip a menstrual cycle, say for vacation or convenience, each ring has enough hormone to last for four weeks. Therefore, simply leave the ring in for a full four weeks, remove, and immediately replace the ring with a new one.
The Nuva Ring is left in during intercourse. Nine out of 10 men reported not feeling the ring at all and the 10% who did, stated that it did not bother them.
If you like the idea of less frequent dosing of hormones and these less labor intensive options but would like to take it even further, perhaps an implant is the answer for you. Implanon is a distant cousin of the once popular implant, Norplant.
Implanon has the convenience of, once being placed by your physician, providing effective contraception for 3 years. Implanon is placed via a simple in-office procedure where by the device is placed just under the skin of the non-dominant arm in the space between the biceps and triceps muscles on the inner-arm. Implanon is a progesterone-only option and although some women will have some irregular bleeding, many have no period, at all, which they find convenient.
Finally, for those women who would like an even longer term and either completely non-hormonal or less-hormonal option, there are intra-uterine devices. These have the benefit of, once being placed, providing reliable, effective contraception for 5-10 years with minimal or no hormone.
Mirena is a progesterone IUD that once placed provides 5 years of contraception with minimal use of hormones. The progesterone that is present in the IUD helps some women decrease the amount of menstrual flow they experience with their periods.
Paraguard is a completely hormone-free copper IUD that, once placed, provides 10 years of hassle-free, cost-effective contraception. Should a couple decide they are ready to conceive again, both IUDs can be removed easily by their physician and the couple can proceed with trying to conceive.
All of the above options have their risks and benefits which must be discussed with your physician. But the women of 2010 have more choices now than ever before and enough freedom to choose to make anyone from the 1960’s envious of the contraceptive environment of today!
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