Dr, will I feel better ? 
Bringing the patient into the decision making process..

Until relatively recently, (and in many cases still recently), doctors have had an arrogance in their approach to advising patients – "trust me I know best". However with Google and other online advice, in many cases patients know a great deal more than the doctors over their specific condition.
In addition much of the advised that most doctors give is based on so-called blinded clinical trials – where the outcome in disease progress, repeat heart attacks etc., and mortality are the basis of their advice to their patients.

It is exciting to see that doctors are now looking at quality of life, and how the patient benefits and feels in them selves, rather than the hard end points of disease and death.
This is especially important in the treatment of cancer - "does having unpleasant chemo which may extend life for some weeks or months, really what is best for the patient and their relatives"," is having this major operation worthwhile,"– in medicine we tend to have the attitude of "if there is something we can do, we usually do it".
Unfortunately also private medicine there is the additional impact of financial remuneration for the doctor and the institution which we must do our utmost to exclude.

It is interesting now in cardiology they are also looking at what is best for making the patient feel better, even if not necessarily for longer. In a publication in the American College of cardiology, they reviewed quality of life comparing angioplasty and bypass surgery and although bypass surgery was possibly slightly better long-term benefit, in many cases the patient would prefer angioplasty rather than the recovery process of a major operation.

In the meantime I think it is important for patients to demand their rights, and asked the doctors for a genuine opinion, if I go ahead with this procedure, is it actually going to make me feel better?

Medicine in 2016 - a Happy New Year?

2016 looks like becoming a very important year in the development of medicine. Over the last few years people have been looking more critically at the direction of modern medicine, at the way in which it has been driven by procedures and drugs, and questioning whether the cost of modern medicine is sustainable and is providing the benefits that are claimed.

 I can see huge changes in the two major killers in today's world – cancer and heart disease.

Cancer – in the past chemotherapy has been blunderbuss essentially damaging the most rapidly dividing cells which are assumed to be the cancer cells but at the same time knocking off any rapidly dividing normal cells in the body as well – giving the well-known side-effects. In recent years however much more selective chemotherapies have been developed which target the cancer cells specifically, giving much fewer side-effects, but more importantly a much better outlook. Unfortunately because the selective drugs are only applicable to selective cancers, the number of patients receiving them are relatively small, and thus it is difficult for the drug firms to recoup their research costs. This makes them extremely expensive, and insurance companies and Governments are going to have to decide which ones to fund, and for how long. While this is a real problem, it does give a real opportunity for quality and increased duration of life for many cancer patients. Example of these drugs include treatments for melanoma, myeloma, lung cancer, prostate cancer, pancreatic cancer and others.
Thus the diagnosis of even widespread cancer no longer needs be seen as a death sentence as it has in the past.

Heart disease – this has tended to be the pinup boy of medicine over the last couple of decades, as doctors have discovered bypass surgery, angioplasty and stenting. The same time the pharmaceutical industry has come up with a variety of drugs both to treat symptoms and to try and reduce the incidence of heart disease.  .

There has been a very strong emphasis on lowering cholesterol, and even though only one of the cholesterol-lowering drugs that have ever been shown to reduce heart disease (the statins),
The emphasis on cholesterol has continued, but more and more conventional doctors are looking critically at the evidence and the advice we have been giving to our patients in the past. By telling people not to eat fat, we have forced them into eating food containing lots of carbohydrates, which is led to an obesity epidemic. Doctors are now looking at whether we should be giving statins as frequently as we are recommending -for most doctors there is no debate - patients with definite heart disease should be on statins, their value in other situations is very debatable, in fact dubious.
People are also looking at the benefits of angioplasty which is being done every time doctors see what appears to be a significant lesion in a coronary artery. The evidence appears that only lesions that are symptomatic should be treated, and there is very little evidence that stenting any
lesion actually reduces the risk of heart attack or death. Over the forthcoming years, I suspect the number of angioplasty procedures will drop significantly.

Because of the increased cost of effective cancer treatments, I suspect that governments and insurance bodies may well be looking more closely at all other procedures, and confirm that they are value before funding them.

But perhaps the most frightening aspect of health which has the prospects of returning us to the Middle Ages is the development of drug resistant bacteria which could render most of our antibiotics impotent. Because of the speed of development of resistance, and the cost of developing new forms of antibiotics, the drug industry is unlikely to be spending a great deal of money on this problem.

Informed consent before angioplasty

Most patients are not given informed consent.

Less than 2% of angioplasty patient are properly informed!

Before taking any prescribed drugs, or undergoing any form of elective treatment, in today's medical world it is assumed that the patient is informed about the need for the procedure, and also its risks and benefits. One of the most frequently performed

procedures in the Western world is coronary artery angioplasty, usually for patients with angina.  A recent study in the JAMA Internal Medicine makes horrifying reading.(click here).  In this paper 59 patients listed for coronary angioplasty had the discussion between themselves and their cardiologist concerning informed consent, recorded. (One would have thought the cardiologist knowing that he or she was being recorded would do better than usual).
There are seven basic elements to informed consent:
1. The patient knows they have a role of the decision.
2. Discussion of the issues and decisions at hand.
3. Discussion of the alternatives.
4. Discussions of the pros and cons of the alternatives.
5. Discussion of the uncertainties.
6. An assessment of the patient's understanding.
7. Exploration of the patient's preference.

Most patients believed that the procedure (angioplasty) reduces the risk of heart attacks and death, but in fact this is not correct. Angioplasty merely reduces the symptoms.

The findings of the study were very sobering – only 3% of the discussions included all elements of informed consent, and just 14% met a more limited definition of the procedure, alternatives and risks. 97% were good at discussing the procedure, but alternative procedures were offered only to 25% of cases. Also the majority of patients were not aware that they had a role in the decision-making process.

There is a real concern worldwide that coronary angioplasty is being performed a great deal more than it should be. There is no evidence, other than reducing symptoms that it does any benefit, and this is not what the general public believe. Even the conservative medical bodies and journals are beginning to discuss this, as not only is the procedure expensive, but it also does have significant risks, and there are other alternatives.

Make absolutely certain that any drug or procedure that you are about to undertake does more good than harm!

What to do when you have a heart attack

What to do when you have a heart attack

What happens:
One in three of us will die of heart disease, and although becoming slightly less common, a heart attack remains the major cause of death.With a heart attack a fat laden plaque in a coronary artery ruptures, causing a clot which blocks the artery. This can lead to a number of consequences:
1. Chest pain – a tight heavy feeling in the chest, throat, left or right arm,

2. Breathlessness, sweating, faintness and a feeling of being generally unwell frequently happen.
3. The heart can sometimes beat irregularly, causing palpitations, sometimes it can stop or beat in an uncoordinated fashion (ventricular fibrillation), leading to sudden death.

Speed is of the essence - both to reduce the amount of heart damage long term, and also reduce the risk of sudden death.   In the cardiology literature - "minutes mean muscle', ie the longer the delay, the more heart damage occurs. 
If we can dissolve the clot in the artery rapidly (less than 30 minutes) no damage is done at all. However there is benefit up to 6 hours, some believed 12 hours. However at any stage a cardiac arrest can occur, which is why the patient needs to be in a cardiac unit or close to a defibrillator as fast as possible.

While doctors can do –
1. Dissolve the clot with drugs given intravenously (thrombolysis). 

2. Remove the clot and open up the arteries in the cardiac catheter lab – angioplasty and stenting.
3. If the heart goes into fibrillation, this can easily be reversed with a defibrillator. These are routinely present in ambulances, places where people congregate (sports stadium, airports, shopping malls) and of course cardiac units.

What you can do –
1. Get to a cardiac unit (or ambulance) as soon as possible.

Call the ambulance using the emergency number (111, 999, 911) and say you have chest pain.
2. Sit down quietly and relax, if you feel faint lie down flat.
3. Chew one aspirin tablet (300 mg) slosh it round the mouth and then swallow it. This prevents the clot in the artery getting bigger.
4. If you have one, use your Nitrolingual spray one or two puffs every five minutes.
5. If you have some available, take some chewable magnesium or liquid magnesium (500 – 1000 mg), and 1000 mg of omega-3 fish oil. Both of these can  reduce the risk of cardiac arrest.

8 year survival curves, shortest delay (top) to slowest (bottom)

A recent study from the Netherlands has shown that in 3000 patients with a heart attack, the 30 day mortality was 2.6% in those with the shortest delay in reaching hospital catheter lab (mean 72 minutes), compared to 7.4% in those with the longer delay (160 minutes).   Five year mortality was also reduced from 22.6% in those with the longer delay to 12.8% in the shortest delay. 

So - getting to hospital as fast as possible saves lives in both the short and longer term.  DO NOT DELAY, don't worry about a false alarm or being a nuisance, any chest pain lasting more than 10 minutes, call an ambulance!