Health screening is part of good preventive care, though over-screening can lead to increased costs, and potential patient harm. Healthcare professional societies have recently developed excellent public service announcements describing the dangers of over-testing, and new research suggests that though additional medical interventions are associated with increased patient satisfaction, they also lead (ironically) to higher mortality rates.
And so, in a system attempting to shift to a “less is more” model of healthcare, why is resistance so strong? When the USPSTF recommended against the need for annual, screening mammograms in healthy women (without a family history of breast cancer) between the ages of 40-49, the outcry was deafening. Every professional society and patient advocacy group rallied against the recommendation, and generally not much has changed in the breast cancer screening world. I myself tried to follow the USPSTF guidelines – and opted out of a screening mammogram for two full years past 40. And then I met a charming radiologist at a women’s medical conference who nearly burst into tears when I told her that I hadn’t had a mammogram. Her lobbying for me to “just make sure I was ok” was so passionate that I simply could no longer resist the urge to get screened.
I knew going into the test that there was a reasonably high chance of a false positive result which could cause me unnecessary anxiety. That being said, I was still emotionally unprepared for the radiologists’ announcement that the mammogram was “abnormal” and that a follow up ultrasound needed to be scheduled. I must admit that I did squirm until I had more information. In the end, the “abnormality” proved to be simple “dense breast tissue” and I was pleased to have at least dodged an unnecessary biopsy or lumpectomy. Did my screening do me any good? No, and some psychological harm. A net/net negative but without long term sequelae.
My next personal wrestling match with screening tests was the colonoscopy. I was seeing a gastroenterologist for some GI complaints, and we weren’t 5 minutes into our conversation before he recommended a colonoscopy. I argued that I was too young for a screening colonoscopy (I was 42 and they are recommended starting at age 50), and therefore was doubtful that anything too helpful would be found with the test. My suggestion was that a careful history and some blood testing might be the first place to start. My gastroenterologist acquiesced reluctantly.
As it turns out the blood testing was non-diagnostic and my symptoms persisted so I agreed to the colonoscopy. In this case I felt it was reasonable to do it since it was for diagnostic (not screening) purposes. I was quite certain that it would reveal nothing – or perhaps a false positive followed by anxiety, like my mammogram.
What it did show was some polyps that had a 50% chance of becoming malignant colon cancer in the next 10 years. I was shocked. If I had waited until I was 50 to start screening, I could have missed my cure window. The uneasiness about screening guidelines began to sink in. As a physician I had done my best to apply screening guidelines to myself and resist the urge to over-test, even with a healthy dose of natural curiosity. Yet I failed to resist screening, and in fact, my life was possibly saved by a test that was not supposed to be on my preventive health radar for another 8 years.
Screening tests are recommended for those who are most likely to benefit, and physicians and patients alike are encouraged to avoid unnecessary testing. But there are always a few people outside the “most likely to benefit” pool whose lives could be saved with screening, and the urge to make sure that’s not you – or your patient – is incredibly strong. I’m not sure if that’s human nature, or American culture. But a quick review of Hollywood blockbuster plots (where tens of thousands of lives are regularly sacrificed to save one princess/protagonist/hero from the aliens/monsters/zombies) testifies to our desperately irrational tendencies.
I am now biased towards over-testing, because my emotional relief at dodging a bullet is stronger than my cerebral desire to adhere to population-based recommendations. Knowing this, I will still try to avoid the temptation to over-test and over-treat my patients. But if they so much as hint that they’d like an early colonoscopy – I will cave.
Cell phones, microwave ovens, wi-fi, smart meters. What do they have in common? They all emit radiation in the radiofrequency range. And they all radiate controversy. Given that these devices are set to become as commonplace as light bulbs, it is understandable that questions arise about their possible health effects. There are all sorts of allegations that exposure can trigger ailments ranging from headaches to cancer. Allegations, however, do not amount to science. And there is a lot of science to be considered.
Let’s start with the fact that an alternating current flowing through a wire generates an electromagnetic field around it. This field can be thought of as being made up of discrete bundles of energy called “photons” that are created as the electrons in the wire flow first in one direction then in the other. Photons spread out from the wire, their energy depending on the frequency with which the current changes direction. The number of photons emitted, referred to as the ‘intensity’ or ‘power” of the radiation, depends on the voltage, the current and the efficiency of the circuit to act as an antenna.
In ordinary household circuits, the direction of the current changes sixty times a second, that is, it has a frequency of 60 Hz, the unit being named after Heinrich Rudolf Hertz, the first scientist to conclusively prove the existence of electromagnetic waves. The photons emitted by such a circuit travel through space and have the capacity to induce a 60Hz current in any conducting material they encounter. Essentially, we have a “transmitter” and a “receiver.” If special circuitry is used to produce current in the range of 10 million (10MHz) to 300 billion Hz (300 GHz), the photons emitted are said to be in the radiofrequency region of the electromagnetic spectrum. That’s because with appropriate modulation at the transmitter (amplitude modulation (AM), or frequency modulation (FM)) these photons can induce a current in an antenna that can be converted into sounds or images.
But what happens when photons in this energy range interact with living tissue, such as our bodies? The greatest concern would be the breaking of bonds between atoms in molecules. Disrupting the molecular framework of proteins, fats and particularly nucleic acids can lead to all sorts of problems, including cancer. However, photons associated with radiofrequencies do not have enough energy to do this, no matter what their intensity. An analogy may be in order.
Consider a weather vane sitting on a roof. It is mounted on a sturdy metal rod, but of course can spin. You decide you want to knock it off the roof, but all you have are tennis balls. You start throwing the balls, but even if you hit the support, nothing happens. You just can’t impart enough energy to the ball to have it break a metal rod. And it doesn’t matter if you gather all your friends, and they all throw balls at the same time. You may have increased the “intensity” of your efforts, but it doesn’t matter, because no ball has enough energy. Of course if you had a cannon, you could knock down the target with one shot. That’s why high energy photons such as generated by very high frequency currents, as in x-rays, are dangerous. They can break chemical bonds! While you are not going to damage the weather vane with the tennis balls, you can surely make it spin, and the friction generated will heat up the base, the extent depending on how many balls are thrown.
Now, back to our photons. In the radiofrequency region, no photon has enough energy to break chemical bonds, but they can make molecules move around, generating heat. The more photons released, the greater the heating effect. This is exactly how microwave ovens work. They operate at radiofrequencies, but at a very high intensity or “power” level, meaning they bombard the food with lots of photons causing the food to heat up. You certainly wouldn’t want to crawl into a working microwave oven and close the door behind you. Similarly, you wouldn’t want to stand right next to a high power radio transmitting antenna, such as used by radio or TV stations, because you could get burned very badly. But the number of photons encountered drops very quickly with distance as they spread out in all directions, so that even standing a few meters from the base of such an antenna would not cause any sensation of heat. Just think of how quickly the heat released by a light bulb drops off with distance.
The “smart meters” that are being installed by electrical utilities monitor the use of electricity and relay the information via a built-in radio transmitter. But the radiation to which people are exposed from these meters quickly drops off with distance, as with the light bulb, and is way below established safety limits. Furthermore, the smart meters only transmit for a few milliseconds at a time for a grand total of a few minutes a day! Cordless phones, cell phones, routers, baby monitors, video game controls and especially operating microwave ovens expose us to similar radiation, usually at far higher levels. Smart meters are responsible for a very small drop in the radiofrequency photon bucket.
It must be pointed out, though, that safety standards are essentially based on the heating of tissues. But what about the possibility of “non-thermal” effects? What if radiofrequency photons cause damage by some other mysterious mechanism? Over the last 30 years more than 25,000 peer-reviewed papers have been published on electromagnetic fields and health, many devoted to non-thermal effects. Health agencies do not find present evidence persuasive of a hazard at ordinary exposure levels, and given the extent of research that has been carried out, it is unlikely that one will be identified in the future.
Although an overwhelming number of studies on cell phones and brain cancer have shown no effect, admittedly some have suggested a barely detectable link. Despite the weak evidence, the International Agency for Research on Cancer has classified electromagnetic fields associated with radiofrequencies as “possibly carcinogenic,” indicating a level of suspicion without any implication that the fields actually cause cancer. This notion pertains to cell phone use and has nothing to do with the far weaker fields associated with wi-fi and smart meters. I would have no issue with a smart meter in my house.
What then about those consumers who claim they have developed symptoms after smart meters were installed? I think it is appropriate to consider John Milton’s poetic view of the power of imagination: “The mind is its own place, and in itself can make a heaven of hell and a hell of heaven.”
Joe Schwarcz, Ph.D., is the Director of McGill University’s Office for Science and Society and teaches a variety of courses in McGill’s Chemistry Department and in the Faculty of Medicine with emphasis on health issues, including aspects of “Alternative Medicine”. He is well known for his informative and entertaining public lectures on topics ranging from the chemistry of love to the science of aging. Using stage magic to make scientific points is one of his specialties.
Although most doctors say they believe in the immediate free flow of information from physician to patient, the reality is that many hospitalized patients don’t receive a full explanation of their condition(s) in a timely manner. I’ve seen patients go for days (and sometimes weeks) without knowing, for example, that their biopsy was positive for cancer when the entire medical staff was clear on the diagnosis and prognosis. So why are patients being kept in the dark about their medical conditions? I think there are several contributing factors:
1. Too many cooks in the kitchen. During the course of a hospital stay, patients are often cared for by multiple physicians. Sometimes it’s unclear who should be the first to give a patient bad news. Should the news come from their primary care physician (who presumably has a long standing, trusting relationship with the patient) or the surgeon who removed the mass but doesn’t know the patient well? In many cases each assumes/hopes the other will give the patient the unpleasant news, and so the patient remains in the dark.
2. Family blockades. It often happens that a patient’s spouse or family member will request that news of an unpleasant diagnosis be delayed. They argue that it would be best for the patient to feel better/get stronger before being emotionally devastated by a test result. In some cases the family may be right – grief and shock could impair their participation in recovery efforts, resulting in worse outcomes. Cultural differences remain regarding how patients like to receive information and how families expect to be involved in care. American-style, full, immediate disclosure directly to the patient may be considered rude and inappropriate.
3. Uncertainty of diagnosis. Sometimes a clear diagnosis only develops with time. Biopsy results can be equivocal, the exact type of tumor may be unclear, and radiology reports may be suggestive but not diagnostic. Some physicians decide not to say anything until all the results are in. They cringe at the prospect of explaining uncertainty to patients, and without all the answers they’d rather avoid the questions. What if it looks as if a patient has a certain disease but further inquiry proves that she has something else entirely? Is it right to frighten the patient with possibilities before probabilities have been established?
Although sensitivity must be applied to the nuances of individual care scenarios, my opinion is that patients should be immediately informed of their test results and their physician’s thought processes at every step along the diagnostic pathway. Family member preferences, however well-meaning they are, cannot trump the individual’s right to information about their health. If physicians are unclear regarding which of them should break the news to a patient then they should confer with one another and come up with a plan ASAP.
The right time to tell the patient the truth is: now. To my colleagues who avoid giving patients information because it is personally uncomfortable (often leaving me or other third party to be the messenger), I have two words: “man up.”
This year’s Fit Family Challenge competitors are smart, savvy, and full of great nutrition-related questions! I just finished a one hour conference call with 10 family finalists from across the U.S. and Hawaii. As part of their challenge to adopt healthy diet and exercise practices, they were asked to send me their most burning nutrition questions. One mom told me that her goal was “to teach her girls how to think critically” about health information. I was so pleased to see those values being promoted that I thought I’d share some of our mythbusting FAQs here on the blog:
1. I live in a community that doesn’t add fluoride to the public water supply. Do my kids need to take fluoride supplements?
Fluoridation of our water supply is considered to be one of the top 10 most effective public health initiatives of the 20th century. Enhancing the natural fluoride content of water results in up to a 60% reduction in tooth decay for kids! The cost to a community of adding fluoride to the water supply is about 50 cents per person per year, so it’s really quite affordable. I’m not sure why your community water hasn’t been fluoridated, but it’s estimated that about 1/3 of Americans still live in communities that haven’t supplemented their water with fluoride (so you’re not alone).
Our teeth use fluoride to strengthen our enamel – and we can get fluoride to our teeth in two ways: 1) from our blood stream (e.g from the water we drink, digest, and absorb) and 2) topically (e.g. from toothpaste). Studies have shown that it’s best to get fluoride via both routes for optimal enamel strength. For children living in areas where the water is not fluoridated, the American Dental Association (ADA) recommends fluoride vitamins until at least age 16. There are two strengths of fluoride vitamins, and the dosage required depends on the fluoride levels in the local water supply (you can ask your local Water Department for that information if you haven’t already). Keep in mind that most children’s permanent teeth (with the exception of “wisdom teeth”) erupt by age 13 – and before that age there is no way to get fluoride to them except via the blood stream. So digesting fluoride (via water or vitamins) is critical to strengthen those teeth that haven’t broken through the gums yet.
2. Should parents be concerned about hormone levels in milk? Is there an advantage to buying organic milk?
All mammals release trace amounts of hormones into their milk. Cow’s milk naturally contains a small amount of bovine somatotropin (bST) which is a protein that is quickly broken down by our stomachs when we drink milk. Some farmers give their cows additional amounts of the hormone to stimulate milk production. This rbST (or BGH) is virtually identical to naturally occurring cow hormones and the decades of research we’ve collected has been reviewed by the FDA (Food and Drug Association), WHO (World Health Organization), NIH (National Institutes of Health), AMA (American Medical Association), and ADA (American Dietetic Organization) – and all agree that rbST is safe for human consumption in the levels it occurs in cow’s milk. Interestingly, studies have shown that milk hormone levels in organic milk is essentially identical to levels in regular milk. There is therefore no advantage in buying organic milk insofar as hormones are concerned.
I believe that cow’s milk is safe and nutritious for kids (so long as they have no milk allergies or lactose intolerances). The milk/hormone scare is kind of an urban legend, so I wouldn’t be too worried about it. Your girls haven’t suffered any harm from drinking regular milk – and it’s great that you all enjoy the skim variety, by the way. Lower calorie options can help you maintain your weight over your lifetime.
3. Are there lifestyle choices that I can make to reduce my risk of getting cancer? Can vitamins help?
You are right that there are lifestyle choices that can substantially reduce your risk (and your childrens’ risk) of getting cancer. However, there is no way to guarantee that you’ll never get cancer, no matter how carefully you control your diet and lifestyle. Nevertheless it’s an excellent idea to do what we can to reduce our risks. Cancer is actually a complicated collection of different diseases, and so specific behavior changes may reduce the risk of certain cancers but not others. For example, a high fiber diet may reduce the risk of colon cancer, but not skin cancer.
Also note that it’s very hard to prove that any one dietary change (such as consuming a larger amount of one particular vitamin or herb) has a direct impact on cancer risk. What works is sometimes more general (such as avoiding becoming obese). Here are some behavior changes that have been scientifically proven to reduce cancer risks or prevent certain cancers:
1. Smoking cessation
2. Regular use of sunscreen
3. A diet rich in fiber (i.e.lots of fruits and veggies and whole grains)
4. Maintaining a healthy weight
5. Regular exercise
6. HPV vaccines (especially for young girls – can prevent cervical cancer) and hepatitis vaccines (can prevent liver cancer)
7. Drinking very little alcohol (no more than 1 drink/day)
Screening for cancer is also important – because catching a cancer early is often the best way to cure it. The most effective screening tests are:
1. Colonoscopies (for adults over age 50)
2. PAP smears (for sexually active women and women who haven’t had hysterectomies)
3. Physical exams to check for skin cancer, oral cancer, and testicular cancers
Mammograms and prostate blood tests are less effective at catching cancers early, but they are recommended by most medical professional associations.
Multivitamins are not recommended for cancer prevention. Although it would seem that vitamins could help reduce the risk of cancer, large studies have shown that they do not reduce the risk of cancer, and may even increase one’s risk (especially vitamin E.) The best source of vitamins is healthy food – and their fiber benefits are excellent as well. For a nice summary of the unhelpfulness of vitamin supplements, please see this ABC News summary of recent research.
If you were invited to be part of a nuclear radiation clean up crew, I bet you’d want to wear protective gear. Not just the white hazmat bunny suit, but the gloves, goggles, mask and booties as well, right? But when it comes to ultraviolet radiation exposure, we often put on “half a suit” as it were. We cover our skin with sunscreen (maybe) but we don’t regularly protect our eyes. I’m not sure why we forget this step, but it’s time to get serious about eye protection.
In a recent interview with dermatologist, Dr. Jeanine Downey, and optometrist, Dr. Stephen Cohen, we discussed the long term damage that UV radiation can cause to the skin and eyes. I hope you’ll listen to our entire conversation here:
Sun damage of the skin has a familiar appearance – dark spots, wrinkles, thinning, and enlarged pores. UV radiation causes visible damage to the eyes as well – yellowish corneas (the “whites” of the eyes), scars (called pterygia), and crow’s feet. Over time, eyelid skin can become cancerous from sun exposure, while eyeballs develop cataracts and macular degeneration (which can lead to blindness). The risk of these diseases and conditions can be greatly reduced with sun protection measures. And it’s not that hard to do…
Some quick tips to protect your eyes:
1. Wear a wide-brimmed hat to protect your face and eyes from the sun.
2. Wear wrap-around sunglasses that absorb at least 99 to100 percent of both UVA and UVB rays for maximum eye protection.
3. If you wear contact lenses, ask your eye doctor about whether or not your lenses have UV protection. ACUVUE® OASYS® Brand Contact Lenses offers the highest level of UV blocking available, blocking at least 90 percent of UV-A rays and 99 percent of UV-B rays. Although UV-blocking contact lenses provide important additional protection for wearers, they do not completely cover the eye and surrounding area, and should not be considered as a substitute for UV-blocking sunglasses. For maximum protection, UV-blocking contact lenses should be worn in conjunction with high-quality, wrap-around, UV-blocking sunglasses and a wide-brimmed hat.
4. Remember that UV rays are more intense when reflected from water and snowy surfaces. Just because it’s the winter time doesn’t mean you don’t need to wear your sunglasses.
So next time you reach for your sunscreen, please remember to take your hat and sunglasses with you too! Fortunately, bunny suits and booties are still optional for UV radiation protection.
Disclosure: Dr. Val Jones is a paid consultant for VISTAKON® Division of Johnson & Johnson Vision Care, Inc.
It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…
I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…
I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…
When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…
I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…