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The Fixation On A Flawed Cancer Screening Test

In the face of accumulating evidence and a U.S. Preventive Services Task Force finding that PSA screening for prostate cancer does more harm than good, the most frequent response I hear from physicians who continue to defend the test is that PSA is all we have, and that until a better test is developed, it would be “unethical” to not offer men some way to detect prostate cancer at an asymptomatic stage. (However, these physicians for the most part don’t question the ethics of not offering women screening for ovarian cancer, which a recent randomized trial concluded provides no mortality benefit but causes considerable harms from diagnosis and treatment.)

I’m currently reading historian Stephen Ambrose’s dual biography of Oglala Sioux leader Crazy Horse and Civil War cavalry general George Armstrong Custer, whose troops were routed by the Sioux at the famous Battle of Little Bighorn in 1876. One premise of the book is that the same aggressive instincts that served Custer so well during the Civil War Read more »

*This blog post was originally published at Common Sense Family Doctor*

The Peddling Of Genetic Tests

In a recent issue of the British Medical Journal (BMJ), journalist Ray Moynihan wrote: “Beware the fortune tellers peddling genetic tests.(Subscription required for full access.) Excerpts:

“For anyone concerned about the creeping medicalisation of life, the marketplace for genetic testing is surely one of the latest frontiers, where apparently harmless technology can help mutate healthy people into fearful patients, their personhood redefined by multiple genetic predispositions for disease and early death.

Again a tool that’s proved useful in the laboratory has escaped like a virus into the marketplace, incubated by entrepreneurs, lazy reporters, and the power of our collective dreams of technological salvation, this time in the form of personalised medicine to treat us according to our individual genetic profiles.

Evaluating genetic tests is a complex business, requiring assessment of how well the test measures what it claims to measure, how well the genetic variation predicts actual disease, how useful the results are in terms of treatment, and what the social and ethical issues might be. Clearly there’s potential for exaggerating the value of a genetic test, which is one reason Germany has imposed severe restrictions on direct-to-consumer testing. In the United States they’re talking of a new test registry on a government website, raising immediate concerns that it could lend legitimacy to unproved and potentially harmful products.
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*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

“Simple Blood Test” For Cancer: Breakthrough Or Nightmare?

That’s the question Dartmouth’s Dr. Gil Welch asks in a column on the CNN website. He reflects on [recent] news about a test in development that might find a single cancer cell among a billion healthy ones — as so many news stories framed it. Welch analyzes:

“But it’s not that simple. The test could just as easily start a cancer epidemic.

Most assume there are no downsides to looking for things to be wrong. But the truth is that early diagnosis is a double-edged sword. While it has the potential to help some, it always has a hidden side-effect: overdiagnosis, the detection of abnormalities that are not destined to ever bother people in their lifetime.

Becoming a patient unnecessarily has real human costs. There’s the anxiety of being told you are somehow not healthy. There’s the problem that getting a diagnosis may affect your ability to get health insurance. There are the headaches of renewing prescriptions, scheduling appointments and keeping them. Finally, there are the physical harms of treatments that cannot help (because there is nothing to fix): drug side-effects, surgical complications and even death. Not to mention it can bankrupt you.

Americans don’t need more diagnoses, they need the right diagnoses.

I don’t know whether this test will help some patients. It might, but it will take years to figure that out. Read more »

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

The Relative Unimportance Of Diagnosis In Psychiatry

Look, he came back! Guest blogger Mitchell Newmark, M.D., put on his armor and came to blog with us again.

The Relative Unimportance of Diagnosis In Psychiatry

As we will soon be witness to the emergence of DSM-V, the new rule book for psychiatric diagnosis, I am reminded of all the pitfalls of diagnosis in psychiatry. In other fields of medicine, diagnosis is based primarily on etiology, with objective findings, rather than on symptoms alone, as it is in psychiatry. When you go to your internist with stomach pain, there’s an endoscopy to look for ulcers, a sonogram to look for gall stones, a blood test to look for hepatitis. But in psychiatry, there is no CT scan to check for bipolar disorder, no blood test to assess if the patient has schizophrenia, no spinal tap to check for major depression.

For the psychiatric community at large, diagnosis is important for many reasons. It helps doctors sort out patients so that clinical trials can be conducted on similar groups of patients. It enhances communication among psychiatrists when behavioral, affective and cognitive symptoms can be categorized. But for the individual patient, it is less useful. Some patients fit nicely into DSM categories, and others don’t. There are many patients who have unique combinations of symptoms across several diagnostic criteria. This leads to assigning multiple diagnoses, and confusing the treatment picture. Read more »

*This blog post was originally published at Shrink Rap*

Life Without A Mental Disorder: Is It Possible?

There’s a noteworthy column in Psychiatric Times, “Normality Is an Endangered Species: Psychiatric Fads and Overdiagnosis,” by Allen Frances, M.D. He was chair of the task force that worked on the Diagnostic & Statistical Manual — DSM-IV — one edition of the “bible of psychiatry.” He is professor emeritus of psychiatry at Duke University School of Medicine. There’s a lot of common ground between what Dr. Frances writes and what Dr. Daniel Carlat (the subject of an earlier blog posting) writes about. Dr. Frances is concerned about the directions that might be taken in the authoring of DSM-V, now underway.


“Fads in psychiatric diagnosis come and go and have been with us as long as there has been psychiatry. The fads meet a deeply felt need to explain, or at least to label, what would otherwise be unexplainable human suffering and deviance. In recent years the pace has picked up and false “epidemics” have come in bunches involving an ever-increasing proportion of the population. We are now in the midst of at least 3 such epidemics–of autism, attention deficit, and childhood bipolar disorder. And unless it comes to its senses, DSM5 threatens to provoke several more (hypersexuality, binge eating, mixed anxiety depression, minor neurocognitive, and others). Read more »

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

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…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

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…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

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…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

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…

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Eat To Save Your Life: Another Half-True Diet Book

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…

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