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Second opinion

Modern medicine has done much to make our lives better and make us live longer, but often the choice between living longer and living better is complicated

Second opinion

Medicine has done much to make human life better but medicine also has its dark side. Innovation might seem great when it first comes on board but in time many new things turn out not to be the best thing. One of the ‘innovations’ with the most dubious record is ‘radiation’ or radiotherapy. Of course, the story of women that used radioactive ‘Radium’ to paint dials on watches and went on to get cancers is a sordid part of history.

In the earlier part of the last century after X-Rays were discovered, many orthopaedic surgeons would fix broken bones by direct manipulation under X-Ray control (fluoroscopy). A great innovation that really made the treatment of broken bones a lot easier, but in time many of these surgeons started developing skin cancers due to radiation exposure.

Many medical specialties still use fluoroscopy for performing different procedures. But now, the physicians performing such procedures wear protective clothing and carry cute little tags that calculate the amount of radiation they are exposed to during a particular period of time and if it exceeds a certain level, they are literally prevented from performing such procedures for a fixed amount of time.

Another story is about something called ‘Scrofula’ that was often due to drinking milk from cows infected with tuberculosis. This would produce bleeding sores in the necks, mostly of children. Many of these children were ‘cured’ by radiation to their necks but in time developed cancers of their thyroid gland. Scrofula has virtually disappeared due to pasteurisation (heating milk to below the boiling point) that kills bacteria and sterilises the milk. Scrofula gives us the adjective ‘scrofulous’ that probably applies to most Pakistani politicians.

There is this great movement about ‘pure’ foods. But it was the added ‘impurities’ that prevented many diseases prevalent a hundred years ago. Iodine in salt is the major reason why we rarely see ‘goitres’ (enlarged thyroid glands in the neck) that were so prevalent when I was a medical student and then a surgical resident some 40 years ago. Removing these enlarged thyroid glands was, I must admit, a surgical challenge and as they say, separated the men from the boys — at least as far as surgical capability was concerned.

Different medicines are frequently taken off the market or restricted in usage in the United States after it is found that they have little efficacy or else have serious side effects.

We might get a bit peeved when we see a ‘store’ brand of bread or milk with the words ‘Calcium, Vitamin A or D or C added’. But the addition of Vitamin D and Calcium in our food has made ‘rickets’ (bow legs and spinal deformities in children) very rare. Vitamin D is produced in the body by exposure to sunlight. The need to ‘stay out of the sun’ has lead to Vitamin D deficiency even among adults leading to poor ‘bone health’. The lack of Vitamin A was one of the major causes of different types of blindness.

As far as Vitamin C is concerned, its lack produced the horrible condition called scurvy where teeth would rot and fall out especially among ‘seamen’ on a long voyage. Having ‘lime juice’ added to their daily ration of rum (grog) on board prevented this from happening and that is why the British seamen were also called ‘limeys’. This was before Vitamin C was discovered.

Another cute story is about what we drink. Many years ago I came across an article that presented an interesting idea. The Chinese evidently have a low tolerance for alcohol while the Europeans do not. The reason postulated was that centuries ago the Chinese drank tea (boiled and flavoured water) while the Europeans mostly drank wine or else contaminated water. The Europeans who drank water died but those who drank wine survived. The reason being that the alcohol in wine like the boiled water in tea kills germs.

Coming to the treatment of cancer, especially breast cancer, 40 years ago it was the accepted idea that not only all of the breast must be removed but much of the tissue around it. The surgeons who could perform the most excessive and mutilating operations were heralded as the best breast cancer surgeons. Within a few decades the entire idea changed. Now it is the least mutilating operation combined with radiation and cancer drugs (chemotherapy) that offers the best outcome.

As far as men are concerned, the commonest cancer among them is that of the prostate gland. It is well known in medicine that if a 70-year-old has a blood test (PSA) that suggests that he has cancer in the prostate gland; it is most likely that he will not die from that cancer. Yet many of these men end up with an operation for removing the prostate gland. This might not make them live any longer but does force them to wear ‘adult diapers’ for the rest of their lives.

Another problem is exaggerated claims for different ‘treatments’ by companies that develop them. Different medicines as well as joint replacement devices and other high cost treatments are frequently taken off the market or restricted in usage in the United States after it is found that they have little efficacy or else have serious side effects that the manufacturers often knew about but did not disclose to the public. Recent law suits in the US against certain anti-diabetic medicines are asking for tens of billions of dollars in damages for patients that received these drugs.

Modern medicine has done much to make our lives better and make us live longer but often the choice between living longer and living better is complicated. While training heart surgeons I spent much time trying to explain to them the difference between a ‘high risk’ patient and a ‘bad risk’ patient.

High risk patients are very sick but if they survive the ‘operation’ or a complicated treatment, they can live a relatively normal and productive life for many years. The bad risk patient on the other hand might survive the treatment but cannot live a normal life and will probably be dead soon after the ‘successful’ treatment due to ‘co-existing’ medical problems.

In the US, all elderly citizens are insured by the state (medicare). One of the reasons why expenses for the care of such patients is going up rapidly is because of ‘end of life’ care that only prolongs life for a short period of time without improving the quality of life. But it is not just the choice between quality and quantity of life that is important. And no, age is not the only consideration.

In my own specialty, putting in ‘stents’ to open blocked heart arteries has become a major ‘financial’ problem in the US as coronary bypass operations were a few decades ago. Different cardiac physicians are being investigated almost every month for performing these costly procedures without appropriate medical ‘indications’. In this matter the reason often is that the physician responsible for diagnosis, recommendation of the ‘appropriate’ treatment, the performance of these procedures, and then getting paid for all these things is often the same person. ‘Second opinions’ are, therefore, strongly recommended in non-emergency situations that require complex treatments.

As they say, never ask the barber if you need a haircut!

Syed Mansoor Hussain

syed mansoor hussain
The author has served as Professor and Chairman, Department of Cardiac Surgery, King Edward Medical University.

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