Weird thing to find in my readings for “Health and Physical Assessment”

My textbook for “Health and Physical Assessment” is called Physical Examination and Health Assessment (first Canadian edition) by Carolyn Jarvis. I’ve only done two readings from it, and it’s mostly what I expect. Largely, it’s written in a very scientific tone. It’s a textbook about anatomy, some common forms of illness, and techniques on how to assess a patient.

What’s surprising is something I found right in the middle of chapter 18, (thorax and lungs). The author uses an emotive, almost poetic voice to describe the baby’s first breath:

Breath is life. When the newborn inhales the first breath, the lusty cry that follows reassures anxious parents that their baby is all right.

(Jarvis, C. Physical Examination and Health Assessment. First Canadian Edition. p. 442)

The chapter continues immediately afterward in its characteristic, professional manner for the rest of the chapter, as if nothing happened. I read it, and had to go back to make sure that I didn’t imagine it. I don’t even know what they’re trying to get at with the whole “breath is life” thing. It’s almost philosophical, but then there’s no content there.

Just weird, that’s all.

Antibiotics and antivirals

More and more often these days, I come across articles about new anti-viral drugs that look really promising. Further, I’m sure we’ve all read or heard about the phenomenon of antibiotic resistance—strains of bacteria who acquire the ability to survive treatment with antibiotics which would otherwise kill the bacteria and cure the patient.

Since the discovery of antibiotics, bacterial infections have been relatively easy to treat, whereas viral infections have been something that can’t be treated directly. The treatment for a bacterial infection is penicillin, but the treatment for the common cold is bed-rest.

What I find interesting about these developments is that we may be entering an age where this is reversed: Bacterial infections may become difficult or impossible to treat directly, while viral infections can be simply and easily cured with drugs.

I will be clean-shaven this Movember

“Movember” is the name of a movement that emphasises men’s health, specifically prostate cancer awareness during the month of November, by encouraging men to grow moustaches. There are two main reasons why I will be clean-shaven this November.

Screening for prostate cancer

When is it rational to be screened for a condition?
When is it rational to be screened for a condition?

The first major problem I have with Movember is the emphasis that is placed on prostate cancer screening for men—even men who are not in a high risk group for this type of cancer.

Not every test is completely reliable. Think about it this way: If you put a toothpick into something you baked and it comes out dry, it’s likely that your baking is done. But it’s also possible that you just poked the wrong part of your banana bread, and the rest of it is all gooey. If that happens, it’s called a “false positive” result for your test, or a “Type I error.”

This isn’t just a problem for bakers. It’s a problem with pretty much all medical tests (or any test at all for that matter) that there is a non-zero chance that you will get a false positive (“Type I error”) or a false negative (“Type II error”) result.

For prostate cancer, there are two methods of screening: a digital rectal exam (DRE) or a prostate-specific antigen test (PSA). The DRE is a physical examination of your rectum by palpation and the PSA is a chemical assay performed on a blood draw. Neither of these tests can be relied upon to give perfectly accurate results all the time.

The problem is that if a doctor finds what he takes to be evidence of a tumour growth in the prostate, he may order a biopsy of the prostate. This is an invasive, expensive, painful (and in the case of Type I errors, unnecessary) procedure that brings its own set of medical risks. A biopsy carries the risk of infection, for example.

Please examine the decision tree I have attached to this post. I have tried to make it as general as possible. If you wanted to be really rigorous, you would assign dollar values to each of the outcomes, and then for each of the branches off a probability node (a circle), calculate the probability of that branch. Then if you multiply the probability value of that branch and the dollar value of the outcome for that branch, and take the sum of all the branches, it will give you the value of that node. Repeat the process from right to left, until you come to a decision node (a square). The branch that carries the highest value as calculated using the algorithm I outlined is the decision that one has most reason to take.

I haven’t done the research to find out what the rates of Type I and II errors are for PSA tests, but they are pretty high, and you can see that if the probability of an inaccurate test result is high enough, and the consequences for having a bad test result are dire enough, that might give you reason to go without testing, provided you aren’t in a high risk group for prostate cancer. Further, a randomised control trial of men showed that there is no significant difference in mortality between a group of men who were screened for prostate cancer and those who weren’t. The evidence shows that prostate cancer screening doesn’t help reduce mortality.

If you are in a high risk group, like if there is a history of it in your family, and you are in a certain age range, then by all means, you should be tested for prostate cancer regularly—but don’t start encouraging young healthy men who are not at high risk for developing this sort of cancer to go looking for it. They may find more trouble than is actually there.

Emphasis on men’s health

The second major problem I have with Movember is their condescending and naive position on “men’s health” generally. Let’s consider a quote from the Movember Canada website:

Let’s face it – men are known to be a little more indifferent towards their health … The reasons for the poor state of men’s health in the Canada and around the world are numerous and complex and this is primarily due to a lack of awareness of the health issues men face. This can largely be attributed to the reluctance of men to openly discuss the subject, the old ‘it’ll be alright’ attitude. Men are less likely to schedule doctors’ appointments when they feel ill or to go for an annual physical, thereby denying them the chance of early detection and effective treatment of common diseases.

(From Men’s health—Movember Canada)

Movember Canada is stating here that it is “reluctance of men,” an “‘it’ll be all right’ attitude” and the general indifference toward issues of health that make men less likely to schedule a doctor’s appointment when they feel ill, or to make an appointment for a regular physical exam.

This is not the case. In Canada, men don’t schedule doctor’s appointments largely because they don’t have a doctor that they can call to make an appointment. I have been on my CLSC’s waiting list for a doctor for over a year now, and unless I go to the hospital or a walk-in clinic, I think it unlikely that I will see a doctor any time soon. This is not because I’m indifferent toward my health. This is because I don’t have a doctor.

It is not men being “too macho for doctors” that’s the problem. It’s that we as a country have made decisions regarding health care in Canada based on economics and politics that have brought about a doctor shortage. I hesitate to call it a “doctor shortage,” because the word “shortage” makes it sound like it was something unavoidable or unforeseeable—not something that was engineered and implemented as a matter of public policy.

The reason men aren’t seeing doctors in Canada is because we have chosen to limit our health care spending by decreasing the number of doctors in Canada who will order expensive tests and procedures. So don’t you dare turn around and chide men for failing to see a doctor regularly, when that is exactly what we have decided we want.

Is Movember all bad?

No probably not, and insofar as it is a fundraiser for prostate cancer research and survivor programmes, I think it is probably a good thing. That said, the message of Movember needs to be changed before I can support it.