After coming a remarkable third place in this year's Tour de France, Lance Armstrong was gracious enough to answer some questions from Dr. Sanjay Gupta - medical correspondent for CNN. Wait a second, doesn't Lance Armstrong's cycling comeback and amazing result at the Tour de France fall into the category of sports? Why is being interviewed by CNN's medical correspondent? Well, Dr. Gupta may be an excellent neurosurgeon but it he was worth his salt as a reporter, perhaps he might have leveraged some his medical expertise in order to shed some light on the doping allegations that have plagued the all star cyclist. Here is the relevant excerpt from the interview:
GUPTA: One of the things you mention -- you talked a lot about during the whole tour was surprise test for doping. They just come and surprise you.
ARMSTRONG: They're not surprises any more.
GUPTA: Not surprising -- 40, I think over 40 tests.
ARMSTRONG: They're 50 -- they're 50 now.
GUPTA: What do you say to the critics? What do you say to the skeptics now at the end of the tour?
ARMSTRONG: Look, I've done this a long time. And I've been at the highest level now since 1992 until 2009. I've been tested more than anybody else. If I can take four years off and come back at the age of 38 with more controls than anybody else on planet Earth and get third in the hardest sporting event in the world, I think we've answered the questions.
Bravo. That's hard hitting stuff, Dr. Gupta. Why does everyone continue to dance around the core issue, namely, the man takes testosterone? He had testicular cancer. He had his testes removed. He has the unique privilege of being allowed to take testosterone. Dr. Gupta doesn't consider that maybe the general public might be interested in what Lance Armstrong's testosterone level is? What if it turns out to be much higher than average but still within the "normal" range? Should other athletes be allowed to supplement in order to bring their testosterone level up to that of Lance Armstrong's? To be honest, I don't even know if these anti-doping labs even test levels, or if they just test urine for banned substances. Maybe if CNN had sent an actual reporter, he or she may have reported on these things.
Anyway, I think this is just one further example that serves to highlight how futile, Draconian and ultimately ridiculous our policies are with regard to doping in competitive sports. As I've said many times before, decisions regarding taking hormones or any other drug are medical decisions and should be kept between an athlete and his or her doctor. Doping is only considered "cheating" because it is against the rules. Change the rules and it won't be cheating anymore.
The L.A.P.D. searched the office of Michael Jackson's doctor yesterday. According to DEA spokesperson Rusty Payne, whose agency is assisting with the investigation, the search warrant was issued relating to the drug propofol. Propofol is a powerful anesthetic and is almost never used outside of an operating room or ICU setting - certainly not the kind of thing any doctor would ever admit to prescribing on an outpatient basis. So far, there seems to be only speculation as to why authorities suspect Michael Jackson had propofol in his system. According to E! online (I'll have more reliabe sources for you when this blog generates enough revenue to hire a full-time researcher) the preliminary results of a second autopsy turned up lethal amounts of propofol.
Obviously, we need a lot more information before deciding on the gullt of innocence of Michael Jackson's doctor. But, what if he did OD on propofol? Maybe that's what his doctor was using to treat insomnia. I'm only playing devil's advocate here, and I challenge the reader to not so quickly dismiss the above described scenario as malpractice at best, manslaughter at worst. After all, in primary care we give patients drugs to help them sleep all the time. These drugs have risks; people can and do overdose on them. Your response is probably along the lines of, "But propofol for insomnia! This is madness. The risks of giving someone propofol in an unmonitored setting vastly outweigh the benefit of helping them sleep!" Sure, I don't disagree with you. But how does one decide where to invoke one's own values preferentially over patient values? I mean, if the patient truly understands the risks, maybe the risk does outweigh the benefit from his or her perspective.
One solution is, simply always let the patient decide. If he understands the risks and benefits of treatment, prescribe whatever he wants. You're just the expert consultant, the patient is the one directing care.
At other extreme are those who wouldn't subject their patients to any risk whatsoever unless they have clear evidence that treatment will result in decreased for morbidity or mortality. Such a doctor will never treat something like insomnia until someone can prove that people with untreated insomnia die sooner or have some other, quantifiable, adverse outcome and that said outcome is worse than the risks of treatment.
Most of us fall somewhere in the middle. But where? How do you decide? This question is particularly relevant to treating patients with chronic pain. How much pain medication do they need? Who decides? The solution I favor is to legalize all narcotics. Make them widely available so that people can treat themselves taking doctors out of the equation completely. There is no science, after all, to inform us as to how much pain medication is "enough." There is no "optimal" dose aside from 0mg PO q4hrs prn. The less you take the better. You don't need a doctor to tell you that. Of course, that doesn't mean you shouldn't see a doctor. Your doctor may be able to diagnose and fix whatever it is that's causing the pain, obviating the need for pain medication. That would be ideal. Unfortunately, doctors aren't always able to do this. Which puts us in the unenviable position of either prescribing or withholding medications that only increase morbidity and mortality and have only subjective benefit?
I had an epiphany today regarding the most concise way to articulate my longstanding position on disparities - be they in health care or in any other sector of society. I may have only written one post on this topic previously...you can find it here. Turns out I wrote it exactly 1 year and 1 day ago.
In his research lecture, one of our faculty members defined disparity in the following way: "A disparity is a mismatch between need and care associated with membership in one socially identifiable and disadvantaged group compared with their non-disadvantaged counterpart. This may include, but is not limited to race/ethnicity, socioeconomic status, culture, rurality and disability."
My qualm has always been with race. I have no problem looking at disparity based on socioeconomic status, or gender or a whole host of other things. These represent real differences and it's fine that they continue to be real differences. We don't need everyone to have the same amount of money, have the same age and to be the same gender. As regards to race, I seem to remember a time when the ideal society was conceptualized as "color-blind" - one where race was not a significant difference and thus peoples of different races would not even be recognizable as socially identifiable groups. What happened to that? I mean, maybe we're not there yet, but isn't this still the end goal? I believe that we reach this goal not by looking at every place where there exists a disparity and correcting it, but rather by ignoring such places as there exist disparity. Paying attention to racial differences only reinforces that they are real and important - which, I think most of us agree, they are not.
We have to work hard enough to overcome our differences as it is. Why place greater emphasis on them than they merit? Whatever happened to the goal of having a color-blind society?
