“I once bought my kids a set of batteries for Christmas with a note on it saying, toys not included.” ~Bernard Manning
1. A Gift Certificate for a CT Scan
This is what inspired my slightly twisted view of Christmas giving. Several Christmas’s ago a new private, for-profit imaging center in our town advertised gift certificates for a CT scan to “give to a friend or loved one”. This marketing ploy implied that it was the kind of gift that showed that “you really cared”. Many local physicians considered it as a good gift, not for your friend, but for your enemy.
Besides the considerable exposure to radiation, at least 30% of CT scans performed have an unexpected “finding”; a shadow or bright spot where none is supposed to exist, an organ or other structure that is bigger or smaller than expected, etc. If the radiologist reading the CT scan is particularly compulsive, aggressive, or extraordinarily risk-averse, that “finding” may be called an “abnormality”. Abnormalities need further work-up that usually involves more radiation, use of intravenous and/or oral contrast medium, more aggressive procedures like inserting scopes into various body orifices, and even needle or open biopsy of one of your favorite organs.
Physicians often call these findings, “ditzels“. Since about one out of three people getting a CT scan will have one or two ditzels that prompt a new cascade of diagnostic testing, this is a perfect gift for an enemy. CT scans are a superb diagnostic tool for people who are sick, but they are so sensitive that they are not so great as a screening tool. If you should ever be told that you have a “finding” on your CT scan, just ask the doctor if it is really significant or is just a “ditzel.”
2. A screening mammogram
The current controversy surrounding the mammogram as a screening test for breast cancer makes this a perfect gift for that passive-aggressive Ex whose impenetrable ambivalence was so vexing. Data about the number of “false positive” or equivocal results in mammograms that generate lots of repeat imaging, more expensive imaging technology, consultation referrals, biopsies, and even “unnecessary” surgery and chemotherapy has reordered the risk/benefit ratio of screening mammograms. Different scientific groups have different guidelines for when (women can be too young or too old) and how often (annual, every three years, once?) women should get one. Several studies indicate that mammogram screening has not improved the survival rate of women with breast cancer at all. A side effect of the drive for early diagnosis is that “if you look really hard , you find forms that are ultimately never going to bother the patient” (1)
3. A Prostate Specific Antigen (PSA) blood test
This is a very suitable response from the woman who gets a mammogram gift from her despised Ex. This very popular test has lost its initial considerably positive blush as more and more data appeared that the PSA has had no real impact on reducing the death rate from prostate cancer (spoiler alert: deaths from prostate cancer itself are so few that most studies try to focus on “quality of life” measures.). The PSA’s simple number can prompt a lot of unnecessary specialist consultations, biopsies, and even aggressive surgery.
Besides raising your Ex’s anxiety while awaiting the results, an “abnormally high result” suggests the presence of cancer. This usually causes your Ex to enjoy a series of awkward digital (by finger, that is) rectal exams and even multiple long needle biopsies. The biopsy needles are inserted just below his scrotum as he lies flat on his back with his feet up in stirrups (“sweet justice” you might say if you have happened to bear any of his children.)
Of interest to you as his Ex, an abnormally high PSA may also be caused by an ejaculation within the previous two weeks. About 7% of men who do get biopsied (an office procedure) have to be hospitalized within 30 days for post-biopsy complications. “The overall balance of benefits and harms results in moderate certainty that PSA-based screening…has no net benefit“.
4. A motorcycle for the one you really hate.
About 4,500 people died in motorcycle crashes last year. That is 1 in 7 of people killed on the nation’s roads annually. This is double the death rate in 1997 while car fatalities decreased by 5% last year. If you are in a motorcycle crash you are 30 times more likely to die than people in car crashes. Of course, if you gift him a helmet he could drop his chances of death by a third. In case he or she doesn’t get the point, include a certificate granting him or her amnesty for NOT wearing a helmet in the 19 states that require it by law. (2)
5. A year’s supply of vitamins and other supplements
This is the perfect gift for that annoying vegetarian marathoner friend who won’t stop badgering you to eat healthier and get more exercise. The initial response of gratitude at your surprising thoughtfulness and respect for his life style may fade as he reads the fine print or comes across select issues of Consumers Report. Multiple studies in peer-reviewed medical journals have found no decrease in cardiovascular disease, cancer incidence, or death for any reason among multivitamin users. In a study of over 35,000 men the incidence of prostate cancer was elevated by 17% in those who took Vitamin E supplements. Supplemental calcium (a 1 gram pill per day) with or without any supplemental vitamin D increased the risk of both heart attack and stroke.
Stocking stuffers for those who don’t want to make a big committment, and two holiday tips:
1. gift certificate for 6 sessions in a tanning booth. (for every 4 visits the risk of skin cancer increased by 15%) (Cancer Research Oct. 2011)
2. gift certificate for an MRI for back pain. (2/3 of asymptomatic people showed “serious disk problems” on their MRI) (NEJM 1994)
3. a bumper sticker that says, “Give your kid a motorcycle for his LAST birthday”.
4. a supply of statins (anticholesterol medication) to anyone over 70 yo. (a high cholesterol may decrease heart attacks in the elderly)
5. a chest x-ray to screen for lung cancer (no benefit) (JAMA Oct.26,2011)
6.. forget the cell phone – it won’t cause brain cancer.
7. But remember, if you leave milk and cookies out for Santa Claus make sure they are lactose-free and gluten-free…and FORGET about peanuts. You don’t want a swollen, wheezing Santa Claus with diarrhea stuck in your chimney Christmas morning.
References:
1. Ann Int Med April 3, 2012 , “Overdiagnosis of Breast Cancer” (Bos Globe,G.Welch, MD A11)
2. Cape Cod Times, Nov. 30, 2012, reporting on a recent GAO Report stating that the 2010 societal costs of motorcycles crashes was $16 billion.
3. Choosing Wisely: Tests to Avoid – http://choosingwisely.org/?page_id=13
4. “Surprising Dangers of Vitamins and Supplements”, Consumer Reports Sept.2012
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This was awesome Hub. Had me chuckling out loud as I read it. Just wish I trusted my patients to appreciate the humor while delivering the same message, especially explaining a ditzel after someone else has ordered a test but wants the PCP to handle whatever has come up unrelated to the original concern. Please keep the blogs coming, they are very entertaining. Cheers Stephanie
Right on. As a PCP I can’t agree enough-just too many ditzels out there.
great work-keep it up. Charlie