Rejected by the New England Journal of Medicine in 2014.
Co-authored with Stephen S. Tower, MD

Allen et al (1) courageously report a woman who underwent heart transplantation when her cardiomyopathy’s reversible cause – arthroprosthetic cobaltism (APC) from bilateral metal-on-metal hips – went undiagnosed. Endorsing their conclusion that clinicians in cardiac, orthopedic, thyroid, rheumatic, and ophthalmic specialties need improved awareness of this multi-system disorder, we would add neurologists, psychiatrists, and, especially, primary care physicians.

Cobalt causes a full spectrum of neuropsychiatric effects, from anxiety and irritability to life- threatening mood and thought disorders, plus peripheral neuropathy, cranial neuropathy, cognitive decline, and gait disorders (2,3).

Primary care physicians are likely to encounter APC early in its course, when its manifestations – including tinnitus, fatigue, disturbed sleep, nausea, “mental fog,” and headaches – are mild, non-specific, and easily dismissed as simple aging (4,5).

However, because APC is both progressive and reversible, we suggest all physicians adopt a low threshold for checking cobalt levels in at-risk patients, even those without hip complaints and those with metal-on-plastic or metal-on-ceramic hips (3).

(1) Allen LA, Ambardekar AV, Devaraj KM, Maleszewski JJ, Wolfel EE. Missing elements of the history. N Engl J Med. 2014; 370: 559-566.   Pubmed 24499215

(2) Sotos JG, Tower SS. Systemic disease after hip replacement: aeromedical implications of arthroprosthetic cobaltism. Aviation, Space, and Environmental Medicine 2013; 84: 242-245.

(3) Catalani S, Rizzetti MC, Padovani A, Apostoli P. Neurotoxicity of cobalt. Hum Exp Toxicol. 2012; 31: 421-437.

(4) Tower SS. Arthroprosthetic cobaltism: neurological and cardiac manifestations in two patients with metal-on-metal arthroplasty: a case report. J Bone Joint Surg Am. 2010; 92: 2847-2851.

(5) Leikin JB, Karydes HC, Whiteley PM, Wills BK, Cumpston KL, Jacobs JJ. Outpatient toxicology clinic experience of patients with hip implants. Clin Toxicol (Phila). 2013; 51: 230-236.

First published on on Nov. 22, 2013

[In response to the question: “Do you recommend vitamin supplements for healthy people?”]

Vitamins have a good reputation. Many people think they can do only good, and never harm. Sadly, this is false.

Biologically, the only difference between a vitamin and a medication is that some amount of the vitamin is necessary for life. Once you go above that amount, however, it is better to think of vitamins as pharmaceuticals, endowed with the potential for both benefit and harm.

In short, despite their positive-sounding name, it is better to think of vitamin supplements as medications, with all their attendant risks.

For example, not many years ago, there was enormous enthusiasm for vitamin E’s potential to lower the risk of coronary artery disease, and many physicians began recommending vitamin E supplementation. Later research has shown no such benefit and, rather horrifyingly, has raised suspicions that vitamin E supplements increase the risk of heart failure. Even a vitamin having no known toxic effects at any dose, e.g. vitamin B12, can cause harm by obscuring the diagnosis of a disease.

Possibly excepting women who are contemplating or experiencing pregnancy, any decision about vitamin supplementation should be undertaken with the same deliberation used in recommending a pharmaceutical. Many supposedly healthy people (discussion of the term “healthy” is a topic unto itself) will indeed benefit from vitamin D or other supplements, but it is far safer to rephrase the question “Do you recommend vitamin supplements for healthy people?” as: “Do you recommend pharmaceutical medications for healthy people?”

First published on on Nov. 20, 2013

[In response to the question: “What is the biggest misconception people have about alternative medicine?”]

Defining “alternative medicine” is the chief pitfall in any discussion of the topic. It is a nebulous term.

The National Institutes of Health defines alternative medicine as a “non-mainstream approach [used] in place of conventional medicine” – effectively exiling it to a desert island and emphasizing that it can only be defined by its relation to mainstream medicine. The NIH notes that true alternative medicine is uncommon, because most people combine it with conventional techniques.

More helpful, I think, is viewing alternative medicine as “proto-medicine,” i.e. as techniques that may some day be adopted into conventional medicine if well-conducted clinical trials show a favorable ratio of benefit to harm.

The classic example of an alternative medicine moving into conventional medicine is the heart medicine digitalis. In the 1700s, Dr. William Withering in Shropshire, England heard that a local witch could do something he couldn’t: successfully treat dropsy (which is today called “edema”). Gaining the witch’s cooperation, Withering painstakingly discovered that, among her potion’s dozens of ingredients, the foxglove plant provided the therapeutic effect. He proved this by conducting formal trials of foxglove, whose scientific name is digitalis. All of this took nine years, but Withering, and the unnamed witch, achieved immortality in medical circles, and their work has benefitted untold numbers of patients. Digitalis derivatives remain in use today.

Physicians are (or should be) pragmatic. If something is provably successful, it deserves to be adopted into conventional medicine and to shed its “alternative” label. To make such a jump, a high level of evidence is required. Investing time, energy, or self in an approach that is unsupported by evidence, no matter how “natural” it seems, is an invitation to disappointment, and worse.

First published on on Nov. 19, 2013

[In response to the question: “Should the eligibility age for Medicare be raised?”]

No. Raising Medicare eligibility age across the board would inevitably eliminate healthcare coverage for some people who simply cannot financially afford it. Why would a compassionate nation want to do that?

At the very least, any proposal to increase Medicare’s eligibility age should add means-testing, so that persons who can afford to pay for their healthcare do so.

This will probably be insufficient, however. Healthcare is already so expensive that the percentage of the population older than 65 who can afford to buy insurance is limited (and declining). Means-testing, therefore, may not exclude enough people to appreciably lessen needs for publicly funded healthcare.

Long term, only one strategy makes sense: give people significant financial incentives to eschew unhealthy lifestyles and to adhere to proven plans that reduce disease burden. It would be the healthcare equivalent of good driver discounts in automotive insurance, and, as with driving, it can have huge effects.

Consider, for example, former Vice President Cheney. Had financial incentives kept him from smoking cigarettes from ages 12 to 37, it is quite possible that onset of his heart disease could have been delayed by 10 years. That would have made him age 79 (not 69) when he was faced with the decision to undergo implantation of an expensive heart-assist device – which ultimately required a 5-week hospitalization, most of it in intensive care – and would have made him 81 (not 71) when he needed a heart transplant – too old to be eligible. He might, therefore, have undergone neither of these very expensive procedures, lowering dramatically his consumption of healthcare resources.

Physicians call such deferral of medical problems (and, therefore, costs) “Compression of morbidity” and view it as the ideal for aging. Helping all Americans attain it would be both compassionate and fiscally sound.

First published on on Nov. 18, 2013

[In response to the question: “If you could change one aspect of the Affordable Care Act, what would it be?”]

Similar to the old comedy straight-line, “When did you stop beating your wife?” this question has a built-in assumption.  From their first day on the wards, medical students are taught never to ask such questions, because they bias a patient’s response.

Instead, phrasing the question as “What would you do to improve healthcare or its delivery in the United States?” would elicit equivalent answers, without bias.

I’m not saying the ACA is the pinnacle of mankind’s legislative accomplishments.  But it’s clearly not the monstrous cancer that loud voices proclaim it to be.  Let us take the energy directed against the ACA and try turning it positive.  Let’s try to make the Act work, and bring healthcare insurance to the tens of millions of Americans who don’t now have it.