I don’t think the examples shown reflect an element of critique.
689 karma · joined August 9, 2010
Chronic Lyme is very controversial and likely not the true etiology
In fact, the scenarios you mention, of post herpetic neuralgia, trigeminal neuralgia, and neuropathy should NEVER be treated with opiates. There are highly effective neuroleptics and medications like carbamazepine, gabapentin, and TCAs that are first line and highly effective for these syndromes. While painful, given that it is neuropathic pain, often with rapid onset and offset, opiates, even PRN medication, is not appropriate management and does not help with its treatment. Adjuvant therapy including topical creams like capsaicin as well as minor procedures like nerve blocks and injections are pursued if first line treatments do not work. Often I see people in clinic who were aggressive about opiates and got opiates for these syndromes and spiral into addiction and problems while the underlying problem is untreated.
Opiates are not a panacea for all pain, and its troubling with patients see it that way, and often insist on opiate medications.
The story starts with an accidental, incidental finding. The wife recently underwent thyroid surgery, and the husband pressures the wife to get an MRI of a different anatomical location when the patient feels well and did not have any symptoms. This mass is an incidentaloma — something found on a fishing expedition and not by looking for a particular cause to a problem. The problems with such an approach are well described in this old New York Times article, however the synopsis is such: When we look for problems with very precise tests, we can always find something to intervene upon and see something wrong. This is a problem well known in the statistics of screening tests in that even very good laboratory tests have significant harms when applied indiscriminately to everyone and everything. For people not in medicine, this can be analogous to not adjusting in frequentist statistics when one does multiple hypothesis testing and simply using one p-value of 0.05 to make decisions.
The article describes the management of a meningioma, of which the vast majority of cases are entirely non-malignant, either non-growing or slow growing, and asymptomatic (often only found on autopsy or incidental imaging). The wikipedia article on meningiomas says this:
In a retrospective study on 43 patients, 63% of patients were found to have no growth on follow-up, and the 37% found to have growth at an average of 4 mm / year.[23] … In another study, clinical outcomes were compared for 213 patients undergoing surgery vs. 351 patients under watchful observation.[24] Only 6% of the conservatively treated patients developed symptoms later, while among the surgically treated patients, 5.6% developed persistent morbid condition, and 9.4% developed surgery-related morbid condition.
The very fact that the article mentions the surgeon thought that a partial resection of the mass was a success suggests that there was little to no concern for malignancy. One does not try to take out only part of a malignant neoplasm (with the potential to grow significantly) without offering chemotherapy or radiation as adjunct therapy. In fact, I would rather argue that the husband’s big triumph was realizing that the two MRIs had shown the meningioma had little to no interval growth — and such a conclusion would recommend against rapid, aggressive surgery.
From all appearances, the article suggests the wife did not have any symptoms. She could have had the meningioma since birth — a harmless birthmark that was hidden until she underwent a superflous but expensive and highly sensitive imaging test. While it is true the meningioma is close to her eye, I would be surprised if a surgeon could intraoperatively tell the progression of the mass more than multiple MRI imaging studies. While it is true that there is always a small risk that a meningioma will grow, the slow progression on MRI suggests to me that symptoms would only slowly occur and there is a low likelihood that she would ever need emergent surgery. Finally, surgical resection causes inflammatory changes in the area which could exacerbate mass effects at the site and there is a high chance that it would come back (particularly with a partial resection).
https://medium.com/@davidouyang/providing-optimal-care-576ab...
[1] http://www.washingtonpost.com/blogs/wonkblog/wp/2014/09/25/t...