USA Today
President Obama boards Marine One at National Naval Medical Center in Bethesda, Md., Feb. 28 after his first physical exam as president. Doctors pronounced him in "excellent health." By Susan Walsh, AP
President Obama's first medical checkup since he took office involved more than just a history, physical and blood tests. His Navy doctors also ordered CT scans, which are rapid-fire X-rays, of Obama's coronary arteries and colon. The CT or "virtual" colonoscopy allowed doctors to look for colon cancer without putting the president to sleep, so he wouldn't have to transfer power to his next in command.
Navy Capt. Jeffrey Kuhlman, who led the medical team, proclaimed Obama in "excellent health." But San Francisco cardiologist Rita Redberg, editor of the Archives of Internal Medicine, says she was "troubled" by the exam. That's because coronary CT scans, which detect calcium deposits in arteries, and virtual colonoscopies aren't recommended for men of Obama's age and medical history, she says. Both boost a person's lifetime risk of cancer.
"Mr. Obama appears to have been administered two cutting-edge, expensive diagnostic tests that exposed him to a radiation risk while likely providing no benefit to his care," Redberg wrote in an editorial. What's more, she says, his doctors' zeal reflects one of the flaws in the U.S. health system that Obama's administration is trying to fix.
"It's low-hanging fruit to rid our system of procedures and tests that we're spending a lot of money on that are actually making people worse," Redberg said in an interview. "Multiplied many times over," she says, cases such as Obama's burden society with "huge costs" and put patients in harm's way.
But doctors have long been rewarded for providing more care, though more isn't always better. Three recent studies show that a doctor's instincts are no match for hard science:
• ASTRAL, a study of about 800 patients with high blood pressure from clogged kidney arteries, found that propping arteries open with stents didn't lower blood pressure and raised patients' risk of side effects, including deaths.
• ACCORD, a $300 million study sponsored by the National Institutes of Health, found that patients with type 2 diabetes who take the billion-dollar Abbott drug called Tricor don't live any longer than patients who don't. Doctors have been prescribing Tricor since the mid-'70s; Abbott is now advertising a newer, more expensive, patent-protected version called Trilipix. A second arm of the study showed that pushing blood pressure below the usual floor in diabetic patients not only failed to help them but also raised their risk of premature death.
• NAVIGATOR, a 9,000-patient study sponsored by Novartis, found that the drug valsartan, sold as Diovan, kept 14% of diabetes-prone people who were given the drug from developing diabetes. But neither valsartan nor nateglinide, sold as Starlix, prevented the heart attacks, strokes or other cardiovascular events that make diabetes so devastating.
"The good news for patients is that you don't have to take a bunch of medications to try to improve your outcome," says Robert Califf, chancellor for clinical research at Duke University.
Doctors and patients often groan when a study yields negative results rather than new hope in an easy-to-swallow pill. Negative results often contradict conventional wisdom, the pet theories of academics and costly ad campaigns for billion-dollar drugs, argues Yale cardiologist Harlan Krumholz. But they reinforce a humbler message, he says, by showing that doctors can sometimes achieve more by doing less — and spending less — and by convincing patients that prevention always trumps medication.
Starting today, Redberg plans to make the case in her journal. Under a new heading, "Less is More," she'll feature studies showing widely used tests, drugs and procedures that don't pass muster.
She'll also make the point by example, as she did in her Obama editorial. Redberg says the CT cancer risk is important; coronary calcium scans cause nine extra cancers in every 100,000 men tested.
White House spokesman Reid Cherlin says Obama's doctors chose to follow "Staying Healthy at 50-plus" guidelines issued by the U.S. Preventive Services Task Force. "Yes, the patient is 48, but those guidelines seemed the most appropriate," Cherlin says.
Cherlin acknowledges that the guidelines say there's "insufficient evidence" to judge the benefits and harms of CT colonoscopy in patients younger than 50. He says the doctors decided to do a coronary CT scan because Obama's LDL, or bad cholesterol, rose. The options were discussed with the president, who gave consent, Cherlin says.
Redberg evaluated the White House response at USA TODAY's request. "The president and his physician can, of course, choose whatever care he would like," she says. "But I do think he would set a great example by getting evidence-based care and not giving the impression that he thinks more technology is automatically better."
And while the task force declined to make a recommendation on CT colonoscopy for patients such as Obama, she says, "it does recommend against the coronary (CT) scan. It would be better for him, as a young man, not to be exposed to unnecessary radiation."
Navy Capt. Jeffrey Kuhlman, who led the medical team, proclaimed Obama in "excellent health." But San Francisco cardiologist Rita Redberg, editor of the Archives of Internal Medicine, says she was "troubled" by the exam. That's because coronary CT scans, which detect calcium deposits in arteries, and virtual colonoscopies aren't recommended for men of Obama's age and medical history, she says. Both boost a person's lifetime risk of cancer.
"Mr. Obama appears to have been administered two cutting-edge, expensive diagnostic tests that exposed him to a radiation risk while likely providing no benefit to his care," Redberg wrote in an editorial. What's more, she says, his doctors' zeal reflects one of the flaws in the U.S. health system that Obama's administration is trying to fix.
"It's low-hanging fruit to rid our system of procedures and tests that we're spending a lot of money on that are actually making people worse," Redberg said in an interview. "Multiplied many times over," she says, cases such as Obama's burden society with "huge costs" and put patients in harm's way.
But doctors have long been rewarded for providing more care, though more isn't always better. Three recent studies show that a doctor's instincts are no match for hard science:
• ASTRAL, a study of about 800 patients with high blood pressure from clogged kidney arteries, found that propping arteries open with stents didn't lower blood pressure and raised patients' risk of side effects, including deaths.
• ACCORD, a $300 million study sponsored by the National Institutes of Health, found that patients with type 2 diabetes who take the billion-dollar Abbott drug called Tricor don't live any longer than patients who don't. Doctors have been prescribing Tricor since the mid-'70s; Abbott is now advertising a newer, more expensive, patent-protected version called Trilipix. A second arm of the study showed that pushing blood pressure below the usual floor in diabetic patients not only failed to help them but also raised their risk of premature death.
• NAVIGATOR, a 9,000-patient study sponsored by Novartis, found that the drug valsartan, sold as Diovan, kept 14% of diabetes-prone people who were given the drug from developing diabetes. But neither valsartan nor nateglinide, sold as Starlix, prevented the heart attacks, strokes or other cardiovascular events that make diabetes so devastating.
"The good news for patients is that you don't have to take a bunch of medications to try to improve your outcome," says Robert Califf, chancellor for clinical research at Duke University.
Doctors and patients often groan when a study yields negative results rather than new hope in an easy-to-swallow pill. Negative results often contradict conventional wisdom, the pet theories of academics and costly ad campaigns for billion-dollar drugs, argues Yale cardiologist Harlan Krumholz. But they reinforce a humbler message, he says, by showing that doctors can sometimes achieve more by doing less — and spending less — and by convincing patients that prevention always trumps medication.
Starting today, Redberg plans to make the case in her journal. Under a new heading, "Less is More," she'll feature studies showing widely used tests, drugs and procedures that don't pass muster.
She'll also make the point by example, as she did in her Obama editorial. Redberg says the CT cancer risk is important; coronary calcium scans cause nine extra cancers in every 100,000 men tested.
White House spokesman Reid Cherlin says Obama's doctors chose to follow "Staying Healthy at 50-plus" guidelines issued by the U.S. Preventive Services Task Force. "Yes, the patient is 48, but those guidelines seemed the most appropriate," Cherlin says.
Cherlin acknowledges that the guidelines say there's "insufficient evidence" to judge the benefits and harms of CT colonoscopy in patients younger than 50. He says the doctors decided to do a coronary CT scan because Obama's LDL, or bad cholesterol, rose. The options were discussed with the president, who gave consent, Cherlin says.
Redberg evaluated the White House response at USA TODAY's request. "The president and his physician can, of course, choose whatever care he would like," she says. "But I do think he would set a great example by getting evidence-based care and not giving the impression that he thinks more technology is automatically better."
And while the task force declined to make a recommendation on CT colonoscopy for patients such as Obama, she says, "it does recommend against the coronary (CT) scan. It would be better for him, as a young man, not to be exposed to unnecessary radiation."
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