Thinking about procreating?

Whatever you call it – up the duff, knocked up, a bun in the oven or eating for two, before getting pregnant there are a couple of things worth considering. Now because I am a doctor and I’m not supposed to get judgmental, I’m not questioning whether it is a good thing for you at this time in your life career or relationship, nor will I question the choice of you partner, I’ll leave that discussion to your Mum. What I would like to suggest is the opportunity to chat about some of the medical issues around pregnancy and if there are tests or other things that need to be done beforehand.

P1030128

If this is your first pregnancy, there is a lot of information out on the internet. You will find everyone has their own opinion on many aspects of pregnancy from trying to predict the gender of your baby, what foods to eat and avoid, how generally how to live your life.

If this is not your first pregnancy, many authorities suggest waiting at least 18 to 24 months before planning to try again.

New technology means you can and your partner can undertake genetic screening. Certainly if there a family history of a chromosomal or genetic disorder, testing has been recommended by RANZCOG.

For everyone else, screening for carrier status for common genetic conditions are available at a price.  These may include conditions such as cystic fibrosis, spinal muscular atrophy and fragile X syndrome. This article from The Conversation discusses whether you may or may not want to spend your money. And what would you do if you discovered both of you were carriers?

Although having a pap smear during pregnancy is not difficult and wont cause a miscarriage, it may be worthwhile getting it done beforehand. Remember that this year how we do cervical cancer screening has changed. And whilst we are talking about pap smears we should mention preventing, screening for and treating sexual transmitted infections, viral hepatitis and HIV.

Do you both need to make some lifestyle changes? Remember, to make a healthy baby it is often said you need healthy sperm and a healthy egg, Not unsurprisingly, a lot of things that many people do on a daily basis can have an adverse effect on a pregnancy. There are some obvious things, like smoking tobacco and cannabis, drinking alcohol and using other drugs.

If you are eating a healthy diet then this is a good start. You may need to be a bit more careful with food preparation to avoid germs such a Listeria and Toxoplasma. The “avoid food list” usually contains paté, soft cheeses (eg feta, brie, blue vein), prepackaged salads, deli meats and chilled or smoked seafood. In addition some fish may contain high levels of mercury which is toxic.

Should you take extra vitamins? Currently there is good evidence for taking extra folic acid and iodine, but if you are eating a healthy diet then multivitamins, including those pregnancy vitamins, are probably a waste of money.

Challenging yourself to keeping to a healthy weight through regular exercise and a healthy diet can help make pregnancy safer. Maintaining a healthy weight may improve the chance of getting pregnant or fecundity. For some women this may mean gaining weight or for others loosing weight.

Prescriptions medications, and I’m not just talking about the contraceptive pill can affect a pregnancy and may need to changed. Medications available over the counter or from the naturopath may also need to be discussed.

We should also talk about known medical illness like asthma, epilepsy, high blood pressure and diabetes before embarking on a pregnancy. How’s your mental health. Are there any pregnancy problems that seem to run in your family?

Do you need to see a dentist? There is some evidence that having periodontal disease can can have an adverse effect on your pregnancy.

Are your immunisations up to date? Some immunisations can’t be used in pregnancy as they contain live virus. These include Rubella and Chickenpox. Both of these illnesses can cause harm to your developing baby and a vaccination will provide protection from these illnesses. Other vaccinations such as influenza and whopping cough (pertussis) are recommended in pregnancy.

Have you planned an overseas holiday when you could be pregnant? Will it be safe to fly, will the airline let you fly. Would you travel insurance cover you having a baby out side of Australia. What would you do if you went into premature labour in Mongolia? Malaria can be bad for a pregnancy. There are some uncertainties around other infectious diseases such as Zika and Dengue fever, to name but a few.

Are there any test that need to be done apart from those mentioned already? I would usually check your blood group and consider other tests as guided by the consultation.

Now lets talk about how you need to have sex to get pregnancy…..oh you already know that. And when is the best time to have sex for a baby not just fun? Great.

 

 

 

 

 

 

Please ask!

Too often I am told whatever you think doc.

I can see the point of this question, after all, I spent four years training to be a pharmacist, then another four to be a doctor, and six more years to pass my fellowship exams to become a GP with ongoing active education. Not a day goes by when I cant say I learn’t something new. My patients are often my greatest teachers.

But may I encourage you to questions your doctor, because it is after all your health we are talking about.

Choosing Wisely Australia is helping healthcare providers and consumers start important conversations about improving the quality of healthcare by eliminating unnecessary and sometimes harmful tests, treatments, and procedures.

Here are 5 questions to ask your doctor

1. Do I really need this test, treatment or procedure?

Tests may help you and your doctor or other health care provider determine the problem. Treatments, such as medicines, and procedures may help to treat it.

I have been taught that you order a blood test to answer a clinical question, for example, could this patient have an over active thyroid? Tests are not for fishing expeditions!

I have had some challenging consultation after a patient has seen a naturopath trying to determine which tests might be clinically necessary. The RACGP has come out with this document to support the decision making process.

2. What are the risks?

Will there be side effects to the test or treatment? What are the chances of getting results that aren’t accurate? Could that lead to more testing, additional treatments or another procedure?

Some tests, treatments and procedures provide little benefit. And in some cases, they may even cause harm. For example, for most lower back pain an x-ray may lead down a path of ending up with more invasive treatments which may not help. 

Even blood tests are not without risk. Any sharp instrument going through the skin can lead to infection!  An imperfect screening test for prostate cancer, Prostate Specific Antigen may lead a bloke on the pathway to a painful biopsy, then surgery which may leave him impotence and incontinent for the rest of his life. All for removal of a potentially slow growing cancer that he may have died with rather than from.

3. Are there simpler, safer options?

Are there alternative options to treatment that could work.

To reduce the risk of a heart attack, should you take a cholesterol lower medication with the risk of side effects or cut back on fast foods and exercise more?

Is it safer to take a tablet or injection to improve you B12 or iron levels?

4. What happens if I don’t do anything?

Ask if your condition might get worse — or better — if you don’t have the test, treatment or procedure right away.

This is a most challenging question because a doctor is trained to do something. Push on a chest, give a drug, order an x-ray, cut out badness…..
But sometimes doing nothing is all that is required. Recently, I chatted with a palliative care nurse who told me about a patient’s distress that the doctor who operated on her cancer didn’t visit in her final week. I replied it was probably because the doctor felt he had nothing to offer, that he had failed to cure her. But the patient wasn’t angry that the surgery didn’t work, she didn’t want more procedures, tests or medicine, she just wanted him to be present for a moment, to be seen at her door, to care. That was all. Sometimes it is okay to do nothing.

5. What are the costs?

Costs can be financial, emotional or a cost of your time. Where there is a cost to the community, is the cost reasonable or is there a cheaper alternative?

I meet people who seem genuinely surprised that they don’t necessarily need to see a specialist dermatologist for a skin cancer check; that a GP is able to do this usually then and there.

 

Why I don’t see Drug Reps

It’s not just about the pen!

A very small part of the Dr Caren’s collection of Drug company pens

Should I continue to use drug reps as my primary source of information about new drugs?

There is certainly support out there if I do go down this path. There are doctors out there who already say no to drug representatives.  http://www.nofreelunch.org/ and http://noadvertisingplease.org/

Dr Brett Montgomery has written on the subject here  https://theconversation.com/why-i-dont-see-drug-reps-a-gps-take-on-big-pharma-spruiking-32435

And it’s not just doctors that they target, nurses are also seen as a way into the prescribing sphere of influence. https://theconversation.com/invisible-influence-why-sales-reps-are-forming-relationships-with-nurses-57061

Here is the New Zealand perspective https://theconversation.com/drug-ads-only-help-big-pharmas-bottom-line-so-why-are-they-allowed-45317

As this paper entitled Following the Script: How Drug Reps Make Friends and Influence Doctors from a few years ago suggests

“Reps may be genuinely friendly, but they are not genuine friends. Drug reps are selected for their presentability and outgoing natures, and are trained to be observant, personable, and helpful.”

Dr Ben Goldacre has blogged on his BadScience website and written on the influence of pharmaceutical companies on drug utilisation.  After eventually making it through his book, Bad Pharma I felt a very pessimistic about the whole process. It’s a bit like House of God, essential junior doctor reading.

A list of problems include

  • Missing clinical data which the rep probably doesn’t know about either
  • Positive paper publication bias
  • Ghost writers instead of academics
  • No decent independent head to head studies, so what if me2 is better than placebo is it better than the first drug?
  • Kick backs to medical journals
  • Half blind public agencies
  • Statistical manipulations and sub-subgroups analysis
  • Glossed over serious adverse effects. “The risk of thyroid cancer with Saxenda is over rated!” or “No that only happens in beagles”
  • Glossy brochures and advertising in journals.
  • Pushy drug reps and their inducements – which do seem limited to lunch rather than international flights these days.
  • Leaving behind drug samples as starter packs
  • Subsidising patients support groups and turning them into pharmaceutical lobby groups
  • Product familiarisation campaigns
  • Breaking news on popular media dressed up as “news” stories
  • Chatting in the ear of the clinic nurses, who also look after the sample cupboard. I wonder if any rep has suggested that the oppositions product be pushed to the back or even in the bin?
  • Paying specialists to “educate” GPs
  • Creating a “disease” to sell a product, eg fibanserin for a woman’s poor libido

As a health professional am I impervious to drug rep propaganda? I think the evidence suggests NO.

A few hints include the average sales force expenditure for pharmaceutical companies is $875 million annually and that is just in the USA. Being Australian, I am of course more skeptical and cynical but even so it has been estimated that in 2012, $30 million was spent by pharmaceutical companies trying to persuade doctors to use their product. I think it safe to assume no one would spend that kind of money if there wasn’t some return.

So where to find unbiased information?

National Prescribing Service would be a good place to start in Australia.

This paper by Richard O Day and Leone Snowden details other useful sources of drug information.

I have also listened to this podcast about conflict of interest. Sam Manger talks about how we may be able to immunise ourselves against drug rep influence.

 

I think these are pretty good reasons why we have decided drug reps don’t visit the clinic I work in.