Friday, June 12, 2009

What if I can't look angry anymore?

I've had a problem with psoriasis on my foot for years. Recently it became rather bad, and I visited a well-known dermatologist in Kilpauk (who also practices at one of Chennai's best-known hospitals).

I have a mistrust of new doctors, so I cross-checked all items on the prescription. They all looked standard stuff for psoriasis; the ointment, in particular, was similar to something I've been prescribed once before (a different preparation of betamethasone, a corticosteroid). So I went ahead with the treatment and the problem cleared up within a week, as it had before.

I then told the doctor that the problem tends to recur after I stop the treatment (even if I keep the area moisturised). She said there is another tablet that she would consider prescribing, but wanted some blood tests done first to be sure it is safe to take it.

Today I went there, blood tests in hand. And while I was waiting, two people got up to the reception to speak. One guy introduced himself as from the company that makes Botox, and he said the young woman next to him will be sitting in the doctor's clinic assisting her; meanwhile they wanted to inform and educate us about this treatment.

I promptly announced that I am cancelling my appointment, scratched my name, wrote the doctor a brief note, and walked out.

I had already been disturbed, on my first visit, at the sight of Botox advertisements in the doctor's clinic, telling patients how they could keep the wrinkles away and stay looking young; but I ignored it because I had strong recommendations to this doctor. (And, for all I know, she is indeed very good.)

There was a time when doctors would not prescribe medicines that were advertised to the public. For example, if you needed an aspirin, they would prescribe not Aspro (advertised in the glossies of the time, and on TV) but Disprin (not advertised). I know times have changed, and I have even seen a few Disprin ads. I can also understand a doctor prescribing Botox for someone who needs it (I first heard of it, years ago, in the context of treating writer's cramp).

But cosmetic Botox is another matter. And direct-selling it to patients, in a doctor's clinic? I find that utterly unconscionable. I mean -- the thing is a neurotoxin, derived from bacteria that cause a deadly form of food poisoning (botulism). Its therapeutic use is in paralysing muscles -- which is sometimes good (alleviating writers cramp), but sometimes surely unnecessary (paralysing facial muscles, which allegedly cause wrinkles not to form). At best, it should be suggested by a doctor after carefully explaining the pros and cons of the treatment -- not direct-marketed by a pharma company on her premises!

And if the doctor indulges in this sort of practice, how can I be sure that the pill that she was going to prescribe me was in my interest and not in the interest of some pharma company or the other?

I've heard it said that the reason for the wooden appearance of several Hollywood celebrities (think Nicole Kidman) is their excessive use of Botox; one quote that sticks in my mind (I forget where I saw it) is, "few actresses are able to look angry any more". [UPDATE: found it.] Well, sometimes I do want to look angry. For example, right now.


Natasha Mhatre said...

R, I've read that UV exposure helps with the psoriasis. Just expose it to sunlight as often as you can and that seemed like enough UV in my case to stop it from recurring.

Rahul Siddharthan said...

Natasha - interesting, will try it. Sunlight tends to make my skin dry, and it seems to me that the flareups are worse when I'm wearing slippers (or barefoot) and no socks. But that could be due to exposure to dust/dirt, rather than sunlight. Exposing it to sunlight for a certain amount of time every day, and keeping it moisturised otherwise, sounds worth trying.

km said...

America may have invented advertising but India takes it to a whole new disturbing level. (Though this is literally in your face :))

Hope you get better.

gaddeswarup said...

Not the main topic. I have psoriasis since 1970. While in India I used Elladi coconut oil (Produced by one Warrior family in Kerlala but was available in Chennai), Now I just use Baby Oil. Once when it got a bit severe, I went for UV treatment for 2-3 months and it helped. In my case, it also led to psoriatic arthritis in 1982 but it has bee mild so far. My impression is that modest exercise, out door life, regular food habits help but somehow I could never do those things systematically. I did notice that in my case, tension worsens it. I lived in Shillong for a while and flights from Kolkata to Gowhati used to be very bumpy. After every flight, my psoriasis used to flare up.
I hear from one professor Viswanath (mathematice, used to work in Madurai and Hyderabad) that his father in law was completely cured by homeopathic treatment after suffering for 27 years. But I think that homeopathy can be dangerous.

Rahul Siddharthan said...

Gaddeswarup - thanks for the interesting comment! I too sometimes borrow the kid's oil. As for homeopathy, the genuine stuff is almost infinitely dilute and should be harmless, if also useless, in my opinion. (Except for the placebo effect, which shouldn't be underestimated.) Unfortunately a lot of what passes as homeopathy is dubious stuff.

Anant said...

Off topic, perhaps, but the internal logical consistency of homeopathy should imply that the less it is used, the more effective it should be? Not my own by a paraphrasing of a lampoon I once heard long ago.

Rahul Siddharthan said...

A colleague of mine claims the following is, roughly, an actual conversation he had with an actual practising (and believing) homeopath. My friend expressed his skepticism on scientific grounds -- the dilution is so extreme that hardly a molecule or two would be expected to remain, if that. The homeopath said, "Have you been to a homeopathic doctor?" My friend said yes. "What happened?" "The doctor asked lots of questions and then prescribed me a medicine." "How long did the questioning take?" "It took about 20 minutes and was very detailed." And, according to the homeopath: "It is the 20 minutes of questioning that is the therapeutic part of homeopathy. The pill is a placebo. It is just a sugar pill."

But I doubt all or most homeopaths will agree with that. And certainly most homeopaths don't individually tailor their prescriptions to specific patients the way they are supposed to, and in many cases the "medicines" they sell are very far from infinitely diluted, and as Gaddeswarup says, could even be dangerous.

And as I said earlier, the placebo effect shouldn't be underestimated: there is lots of research saying it really works in many cases. The mind-body connection is strange and ill-understood.

Sunil Mukhi said...

The joke Ananth is referring to is about a patient who forgot to take his homeopathic medicine - and thereby died of an overdose...

Of course the placebo effect is very real. It seems to be an inversion of the causal connection: "I feel better, therefore I believe the medicine works" to become: "I believe the medicine works, therefore I feel better". Indeed it deserves more study.

There is an analogy I once noticed in research: I had given a very smart student a short research-oriented problem to try and solve. He came in and said it couldn't be done. The next morning I waved a sheet of paper in front of him and said I had worked out the solution myself (I wasn't bluffing, I had actually done so). Thereafter he succeeded in finding the solution on his own!

Rahul Siddharthan said...

Sunil -- next time try bluffing, with an unsolved problem: maybe the student will come up with something significant :)

gaddeswarup said...

I am sure that all of you know this story but I cannot resist repeating it. From:
"...he enrolled in the doctoral program in mathematics at the University of California, Berkeley studying statistics under mathematician Jerzy Neyman. In 1939, he arrived late to his statistics class. Seeing two problems written on the board, he assumed they were a homework assignment and copied them down, solved them and handed them in a few days later. Unbeknownst to him, they were examples of (formerly) unproved statistical theorems. Dantzig's story became the stuff of legend, and was the inspiration for the 1997 movie Good Will Hunting."

gaddeswarup said...

You may have already seen this article:
This part sounds a bit like homeopathy:
"Indeed, several of the drugs now being tested against cancer have been around for decades, but in the past were used in the wrong way for the wrong reason. Azacitidine, for example, was first discovered in Czechoslovakia in the 1960s as a traditional chemotherapy drug, and doctors used it to kill cancer cells the old-fashioned way: giving as much as patients could tolerate. Jones, a South African by birth who now heads the Norris Comprehensive Cancer Center at USC, discovered in the 1980s that the drug had another mode of action: it could turn genes back on by stripping away the "duct tape" of DNA methylation that muffled genes. This suggested a different kind of attack on cancer—not by killing cancer cells outright, but by reversing the epigenetic changes that make a cell cancerous in the first place.

In the 1980s, as a young oncology fellow at Mount Sinai School of Medicine in New York, Lewis Silverman proposed testing azacitidine as an epigenetic drug—that is, at lower doses than is typical for traditional chemotherapy, where it still might be effective reversing silenced genes. Silverman has since shown that low doses of the drug reduce the symptoms of a type of leukemia and allows patients to live longer. The Food and Drug Administration approved azacitidine in May 2004; the drug is now marketed as Vidaza."