medical


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Anyone who has endured back pain knows it is an erratic dictator. It takes hold of your psyche, demanding your attention and devotion before all else—before you can plan a hike, return to a work routine, pick up your child for a hug. So when someone offers to make that dictator disappear, it’s hard to resist—no matter what the price.

“People in pain are poor decision-makers,” says the investigative journalist Cathryn Jakobson Ramin, author of a new book, Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery.

Millions such bad decisions, she argues, have fueled a $100-billion-per-year back pain industry in the US—one that’s largely selling Americans wrong and even dangerous responses to back discomfort. These include unnecessary painkillers, injections, surgeries, and chiropractic “adjustments.”

About 80% of Americans are expected to suffer from at least one episode of lower back pain in their lifetime, and millions with chronic pain are already lost in the industry, subjected to pseudo-interventions, or taking unnecessary and addictive opioids like Vicodin or Oxycontin, then doubling down on the drugs as their tolerance and the pain escalates. (In some cases, the increased pain is actually caused by the opioids.)

The truth is, as Ramin’s extensive research indicates, all that most people need to do is keep moving.

From diagnosis to treatment, a dearth of evidence

It’s hard to choose one data point from Crooked that lays bare all the misrepresentation and snake oil in the back pain industrial complex, but a few key statistics that Ramin has collected stand out.

Spinal fusion surgery, for instance: Involving the removal of worn-out or injured discs, then the fusing together of the vertebrae above and below that disc with metal screws and cages, this is the form of elective surgery that people spend the most on in the US, costing a total of $40 billion per year. The problem is, it rarely works.

The procedure, with a price tag averaging $80,000, has a success rate of about 35%. Those most likely to benefit are the young, trim, and athletic, not the typical surgery candidates, whose average age was 54 in a 2008 study by the Spine Research Foundation. (Smoking, being overweight, and taking opioids before the surgery each also reduce the likelihood of a positive outcome.) Even its “successful” patients often end up on painkillers two years after the surgery, according to studies, Ramin writes.

Such conclusions should have shut down the market for unnecessary fusion surgeries, she proposes. Instead, the number of operations performed every year increased 600% between 1993 and 2011, jumping from 61,000 annual procedures to more than 465,000.

Also consider this: In a poll at a 2009 conference in Bonita Springs, Florida, 99 out of 100 surgeons who were asked whether they’d elect to have lumbar fusion surgery if it were recommended to them said “absolutely not.”

They were too keenly aware of the odds, and they would have known that after the invasive operation, the spinal sections around the welded-together vertebrae are more likely to weaken, since they’re forced to compensate for the unnatural immobility of their neighbors. Some surgeons recommend a second or third revision operation, with the rates of success dropping each time.

The procedure itself is risky, too. When you go in through the abdomen for any spinal surgery, Ramin tells Quartz, “you have to go through muscle. You detach muscles, you detach ligaments, and ligaments in particular don’t regenerate quickly at all, so you weaken the entire system.” Even when the surgeon enters the patient’s body through his or her back or side, the actual fusing is done perilously close to the spinal cord.

Another common operation, decompression surgery, or a discectomy, has better evidence to support its outcomes, especially to resolve leg pain, Ramin acknowledges. But she says even this cheaper and less invasive procedure, which eases pain by removing bone or tissue that’s putting pressure on a spinal nerve, may not be necessary for many patients.

“The problem is, when you look at the studies, two years out, the outcomes from having that procedure [for a disc herniation] and not having that procedure are the same,” she explains. “Because there is a lot of rehab involved if you do have it, and the natural history of a disc herniation is that it will go away and disintegrate within a month or so, and disappear.”

It also carries similar risks as fusion surgery. Ramin points to Steve Kerr, coach of the Golden State Warriors NBA team, who underwent decompression surgery two years ago: it apparently led to a spinal fluid leak, which caused debilitating headaches and nausea.

Even the diagnosis of back pain can involve some chicanery. Spine surgeons told Ramin that in an estimated 80% to 85% of cases, they can’t point to a person’s source of pain with accuracy, although they can see something abnormal on an X-ray or MRI. That’s because studies have shown that most people are walking around with bulging or worn out discs, but feel nothing, so these indicators on an MRI aren’t always meaningful.

As Ramin writes in Crooked, “The ambiguity inherent in diagnosing back pain makes it possible for surgeons to do practically anything they want.”

Finally, bad news for those who have turned away from modern medicine and toward chiropractors (practitioners of a drug-free approach that has gained mainstream approval): Ramin also spends a chapter debunking traditional chiropractic, that which involves cracking and “adjustments.”

Her summary of the treatment’s roots certainly inspires skepticism:

A self-proclaimed healer born in 1845 near Toronto, Daniel David Palmer was the father of chiropractic. He began as a revival tent mesmerist and entertainer who could make people fall asleep, dance wildly, or tumble into convulsions. Later, he described a “vitalistic force” or “innate intelligence” that existed in the spine; it could organize, maintain, and heal the body. But vertebral subluxations could derail that energy, with dire physiological consequences.

Subluxations are said to be spinal joints that have slipped out of alignment, and some chiropractors will explain that they lead to back pain, digestive issues, mood disorders, and more. Ramin reports that they are impossible to point at on an x-ray, because they don’t exist; a dislocated joint in your spine would be the result of a horrendous injury that sends you to the hospital, she explains, not to a massage table.

Chiropractic manipulation combined with other treatments, such as heat applications and massage, has been found to offer short- to medium-term relief for lower back pain and disability. Critics say, however, that the the forceful thrusts that chiropractors apply to the spine push the vertebral joint beyond its natural range of motion, and the World Health Organization says the modality is counter-indicated for several conditions (PDF).

If someone feels less pain after a chiropractic visit, it’s usually the result of a rush of endorphins, which eventually run out, Ramin said in a Canadian Broadcasting Corporation radio interview. Typically, the pain returns. If it doesn’t, there’s a chance a person would have had the same outcome without care.

Importantly, there are non-conventional chiropractors who have walked away from “adjustments” and other questionable therapies over the past decade or so. “They have restyled themselves as rehabilitation specialists,” which means they’re training patients in effective back-strengthening exercises as a reliable physical therapist would, she tells Quartz, “and are doing a great job with it.”

A back pain folk hero is born

Ramin wasn’t fully aware of spinal surgery’s poor rates of success when she decided to see a back surgeon for her own chronic back and leg pain nearly a decade ago. Then a freelance journalist, having just published a book on memory in middle age, she was frustrated and baffled by her own lack of progress, and her questions led her stumbling into a public health story that would take more than 600 interviews and eight years to write.

Crooked weaves together her compelling personal story and those of compatriots in back pain of all ages. It also follows the money, revealing the hidden motivations of many industry players: workers compensation insurance companies, pain management specialists, the drug companies that make narcotic painkillers, personal injury lawyers, spinal device makers, and spinal surgeons, especially the ones who advertise late at night, often touting their laser surgery. All appear to make a living by exploiting the “fix me” pleadings from people in pain.

This is not to suggest that all spine surgeons or specialists are villains, of course. Sometimes surgery is necessary, though many top spine specialists interviewed for Crooked agreed that surgery is overused. A spinal surgeon at Cedars-Sinai Medical Center in Los Angeles, Hyun Bae, explained why this might be, saying, “It’s not only a financial conflict. It’s an emotional conflict. We get paid to do the work. We want to make the patient better. So we concentrate on the good results and we dismiss the bad results.”

The problems often begin, Ramin tells Quartz, when patients are ill-informed. They might demand MRIs for acute pain, though their primary care doctor discourages it. They might also be influenced by direct-to-consumer advertising from less reputable spine centers. “When they go see his surgeon and the surgeon says, ‘I’m sorry I can’t help you this. There’s nothing I can do for you,’ the tendency is to misunderstand that, and to think ‘You’re not smart enough. You’re not good enough; you don’t have the right high-tech whiz-bang tools,’” she tells Quartz, “and I need to keep looking. I need to find someone who is smart enough to do this.’”

Carol Hartigan, M.D., medical director of the Spine Center and the Spine Rehabilitation Program at New England Baptist Hospital, tells Quartz that she agrees with most of Ramin’s critiques, though she finds the author extreme in her opinions—for example, by saying that a person should never have back surgery. Still, Hartigan says, “She did an outstanding job of researching. She had an eye for looking for flaws in the ‘industry,” and she interviewed the highest level players. She should be commended.”

Most reputable spine surgeons will discourage people from surgery when they don’t think it will be helpful, but “You do see some crazy ways that people are treated by high level clinics,”says Hartigan. They neglect to offer people an option to get better, she asserts, which, in her practice, would involve physical rehabilitation and systemically progressive resistance exercises.

After only a month in bookstores, Crooked began shooting up the Amazon bestseller list, because back pain is so universal and so emotional. “It’s part of the human condition,” Ramin told San Francisco public radio. “Few of us will make it off this mortal coil without it.”

As a person ages, the discs in one’s back naturally dry up, especially when a person isn’t active, and our lifestyles have only become more sedentary and sitting-focused, complicating matters tremendously. A meta-study published in the British Medical Journal found lower back pain to the be the number one cause of disability worldwide, affecting 83 million people globally.

Doctors are now advised not to turn to pain medication for garden variety back pain, but for years, we know too well, powerful painkillers, whose drug companies spent millions on marketing, were over-prescribed for back pain, arthritis and other conditions, creating an environment that made the drugs easy for anyone to access, and led to today’s opioids (and related heroin) crisis.

Dependence comes easy with these drugs: In March 2017, a report from the Centers for Disease Control and Prevention found that when a person takes a narcotic painkiller for one day, there’s a 6% chance that he or she will be still taking that pill a year later. If the prescription is for eight or more days, that probability rate jumps to 13.5%.

The unpopular truth about recovery

The media has raised awareness about the hustlers of the back pain industrial complex before Crooked’s publication. Surgery has been outed as, for many patients, “useless.” When, in early 2017, the American College of Physicians issued new guidelines saying that strong opioids such as Vicodin and Oxycontin should only rarely be prescribed for nonspecific back pain, reporters helped get the word out, while calling out the back pain businesses for their role in the current opioid crisis.

Nonetheless, the prescriptions and surgeries continue, partly because patients want the pain to go away—now. To many it seems counterintuitive that exercise is doable or the right solution when someone is already suffering.

As Ramin also told CBC radio, the psychologists she spoke to for the book talk about a cognitive shift that’s needed to “understand that yes when you start exercising there will be pain. There definitely will be because you are just as out of shape as all get out. But in the right hands, in the hands of a back whisperer, you can get through that and you can get strong and you can get your back muscles and the rest of your body balanced and you can straighten out your gait and you can straighten out your posture.”

The second half of Crooked is a guide to finding those right hands. Ramin shares her tips for tracking down a back whisperer—such as a physiologist or a doctorate-level physical therapist who’s also an orthopedic clinical specialist—to coach you through recovery.

She introduces Stuart McGill, a professor of kinesiology at University of Waterloo, in Ontario, Canada, and a globally recognized “back mechanic,” whose “big three” exercises she does daily:

The author is often asked for her thoughts on certain forms of exercise, such as yoga or pilates, which she also covers on her website. What she tells people, repeatedly, is that “movement is essential.”

“We’re sitting for 50 to 60 hours per week,” she says. We sit at our desks, in our cars, at the dinner table, and we sit to write email messages from bed at night. “We think three hours of exercise on the weekend will undo the problems that creates,” she laments. Even standing desks aren’t the easy out, as standing the wrong way all day can lead to different issues. Her mantra: “The best posture for sitting is always the next posture.”

Unfortunately, even as pro-exercise messages gain more traction here, some of the shadier players of the back pain industrial complex are taking their very different mantra into new markets. Ramin found that in China and Japan, spinal surgeries “are expected to nearly triple in number between 2014 and 2020, and almost double in revenues, with more than a little encouragement from US spinal device manufacturers.”

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Giving old mice blood from young mice can reverse age-related impairments in learning, memory and neuronal function, according to US research.

These findings, published in the journal Nature Medicine, suggest that circulating factors from young blood could reverse the effects of aging in the brain.

Future studies in humans are necessary before similar conclusions can be made about effects in people.

A second set of studies in the journal Science joined a young and old mouse together with a single circulatory system and found that age-related impairments and DNA damage in the muscle stem cells, or satellite cells, of the older mice were reversed.

Tony Wyss-Coray of Stanford University and colleagues found that repeated injection of blood from young, three-month-old mice into old 18-month-old mice can improve their performance in learning and memory tasks.

Heating the blood, which alters the structure of its proteins, before injecting it into older mice abolishes these effects, suggesting a circulating heat-sensitive factor reduces these positive effects.

The aged mice showed a reversal in age-related impairments in their brains at the structural, molecular and functional level.

Of course as blood cells have a 90 day life span this [potentially] would mean a transfusion every 90 days at minimum.

Over the last couple of days I have been trying to help a fellow trader and weightlifter with an injury. It can serve as a salutary reminder that seeking help early is usually a good idea.

Can we take a break from the markets for a second?

I am the type that doesn’t step foot inside of a doctors office or a hospital unless I need stitches.
But I can’t take it anymore. My left shoulder has some serious issues.

This is something that has bothered me for over a year now, but it keeps getting worse. I know its getting worse is because of the pain I get at the gym.

I know its a long shot to diagnose someone online, but here it goes:

1. The point of pain is when my arm is parallel to the floor, I cross my arm “across” my body and I raise upwards.

2. My doctor thought it was a rotator cuff injury

3. Both x-ray and MRI showed no problems

4. My doctor then says it must be that “the ball came out of the joint” – wouldn’t that show up in the x-ray?

5. The exercises that are most painful are; military press, pull-ups and tricep raise (behind head)

6. After a workout, my left arm feels broken, while my right arm feels “pumped”

To be honest, I don’t care about the pain.

What I do care about is that I can’t lift heavy and my whole left arm looks like a little bitch (probably like chivo) compared to my right.

I’m supposed to see a physiotherapist, but for some reason I imagine these people to be something like a yoga instructor.

I guess I have a hard time believing that swimming in a pool with a bunch of old people doing some stretches is going to fix my problem

or whatever it is they are gonna tell me to do.

I don’t know if its related but starting just last week, I could barely raise my head to get out of bed because the left side of my neck, lat, shoulder blade hurt so bad.

Any advice? I don’t want to waste another 6 months.

Thanks in advance.

go2 received numerous replies, diagnoses, wild guesses and tips. I won’t bother with any of them. The most egregious was from someone claiming to be a doctor. As with almost anything, a medical diagnosis is made on numerous steps being completed. The first is a comprehensive case history. It can be done online, it’s not ideal, far from it, but it can elicit some useful information:

duc says:
July 15, 2011 at 3:20 pm

go2,

In any diagnosis there is a methodology.

Onset:
You mention that this has been worsening for about a year. [i] Can you remember what you were doing? In other words can you link a causative event? [ii] You state that it is worsening. Is this just lately? To leave it so long suggests that it was not so bad, bearable, then suddenly started to worsen, now involving Csp, upper back. [iii] Any symptoms radiating into arm/fingers? Numbness, pins&needles, pain, burning or other odd symptoms? [iv] You continued to train with the injury, has your training of the injured area changed or been modified in any way just recently? [iv] Did you ever rest/rehab it from the original injury, or did you simply train through the pain?

Distribution
You have described the anatomical position where pain is triggered. [i] Where exactly, in that position does it hurt? [ii] Does the pain travel anywhere else? [iii] At rest is there any pain? [iv] At rest if any pain, does it travel anywhere else?

Nature of pain
Is the pain present at rest? [ii] Is the pain sharp in nature upon movement only, or [iii] is the pain constant, dull ache in intensity, increasing with movement?

Aggravating/Relieving Factors
Apart from movement already mentioned, anything else reproduce the pain? [ii] How quickly can you reproduce the symptoms? [iii] Has this changed?

What if anything provides relief? [eg. anti-inflamms, heat, ice, positioning, etc] [ii] How quickly/slowly is relief provided by the factor employed?

Medical History
Are you using any anabolics [due to the legal implications answer by e-mail] If so [i] what drug [ii] what doseage [iii] what duration. AS can create muscular tears, avulsions through creating physiological imbalances.

To date, you have not been diagnosed. Without a diagnosis, no treatment protocol can be either recommended, nor implemented. The purpose of a diagnosis is to provide a baseline, to which expected results from a treatment plan can be tested against, this is a prognosis. Like many things, diagnosis is not a science, it is an art, an art based on empiricism.

To date, all the responses in the comments section, while well meaning are uninformed guesses, the most egregious being the fraud claiming to be a doctor.

The prior, constitutes the history, somewhat condensed. The second part of a diagnosis is an examination. This would constitute both an active and passive examination, possibly including a systems examination. This for your case would likely constitute a neurological clinical exam. The purpose of a physical exam is to isolate anatomical structures, and reproduce the symptoms, thereby identifying the structure. This structure and pain produced is confirmed via its function.

Imaging, MRI etc are not diagnostic. They are used to confirm/reject a diagnosis based on a thorough history and clinical examination. Anything less is negligent.

I can certainly help you through the first part, and give you some ideas as to possible areas that would require attention in any physical exam.

jog on
duc

The response:

go2jupiter says:
July 16, 2011 at 10:01 pm

duc,

Onset:

[i] I don’t remember exactly but I probably injured it at the gym (military press, tricep extension behind head) or I could of “fallen” on it.
[ii] Yes, its just been worsening lately. I’ve never been this lean before. <8% bf. So maybe the extra cushion is gone.
[iii] I get a pain through the "bicep" / arm bone. It feels like the arm is going to break like a twig. It doesn’t go right to my elbow, but more like straight down “in the middle”.
[iv] My workout has remained pretty constant
[v] Never done rehab, I just trained through the pain.

Distribution:

[i] Sharp pain is at the side and side/front of the delt. During rest sometimes at the back of the shoulder. Its hard to pinpoint + the recent neck pain and this why its been hard for me to fix it.
[ii] Pain travels down "the bone" of my arm
[iii] There is an ache at rest and occasionally a "pulsing" discomfort in my shoulder
[iv] The pain present at rest does not travel

Nature of pain:

[i] There is discomfort in my shoulder at rest but I wouldn't call it unbearable
[ii] Sharp pain during movement, dull ache at rest

Removing my shirt by lifting my arms causes pain but other than that I rarely put my arms in a position for it to hurt.

Instead of a pumped feeling like my other arm, it feels like its about to snap.

Aggravating/Relieving Factors:

[i] The best way to reproduce the shoulder pain is to raise my arm upwards while crossed over my body with palm facing down. The pain down my arm comes with lifting during any exercise.
[ii] Symptoms are reproducible every time I try
[iii] No this has not changed

What if anything provides relief?

[i] The only thing that provides relief is not lifting with it

Medical History:

[i] I am not using any drugs or medication for the pain

Also, the left side of my chest (the side with injured arm) is larger than my right chest

I guess during chest exercises the left arm is just not taking any weight and transferring it to the chest instead.

Lifting weights does not always produce the sharp pain in my delt, (bench press for example) but the “weakness” in my arm is there for every exercise, as if the arm can’t handle any weight at all. (due to the shoulder instability?)

I tried my best to answer, thanks for taking the time.

Further questions:

duc says:
July 17, 2011 at 2:24 am

go2,

A few more questions for clarification:

[i] When you perform Military Presses how do you set up for the exercise? Do you use a Smith machine, some other form of machine, or do you use olympic bar + plates. If free weights: off a support stand, or, do you clean the weight to shoulder position?

[ii] You state that you could have fallen on it: expand on this, do you partake in some form of martial arts, possibly at work, accident that stands out in your memory, etc.

You state:

[i] The best way to reproduce the shoulder pain is to raise my arm upwards while crossed over my body with palm facing down. The pain down my arm comes with lifting during any exercise.

This is adduction of the glenohumeral joint. Functionally, it is a relief to the supraspinatus tendon that passes through the space created by the acromion and humeral head and would be expected to relieve symptoms. Abduction of the glenohumeral joint would be expected to aggravate symptoms, reproducing them.

Can you expand on this area?

Lifting weights does not always produce the sharp pain in my delt, (bench press for example) but the “weakness” in my arm is there for every exercise, as if the arm can’t handle any weight at all. (due to the shoulder instability?)

There is tremendous pressure through the glenohumeral joint in any form of bench press. If there was glenohumeral “instability” this I suggest would be very apparent. In addition, particularly in a free weight bench press, the stabiliser muscles, rotator cuff musculature, amongst others, would be strongly stimulated, causing pain. That no pain is caused is intriguing.

Weakness of the arm however is a different.

You mention;

Also, the left side of my chest (the side with injured arm) is larger than my right chest

Is there muscular atrophy of the upper extremity? Tricep mass, bicep mass?

Any family history of bone cancer, or any cancers?
Your age?
Your occupation?
Would any past occupations expose you to toxic material of any description: chemicals etc?

Any additional symptoms that you may have that you do not associate with the symptoms in the arm/shoulder?
The weight loss that you mention:

[ii] Yes, its just been worsening lately. I’ve never been this lean before. <8% bf. So maybe the extra cushion is gone.

[i] how caused? Are you eating less? Dieting for a particular reason? Increasing aerobic based exercise for any particular reason?

If none of the above, can you explain the weight loss in a rational manner?
If no explanation, then how long have you noted the weight loss? Is it predominantly fat, muscle, or a mixture? From what areas of the body? Is it general? Or site specific?

I'll wait to hear the answers.

jog on
duc

At this point we have moved to e-mail, so the communication must remain private. Suffice to say we have moved onto the second stage of a diagnosis, the physical testing. This is performed in the clinic and comprises both active and passive tests. These may be augmented through a systems test, and this case would require a neurological examination at the very least. Now as I am in NZ and the patient is in I think the US, obviously I won’t be performing the tests, but they can for the most part be reproduced by the patient and reported. We’ll see.

The point is this: if you have an odd presentation, and you visit your GP, this is the sort of questioning that you should expect. If you are fobbed off with 5mins and a prescription for XYZ, your doctor is not providing a professional service. Lose him.

The second point is this: don’t leave something that starts out as a minor problem, to grow into a major problem, unless you absolutely know what the problem is, and can take the necessary steps to correct or rehabilitate the problem.

This appeared the other day on the StockTwits list of bloggers.

Question: What do you call a D student who graduated medical school? Answer: Doctor

How do you know if the guy that gropes and tests you got an A or a D in med school? You don’t. It’s like boarding a 747 after the pilot went on a coke binge, killed his wife, left her on the kitchen floor, had a few Mimosas and then started up the engines to fly you over the Atlantic. It’s a trust thing, you have no control.

I always said if I had anything really wrong with me I would want Dr. House to do the operation as he is the only Dr. I could see myself trusting. Unfortunately he isn’t real so that ain’t happening.

Over the past year I have had some intermittent stomach pain. I chalked it up to a bad burrito or the occasional Big Mac. Lately though, the pain was more frequent, and over the last two weeks the pain which used to last twenty minutes, has duration of three to ten hours. The way I can describe this pain is simple. If you remember the last scene of Braveheart when Mel Gibson had his entrails ripped out, well, that’s how it feels.

So I did what I have never done. I went to WebMD because of extreme curiosity. My Mom had her gall bladder removed years back and that is what I thought it might be. Anyway after my search, I found that I had about ten out of ten of the symptoms of gall stones. I knew it had to be gall stones.

I went to my Doctor the next day and described my symptoms. I told him that my Mom had gall bladder issues and I thought I may have the same thing. He looked at me thoughtfully and said ” I really doubt it, I think you may have really bad indigestion”. He sent me for a full abdominal sonogram and an upper gastro test which required me to drink about a pint of a chalk like substance.

After the test I described my symptoms again to this new Doctor in extreme detail. He was the” specialist”. He looked at me and said something that I never though an expert in this area would say. ” Hmm, I never heard of this”, he then asked “Do you have stress?” I responded that I was on wall Street for over twenty years, trade stocks and have two teenagers, what do you think Dr. Shit For Brains? No I didn’t call him shit for brains, but I wanted to.

Friday I got the results back. It was my gall bladder. Schmucks.

This is a minimally invasive procedure these days and I will have this useless organ ripped out in the next week or two. I just hope i don’t get the D student.

Obviously this chap is somewhat underwhelmed by the diagnostic prowess of the doctors in encountered. Using WebMD he feels rather superior, that based on matching 10 symptoms, although some of them might have actually been signs, although the distinction seems to have made no impression on our self diagnosing patient.

The tests he was subjected to, did actually confirm the diagnosis. Now further investigations, which are scans of various types, are all listed under further investigations, and are not diagnostic, rather they are confirmatory of an existing diagnosis [or not as the case may be] So all ended well.

Well possibly not.

The last sentence highlights the problems associated with a lay diagnosis, and unfortunately the doctor seems at fault here again: the gallbladder is very far from a useless organ. It has myriad physiological functions. The primary function being the emulsification of fats in the digestive and absorption process. Fats are a component of every cell in the body. They are particularly important within neural cells, which for this chappie, involved in the financial markets, is a rather crucial area. Of course the other major issue is the aetiology of the gallstones, what, why and how they formed. This pathological process that resulted in a gallstone, could and likely does, have a pathology that acts as an early warning to a more serious, or continuing pathology.

The one that immediately leaps to mind is excess estrogen. Yes, I know estrogen is a female hormone, but it is ubiquitous, and in the male with gallstones, is a prime suspect. The issue with estrogen levels that are high in men is the increase in cholesterol that they induce. High cholesterol levels lead inexorably to atherosclerosis, which commonly manifests as Coronary artery disease. Depending on other lifestyle factors, are you a fat bastard, are you a fat bastard because you are a lazy bastard guzzling beer, fags and high fat while watching a 3 hour football game on TV, can lead to what’s commonly described as a heart attack, add in some age, and you start to multiply the probabilities.

Now when I went to Medical school, there were indeed the A students, and there were the D students. I have to say the D students were pretty damn dangerous and should never have been unleashed on the public. In fact the whole Medical industry is dirty, so dirty that I have never bought stock in the industry, I may have daytraded a few issues, but never on an investment basis.