Thursday, September 30, 2010

Help Your Doctor Make the Diagnosis

When patients and doctors communicate effectively, the patient has the best result. Not every doctor asks the critical question that can cinch a diagnosis.  Yet good communication, coupled with good diagnostic skill can be worth more than $10,000 in tests and referrals to consultants.  You can help your doctor figure out what is going on by thinking and communicating like a physician.  Whether you have a new problem or something that has been bothering you for a long time, here are some things that the doctor will want to know.

1.  What are the symptoms?  Be specific.  Don't just say "Sometimes I have a pain in my stomach."  Since more than 80% of health problems can be diagnosed based on information that you provide, make sure you can verbalize what you are feeling.  Is it crampy?  Does the pain come and go?  Where is it located?  Is it sharp or more like an ache?  These specifics are giving information that your doctor can use as she thinks of the anatomy, physiology and causes of pain.

2.  How long has it been going on?  Try to be specific.  "Awhile" doesn't mean anything to a doctor.  That could be 2 days or two years.  Did it come on gradually or suddenly?  There is a different cause for any symptom that is chronic (over several weeks) vs. sudden or acute.  Did anything precede the symptoms?  Travel, trauma, life stress can point to different causes.

3.  What other symptoms have you noticed?  Don't worry if you give too much information.  Everything is important.  Fatigue, weight loss or weight gain, difference in balance or smell or taste? New cough or headache you have never had before? Change in diet or appetite or fever are clues that help the physician narrow down the diagnosis.

4.  Other info that might or might not play a role.  Do you drink alcohol or take drugs?  Are you taking over the counter medication?  Are you worried you have cancer or AIDS?  By communicating these worries, the doctor can alleviate your fears or order the correct test to prove it.

Physicians are trained to think about the most serious, life-threatening conditions and then work backward when making a diagnosis.  A good doctor doesn't just order every test in the book, they tailor the follow-up testing for the most likely "differential diagnosis".  Most conditions will respond with easy treatment (or no treatment) so there is always time to make the tough diagnosis if the doctor and patient have close, tight follow-up.

If you are not completely back to normal after treatment, it is important to return and communicate the continuing symptoms.  I always know if I have good follow-up planned (via email or another office visit) we will get to the bottom of the problem 100% of the time.

(btw:  I can't stand the series "House")

Wednesday, September 29, 2010

Sign Up for EverythingHealth

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Coffee Gives the Buzz in Health Care

I could have told you without the study, but the results are in:  Coffee is the fuel that keeps hospitals and doctors and nurses going, both day and night.  OK, I admit the study was commissioned by Dunkin' Donuts, but I believe the results because I have witnessed it.  Health professionals are more dependent on coffee than any other profession.

The national survey included more than 3,600 workers and the results showed the professions most dependent on coffee.  Here they are:
1.  Nurses
2.  Physicians
3.  Hotel Workers
4.  Designers/architects
5.  Financial/insurance sales reps
6.  Food preparers
7.  Engineers
8.  Teachers
9.   Marketing/public relations
10. Scientists

They also found that younger workers were more dependent on coffee and nearly one in four younger workers said they buy coffee as a way to treat themselves for a job well done.

Thirty seven % of workers said they drink two or more cups during regular day and 43% of younger workers said they have lower energy if they don't get their daily java jolt.

Many hospitals have a kiosk in the lobby that serves lattes or coffee and there is usually a line of health workers just waiting for their jolt.   I would like to see a study that looks at coffee drinking and sleep patterns.

My hypothesis is that people who get enough sleep don't drink as much coffee.

Tuesday, September 28, 2010

Omega 3 and Green Tea

We have know for some time that there are health benefits from drinking green tea.  Research also shows that Omega 3 fatty acids have  beneficial effects on a number of organs in the body, including the cardiovascular system, brain and even depression.
Dr. Fereidoon Shahidi, research professor in the Department of Biochemistry at Memorial University in Newfoundland, Canada is hoping to show that green tea polyphenols, particularly epigallocatechin gallate (EGCG), may also prevent colon cancer and even have anti-viral effects when combined with certain Omega 3 fatty acids..
“We know from experience that green tea is not well absorbed by the body,” he said. “Our premise was to see if by adding something to it that has its own benefits, like Omega 3 fatty acids, we might get an entity that would have improved properties in terms of its absorption and health benefits,” Dr. Shahidi said.
Their research proved that it was indeed the case, but further testing on animals provided other surprising results.
“When mice which had been exposed to carcinogens that usually produced significant numbers of tumors were given the green tea/Omega 3 compound at the same time there was absolutely no tumor formation,” said Dr. Shahidi. “That was quite exciting to us.”

Although the results are early, the idea that Omega 3 can be combined with other compounds to augment the benefits of both is a new frontier.

I had forgotten that I once wrote a blog on green tea and on Omega 3. I suggested that folks take Omega 3 supplement and wash it down with green tea.  Little did I know that researchers would find the combo to be potentially more beneficial than each food alone.

Sunday, September 26, 2010

Things Growing in Lungs

Last month an elderly man in Massachusetts developed a collapsed lung and pneumonia. Usually this means an undiagnosed cancer is lurking.  Imagine his relief and surprise to find out it was a pea growing in his lung.  That little accidentally inhaled pea started sprouting.  It seems that odd things found in lungs is not all that rare.  The trachea and the esophagus are really side by side and it is easy to "aspirate" and have food, liquid or objects head into the trachea and then to the bronchus, where it should not be.

What other things have been found in the bronchi and lungs?  One surgeon found a belly button ring.  Fishbones as well as nuts, beans, little candies or food particles are easily inhaled into the bronchial tubes.   Balloons are common as are hot dogs and even small toys.  Even partial dentures are found and many times the elderly person didn't know where they lost it.

Children are especially susceptible to foreign body aspiration. 90% of all incidents happen in children under age 4. Small lithium "button" batteries are dangerous for children and are often swallowed.  The national Capital Poison Control Center even has a special 24-hour hotline for battery ingestion cases at 202-625-3333.  Swallowing one of these batteries is a medical emergency.

What is the most common foreign body (after food)  that gets stuck in children?  You guessed it...coins.

Saturday, September 25, 2010

Musings on ESP

Extra Sensory Perception (ESP) is defined as reception of information not gained through the recognized senses but sensed with the mind.  Other terms are psychic abilities or precognition or even a "hunch" or gut instinct that can't be readily explained.  Haven't we all had experiences like that?  The scientific evidence is weak and inconsistent,  but this morning's events are causing me to ponder about it again.  Here is what happened:

I was slowly getting dressed and doing early weekend chores while waiting for a notary public to come to our house to sign some loan documents.  I have some neat Massai bracelets that are a remembrance of the wonderful Massai warriors that we hosted from Kenya over the past few years.  I haven't thought about or worn these bracelets for over a year.  This morning I put them on my wrist in a cluster.

Imagine my surprise to find that the Notary was a young woman from Nairobi, Kenya.  When she saw me she said "Oh, you know a Massai."  Wow.  Why did I decide to wear those bracelets today?  Random coincidence or some type of precognition?

A number of animal studies have shown that dogs know when their keepers are within miles of coming home.  Their behavior changes and they will go to the window or door.  Could we have some of those same "intuitions" that are not  completely gone from our genes?

I definitely subscribe to the rapid cognition thinking that Malcolm Gladwell wrote about in Blink.  It is the thinking and decision making that happens in an instant and of which we are not consciously aware.  It influences our choices or thoughts and we don't even know it.

But this is a little different.   My morning experience with the lady from Kenya and my beautiful Massai jewelry choice happened before I saw her or had any knowledge of who the notary would be.  What do readers think?

Wednesday, September 22, 2010

How Health Reform Helps Right Now

Obama and the Dems have done a terrible job at marketing Health Care Reform, also known as the Patient Protection and Affordable Care Act.  The statute that is now law has new provisions that go into effect as early as September 23, 2010 and millions of people will benefit.  Here are a few benefits that you probably haven't heard much about:

  • College graduates and dependents will be able to stay on their parents' insurance until they are 26 years old.  Since many young adults can't get their own insurance, this gives them cheaper rates and coverage as they try to enter the real world.
    • No insurance plan can place lifetime limits on health coverage or catastrophic events.  This is huge and should give us all comfort that we won't be dropped if we get sick.
    • All insurance plans are mandated to have a medical loss ratio that is at least 80-85%.  This means they have to spend more on our care and less on wall street profits.
    • There is no co-pay or deductible for preventive care under new insurance plans. (Note: this only includes new plans, not those already in effect with the healthcare reform law passed)
    • No coverage denial for children with pre-existing conditions.
    • Patients will have two ways to appeal coverage decisions or claims: through their insurer or through an independent decision-maker.  For me...I'll take the independent decision maker every time! (Note: this only includes new plans, not those already in effect when the healthcare reform law passed)
    • Expansion of the primary care workforce.  It creates additional primary care residency slots, establishes new nurse practitioner-led clinics, and encourages states to expand their primary care workforce to meet increased demand.  
    • Expansion of the National Health Service Corp, to increase the number of primary care providers who practice in rural America and under-served areas.
    • Prevention and Public Health Fund to promote prevention and public health and address tobacco use, poor diet, lack of exercise and alcohol abuse.
    All I seem to read about are States and Insurance Conglomerates suing the government in an attempt to overturn the Patient Protection and Affordable Care Act.  In the meantime, the new law might just be doing some good.

    Monday, September 20, 2010

    Preventing Kidney Stones

    Over the years I have had a number of patients with painful kidney stones and once they have passed (or been removed) I have felt at a loss to helping them prevent them.  "Stay hydrated" somehow didn't seem adequate, although we know fluid intake can help stave off recurrent kidney stone attacks.  Some textbooks said "avoid calcium"  since most stones are made of calcium oxylate.  High oxylate levels can be found in some fruits and vegetables, as well as in nuts and chocolate.  Yet there was no real scientific evidence that these foods caused stones.  The evidence for who got kidney stones was all over the ballpark and for a physician, that means no prevention advice is really proven.

    A new study published in Clinical Journal of the American Society of Nephrology says that calcium rich foods - such as low-fat milk and yogurt-can be protective.  What?  Eat more calcium to prevent calcium containing stones?  It seems that higher intakes of calcium are actually associated with a reduction in kidney stone risk.

    Dietary calcium binds with oxalate, which is a  waste product in the digestive system.  The two substances crystallize and leave the body long before there is a chance to form a kidney stone.

    Dr. Eric Taylor, a renal specialist at Brigham and Women's Hospital in Boston, analyzed the diets of 3,426 people over a long period of time.   He found people with higher intake of fruits, vegetables, nuts and legumes, low-fat dairy and whole grains were less likely to develop kidney stones by 40-45%.  This is the DASH diet, which is similar to a Mediterranean-style diet, that is the most effective diet for people with high blood pressure.

    Like so many things in the body, it is likely a number of factors that intertwine to cause a disorder.  But it is always reassuring to find preventative recommendations that we know are healthy and that might prevent a number of problems.  Since both hypertension and kidney stones are more prevalent in men over age 40, the DASH diet might be the answer.

    Saturday, September 18, 2010

    Welcome International Blog Visitors

    Every so often I like to give a formal blog welcome to visitors from around the Globe.  What a thrill it is to see how interconnected we are and to share knowledge so freely.  My hearty welcome to visitors within the last 24 hours from:
    Oranjestad, Aruba; Tiaret, Algeria; Puntarenas, Costa Rica; Buenos Aries, Argentina;  Melbourne, Australia; Perth Australia; Aukland New Zealand; Abu Dhabi, UAE; Delhi, India; Seremban, Malasia; Edmonton, Canada;  Veracruz-Nave, Mexico; Guadalajara, Mexico; Monterrey, Mexico; New Westminster, BC, Canada; Halifax, Nova Scotia;  Invermere, BC, Canada; Paris, France; Moscow, Russia; Ankara, Turkey...

    And others I may have missed.
    Greetings and visit Everythinghealth again soon.

    Thursday, September 16, 2010

    Hugs and Hand Holding in Medicine

    The New York Times asks, "Should the Doctor Hold a Patient's Hand" during emotional times or if the patient is crying.  The comments that follow the short article are the most interesting.  Most readers say this question shouldn't even be asked and that human compassion should always win out.  Touch is a human gesture of comfort and understanding.

    But some readers disagree.  One said she recoiled when the doctor reached out to touch her hand after telling her that her cancer had returned.  It felt really creepy to her.  Another asked, "What if the physician is also a Catholic Priest or a pediatrician and a Priest."  Whoa, it becomes more complex when you get into the psyche of  the abused.

    I have often thought that one of the appeals of chiropractors is that they "lay on hands" and touch and manipulate patients.  With 21st century modern medicine, physicians can treat entire episodes of illness with tests, scans and robots and never actually touch the patient.  No wonder people feel "dehumanized" and wonder if doctors really care.  Touch and compassion are part of the entire human experience and the physician is present during a patient's most stressful time.

    But wait, there is another side...

    I know a physician who is absolutely wonderful.  He is warm and compassionate and provides excellent care. One of his patients filed a complaint with the medical staff because he hugged her and she felt it was inappropriate.  She believed he had crossed the professional line by hugging.  Here is a physician who genuinely cares and spontaneously hugged a patient and she complained that it was intrusive and even went so far as to call for an official investigation.  It was devastating for him.

    None of us can read minds. The best we can do is look for non-verbal cues from patients and try to respond based on intuition.  I guess that is the "art" of medicine.  What do you think?  Should physicians hold a patient's hand or offer a hug?

    Tuesday, September 14, 2010

    Adult Chickenpox

    We think of chickenpox as a childhood disease but there are adult cases and they tend to lead to more serious complications.  Chickenpox is caused by the varicella virus and it is extremely contagious.  Most people are exposed in childhood (or they receive the chicken pox vaccine) and so adults rarely contract it.  It is especially dangerous for pregnant women because the fetus can become infected.  The latency period from infection exposure to disease is 10-21 days.

    Some people call Shingles adult chickenpox.  Shingles (Varicella Zoster) is caused by a latent chickenpox virus that has lain dormant for years in the nerve root and rears it's ugly head later.  The cause of the reactivation of the virus is usually never found and it occurs most commonly in people over age 60.  Shingles does not spread over the skin like chickenpox and stays in one discrete nerve dermatome area.  It can be extremely painful, causing burning pain and skin sensitivity.

    Shingles can be contagious to people who have never had chickenpox and exposure will cause a chickenpox (not a Shingles) outbreak.

    Treatment for both adult chickenpox and shingles is acyclovir or Famvir or Valtrex.  The sooner these anti-viral medications are started, the better they work to shorten pain and time of the infection.  For information on the Shingles vaccine go here.

    Photo credit to medicinenet and consultantlive

    Sunday, September 12, 2010

    Kids Lack Opportunities for Physical Activity

    One out of 3 children in the United States is overweight. Increased consumption of  nutrient-poor foods with high levels of sugar and saturated fats, combined with reduced physical activity, have led to obesity rates that have risen three-fold or more since 1980.  Our kids are not to blame. We are.

    The Center for Disease Control has found that only 20% of blocks nationwide have parks within a half-mile of their boundary.  Fifty percent of kids say they lack access to parks, community centers and sidewalks in their neighborhoods.

    Only 17% of high school students report getting the recommended 1 hour of exercise per day.  Only 20 states require or recommend that elementary schools provide scheduled recess.  Let me say that again.  The majority of states do not even require scheduled recess for grade school kids.

    Too many kids live in neighborhoods that aren't safe and have no access to sports leagues or after-school activity programs.

    Our nation needs to realize that all of the health care reform in the world will not improve the health of  the nation if we don't start focusing on what we know will lead to good health.  Every study ever done confirms that good diet and exercise is the magic that makes us healthy.  Yet we are not putting our money or our education where we know it will do the most good.  We must create opportunities for kids to be active and every neighborhood should have a park and community center.

    I would like to see a national focus on creating parks where there are none and programs for kids to be active.  Every city has dilapidated areas that could be developed into park lands.  I don't think the politicians and civic leaders will step up to the plate until parents and teachers make some demands.  The first step for us is awareness.

    Tuesday, September 7, 2010

    Overpriced Medicine

    I took Tracy's (the faithful follower) advice and went to the link she provided in her comment from my blog on patients going to the Emergency Department for expensive health care.  The blog post  was a really good one that I wanted to share so click here and read a cost analysis from  young doctor Sara in Israel. 

    And for those of you who think the U.S. has the BEST HEALTH CARE IN THE WORLD...think again.  We lag behind other nations in terms of access, quality outcomes, infant mortality and prevention.  Despite that, we are the most expensive.  Read her article and ponder....

    Emergency Rooms Used for Routine Care

    The Patient Protection and Affordable Care Act (Our government's name for Health Care Reform) may make our already crowded emergency rooms swarm with more patients. A new study from Health Affairs
    shows that more than a quarter of patients who currently visit emergency departments in the U.S. are there for routine care and not an emergency.  New complaints like stomach pain, skin rashes, fever, chest pain, cough or for a flare up of a chronic condition should not be treated in emergency rooms.  They are best worked up and treated by an Internist or Family Physician...preferably one who knows the patient.

    So why are these patients waiting for hours and spending up to 10 times as much money for Emergency Department care?  The study shows it is a problem of limited access to primary care services.  Patients cannot get in to see a primary care doctor or it is on a weekend when they are not open.  Two thirds of the minor acute care visits to emergency departments took place on weekends or on a weekday after office hours.

    Nationwide there is a shortage of primary care physicians and many have closed practices, limit Medicare patients and take no Medicaid at all.  When a patient has stomach pain and is told the next available appointment is in 2 weeks, it is no wonder they head for the ED.  Once there they will likely get a battery of tests that may not be needed and even Cat Scans before they are told to go home with a diagnosis of "gas".

    The good thing about the Patient Protection Act is that millions of new people will get insurance of some type.  The bad thing is, unless we address the primary care shortage in a real meaningful way, it may just lead to more expensive care in the Emergency Rooms across America.

    Robin Weinick of the RAND Corporation and a coauthor of the study said that urgent care centers could potentially manage between 14-27% of all emergency department visits and save $4.4 billion - or .2% of national health care costs annually. 

    We need to expand the capacity and weekend hours at community health centers.  We have already passed the window to increase the supply of primary care physicians by ignoring the crisis.  But it is not too late to change the incentive structure for payment and try to lure more young doctors into primary care.  It worked for Radiology and Anesthesiology and Urology.  The nation would be the beneficiary.

    Saturday, September 4, 2010

    I hate canker sores

    Why do I hate canker sores?  First they are painful and mouth pain cannot be ignored.  Second, they are difficult to prevent and you just have to cope with them until they go away. And 3rd, we have no idea what causes them.  For a doctor, the 3rd reason is the most difficult to accept.  What the hell are canker sores?

    The medical term is apthous ulcers and they are  round or oval painful ulcers that appear on the tongue, inner lips, side cheeks or palate of the mouth.  Up to 40% of people have experienced canker sores.  So why have the remaining 60% never had them?  We don't know.

    They are more common in young people and occur more frequently in white people, non smokers and people with high socioeconomic status.  Why?  We don't know.

    What we do know is that they are not contagious and they are not caused by the herpes virus.

    Once a person has had a canker sore they are easy to self-diagnose going forward.  Some diseases cause canker sores to coalesce and form larger ulcerations.  People with AIDS, Bechets disease and even ulcerative colitis can experience large canker sores that can respond to immune suppressive drugs.

    But the average person who has canker sores is advised to take pain medication and wait until it goes away.  That can take a week to 10 days.  Obviously any mouth sore that does not heal within 2-3 weeks needs to be evaluated by a physician. (See my last post on Michael Douglas's oropharyngeal cancer.)

    Full disclosure for this article...I have a canker sore on the hard palate (roof of mouth) right now and I truly hate canker sores.

    Friday, September 3, 2010

    Michael Douglas Has Oropharyngeal Cancer

    Michael Douglas announced he has"stage IV throat cancer" on late night TV this week.  Any announcement of cancer causes people to stop and take a deep breath but the idea of throat cancer is particularly scary.  So what exactly is throat cancer?  How is it diagnosed and treated? 

    The clinical term is oropharyngeal cancer that involves the base of the tongue, the mouth, the tonsils, or the front and back walls of the throat.  Michael Douglas says he has a walnut-size tumor at the base of his tongue.  This is actually a pretty common site and it is usually caused by smoking or chewing tobacco.  The combination of smoking and alcohol use increases the risk and we know that Mr. Douglas battled alcohol addiction and smoking years ago.  There has been a steady increase in oral cancer and recent studies show the cause is infection with human papillomavirus (HPV).  Sixty percent of all oropharyngeal cancers are associated with the virus.

    Cancers that start at the base of the tongue are often painless and they are often advanced when diagnosed. Any change in the voice, difficulty talking or swallowing or a growth in the mouth that lasts longer than 3 weeks should be checked out by a physician.  Ear pain that lasts could be from the base of the tongue and should be check out. Many mouth cancers are found by a dentist doing a mouth exam.

    Stage IV cancer, like Michael Douglas reports,  has spread to tissues near the oropharynx or has spread to one or more lymph nodes.  Stage IVC  cancer has spread to other parts of the body.  Treatment for Stage IV is usually surgery followed by radiation therapy and possibly chemotherapy.

    The treatment for oropharyngeal cancer is pretty brutal and Michael Douglas is in for a long haul.  Fortunately he has a good chance of beating it (60%) if the cancer hasn't spread to the lymph nodes.

    I loved him in Wall Street ("Money never sleeps, pal") and remember the chiller, Fatal Attraction, when Glenn Close stalked him after his indiscretion?  Romancing the Stone made him and Kathleen Turner big stars.    His film career is long and I certainly hope he beats this terrible diagnosis.

    There is no screening test for head and neck cancer.  I don't need to say stop smoking, do I? 

    When to Use Urgent Care

    We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solu...