Sunday, May 30, 2010

How to be a Healthier Patient

The list that follows is by all means not inclusive, and if any of you out there want to contribute to the list, please do so.

1) Please inform the doctor if you plan to (a) change the dose of a medicine or drop it entirely, or (b) not see the specialist to whom you were referred, or (c) plan not to do a suggested test.

2) Be aware of your family history. The risk of diabetes increases with age, and even more so if any relative has adult-onset diabetes and you are overweight. The risk for Alzheimer's Disease and coronary artery disease is also inherited. If either parent smoked and developed lung cancer, you shouldn't even think about smoking. If either parent or sibling had colon cancer, you should start colonoscopies at age 40, and have one every 5 years.

3)Feel free to search the internet about your disease, at the same time that you try to ignore the well-meaning advice from family members and friends. They may be angry with you for not asking for a different test, not getting another opinion, not seeing the doctor they recommend, etc.,, but remind them that it is your body, and it is more important to please yourself and feel comfortable with your medical decisions than to please them Discuss the internet results with at most one person. Once you have decided on a treatment plan, try not to second-guess yourself.
Never look up your symptoms, because you may imagine you have horrible diseases, as many second-year medical students do during their course in abnormal human pathology.

4)Be sure you have a signed and notarized copy of your pre-terminal and terminal wishes, and discuss this with your doctor and make sure both he and your medical power-of-attorney have copies.

5) Please make sure that your tetanus, shingles, pneumovax vaccines etc. are received at the recommended time intervals. (Vaccination is discussed in an earlier blog.)

6)You can be the best patient in the world, but sugar, cholesterol, and blood pressure all usually increase with age. By observing your doctor's recommendations, you can reduce the rate of increase of risk.

7)Avoid brand new "treatments" that only one doctor knows about. There are very few secrets in medicine, because all doctors want to cure their patients. If you hear/read about a new medical "development", you should wait for the second published paper. If it is an announcement after a talk at a medical conference, or shown on a TV talk show, then the results probably weren't reviewed at all. (Remember when a "study" claimed to show that coffee drinking increased the risk of pancreatic cancer? Or that lemon in hot tea in a styrofoam cup leached out a dangerous and carcinogenic chemical?) For that matter, they jury is still out on the safety of charcoaling meat, but no one seems to worry about this any more.

8) Please make sure your family doctor gets a copy of ALL your tests, both blood and Xrays, wherever they are done, especially including the emergency room. It is important for your health that at least one doctor has all your health records. (And if you want your doctor to use an electronic record storage system, I have received notices in the past 2 years from 3 Veterans' Hospitals that their system was hacked. Would you trust the fact that you are a married, bisexual, cocaine-using AIDS patient to the security of the internet?)

9) If you can, try to exercise non-stop for at least 30 minutes 3 times a week. The maximum exercise pulse rate is a myth. (Bjorn Borg's resting pulse when he won the French Open was 34, which is also typical of many marathoners.) You should exercise at such a rate that at the end of your workout you feel that you have exercised. Walking is great, swimming is a no-load exercise that shouldn't stress any joints, and if you use a treadmill, setting it on an incline leads to an unusual walking pattern.

10) If you want to lose weight, remember that no one stays on a fancy diet forever. Just use portion control, and be satisfied with a spoonful of chocolate ice cream rather than the whole pint. You burn fat when you feel hungry, so always leave the dinner table before you feel full. You don't even need a scale. Just feel how your clothes get looser. For a man, one belt notch, aka 2" around the waist, is about 10 pounds. If you are more than 100 pounds overweight and a diabetic, the most certain treatment to date seems to be gastric banding, but ask the surgeon how many he/she does a year. Also, remember that your metabolism slows down each year until you are about 75 years old, so if you don't reduce what you eat, you will probably gain 3 to 4 pounds each year. Just recall what you weighed when you graduated high school or college, or before you got married, or before your first pregnancy.

11) As of this date, there is NO evidence that treatment of prostate cancer saves lives (which doesn't mean that it does not, but only that there is no proof of its effectiveness.) However, I have never seen a wife who would let her husband not treat his cancer, so if you believe in "watchful waiting", then don't have the PSA test if you are married.

12) Please tell the doctor the whole truth and any and all complaints, whether the doctor asks you about them or not. Too many patients are embarrassed to discuss certain issues (is sex with your partner satisfying?), or do not raise certain complaints because they fear the possible diagnostic consequences. Too many men minimize their symptoms (men will almost always be macho with other men). Patients rarely discuss habits that they feel are demeaning or childish, or make them seem less than perfect in their own eyes or the eyes of their doctor. Remember that we doctors have really seen it all, both in our offices and in the emergency room, and we are not shocked, censoring, or belittling. We really do want to help you, and it is no longer true that an alcoholic is any patient who has a drink a day more than his/her doctor does.

13) Please only have protected sex. Too many of my college students don't. I tell all my female patients to keep a condom in their purse, don't tell the guy that you are on the pill, and that "if he doesn't put it on, he doesn't put it in".

14) If you are concerned that you may have AIDS or another sexually transmitted disease, then donate a unit of blood to the Red Cross. They will test your blood for AIDS, syphilis, hepatitis A,B,and C, West Nile Virus, and a few other disease, and the tests are run free of charge. Also, the country can always use another unit of blood, and there will be no record in your doctor's office chart for your life insurance company to wonder why you had an AIDS test.

15) Whether or not you have high blood pressure or diabetes, you should review your diet with a competent nutritionist.

16) For what it's worth, there have been at least two studies showing that women (but not men) who drink regular coffee decrease their risk of developing adult-onset diabetes.

17) Lastly, even the government now admits that daily (for men) and thrice weekly (for women) alcohol ingestion decreases the risk of coronary artery disease, heart attacks, and strokes. (See my previous blog for more details about the health benefits of alcohol.)

18) And you should probably see your doctor to review your health and be thoroughly examined once a year, but I know of no studies that support this suggestion.

Saturday, May 29, 2010

A Day in the Life of an Internist

I received what I think was the best clinical training in the USA, both at my medical school and in my internal medicine residency at a big-city hospital with a long and meritorious history of treating both private and ward patients. I learned from my mentors that the patient should always be treated with the utmost courtesy, and listened to as carefully as possible. It is absolutely true that a properly taken history will give the correct diagnosis 85-90% of the time, and the physical exam and lab tests usually just confirm your impression. Since I have observed both from what my patients tell me and from observing my medical interns and residents at work that human doctor-patient interactions have deteriorated (which does not, unfortunately, show up in the morbidity or mortality tables), I would like to describe to all my readers how I practice medicine.

When I started practice, I allotted 60 minutes to a new history and physical, 45 minutes for an annual physical, and 30 minutes for any other visit. I have had to reduce this to 45 minutes, 30 minutes, and 20 minutes respectively, because office fees keep on dropping, but I think what I have now is a irreducible minimum amount of time for a visit, and I could not lower it further in good conscience. My patients also know that if they call my office before 10AM I will see them that day. I also always maintain eye contact, taking very few notes, and NEVER looking down at the keyboard of a laptop (I don't have one in the office) while I am taking a history.

I begin by going out to the waiting room and escorting the patient into my consulting room. (No, I have no PA's or NP's, but only a lab tech who does EKG's and gives vaccinations.) After talking with the patient, I then escort the patient into the exam room, and then wait outside while they disrobe and put on an examination gown. I then enter the room (with a chaperone if it is a physical exam of a female patient) and examine the patient. I then leave the room, the patient dresses, and comes back to the consultation room. I then discuss my findings and tentative diagnoses, and discuss the lab tests and Xrays I am ordering, and review the EKG with the patient. Then I explain why I am prescribing medicine, what I am expecting the medicine to do, and when or under what circumstances the patient should call me (or I the patient). When the lab tests and Xray reports are received by me, I make a copy of them and mail the copy to the patient along with a note discussing with the patient our next plans, and always ask the patient to call or come in to see me for further clarification. A copy of my note is also placed in the patient chart.

I feel that a good doctor is a good teacher, and one of my obligations is to educate my patients as well as possible. I also suggest they use the internet only to look up diseases, and not symptoms, because all symptoms can be due to AIDS, Alzheimer's disease, and cancer.
I normally can explain things to my patients' satisfaction, and refer them to a specialist if I cannot. The problem always arises when the patient is satisfied with less medical information than the spouse, other family members, or friends want to know. I firmly believe in patient privacy, and that the patient is always right. (Although the patient can be legally right and morally unfair; e.g. in not disclosing a diagnosis of cancer to the spouse.) But if I tell a patient that his Chest X-ray shows a mass and I want to get a CT scan of the lesion to help diagnose it, and he does not ask me if the mass could be cancer, then he is not prepared to consider that diagnosis at this time.

Every patient has certain medical beliefs, and therefore will accept some treatments and tests, but not others. I have no Christian Scientists in my practice, but I do have some Jehovah's Witnesses who will not accept blood transfusions. At Yom Kippur, a few Orthodox Jews always ask me if fasting includes not taking any medicines, and I tell them to verify with their rabbi that health takes precedence over religious practices. I do have diabetic patients who will not take insulin, because in their belief system if you take insulin you are a true diabetic, while if you only take pills you just have a "sugar problem". I have patients who refuse mammograms, vaccinations, fecal blood tests, pap smears. I have patients who refuse to let me take their weight. I have patients whose spouses don't believe in sleeping pills, or perhaps in antidepressants, so they have to hide them, and pay for the drugs themselves if they are on their spouse's medical plan.

Every patient with "bad" habits knows that reform is needed, but they are not prepared yet to give up the pleasures of smoking, or deny themselves oral gratification to lose weight. The human brain doesn't handle the future very well, so to us a "bird in the hand is worth two in the bush", or $10 today is better than $20 one year from now. We'd rather look for amulets and gimmicks: copper bracelets to treat rheumatism, ear staples to reduce hunger, or magnets in your shoes (should the North Pole or the South Pole of the magnet face up?) to treat back pain.

So I give my patients the best advice I know and educate them as well as I can using anatomy books, skeletons, etc. But my ego is never on the line,so I never take it personally when a patient doesn't follow my advice, but I do ask them to let me know if they are going to stop a prescribed medicine. I also don't take it personally if they change doctors, since they have an absolute right to their body. Too many patients stay with a doctor or dentist with whom they are dissatisfied
because they don't want to be rude and hurt the doctor's feelings.

One frustration with HIPAA: In the "Old days", if I felt a patient had become an unsafe driver, I could write a letter to the DMV, and they would require a repeat road driving test within 60 days, or the license would be revoked. The DMV has now informed me that due to the HIPAA
laws, I cannot write such a letter without the patient's explicit consent.

I am on call from 8AM Monday morning until 5PM Friday afternoon. I split weekend coverage with another group (I am a solo practitioner, in part because doctors get paid more for doing the cardiac cath. than diagnosing that the cath. is needed). I tell my service to find me if they cannot find my covering doctor. I also tell my service that I don't do pharmacy refills after 6PM. I tell my patients that whether they call the office or my answering service, if I don't call them back within 30 minutes they should call me again to make sure I got their message. You might note that my total hours on call greatly exceed those allowed for medical residents, although I am 30 years older than most of them, and certainly don't have as much non-sleep stamina as they do. I also don't have the luxury of calling an older attending for advice. But if I told a patient who calls me at 10PM with a medical problem that I have been up and on call for 16 hours, and they should go to the Emergency Room to be seen by a well-rested physician, I don't think they would like the suggestion.

I might mention that for me physical diagnosis is fairly straightforward, and I see one of my main jobs as reducing stress in my patients. I have a T-shirt that says "Stress is when your gut says "No", and your mouth says "Of course. I'd be glad to." Therefore, I ask all my patients the same two questions at their annual physical: (1) Do you look forward to going to work in the AM? (or your spouse's leaving the house). (2) Do you look forward to coming home to your spouse and household at the end of the day (or seeing your spouse come home)?

Anything you do that your brain does not want you to do will cause stress, and the more stress, the more pain your unhappy brain will cause your body. As a trivial example, most females traveling away on a weekend business trip are constipated while they are away from home---something to do with strange toilets. This is just an observation and not an anti-female statement. Similarly, most males who have not served in the armed forces have difficulty urinating if another male is at the urinal immediately next to them. In this vein, I tell all my young adult patients to make sure they like their jobs before they acquire a spouse, 2 children, and a mortgage.

For completeness, but also to safeguard my patients, I keep a complete problem list (operations, treatable conditions, allergies, home stresses, medicines) in the front of the chart, but any fact that might cause embarrassment if read by a spouse is written in my private code(e.g. uses cocaine, has affairs, gave a baby up for adoption at age 14, etc.) Again, my patient is always
right, and I will defend this right as firmly as I can. And if you haven't already guessed, I think that internal medicine is the most wonderful field in the world!

Thursday, May 27, 2010

Health benefits of Alcohol

Those of you who have read my blog regularly know that I think that alcohol is a valuable medicine that lowers the heart-attack risk. This whole subject was recently reviewed in the Journal of the American Medical Association in the May 26, 2010 issue (vol. 303, # 20, pp. 2065-2073). It is a fairly comprehensive review, with an extensive list of references. Before summarizing the review, I should like to iterate my opinions:

(1) We should lower the legal drinking age to 16. The age was forcibly raised to 21 by the U.S. Gov't, who threatened to reduce federal aid for highway construction to any state (e.g. New York) that did not raise the age to 21. The result is that many adolescents do their first serious drinking at college, away from parental supervision, and without the necessity of coming home to their parents in a somewhat sober condition. The system is even worse at state colleges. My daughter went to a state college, which was kept rigorously dry, even in the fraternity houses. The only result is that the students went off-campus to drink, and drove back to their dorms drunk. I hardly think that this is an improvement.

(2) If the greatest fear is that of teen-age drunken driving, then why not make it legal for teenagers who do NOT have a driving license to drink?

(3) My oldest grand-nephew just finished a 3 year tour in the Marines. He is allowed to drive a tank, operate a 50. caliber machine gun, a SAW, and kill our enemies, but was not even allowed to drink 3.2 beer on his base. There is something wrong with this picture if we trust him to kill responsibly, but not to drink responsibly.

The JAMA article made the following points, all of which were referenced to published articles. I should add that we still do not know the direct mechanism by which alcohol exerts its beneficial effects.

(1) Alcohol increases the "good' cholesterol HDL-C, in a dose-dependent effect.

(2) Alcohol decreases the level of fibrinogen, a clotting factor.

(3) Alcohol increases insulin sensitivity, and decreases the generation of glucose by the liver, so its ingestion opposes diabetes by two different mechanisms.

(4) Alcohol prolongs bleeding time.

(5) There is also an inverse relationship between alcohol intake and risk for stroke.

(6) All alcoholic beverages appear to be equipotent, and seem to benefit men more than women, provided that the alcohol is ingested on a regular basis.

(7) Alcohol does contain calories, and also increases a woman's risk for breast cancer (but the latest Danish study showed that pregnant women can imbibe a drink a day without harm to the fetus).

Overall, since cardiac disease causes the most deaths in the US, and since regular alcohol use can reduce the risk of coronary artery disease by as much as 30%, I think that doctors should consider recommending this as a daily medicine to men, and perhaps thrice weekly to women.