Tuesday, July 31, 2012

The Doctor-Patient Interaction

     The practice of medicine is both an art and a science, and a proper understanding  of the mind-body interaction (pace Rebecca Goldstein's novel "The Mind-Body Problem") is important. In this blog I will restrict myself to a discussion of interactions in the office, because diagnosis in the emergency room calls on a different mind-set. My general practice is to greet the patient in the waiting room, escort the patient to my office for the interview, and  then escort the patient to the exam room where the patient changes into an examination gown with the possible assistance of my office nurse. I then examine the patient, making conversation as I do so, sometimes disease directed and sometimes not, and then see the patient again in my office to discuss my findings, my conclusions, and my suggestions for treatment and/or further tests, but always with at least a partial explanation of what I think are the cause(s) of my patient's symptoms.

     Gestalt and understanding  plays an important part in diagnosis. I always have a mental image of the visage and ambulation of my patient at our last meeting, and I automatically superimpose that image on their present gait, posture and facial expression. It is not then difficult to determine that the patient feels happier, or more tense, or healthier, or more tired even before a word is spoken and a single complaint is voiced. The patient rarely denies my observation of his/her change in appearance, but we may differ in our assessment of the cause, and our degree of difference in our two interpretations often depends on the patient's presence or lack of both insight and denial. Needless to say, my interpretation is greatly facilitated by my previously having obtained the patient's mental map of disease at our first meeting: what it means to the patient to be sick, how he/she feels about doctors in general and taking medicine in particular, previous experiences with doctors  for the patient , especially as a child,  and what resolution the patient is looking for. A secondary question of some import is whether the answer and treatment agreed upon has to satisfy only the patient, or if the spouse's wishes and beliefs must also be taken into consideration.

     Unlike Newton's Third Law, where each action has an equal and opposite reaction, in humans the smallest action (i.e. input to the system, usually verbal) can create a reaction quite out of proportion to the inciting incident. This is most easily seen in patients with poor control of explosive anger. Unfortunately we have no pills to treat anger. We also have many symptoms that may be  caused by the turning of anger inward or by anxiety:  irritable bowel syndrome, headaches, sweating, palpitations, shortness of breath, chest pain, dizziness, insomnia, fatigue, muscle aches, peripheral numbness, etc. An important duty of the internist or family doctor is to decide, with the help of history taking, physical examination and tests whether the constellation of symptoms is due to a disease process, to stress/anger/anxiety, or to a combination of the two in that certain symptoms may heighten a patient's anxiety.

     Just as in physics experimental facts are interpreted in the light of a theory, so in a patient symptoms must be interpreted in light of the physician's knowledge of disease, disease processes, and anatomy. It is  true that if the patient is listened to carefully enough (i.e. in the proper diagnostic framework) he/she will tell the doctor the cause of the symptoms at least 80% of the time. Unfortunately, the correct interpretation of the patient's history is sometimes obvious only in retrospect, e.g. at a CPC conference. Part of the problem is that  if a physician does not think of a disease, he/she will not diagnose it. (And let us not forget the diagnostic computer algorithm that could never diagnose pregnancy because pregnancy was not listed as a disease.)

     There are always three questions that a competent physician must ask on each interaction with a patient: (a) is the patient ill, (b) does the patient need hospitalization, and (c) what condition could the patient have that may shortly cause an avoidable death if it is not diagnosed? (The same questions should be asked regarding a patient seen in the emergency room, but since the patient may be lost to follow, the diagnostic/investigative pattern is different than for the office.) This is where having a family doctor who knows the patient is important. We  know which patients maximize or minimize their symptoms, what diseases run in the family, how well the patient follows advice and which patients will only volunteer additional symptoms when asked directly. The answers and the results of the physical exam are our data, and our conclusions and "write-up" are the  suggestions and prescriptions that follow. The patient also must be satisfied with  (i.e. accept) your diagnosis and plan of treatment or else compliance will not follow.

     The physician's diagnostic acumen and interactive skills really come into play when the physical exam is totally negative. If the patient has a complaint, the statement "I find nothing wrong with you" usually falls on unhearing or disbelieving ears. This is not the same as saying "it's not serious", which is what most patients would like to hear. The physician should list the significant and worrisome diseases the patient does not have, e.g. heart failure, appendicitis, throat cancer. At this point the patient should also be asked what diagnoses the patient has entertained or is most worried about, and be reassured as much as is possible. And whether or not a precise diagnosis is arrived at, the plan for following-up must be carefully explained and written out. I also often call the patient the next day to see if there are any further questions that occurred to the patient.

Wednesday, July 25, 2012


     Several readers have asked me to write a blog on osteoporosis. They are confused by the welter of stories about whether or not there is a reliable way to prevent osteoporosis, the benefits and side effects of treatment of osteoporosis with bisphosphanates, and what exactly a bone density study measures and its reliability as a clinical tool. Again, all of my comments are general observations and conclusions based upon my training as a physicist and experience as an internist, and the final decision should ideally be made in concert with your doctor. I will restrict my comments to the results of clinical studies, and indicate the unknowns as well.

     In order to make bone, the body needs calcium in the form of the (Ca++)  cation, vitamin D, phosphate in the form of the (PO4---) anion, and parathyroid hormone. The body does NOT care and canNOT tell the difference between various sources of calcium: milk, calcium supplements with vitamin D added, calcium carbonate (as is contained in TUMS),  calcium from oyster shells, calcium from the white cliffs of Dover,  pills containing calcium-phosphate compounds, etc. The biochemistry of the body just looks for (Ca++), and the source is immaterial. In a similar fashion, the body will utilize the vitamin D that sunlight creates in your skin from cholesterol equally well with any vitamin D supplements you ingest. (To be precise the UV waves present in sunlight activate the 7-dehydrocholesterol that is normally present in your skin into vitamin D.) The use  of cod liver oil as a source of vitamin D originated in public health suggestions in the 1800's  when children in industrial countries growing up in tenements and working 12 hours a day 6 days a week in factories were observed to develop rickets in their growing bones because of their  insufficient exposure to sunlight, as opposed to children growing up on farms who had  an adequate supply of both milk and  sunlight.

     Wolff's law is an expression of the clinical observation that under a load bone will thicken its shaft to help it withstand the load. The most direct example of this is the bunions that women but not men develop. When walking in high heels, the foot tends to slide forward, and much of the body's weight is transferred to the medial part of the metatarsal joint of the first toe, known as the hallux. The bone's response is to thicken at the base of this hallux metacarpal joint to the extent that wearing shoes eventually becomes painful because the periosteum, or covering of a bone, is exquisitely supplied with pain nerves. In a similar fashion, I have played tennis my whole life, usually singles, on an average of two to three times a week, beginning at age eight. I have an Eastern forehand grip, which means that at the moment of contact my wrist is locked into a right angle. Much of the force of the forehand stroke is transferred to the base of the metacarpal bone that is proximal to my first finger, and this bone has a palpable swollen end just distal to my right wrist.

     There is no clinical practice that is proven to prevent osteoporosis, but we know several ways to avoid osteoporosis or, to be precise, we know what predisposes a patient to developing osteoporosis: getting older, bed rest, alcoholism (by depleting the phosphate ion and  in your body), smoking, menopause, hyperthyroidism, and treatment with glucocorticoids. The most rapid development of osteoporosis occurs with surgically induced menopause (i.e. removal of both ovaries) or with treatment with prednisone. The bone loss with the latter is so rapid that most authorities recommend instituting Fosamax or other bisphosphanate treatment simultaneously with the initiation of steroid treatment. If there is to be screening for osteoporosis, it would make clinical sense to screen individuals at risk more frequently than the rest of the population. A case could also be made for screening anyone who develops a bone fracture, compression or otherwise, for osteoporosis.

     This is the appropriate place for some definitions. A DEXA or bone-density scan measures the absorption of two different x-rays of different energies by the calcium in your bone. Every element absorbs only certain x-ray wavelengths, so the results are specific to calcium. There is no dangerous exposure to radiation in this procedure. Your T-score compares your measured bone density to that of a mythical 30 year old adult. Your Z-score compares your bone density to other patients of your age and sex. Therefore the T-score is absolute, and the Z-score is relative. The measurement of the  bone density of 30 year olds, is distributed in a Gaussian curve, the familiar error curve. The most common density is called the mean, or average density, and this is what your density is referred to. The width of the curve of measurements is determined by the standard deviation---by definition 67% of the measurements will fall within one standard deviation higher or lower than the mean value. In addition, 2.5 standard deviations encompasses approx. 98% of all the measurements, with 1% being higher than the mean plus 2.5 standard deviations, and 1% being lower than the mean minus 2.5 standard deviations. By consensus (or definition, the two words are used interchangeably here) if your T score is minus 1 or less, meaning that you have 33% less bone density than the average 30 year old, you are labeled as having osteopenia. Similarly, if your T score is minus 2.5 or less, meaning that you have 98% less bone density than the average 30 year old, you are labeled as having osteoporosis.

     Now come the myriad of questions, some of which we can answer from clinical studies, and some of which we cannot (as yet).  All my following statements apply to the average patient, with no known risk factors for osteoporosis. And again, final decisions should be made in consultation with your doctor. In what follows, "may" means that the data is suggestive but not statistically significant.

     1) No one knows if treating osteopenia prevents progression to osteoporosis.

     2) Treatment of osteoporosis with bisphosphanates prevents hip and back fractures.

     3) No one knows for how long you should be treated with bisphosphanates but we do know that the bisphosphanate molecule binds to your bone and stays there for between 5 and 10 years.

     4) No one knows at what age DEXA screening should start, nor how often you should be screened (a) if you have normal bone density, (b) if you have osteopenia, or (c) if you have started treatment.

     5) Patients who have taken bisphosphanates have an increased incidence of osteonecrosis of the jaw, which often appears after tooth implants. There may or may not be an increase in atypical fractures of the femoral neck---two conflicting studies have been published.

     6) Calcium supplements alone (assuming your diet has the proper amount of calcium) will not prevent osteoporosis.

     7) Daily calcium plus 400 Units of Vitamin D appears to confer no benefit, but daily calcium supplements plus 800 Units of Vitamin D may prevent hip fractures. In this case I say "may" because the positive conclusion was drawn from a meta-analysis of several studies, and meta-analyses have statistical problems and rest on an unproven mathematical assumption. (The interested reader is referred to two earlier blogs of mine as well as my article in "Chance", a statistical journal.)

     8) Daily exercise will increase bone density and may or may not prevent hip fractures.

     9) Bisphosphanates can cause reflux esophagitis, or make existing GERD worse, and there are no studies to show if taking stomach acid inhibitors prevents this effect.

     I am sure that there will be other clinical studies published in the future, because of the paucity of definitive clinical answers. And your decision will depend, in part, on how you feel about taking medicine for prophylaxis against an event that may or may not happen. Will you blame yourself if you do not take a bisphosphanate and develop a hip or spine fracture, or will you blame yourself if you do take this medicine and develop an unfortunate side effect? Either way, as I tell everyone, please don't second-guess yourself.


Wednesday, July 18, 2012

PSA (again)

     Every time I think that the question of PSA testing has been laid to rest, another outcry arises, sometimes pro and sometimes con. I realize that what we are dealing with here is a medical belief system, and belief systems are notoriously impervious to data and facts. I can recall the brouhaha that arose when one group announced that a clinical study showed no benefit of mammograms to women in the 40 to 49 year old age group.

     Let us begin again by realizing that no one argues about the speed of light, or whether or not Albany is the capital of New York State, or if 7 x 8 = 56. No one usually argues about agreed-upon facts that can be measured. The problem arises when two people  try to fit the same data into two different  heuristic structures, because your theoretical picture will frame and interpret the data you view, as all epistemologists acknowledge. There is even more argument when we try to interpret or predict  the result of an intervention on human behavior: we still cannot agree on whether or not the data shows that teaching about sex education and contraception  in high school encourages high school students to have sex. As a general rule, when the data does not lead to an immediately verifiable conclusion (viz. the question of global warming) there is a tremendous amount of heat generated in the argument/discussion with correspondingly little light.

     The broadest discussion to date about the pros and cons of screening with the PSA is contained in this month's issue of the Annals of Internal Medicine (17 July, 2012) , vol. 157, no. 2. There are three articles: The USPSTF (U.S. Preventive Services Task Force) recommendation against PSA screening, with the proviso that the final decision should be one  of "shared decision making" between the doctor and the patient (pp 120-134), a shorter review which concurs with the recommendation of the USPSTF (pp 135-136), and an equally short review that opposes the recommendations (pp 137-138). I will  summarize the three articles from a strictly scientific point of view ---i.e. based on the data cited,  and then try to illustrate where personal beliefs and projected feelings about the quality of life with and without  treatment  may have crept into the discussion. I will also carefully point out the unknowns in this decision making. And let us not forget that the USPSTF recommendations are only recommendations, and each patient will make a decision that is ego-syntonic with his own medical belief system.

     First a caveat. In my practice I have never seen a wife permit her husband to do "watchful waiting" once a biopsy shows prostate cancer. So if you are a husband who would not agree to any treatment, then don't ever do the PSA test.

     1) The only screening method referred to in all the studies is the serum PSA, and not a rectal exam.

     2) More men die with prostate cancer that from prostate cancer. In the latest autopsy study, 70% of men in their 70's have microscopic foci of prostate cancer.

     3) Some groups are at increased risk for prostate cancer: black men and men with first degree relatives who have or have had prostate cancer.

     4) If we define "overdiagnosis" as the detection by PSA of a tumor that will not spread and cause symptoms in the patient's lifetime, then the two largest trials suggest overdiagnosis rates of 17% to 50%.

     5) No study reported on the effect of screening on the development of metastatic disease.

     6) In looking at all the studies, the chance of a non-screened man of dying from prostate cancer in 10 years is 5 in 1,000. The chance of a screened man dying is either 4 or 5 in 1,000, so the net benefit is between 0 and 1 man per 1,000 men screened.

     7) NO study showed a reduction in all cause mortality(!) The one study that showed a slight decrease in mortality from prostate cancer showed an increase in deaths from other causes, usually cardiovascular, so there was no net extension of lifespan that resulted from PSA screening.

     8) When the PSA cutoff is between 2.5 and 4.0, the false positive PSA rate is 80%.

     9) Overdiagnosis makes screening appear to save lives when it does not do so.

     10) The median follow-up time was 10 years.

     11) Because of lead-time bias, patients diagnosed earlier by asymptomatic screening appear to live longer with cancer. This is a problem with all screening methodologies for all fatal diseases.

     12) The American Cancer Society and the American Urological Society both recommend informed decision making rather than routine PSA screening.

     13) Radiotherapy and surgery both cause urinary incontinence in 20% of those so treated and erectile dysfunction in 30% (on the average).

     14) Radiotherapy can also cause chronic diarrhea and/or colonic irritability.

     15) "We need to practice medicine on the basis of evidence and not on the basis of faith."

     And again, despite all recommendations and readings, there is no substitute for a full discussion with your family doctor of your likes, your dislikes, your wishes, your fears, and your desires. You should never feel pressured into making a decision about your health with which you do not feel comfortable. It is your body and your mind, and you have to live comfortably with them both. And once you make a decision, please don't second-guess yourself. (You  have enough well-meaning friends who will do that for you.)


Monday, July 16, 2012

Who Needs Vitamin D Supplements, and How Much?

     Vitamin D seems to be the "hot" new supplement, whether it is our old friend contained in  cod liver oil, or in calves' liver,or  in pills of Vitamin D,  or in the form of Vitamin D1, D2, or D3. There was a recent overview and critique of the many studies of this vitamin which was published in the New England Journal of Medicine by R.P. Heaney: NEJM vol 367, no. 1, pp 77-78 (July 5, 2012). I will try to summarize his article as well as to  add some observations of my own, and I will make no statements that cannot be verified by reference to the scientific literature or that have not been validated by clinical studies and tests. (Standard disclaimer---I have no vested monetary interest in whether or not you buy and ingest any form of Vitamin D.)

     You should all be made aware that Vitamin D is similar to Vitamin A and vitamin E in that it is fat-soluble and hence stored in your liver. Unlike the B vitamins or Vitamin C , it is not immediately excreted by your kidneys if ingested to excess, but rather the excess is stored in your liver. In fact  so much Vitamin A and D can be stored in the liver of an animal that Eskimos have died from ingesting the liver of polar bears that they have killed. And we know from separate clinical studies that hypervitaminosis A can harm you, and that excess dietary supplements of Vitamin E can increase your risk of having a heart attack. So far the only demonstrated damage from prolonged ingestion of excessive amounts of Vitamin D is band keratopathy, or deposits in your cornea.

     Vitamin D is needed, along with calcium and phosphorous, to form bones that are not thin and subject to fracture (osteoporosis) and that  do not bend under the normal load of supporting the body (rickets). The process of normal bone formation is regulated by parathyroid hormone, which is secreted by  four  glands situated in your thyroid gland, usually two on each side. Vitamin D is not a true vitamin because unlike all the other vitamins it can be synthesized by your body from cholesterol and sunlight, which is not to say that we all have enough of it. When  taking supplements we usually ingest Vitamin D2 or D3. The amount of dynamic Vitamin D that is available to you  for bone synthesis and strength is determined by measuring your blood  level of 25-OH (hydroxy) Vitamin D, and then taking  Vitamin D supplements if your 25-OH level is low. With regard to sunlight, the latest studies indicate that after age 35 it is too late to reduce your risk of skin cancer by reducing the amount of UV sunlight that strikes your skin, and the majority of the damage has already been done by age 18.

     It has never been shown that once you have a normal level of Vitamin D in your body that taking additional Vitamin D as a  supplement has any positive effect. There is a meta-analysis showing that taking 800 IU of vitamin D was "somewhat favorable in preventing hip fracture", but "somewhat favorable" is a very imprecise scientific statement. In addition, I have shown elsewhere that all meta-analyses have inherent statistical weaknesses, and should only be used to generate a hypothesis which then should be tested by a properly constructed double-blind clinical study.

     There are correlations of low levels of vitamin D with certain medical findings in addition to osteoporosis, but it has never been shown that taking vitamin D prevents or reverses  these conditions. Some of these conditions are Alzheimer's Disease, immune response, and pre-eclampsia. Once again I must remind my readers that correlation is not causation, and that moving the arrow over the elevator door in the lobby of a building does not move the elevator.


Friday, July 13, 2012

How to Make Primary Care Financially Rewarding

     I have noticed with deepening regret the diminishing numbers of medical students who choose to go into internal medicine and become providers of primary care. The problem is that the insurers reward doctors for doing, and not for thinking and diagnosing. This may be in part because thinking cannot be measured, but a biopsy is proof that the doctor did something. Now that many students graduate with massive load debts, it is even less financially attractive to go into primary care. And for those who are concerned, as they should be, with their quality of life, the hours required to make a living from a primary care practice seem expecially onerous.

     There is something wrong with the financial reward system for physicians when the fee Medicare pays me for a rigid sigmoidoscopy, which takes 5 minutes to do   and is easy to learn, is 3 times the fee they pay me for 15 contact minutes with the patient during which I diagnose and examine and apply my skill and art that is the product of  7 years of study and practice.

     OTOH, dermatologists have a very nice and lucrative life, so much so that it is now the most competitive residency, with some programs looking back at the students' MCAT scores to help them pick future residents. This leads me to my plan to increase the income of primary care physicians. I was led to this in part by the many ads and faxes I get offering to train me in Botox injections and other dermatological procedures.

     All fourth year medical students should have a mandatory month of dermatology. In the morning they would go to dermatology clinic. In the afternoon, they would be taught how to do simple skin and lesion biopsies, to inject Botox and Restalen, and to do other uncapped dermatology/plastic surgery procedures. Then when they open their practice of internal medicine, they could set aside each Friday for dermatological procedures. They would probably make as much in that one day as they did the rest of the week. They even have the most powerful selling line in the world: "I don't think that bump is cancerous, but let's biopsy it to make sure". In this manner they could easily double their incomes and afford to practice internal medicine.

Thursday, July 12, 2012

Does Azithromycin (Zithromax) cause Cardiac Deaths?

     I was asked to address this subject by one of my more literate physician readers. I would like to remind everyone again that correlation does not equal causation. In particular, if patients with disease B have ingested A more often than those without disease B, we now have a hypothesis. The next scientific step would be to select a random group of matched individuals, have half of them ingest A, and then observe if they developed disease B in statistical excess of those who did not ingest A. It is extremely unlikely that such a clinical study would ever be undertaken. OTOH we  have several  retrospective studies which suggested  that patients who ingested C had disease D less frequently, and then a forward, prospective, single-blind study was done to see if ingesting C prevented or reduced the incidence of disease D.

     As a concrete example, several retrospective studies seemed to indicate that women with a low fat diet had a lower incidence of both breast and colon cancer. A five-year prospective study was then done, limiting women in the study group to a diet containing no more than 15% of its calories from fat. No decrease in the incidence of either cancer was noted. The organizers of the study therefore concluded that there was no evidence that a low-fat diet prevented colon or breast cancer. At the same time, the proponents of the benefits of a low-fat diet claimed that the % of fat in the diet should have been 5%, not 15%, while simultaneously admitting that such a diet was almost impossible to achieve in practice.

     Now as to the case at hand. It was well known that macrolide antibiotics can lengthen the QT interval (on an electrocardiogram). It is also known that an electric cardiac phenomenon known as "R on T" can trigger ventricular tachycardia and thereby lead to sudden (cardiac) death. If the QT interval is increased, then there is a longer (by milliseconds) time interval in a cardiac cycle during which  the "R on T" phenomenon can occur. In theory, therefore, any drug which lengthens the QT interval could pre-dispose the patient to sudden death. An increased incidence of ventricular tachycardia has been demonstrated in patients taking  certain cardiac drugs that lengthen the QT interval, and such drugs are required to carry a "black box" warning because of this. Tricyclic antidepressants can also cause an increase in the QT interval, but usually the increase is not large enough to require a discontinuation of the drug.

     An article was published recently in the New England Journal of Medicine (2012;366(20):1881-1890). It  examined retrospectively the rate of cardiovascular (i.e. sudden) death of patients prescribed a five-day course of azithromycin (Zithromax)(Z-Pak) with those either taking no drug at all or taking amoxicillin, a different antibiotic. They found an excess of sudden death (called "cardiovascular deaths") in those taking azithromycin. The precise numbers were an additional 47 cardiovascular-related deaths per 1,000,000 courses of azithromycin in the patient population, and a further increase to 247 deaths per 1,000,000 in those at elevated risk for cardiovascular "adverse events".

     This antibiotic and others of the macrolide class will now have an FDA-mandated warning. Again, this is a retrospective study, not a prospective one. I am just concerned that the study was of Medicaid patients, which means that they received generic Zithromax (i.e. azithromycin) and we have no way of knowing whether or not the brand name formulation is equally dangerous. If the result is a class effect, which it seems to be, then  it should be  equally dangerous, but no one knows for sure. I may or may not be splitting hairs here, and we will never find out.

Monday, July 9, 2012

How to be a Healthier Patient

     What can the individual do to extend his/her life? I am not going to talk about the obvious suggestions such as "lose weight", "get more exercise", "stop smoking", etc. Rather, I wish to consider simple modifications of habits that do not involve a life-long commitment, but rather are situational responses.

1) Be sure to finish the entire bottle of medicine. Too many patients stop talking the medicine, especially antibiotics, when they feel better. The problem with this is that the first seven days of a ten day course of penicillin may have only reduced the bacterial load to a level that you do not notice, but there are still enough left to "become fruitful and multiply" and make you sick again.

2) Never ignore blood in the stool.  Too many patients ignore it until it goes away, and then never mention it to the doctor unless specifically asked about it (and sometimes not even then).

3) Tell the doctor all the drugs that you ingest, including vitamins and other over-the-counter products. There may have been a recent article in a medical journal pertaining to your supplement. For instance, there have been at least two published clinical studies demonstrating that taking vitamin E supplements increases your chance of having a heart attack. In this vein ( no pun intended) if you are taking a nutritional supplement, you should bring in to the doctor a list of all the compounds in the supplement.

4) Doctors are not opposed to alternative medicine per se, but to us "alternative" is another term for "not clinically proven to help", which is not to say that you are not benefiting from your particular treatment.  And  we do want to know about any such treatments you are undergoing, because it can impact on your overall health. We are are interested in all your health provider contacts: acupuncture, chiropractor, nutritionalist, yoga instructor, pilates, tai chi, biofeedback,-----.

5) Please also tell us about any illegal drugs you are using, not the least because they may interact negatively with a medical condition you have or with a prescribed or OTC drug you are taking.

6) Never stop or decrease a prescribed drug you are taking without notifying your doctor. Some drugs can cause rebound problems: abruptly stopping some anti-hypertensive medications has caused  a rebound upsurge of blood pressure and a stroke. If you reduce an asthmatic drug too rapidly and get an asthma attack, the old inhaler may not be able to be inhaled to the proper depth in your lungs (because the resistance to the flow of air in your lungs varies inversely as the fourth power of the radius of the bronchioles). If you reduce an anti-depressant drug too rapidly you may need an even higher dose of the anti-depressant to control a recurrence.

7) Almost every patient has at one time or another tried a friend's or relative's sleeping pill or tranquilizer. Please tell your doctor, because whether the borrowed medicine worked or did not work is useful information for the doctor to know. (BTW, borrowing someone else's controlled medicine is probably the most commonly committed drug-related felony in the US, although few people think of it as such.)

8) At your annual physical, if the doctor does not ask, please tell him/her about any sources of emotional stress, especially if it involves your relationship with your spouse or SO, your parents, your children, your siblings, or your boss. Unresolved stress can lower your pain threshold as well as contribute to insomnia and depression. It is easier for the doctor than for you  to see a possible solution to your problem , because your physician is thinking "outside the box" of your relationships.

9) The internet is full of truths, half-truths and lies. I generally tell my patients that it is OK to look up their disease, but not their symptoms. Almost every symptom is listed as a possible symptom of cancer, AIDS,  Alzheimer's Disease, or multiple sclerosis, and reading about it will cause you to worry needlessly. The mind can imagine and worry in unbelievable amounts. Most medical students, during their second-year course in pathology, imagine that they have at least one of the diseases that they are studying.

10) If you are thinking about leaving your internist/gynecologist/dentist/..... but are hesitating to do so because you don't want to hurt his/her feelings, or the doctor is a relative, or a close friend, please leave anyway. It is your body, and the doctor should feel that it is a privilege to treat you. And if the doctor takes it the wrong way or gets angry,  the doctor's ego is too big.