There have been many articles written by family doctors in medical magazines about the present difficulties in the profession, the "good old days", and reasons for retiring early, but few, if any written for the patients, so they can understand the problem. The following is an attempt to remedy that lack. (And please feel free to forward this blog to your local Congressman, Senator, and legislators in your state's capital.) I was stimulated to write this blog by a friend of mine who has recently retired from the solo practice of internal medicine, because (a) he was spending more time on the phone with insurers and with paperwork than he does on patient care, and (b) because his net income was dropping each year so that his retirement annuity now exceeds his net income, even though he still enjoys the practice of internal/family medicine.
The main problem revolves about the amount of time that he needs to spend in non-patient care, and time is his least fungible resource. For instance, he now has to certify the need for home visits by a nurse weekly rather than monthly, and name stamps or his secretary's signature is not accepted.
This is an additional 23 pieces of paper he had to sign every Monday.
If a deaf MCR patient requires a sign language interpreter, the doctor must pay for it out of his own pocket, which costs more than what MCR pays him for the visit.
The HMO's such as Oxford keep on writing him letters to fulfill their HEDIS requirements to the government asking him why his diabetic patients have not received their yearly eye exam or his female patients their yearly mammogram. He then has to take time to explain to Oxford that the patient saw a non-Oxford ophthalmologist or radiologist, and since he was not the referring doctor he does not have a copy of the report.
He continually has to get permission for a MRI rather than a CT scan (HMO, not MCR), or explain to MCR part D that the generic medicine does not work, and the patient needs the brand name, or explain to the HMO that OTC Claritin does not work in this patient, so he/she needs Rx. Allegra or Xyzal.
He gets paid much more for doing than for thinking: MCR pays more for a 10 minute pulmonary function test than for a 30 minute visit. This is because MCR and HMO's can't measure thinking and diagnosing, but they can ask for a copy of the test.
The hospital now has an electronic order system. It used to take him 5 minutes with pen and paper to admit the patient, and now it takes 25 minutes to go through all the templates, including the birth date of the doctor (and how does that help patient care?) and whether or not his private patient should get a flu shot at discharge. Again, all this takes time, time, and time.
But if he wants to give a Botox or Restalen injection, which HMO's and MCR don't pay for, he needs supply them no proof, get no permission, and charge whatever the local traffic will bear.
A few years ago, MCR asked him why he did more flexible sigmoidoscopies than any other internist in his county. He wrote back to MCR asking them why more internists didn't look for colon cancer in their patients. He never heard from them again. Clearly MCR was more interested in reducing the number of (more expensive) financial outliers than in ensuring the good health of MCR patients.
If I write you a prescription for a sleeping pill, I make it PRN, i.e. take it if you can't fall asleep. That has been an illegal order for any MCR patient in a nursing home since 1996. MCR decided that the nursing home nurses on the night shift would be tempted to drug their patients so the nurses could have a quiet night. So I either have to write for a sleeping pill every night, which is bad medicine, or come in to the nursing home on the same day I want a patient to have a sleeping pill. The answer: I stopped seeing all nursing home patients, and let the assigned nursing home doctor worry about the problem. Once again, I didn't have the extra time.
And if I saw two nursing home patients in a nursing home the same day, I got paid less for the second one, because MCR claimed I was there already, so maybe I didn't really have to see the second patient. This was another reason to stop seeing nursing home patients, because again it took up extra time that I didn't have.
Federal MCR rules require that the rear doors of nursing homes be locked during the night, so demented patients can't wander off, but state laws forbid the locking or rear fire escape doors at any time while the building is occupied.
HMO's have their preferred list of brand name drugs, and it takes a lot of arguing with them to convince them that Prevacid works and Prilosec does not in my particular patient, or that I want my diabetic hypertensive patient to have Coreg as a beta-blocker because it is the only beta-blocker that has been shown to reduce microalbuminuria in these patients.
If I had my way, no insurance company, HMO, or MCR outfit would be allowed to challenge any Rx, Xray or blood test ordered by a doctor, and we would really save a lot of time.
The government is pushing computerized EMR's and drug ordering systems, which is another recipe for wasting time. There are a lot of (sometimes theoretical) drug conflicts listed in the PDR, and the computerized order system mindlessly follows them. The fact that the warning has been superceded by more recent research never makes it into the PDR, because it would cost the drug companies too much money. For instance, it is NOT true that beta-blockers cause depression (see, for instance, NEJM article from 3 years ago), but every time I try to add a beta-blocker to a patient on an antidepressant, my hospital's computer flashes an alert, and I have to manually put in an override command. I even got flashed for putting a young patient on a calcium channel blocker, with the warning that there were more efficient anti-hypertensives. In fact, I was using the Ca++ blocker for the well-recognized off-label use of reducing esophageal spasm, and again this explanation/override took time. And don't even think of using a tricyclic anti-depressant for stomach acid suppression----no computer has ever heard of such a use!
Unlike lawyers, doctors cannot charge for telephone advice, but we can be sued for it.
And we don't need tort reform so much as we need removal of the contingency fee from medical malpractice cases. Let it all be no-fault, similar to some states' mandatory automobile insurance policies, and let the workman's compensation fee schedule prevail for doctors and lawyers. And no, the threat of being sued for malpractice doesn't make a doctor a more careful physician. No doctor wants to harm a patient, either by omission or commission. But the threat of malpractice suits makes us order many more Xrays and specialty consults than we think the patient really needs, and in some counties (e.g. in Florida) no neurosurgeon covers the emergency room, because all automobile accident injuries end up in court. Similarly, no OB attending trains his residents in the use of forceps, because of the risk of a malpractice suit when the doctor is asked:"if there was a problem, why didn't you do a C-section?" That is why the number of C-sections has increased.
I still think that medicine is the most wonderful and rewarding profession in the world, and I also feel that internists have the most enjoyable specialty because we get to be real family physicians and take care of three generations of the same family. But all my children are educated and married, my mortgage is paid off, and I don't need that much income. I don't know if I would choose this specialty if I were starting off today.
I wish all doctors had time enough to spend more time with each patient, but I have no idea how to achieve this.
Sunday, September 26, 2010
Tuesday, September 14, 2010
Basic Care by Doctors for Patients
There have been articles (and even books) written about what a patient should expect from a doctor, but I have found none of them to be of practical use. Let me tell you about the basic behavior I expect from my medical residents. Some if it is what I call "good housekeeping", some of it is common sense, and some of it is based on over 25 years of experience of taking care of ward and office patients. This list is not complete, and it is not a check list of what the doctor should do, because check lists are mechanical, and are not insightful for the doctor. Rather, if your doctor does NOT do several of my suggested actions, it may be time to find a "luckier" doctor for you, i.e. one who is more thorough with his/her patients.
Every patient should be asked about past transfusions (most usually occur during childbirth, so ask specifically). If any transfusions before 1985, do blood test for Hepatitis C antibodies, and, if positive, for Hep. C. RNA.
Ask about blood donations (immediate check for Hepatitis A,B,C, syphilis, West Nile disease, etc.).
In the appropriate neighborhood or background, skin test for TB on high risk patients. Always skin test on admission to a hospital, rehab center, assisted living, or nursing home. Patients from the Caribbean, especially the DR, have usually had BCG vaccine to protect against bovine TB, but the PPD should still be planted. Ask about prior TB skin tests, + or -.
Check on last Tetanus booster (at least one every 10 years), and Pneumovax and cervical herpes vaccine if appropriate. Offer flu vaccine.
Ask about any foreign travel in the past 5 years, and any illnesses while traveling or shortly after return home. Ask if took malaria prophylaxis, if appropriate.
Over age 50, one test for Vitamin B-12, as well as 25-OH Vitamin D. Also test for Vitamin D and Calcium after any bone fracture.
ANY patient put on steroids for longer than one month should be placed on Fosamax or its equivalent to help prevent steroid-induced bone loss.
If patient requests Viagra or its equivalent, check free and total testosterone level as swell as prolactin level. If either testosterone test is low, check the pituitary FSH/LH.
In irritable bowel disease, always check for lactose intolerance and celiac disease/malabsorption. Both can occur at any age.
There are only two acceptable reasons for not doing a rectal exam at the annual physical: no rectum, and no finger.
If no mammogram in the past year, examine breasts.
In hospital visit, always SIT DOWN. The patient should not feel rushed. You should always at least take the patient's pulse for physical contact and reassurance.
Ask about allergies, and request copies of written Xray reports and all past operative reports.
Ask about any veneral diseases, specifically herpes.
Last ophthalmology, dental and GYN visit, and any abnormalities. Can the patient read street signs at night when he/she drives?
Birth control used, sexual satisfaction with partner, and sex of partner.
Any stresses in life. Children or parents with mental or physical problems. Do you like your job?
When was your last vacation? Do you exercise regularly? Do you fall asleep easily? Any pets at home?
Check blood pressure in both arms. If over 50 (or 40 with certain medical conditions such as diabetes), listen for murmurs in the carotid arteries in the neck.
Do NOT tell the patient your own problems. You are wasting their time, because you are there to help them with their problems.
Keep a shadow chart in code of embarrassing facts the patient does not want released, and NEVER copy the shadow chart (OK to verbally give info to treating doctors with secrecy caution): e.g.; adultery, uses cocaine, prior pregnancy and surrender for adoption or abortion, bisexual, hole in nasal septum, lax anal sphincter.
Only try to diagnose treatable diseases (e.g. atrial fibrillation due to hyperthyroidism, and not atrial fibrillation secondary to cardiac amyloid).
The test may not be the patient's, so always repeat any abnormal blood test before you alarm the patient.
If the patient has syphilis and you suspect neurosyphilis, send the spinal fluid only for a VDRL, and never for an FTA, because no one knows what to do with a positive CSF FTA. Remember that Lyme disease is also caused by a spirochete, and is the cause of many false positive VDRL/RPR screens for syphilis.
Ask about orgasms. Ask about suicidal thoughts or attempts or plans. If sex drive low or sex with partner infrequent, ask about masturbation.
Undiagnosed Addison's disease can kill, and you won't make the diagnosis if you don't think of it.
If you have been on prednisone or other oral steroid in the past year, ask the doctor about stress doses of steroids if admitted to the hospital with an acute illness or infection, or for surgery.
If there is a dog in the house, the dog should get the monthly drop on the neck to keep Lyme ticks off.
If the patients says 2 drinks/day, ask how big the drinks are. (In some groups "two beers" means "two six-packs".)
Last menstrual period, and consider pregnancy test (must be done on every hospital admission.).
Ask the patient (1) what he/she thinks is medically wrong, and (2) if there are any other questions.
Most important: try to deduce the patient's model of disease, because any prescribed treatment that is in conflict with this model will not be properly applied.
(Trivial) if patient is low in serum potassium, check urine potassium, and serum magnesium; serum PTH usually not needed.
If kidney stone, 24 hour urine collection for Ca++, urate, and Ox-- so can treat to prevent further recurrences (if untreated, 50% have recurrent attack in 5 years).
Ask about unprotected sex (there is always some), and berate patient appropriately.
ALWAYS skin test for TB (and strongoloides as well?) when immunosuppressing with steroids, imuran, etc.
You may not be worried about lung cancer, but if you are a smoker your doctor should tell you that you are 100% guaranteed to develop emphysema, and spend the end of your life on an oxygen tank if you live long enough.
Why does the dentist go into the other room when taking dental Xrays if they are so safe?
Your doctor should never complain to you about his/her personal problems, but bitching about Medicare, HMO's and Electronic Medical Records is perfectly appropriate.
Never be afraid to leave a doctor because you don't want to "hurt his/her feelings". You should always find a doctor with whom you are gemutlich. I always tell my patients that my ego is not on the line: I give them my best professional advice, and they take it or not.
50% of our current medical knowledge will be obsolete in 5 years, but we don't know which 50%.
Leeches for high blood pressure, anyone?: (They did work , which makes it all the more surprising that the Red Cross will not let anyone with high blood pressure donate blood!)
And finally, do you feel "good" about your doctor?
Every patient should be asked about past transfusions (most usually occur during childbirth, so ask specifically). If any transfusions before 1985, do blood test for Hepatitis C antibodies, and, if positive, for Hep. C. RNA.
Ask about blood donations (immediate check for Hepatitis A,B,C, syphilis, West Nile disease, etc.).
In the appropriate neighborhood or background, skin test for TB on high risk patients. Always skin test on admission to a hospital, rehab center, assisted living, or nursing home. Patients from the Caribbean, especially the DR, have usually had BCG vaccine to protect against bovine TB, but the PPD should still be planted. Ask about prior TB skin tests, + or -.
Check on last Tetanus booster (at least one every 10 years), and Pneumovax and cervical herpes vaccine if appropriate. Offer flu vaccine.
Ask about any foreign travel in the past 5 years, and any illnesses while traveling or shortly after return home. Ask if took malaria prophylaxis, if appropriate.
Over age 50, one test for Vitamin B-12, as well as 25-OH Vitamin D. Also test for Vitamin D and Calcium after any bone fracture.
ANY patient put on steroids for longer than one month should be placed on Fosamax or its equivalent to help prevent steroid-induced bone loss.
If patient requests Viagra or its equivalent, check free and total testosterone level as swell as prolactin level. If either testosterone test is low, check the pituitary FSH/LH.
In irritable bowel disease, always check for lactose intolerance and celiac disease/malabsorption. Both can occur at any age.
There are only two acceptable reasons for not doing a rectal exam at the annual physical: no rectum, and no finger.
If no mammogram in the past year, examine breasts.
In hospital visit, always SIT DOWN. The patient should not feel rushed. You should always at least take the patient's pulse for physical contact and reassurance.
Ask about allergies, and request copies of written Xray reports and all past operative reports.
Ask about any veneral diseases, specifically herpes.
Last ophthalmology, dental and GYN visit, and any abnormalities. Can the patient read street signs at night when he/she drives?
Birth control used, sexual satisfaction with partner, and sex of partner.
Any stresses in life. Children or parents with mental or physical problems. Do you like your job?
When was your last vacation? Do you exercise regularly? Do you fall asleep easily? Any pets at home?
Check blood pressure in both arms. If over 50 (or 40 with certain medical conditions such as diabetes), listen for murmurs in the carotid arteries in the neck.
Do NOT tell the patient your own problems. You are wasting their time, because you are there to help them with their problems.
Keep a shadow chart in code of embarrassing facts the patient does not want released, and NEVER copy the shadow chart (OK to verbally give info to treating doctors with secrecy caution): e.g.; adultery, uses cocaine, prior pregnancy and surrender for adoption or abortion, bisexual, hole in nasal septum, lax anal sphincter.
Only try to diagnose treatable diseases (e.g. atrial fibrillation due to hyperthyroidism, and not atrial fibrillation secondary to cardiac amyloid).
The test may not be the patient's, so always repeat any abnormal blood test before you alarm the patient.
If the patient has syphilis and you suspect neurosyphilis, send the spinal fluid only for a VDRL, and never for an FTA, because no one knows what to do with a positive CSF FTA. Remember that Lyme disease is also caused by a spirochete, and is the cause of many false positive VDRL/RPR screens for syphilis.
Ask about orgasms. Ask about suicidal thoughts or attempts or plans. If sex drive low or sex with partner infrequent, ask about masturbation.
Undiagnosed Addison's disease can kill, and you won't make the diagnosis if you don't think of it.
If you have been on prednisone or other oral steroid in the past year, ask the doctor about stress doses of steroids if admitted to the hospital with an acute illness or infection, or for surgery.
If there is a dog in the house, the dog should get the monthly drop on the neck to keep Lyme ticks off.
If the patients says 2 drinks/day, ask how big the drinks are. (In some groups "two beers" means "two six-packs".)
Last menstrual period, and consider pregnancy test (must be done on every hospital admission.).
Ask the patient (1) what he/she thinks is medically wrong, and (2) if there are any other questions.
Most important: try to deduce the patient's model of disease, because any prescribed treatment that is in conflict with this model will not be properly applied.
(Trivial) if patient is low in serum potassium, check urine potassium, and serum magnesium; serum PTH usually not needed.
If kidney stone, 24 hour urine collection for Ca++, urate, and Ox-- so can treat to prevent further recurrences (if untreated, 50% have recurrent attack in 5 years).
Ask about unprotected sex (there is always some), and berate patient appropriately.
ALWAYS skin test for TB (and strongoloides as well?) when immunosuppressing with steroids, imuran, etc.
You may not be worried about lung cancer, but if you are a smoker your doctor should tell you that you are 100% guaranteed to develop emphysema, and spend the end of your life on an oxygen tank if you live long enough.
Why does the dentist go into the other room when taking dental Xrays if they are so safe?
Your doctor should never complain to you about his/her personal problems, but bitching about Medicare, HMO's and Electronic Medical Records is perfectly appropriate.
Never be afraid to leave a doctor because you don't want to "hurt his/her feelings". You should always find a doctor with whom you are gemutlich. I always tell my patients that my ego is not on the line: I give them my best professional advice, and they take it or not.
50% of our current medical knowledge will be obsolete in 5 years, but we don't know which 50%.
Leeches for high blood pressure, anyone?: (They did work , which makes it all the more surprising that the Red Cross will not let anyone with high blood pressure donate blood!)
And finally, do you feel "good" about your doctor?
Wednesday, August 25, 2010
How to Minimize Arguments with your Teenagers, Part 1
My wife and I raised 3 children so we were always outnumbered. Nevertheless, I think we minimized our battles with our children. Without pontificating, I think it is a matter of being reasonable, drawing clear lines about safety, requiring respect for one another, and realizing that not all children have the same drive (or ability) to do well in school. Our children all went on to college, got married with no divorces yet, and seem to be reasonably happy in their jobs.
Of course the first two things we all do when we become parents is to stop smoking grass (or at least hide it very well), and start attending a church or synagogue. So immediately we are telling our children (even before they know it) to "do as I say, and not as I did". This should not be a problem until the child reaches high school or bar mitzvah or confirmation age and starts to ask embarrassing questions about drugs, sex, and religion, but that is off in the future for new parents. But you should start to think about how you will convince your children to do as you say, and not as you did, and what to say when they ask you if you ever drank alcohol under age, let alone used marijuana.
"Because I said so", and "because it doesn't feel right to me" are both perfectly valid veto messages to your children (e.g. your child from Bergen County, N.J. wants to drive to Provincetown, Cape Cod on the night of her senior prom and stay over there with some friends).
It is "obvious" to most teenagers that older people deliberately discriminate against them and not "for their (sic) own good". The most egregious example is the 55 years old and older housing developments in Arizona and Florida. If the development's founding compact stated that Blacks or Jews could never buy there, and only live there for two weeks out of 52, there would be an immediate outcry, and the courts would rule it was a 14th amendment violation, or somesuch. But if the discriminated against group is under 18 (for living) or under 55 (for buying), the courts have upheld it. I guess older people and builders have a lot of voting clout, or donate more money to politicians than do younger people.
Please make sure your teenage daughter sees her own gynecologist before she goes off to college, and do NOT go in to the consulting room with her, or ask her what she discussed with the doctor. If your daughter wants you to know, she will tell you. It is reasonable as a responsible parent to ask her if she has any questions, but also to reassure her that the doctor is forbidden to discuss or reveal anything your daughter said in private.
Since no records are ever kept totally secret, tell your teenagers that if they are asked to fill out a form as to whether they ever drank under age, drove drunk, used illegal drugs, etc., the answer is always never. The penalty to the releaser of privileged information is never as great as the embarrassment or job prejudice that a teenager would suffer from such release. And be sure to remind them that ANY electronic information they send or receive, such as e-mails, voice mails, twitter, smart-phone photos, etc., can and probably will be viewed by someone else. Most teenagers are relatively innocent, naive and trusting, and they think that if they are upright and honest, then anyone they meet will also have these traits. This was somewhat true in the days of personal introductions, but certainly not over the internet.
In the same vein, too many teenagers and young college adults have sex without protection (and one is really too many). I tell all my patients of either sex never to have the first sexual contact with a new partner take place without a condom. Rather than warn them about accidental pregnancy or AIDS, I have found it much more useful to talk about herpes and venereal warts and how they are spread by direct contact by people who may not even know that they are infected or are carriers. And, as I have said before, if they are starting a new relationship and want to be tested for AIDS, I suggest instead their donating a unit of blood to the Red Cross, who will test the blood for many STD's.
The real problem, of course, is that for most children, teeenager seems to be a time of natural rebellion "all me friends are doing in" They are simultaneously pulling away from you and scurrying back for safety. In the mall. they don't want to walk next to you (not "cool"), but they do want to know where you are (!).
To most male teenagers, school is a form of jail. (And on a little reflection, I am sure you will agree that school is run for the females, and the business world is run for the males (topic of a future blog). I think you have to admit this, and point out to your (usually male teenager), that in the real world they will have to shovel an awful lot of crap, so they better learn about how to do it now. (My teacher insisted on a script "Q" rather than a printed "q". They both conveyed the same meaning, but she was the boss. Explain to your teenager that work rules make even less sense, but he/she has no chloice but to follow them.
Of course the first two things we all do when we become parents is to stop smoking grass (or at least hide it very well), and start attending a church or synagogue. So immediately we are telling our children (even before they know it) to "do as I say, and not as I did". This should not be a problem until the child reaches high school or bar mitzvah or confirmation age and starts to ask embarrassing questions about drugs, sex, and religion, but that is off in the future for new parents. But you should start to think about how you will convince your children to do as you say, and not as you did, and what to say when they ask you if you ever drank alcohol under age, let alone used marijuana.
"Because I said so", and "because it doesn't feel right to me" are both perfectly valid veto messages to your children (e.g. your child from Bergen County, N.J. wants to drive to Provincetown, Cape Cod on the night of her senior prom and stay over there with some friends).
It is "obvious" to most teenagers that older people deliberately discriminate against them and not "for their (sic) own good". The most egregious example is the 55 years old and older housing developments in Arizona and Florida. If the development's founding compact stated that Blacks or Jews could never buy there, and only live there for two weeks out of 52, there would be an immediate outcry, and the courts would rule it was a 14th amendment violation, or somesuch. But if the discriminated against group is under 18 (for living) or under 55 (for buying), the courts have upheld it. I guess older people and builders have a lot of voting clout, or donate more money to politicians than do younger people.
Please make sure your teenage daughter sees her own gynecologist before she goes off to college, and do NOT go in to the consulting room with her, or ask her what she discussed with the doctor. If your daughter wants you to know, she will tell you. It is reasonable as a responsible parent to ask her if she has any questions, but also to reassure her that the doctor is forbidden to discuss or reveal anything your daughter said in private.
Since no records are ever kept totally secret, tell your teenagers that if they are asked to fill out a form as to whether they ever drank under age, drove drunk, used illegal drugs, etc., the answer is always never. The penalty to the releaser of privileged information is never as great as the embarrassment or job prejudice that a teenager would suffer from such release. And be sure to remind them that ANY electronic information they send or receive, such as e-mails, voice mails, twitter, smart-phone photos, etc., can and probably will be viewed by someone else. Most teenagers are relatively innocent, naive and trusting, and they think that if they are upright and honest, then anyone they meet will also have these traits. This was somewhat true in the days of personal introductions, but certainly not over the internet.
In the same vein, too many teenagers and young college adults have sex without protection (and one is really too many). I tell all my patients of either sex never to have the first sexual contact with a new partner take place without a condom. Rather than warn them about accidental pregnancy or AIDS, I have found it much more useful to talk about herpes and venereal warts and how they are spread by direct contact by people who may not even know that they are infected or are carriers. And, as I have said before, if they are starting a new relationship and want to be tested for AIDS, I suggest instead their donating a unit of blood to the Red Cross, who will test the blood for many STD's.
The real problem, of course, is that for most children, teeenager seems to be a time of natural rebellion "all me friends are doing in" They are simultaneously pulling away from you and scurrying back for safety. In the mall. they don't want to walk next to you (not "cool"), but they do want to know where you are (!).
To most male teenagers, school is a form of jail. (And on a little reflection, I am sure you will agree that school is run for the females, and the business world is run for the males (topic of a future blog). I think you have to admit this, and point out to your (usually male teenager), that in the real world they will have to shovel an awful lot of crap, so they better learn about how to do it now. (My teacher insisted on a script "Q" rather than a printed "q". They both conveyed the same meaning, but she was the boss. Explain to your teenager that work rules make even less sense, but he/she has no chloice but to follow them.
Saturday, August 21, 2010
Medical Myths and Magical Thinking
Everyone has a certain degree of belief, aka myths, about medicine, their body health, and illness. If we all took a course in human physiology as seniors in high school, we would understand our bodies better, but since a recent poll showed that 75% of Americans believe in the existence of angels, we still would have beliefs as well as facts controlling our reaction to illness and doctors. I recall my parents' friends all ate a lot of wheat germ because they listened to a weekly radio program by Carleton Fredericks, and Dr. Jarvis' book on Vermont country medicine and the beneficial uses of apple vinegar is certainly well written and convincing.
It is of vital importance for a doctor to talk to his/her patient in enough depth to understand the patient's belief system, and I do not mean Catholic vs. Protestant, or Jehovah's Witnesses, or Christian Scientists, but rather how much medicine is acceptable to the patient, both in words and prescriptions. All beliefs about medicine are true beliefs, in the sense that the patient is committed to them, the recitation of facts and research will not sway them, and they will feel stressed if forced by circumstances to act against them. For instance, I can usually convince a committed vegetarian to take 1 mg/day of Vitamin B-12, which is needed to make animal DNA but not vegetable DNA, but it is not easy.
I have tried, with some success, to convince the medical residents under my direction that a patient's refusal to take a medicine is not grounds for an immediate psych consult. The last study of pharmacology behavior (or " pharmacological autonomy" if you want to be politically correct) showed that 25% of patients who leave the doctor's office with a prescription never fill it, 25% of those who fill it never take it, and 25% of those who take it stop before the indicated date, or rarely take it 3 times a day when so prescribed. Medical residents are guilty of the same behavior. At the same time, the most frequently committed federal or state felony is taking one of your relatives' or friends' controlled substances for pain, to sleep or to relieve anxiety, but no one seems to get reported or arrested for this.
I have male diabetic patients who refuse to take insulin:They believe that if they take insulin, then they are admitting that have diabetes, but if they just take pills, then they only have a "sugar problem". I have patients whose blood pressure is normalized with medicine asking me if they can stop their medicine now that their blood pressure is under control, or stop taking their statin now that their cholesterol is below 200. 25% of female high school seniors in the upscale, medically knowledgeable area in which I practice have never seen a gynecologist; I don't know if their parents think that seeing a gynecologist = approval of sex, but a girl should have her first pelvic done by an experienced gynecologist, who has time to ask questions and make the patient feel at ease, and not some GP in a college clinic who is just looking for vaginitis and STD's (and I apologize to those college physicians who are true gynecologists).
I have thousands of wives telling their husbands what to eat, not realizing that eating cholesterol (egg yolks) does not raise your cholesterol as much as eating animal fat does. For that matter, french fries and potato chips, both of which contain no cholesterol, contain enough fat to raise your cholesterol, and when Frito-Lay wanted to advertised their potato chips as having absolutely no cholesterol (which is a true statement for any vegetable product), the FTC made them pull the ad, because they were afraid that the public would equate "no cholesterol" with " "no fat".
I don't believe there is any such thing as "junk food" or "useless calories", but rather eating too much or to little. I don't care what you eat so long as you gain no weight, and have a daily multivitamin to cover whatever you may be missing. One of my children lived for a year on peanut butter and fluff,(and Poly-Vi-Flor vitamins) with no apparent ill effects, since he made the Little Leagued All-Star team as a pitcher. Exercising for 30 minutes non-stop every other day helps as well. White potatoes (and French fries, of course) have the highest glycemic index of any of the common foods, and therefore put the most stress on the glucose-insulin-fat system, so if you are on a diet, white potatoes are absolutely verboten.
It is not true that if you make love standing up you will not get pregnant. And you can't possibly douche soon enough to keep rapid swimmers out of the uterus. And if you follow astrology, what counts is the configuration of the planets at the moment of insemination, because a sperm is easier to direct than is a whole embryo. So you must know the planetary configuration at the moment of insemination (even better is at the moment that the father's sperm entered the cervical os, or the Fallopian tubes).
It is not true that a bowel movement a day is necessary for good health. Some of my patients average three movements a day, some three a week, and some three a month. In my human physiology class we were told that the longest time between movements was recorded as a year and a day, but since they had to then operate on the patient and use a hammer and chisel, perhaps that is a bit too long.
Too many mothers overemphasize their effect in the nature-nurture result. His mother did not give Derek Jeter the ability to hit major league pitching, or Frank Sinatra the ability to sing. I'm not sure what Midori's mother ate on the night of her creation, or if she listened to Mozart while she was pregnant with her.
Some patients will always see the glass as half full, and others as half empty. (And I see the glass as too large, but I generally think "out of the box".)Some are born salesman, and some are born daydreamers. We should also remember that the result of all tests are effort-dependent: hearing, PSAT, GMAT, 4th grade arithmetic, stress tests, and pulmonary function tests. Many students do not give the test 100% effort, but this is impossible to determine. In fact, some free-thinking students realize that since the state-wide test results do not affect their grade then they are guinea pigs, and put down "(a)" or whatever suits their fancy for every answer; why should they study hard and work on a test that is promised not to affect their grade.? In fact, if they do poorly, their school district can get even more money for supplies, so perhaps they are really helping. I myself never rewrote any humanities term paper in college, because (a) I was a physics major, and (b) the required effort to rewrite a B+ into an A- paper wasn't worth it to me. The one exception was a paper on Zoroastrianism in my course on Oriental Religions, because I was really interested in the subject.
Patients also think that the less medicine they take, the less sick they are. So when 40mg of Zocor was replaced with the equipotent dose of 10mg of Lipitor, they were very happy, and even happier with 5mg of Crestor. And Vytorin is one pill, not two, which is also good. They also think that the less asthma medicine they can take, the less serious their asthma is, and they are forever skipping doses of inhaler and believing that their breathing is not affected. On the other hand, 50 mg of Viagra must be better than 10 mg of Levitra, because the Viagra pill is bigger, has a great blue color, and is a larger dose.
Along with the above, the most surprised patients are those who survive a heart attack and go home on five new medicines. These many medicines do not mean that you are very ill, but rather that physicians know from experimental studies that each of these five medicines will reduce your chance of a second heart attack (and remember that the single greatest risk for having a heart attack is already having had one). The medicines are: a platelet blocker (aspirin, Plavix, or Coumadin), a beta-blocker, a statin to lower your cholesterol and stabilize any atheromatous plaques in your coronary arteries, an ACE inhibitor or an ARB, and, if you are in any heart failure at all, spironalactone. Again, these are all to reduce your chance of having a second heart attack, and should be taken exactly as prescribed.
If your doctor and you have a clash of opinions that is too strong for you to feel comfortable with him/her, then you should find another doctor. Never feel guilty about this, because it is your body and mind, and therefore your privilege to see or stop seeing whomever you want to. Speaking for myself, I do not want my patients to feel guilty about calling me after hours or when I am not in the office; when I am on call, I expect to be called. Your "job" is to tell me your symptoms, and mine is to worry about them and interpret them. We are both partners in your physical and mental well-being.
Added note: If your doctor spends more time talking about his/her problems than listening to yours, it is definitely time to find another doctor!
It is of vital importance for a doctor to talk to his/her patient in enough depth to understand the patient's belief system, and I do not mean Catholic vs. Protestant, or Jehovah's Witnesses, or Christian Scientists, but rather how much medicine is acceptable to the patient, both in words and prescriptions. All beliefs about medicine are true beliefs, in the sense that the patient is committed to them, the recitation of facts and research will not sway them, and they will feel stressed if forced by circumstances to act against them. For instance, I can usually convince a committed vegetarian to take 1 mg/day of Vitamin B-12, which is needed to make animal DNA but not vegetable DNA, but it is not easy.
I have tried, with some success, to convince the medical residents under my direction that a patient's refusal to take a medicine is not grounds for an immediate psych consult. The last study of pharmacology behavior (or " pharmacological autonomy" if you want to be politically correct) showed that 25% of patients who leave the doctor's office with a prescription never fill it, 25% of those who fill it never take it, and 25% of those who take it stop before the indicated date, or rarely take it 3 times a day when so prescribed. Medical residents are guilty of the same behavior. At the same time, the most frequently committed federal or state felony is taking one of your relatives' or friends' controlled substances for pain, to sleep or to relieve anxiety, but no one seems to get reported or arrested for this.
I have male diabetic patients who refuse to take insulin:They believe that if they take insulin, then they are admitting that have diabetes, but if they just take pills, then they only have a "sugar problem". I have patients whose blood pressure is normalized with medicine asking me if they can stop their medicine now that their blood pressure is under control, or stop taking their statin now that their cholesterol is below 200. 25% of female high school seniors in the upscale, medically knowledgeable area in which I practice have never seen a gynecologist; I don't know if their parents think that seeing a gynecologist = approval of sex, but a girl should have her first pelvic done by an experienced gynecologist, who has time to ask questions and make the patient feel at ease, and not some GP in a college clinic who is just looking for vaginitis and STD's (and I apologize to those college physicians who are true gynecologists).
I have thousands of wives telling their husbands what to eat, not realizing that eating cholesterol (egg yolks) does not raise your cholesterol as much as eating animal fat does. For that matter, french fries and potato chips, both of which contain no cholesterol, contain enough fat to raise your cholesterol, and when Frito-Lay wanted to advertised their potato chips as having absolutely no cholesterol (which is a true statement for any vegetable product), the FTC made them pull the ad, because they were afraid that the public would equate "no cholesterol" with " "no fat".
I don't believe there is any such thing as "junk food" or "useless calories", but rather eating too much or to little. I don't care what you eat so long as you gain no weight, and have a daily multivitamin to cover whatever you may be missing. One of my children lived for a year on peanut butter and fluff,(and Poly-Vi-Flor vitamins) with no apparent ill effects, since he made the Little Leagued All-Star team as a pitcher. Exercising for 30 minutes non-stop every other day helps as well. White potatoes (and French fries, of course) have the highest glycemic index of any of the common foods, and therefore put the most stress on the glucose-insulin-fat system, so if you are on a diet, white potatoes are absolutely verboten.
It is not true that if you make love standing up you will not get pregnant. And you can't possibly douche soon enough to keep rapid swimmers out of the uterus. And if you follow astrology, what counts is the configuration of the planets at the moment of insemination, because a sperm is easier to direct than is a whole embryo. So you must know the planetary configuration at the moment of insemination (even better is at the moment that the father's sperm entered the cervical os, or the Fallopian tubes).
It is not true that a bowel movement a day is necessary for good health. Some of my patients average three movements a day, some three a week, and some three a month. In my human physiology class we were told that the longest time between movements was recorded as a year and a day, but since they had to then operate on the patient and use a hammer and chisel, perhaps that is a bit too long.
Too many mothers overemphasize their effect in the nature-nurture result. His mother did not give Derek Jeter the ability to hit major league pitching, or Frank Sinatra the ability to sing. I'm not sure what Midori's mother ate on the night of her creation, or if she listened to Mozart while she was pregnant with her.
Some patients will always see the glass as half full, and others as half empty. (And I see the glass as too large, but I generally think "out of the box".)Some are born salesman, and some are born daydreamers. We should also remember that the result of all tests are effort-dependent: hearing, PSAT, GMAT, 4th grade arithmetic, stress tests, and pulmonary function tests. Many students do not give the test 100% effort, but this is impossible to determine. In fact, some free-thinking students realize that since the state-wide test results do not affect their grade then they are guinea pigs, and put down "(a)" or whatever suits their fancy for every answer; why should they study hard and work on a test that is promised not to affect their grade.? In fact, if they do poorly, their school district can get even more money for supplies, so perhaps they are really helping. I myself never rewrote any humanities term paper in college, because (a) I was a physics major, and (b) the required effort to rewrite a B+ into an A- paper wasn't worth it to me. The one exception was a paper on Zoroastrianism in my course on Oriental Religions, because I was really interested in the subject.
Patients also think that the less medicine they take, the less sick they are. So when 40mg of Zocor was replaced with the equipotent dose of 10mg of Lipitor, they were very happy, and even happier with 5mg of Crestor. And Vytorin is one pill, not two, which is also good. They also think that the less asthma medicine they can take, the less serious their asthma is, and they are forever skipping doses of inhaler and believing that their breathing is not affected. On the other hand, 50 mg of Viagra must be better than 10 mg of Levitra, because the Viagra pill is bigger, has a great blue color, and is a larger dose.
Along with the above, the most surprised patients are those who survive a heart attack and go home on five new medicines. These many medicines do not mean that you are very ill, but rather that physicians know from experimental studies that each of these five medicines will reduce your chance of a second heart attack (and remember that the single greatest risk for having a heart attack is already having had one). The medicines are: a platelet blocker (aspirin, Plavix, or Coumadin), a beta-blocker, a statin to lower your cholesterol and stabilize any atheromatous plaques in your coronary arteries, an ACE inhibitor or an ARB, and, if you are in any heart failure at all, spironalactone. Again, these are all to reduce your chance of having a second heart attack, and should be taken exactly as prescribed.
If your doctor and you have a clash of opinions that is too strong for you to feel comfortable with him/her, then you should find another doctor. Never feel guilty about this, because it is your body and mind, and therefore your privilege to see or stop seeing whomever you want to. Speaking for myself, I do not want my patients to feel guilty about calling me after hours or when I am not in the office; when I am on call, I expect to be called. Your "job" is to tell me your symptoms, and mine is to worry about them and interpret them. We are both partners in your physical and mental well-being.
Added note: If your doctor spends more time talking about his/her problems than listening to yours, it is definitely time to find another doctor!
Medical Information and Mis-information (Part 1)
I have always been struck by the number of medical "facts" that my patients "know" that just aren't so (e.g. there is no evidence that an hour of sleep before midnight is equal to two hours of sleep after midnight), so I thought I would devote this blog to a discussion of such "facts".
I first must explain the difference between correlation and causation. Often medical epidemiologists will examine a homogenous group of patients with disease X, to see what , if any, their life styles have in common compared to patients without disease X. However there will always be some accidental correlation: if you shoot at a tree you are bound to hit a leaf, but unless you specify in advance what leaf you plan to hit, this information is of no use. Similarly, in a given state, some county will have the highest prevalence of breast cancer, and another will have the lowest, but I wouldn't recommend rushing to move to the county with the lowest incidence. So although it appears epidemiologically that females who have pet cats or kittens under the age of 16, or who live north of the Tropic of Capricorn or south of the Tropic of Cancer (i.e. not in the tropics) until age 16 have an increased risk for developing multiple sclerosis, we should treat this correlation as a hypothesis to be proved. Now we have to do the forward experiment, and see the effect of giving or not giving kittens to matched young girls (which is, of course, not ethical). Similarly, there was a great hooraw in the news when it was found that coffee drinkers had a greatly increased risk of getting a heart attack compared with non-drinkers, until it was realized that many more coffee drinkers smoked cigarettes than did non-smokers. Also, although low fat diets seem to be epidemiologically connected to lower breast and colon cancer rates, a five-year forward study of females placed on a low-fat diet showed no diminution of cancer incidence. As I tell all my patients ALWAYS WAIT FOR THE SECOND AND CONFIRMING STUDY.
Some of you may not agree with my statements, but again I must emphasize that if you think my statement is incorrect, you should find a published refereed research paper (you can check through PubMed) that disagrees with my statements. In fact this is the trouble with all newspaper stories, that they quote from and interpret the research study, but never include a link where you can read the original research and decide for yourself. You should also beware of all statements made at scientific meetings, since until they are published they have never been reviewed for accuracy.
1) The recommended maximum pulse rate for efficient exercise is a fiction. The study group was young healthy men, and the 80% was pulled from God knows where. When Bjorn Borg won the French Open, his resting pulse was 34 (similar to many marathoners). If he ever tried to get his heart rate up to 0.8x(220-age), he would have either failed or died trying.
2) Where is the evidence for waiting one hour after eating to go swimming?
3) What is the scientific basis upon which the government specifies the minimum amount of square feet an egg-laying hen should have? Dr. Kandel was fortunate that when he did his Nobel prize-winning memory experiments on Aplysia, the government didn't care how many snails he kept in a box, or how often or what he fed them.
4) For any children reading this, it is not true that if you swallow watermelon seeds you will grow a plant in your stomach.
5) Barry Bonds was indicted for perjury for denying using performance-enhancing drugs. Steroids may bulk you up, but I know of no medical article that demonstrated that taking steroids improves your baseball performance. It shouldn't matter what we think, what the government thinks, or what Mr. Bonds thought. If you deny an impossibility, I don't see how it is perjury. (When I went to college my performance-enhancing drugs were a cup of Choc-Full-O-Nuts coffee and two of their brownies.)
6) For years, heavyweight fighters and other athletes were told not to have sex the night before a crucial game. But Joe Namath, Mickey Mantle, and other top athletes have told us that this is not true either (at least it wasn't for them) and beer helped Bobby Lane, the former Detroit Lions' quarterback. Maybe that's why Tiger Woods is having trouble winning now.
7) Radiation can be used to kill virtually ALL germs, eggs and insects. We could safely sterilize our food supply and avoid disasters such as the egg-borne salmonella epidemic, the hamburgers that carried E. Coli, and the lettuce that carried hepatitis. But there is such an ingrained fear of the effects of radiation that even though it is only the food that is irradiated, and there is no residual radioactivity in the food, public opinion prevents Congress from permitting this, let alone requiring it.
8) There is no evidence that colonoscopy reduces the incidence of colon cancer more than rigid sigmoidoscopy does, but since it seemed "obvious" that examining the whole large bowel would produce better cancer prevention than a partial examination, a comparison study of the two was never done. But if colonoscopy were a drug, the FDA would have required a comparative study with cancer or pre-cancerous polyps as an endpoint.
9) Lately, dermatologists have been telling my patients that the growth they removed is "pre-cancerous". That is a ridiculous statement. Your whole body, including your skin, is "pre-cancerous". The medically correct term for such a growth is "not cancer".
10) How often should you have a mammogram, stool for blood, pap smear, etc. No one knows!
Cancer has occurred between annual screening tests. We doctors sort of pull numbers out of the air, modified by what the insurance companies will pay for. If Medicare only pays for cholesterol profiles every 4 months, then that is what we recommend. But maybe you should have a mammogram every six months, or every three. Maybe men over 50 should have a stress-thallium test of their heart every three months, or maybe an echocardiogram every month.
11) Medicare usually does not pay for screening tests. So if a doctor thinks you have a thyroid problem, and he/she puts down "possible thyroid problem", then MCR will not pay for it, and you will probably refuse to have the test done, not wanting to pay for it yourself. So we put down 244.9, which is a thyroid condition, to have MCR pay for the test. Similarly 780.79, "general fatigue", is an acceptable diagnosis to test for anemia with a CBC. On occasion, doctors have even used 799.99, "unknown disease", because we all have at least one of them (which is generally found at autopsy). So we tell all our MCR patients to ignore any diagnoses, and that we put down "Brain tumor" to get their MRI of the brain paid for by MCR or their HMO.
12) How does anyone know what babies want or need? You can't ask the babies, and no eighteen-year comparative studies are done. Right now playpens are out of favor, and we still have no agreement on how long a baby should be left to cry until being picked up. We still argue whether babies' food allergies are reduced or increased by early exposure to proteins. Despite the existence of cat-scratch fever and toxoplasmosis, we still permit kittens and cats to be around pregnant women and new-born babies. I might also mention that dander (cat saliva applied by licking to cat fur) helps induce bronchospasm and possible asthma in humans of all ages, and some states still permit children to keep turtles as pets despite the fact that they are known carriers of salmonella.
13) Medicine can be counter-intuitive: one way of reducing the incidence of calcium kidney stones is by INcreasing the amount of calcium in the diet (and thereby complexing oxalate in the gut and keeping it out of the urine).
14) Speed kills. During the Carter administration, with a maximum highway speed limit of 55 mph, traffic fatalities per mile traveled decreased, only to increase when 65 mph was reinstated. Because of kinetic energy, the amount of damage in an automobile accident goes up with the square of the velocity.I am not aware of any auto driver or passenger fatalities occurring as speeds under 35 mph, but we don't want to sacrifice that much time. (We also don't know why in most states when seatbelts were introduced the rate of pedestrian fatalities increased.) You should protect yourself by driving the heaviest car you can, like an SUV, since if you are unfortunate enough to be in an accident, you want the other vehicle to bounce off you, and not to crush you.
15) If you don"t "believe" in sleeping pills, then if you are a woman try OTC Benadryl 25 or 50 mg at bedtime. It is so safe that we give it to pregnant women. A future blog will address medical belief systems. And if you husband doesn't believe in them, hide them from him. It's your body.
16) There has been no study to show that if you post the number of calories next to food that people will lose weight.
17) The FDA does not have the authority to clear or license any new surgical procedure, including robotic surgery. Any surgeon can do any surgical procedure if he/she can convince the patient to permit it. I have read articles that it takes 150 to 250 operations to become proficient, for instance, in robotic prostate surgery. So don't be the first human on whom your surgeon is doing a new procedure.
18) The only way to find out who is a good surgeon, or the ability of any other doctor is to do as I did, and ask the residents who work with them. The residents see it all: in the operating room, post-op care, medical diagnosis and treatment, etc. If you ask your friends, all you get is their opinion. Even the published ratings are a joke, as any doctor will tell you. And hospitals can improve their open heart surgical death rate by not operating on the sickest people. (As I recall, there was an Op-Ed piece in the NY Times about 10 years ago by a columnist who had a very difficult time trying to find a cardiac surgeon who would operate on his mother for this very reason.)
I first must explain the difference between correlation and causation. Often medical epidemiologists will examine a homogenous group of patients with disease X, to see what , if any, their life styles have in common compared to patients without disease X. However there will always be some accidental correlation: if you shoot at a tree you are bound to hit a leaf, but unless you specify in advance what leaf you plan to hit, this information is of no use. Similarly, in a given state, some county will have the highest prevalence of breast cancer, and another will have the lowest, but I wouldn't recommend rushing to move to the county with the lowest incidence. So although it appears epidemiologically that females who have pet cats or kittens under the age of 16, or who live north of the Tropic of Capricorn or south of the Tropic of Cancer (i.e. not in the tropics) until age 16 have an increased risk for developing multiple sclerosis, we should treat this correlation as a hypothesis to be proved. Now we have to do the forward experiment, and see the effect of giving or not giving kittens to matched young girls (which is, of course, not ethical). Similarly, there was a great hooraw in the news when it was found that coffee drinkers had a greatly increased risk of getting a heart attack compared with non-drinkers, until it was realized that many more coffee drinkers smoked cigarettes than did non-smokers. Also, although low fat diets seem to be epidemiologically connected to lower breast and colon cancer rates, a five-year forward study of females placed on a low-fat diet showed no diminution of cancer incidence. As I tell all my patients ALWAYS WAIT FOR THE SECOND AND CONFIRMING STUDY.
Some of you may not agree with my statements, but again I must emphasize that if you think my statement is incorrect, you should find a published refereed research paper (you can check through PubMed) that disagrees with my statements. In fact this is the trouble with all newspaper stories, that they quote from and interpret the research study, but never include a link where you can read the original research and decide for yourself. You should also beware of all statements made at scientific meetings, since until they are published they have never been reviewed for accuracy.
1) The recommended maximum pulse rate for efficient exercise is a fiction. The study group was young healthy men, and the 80% was pulled from God knows where. When Bjorn Borg won the French Open, his resting pulse was 34 (similar to many marathoners). If he ever tried to get his heart rate up to 0.8x(220-age), he would have either failed or died trying.
2) Where is the evidence for waiting one hour after eating to go swimming?
3) What is the scientific basis upon which the government specifies the minimum amount of square feet an egg-laying hen should have? Dr. Kandel was fortunate that when he did his Nobel prize-winning memory experiments on Aplysia, the government didn't care how many snails he kept in a box, or how often or what he fed them.
4) For any children reading this, it is not true that if you swallow watermelon seeds you will grow a plant in your stomach.
5) Barry Bonds was indicted for perjury for denying using performance-enhancing drugs. Steroids may bulk you up, but I know of no medical article that demonstrated that taking steroids improves your baseball performance. It shouldn't matter what we think, what the government thinks, or what Mr. Bonds thought. If you deny an impossibility, I don't see how it is perjury. (When I went to college my performance-enhancing drugs were a cup of Choc-Full-O-Nuts coffee and two of their brownies.)
6) For years, heavyweight fighters and other athletes were told not to have sex the night before a crucial game. But Joe Namath, Mickey Mantle, and other top athletes have told us that this is not true either (at least it wasn't for them) and beer helped Bobby Lane, the former Detroit Lions' quarterback. Maybe that's why Tiger Woods is having trouble winning now.
7) Radiation can be used to kill virtually ALL germs, eggs and insects. We could safely sterilize our food supply and avoid disasters such as the egg-borne salmonella epidemic, the hamburgers that carried E. Coli, and the lettuce that carried hepatitis. But there is such an ingrained fear of the effects of radiation that even though it is only the food that is irradiated, and there is no residual radioactivity in the food, public opinion prevents Congress from permitting this, let alone requiring it.
8) There is no evidence that colonoscopy reduces the incidence of colon cancer more than rigid sigmoidoscopy does, but since it seemed "obvious" that examining the whole large bowel would produce better cancer prevention than a partial examination, a comparison study of the two was never done. But if colonoscopy were a drug, the FDA would have required a comparative study with cancer or pre-cancerous polyps as an endpoint.
9) Lately, dermatologists have been telling my patients that the growth they removed is "pre-cancerous". That is a ridiculous statement. Your whole body, including your skin, is "pre-cancerous". The medically correct term for such a growth is "not cancer".
10) How often should you have a mammogram, stool for blood, pap smear, etc. No one knows!
Cancer has occurred between annual screening tests. We doctors sort of pull numbers out of the air, modified by what the insurance companies will pay for. If Medicare only pays for cholesterol profiles every 4 months, then that is what we recommend. But maybe you should have a mammogram every six months, or every three. Maybe men over 50 should have a stress-thallium test of their heart every three months, or maybe an echocardiogram every month.
11) Medicare usually does not pay for screening tests. So if a doctor thinks you have a thyroid problem, and he/she puts down "possible thyroid problem", then MCR will not pay for it, and you will probably refuse to have the test done, not wanting to pay for it yourself. So we put down 244.9, which is a thyroid condition, to have MCR pay for the test. Similarly 780.79, "general fatigue", is an acceptable diagnosis to test for anemia with a CBC. On occasion, doctors have even used 799.99, "unknown disease", because we all have at least one of them (which is generally found at autopsy). So we tell all our MCR patients to ignore any diagnoses, and that we put down "Brain tumor" to get their MRI of the brain paid for by MCR or their HMO.
12) How does anyone know what babies want or need? You can't ask the babies, and no eighteen-year comparative studies are done. Right now playpens are out of favor, and we still have no agreement on how long a baby should be left to cry until being picked up. We still argue whether babies' food allergies are reduced or increased by early exposure to proteins. Despite the existence of cat-scratch fever and toxoplasmosis, we still permit kittens and cats to be around pregnant women and new-born babies. I might also mention that dander (cat saliva applied by licking to cat fur) helps induce bronchospasm and possible asthma in humans of all ages, and some states still permit children to keep turtles as pets despite the fact that they are known carriers of salmonella.
13) Medicine can be counter-intuitive: one way of reducing the incidence of calcium kidney stones is by INcreasing the amount of calcium in the diet (and thereby complexing oxalate in the gut and keeping it out of the urine).
14) Speed kills. During the Carter administration, with a maximum highway speed limit of 55 mph, traffic fatalities per mile traveled decreased, only to increase when 65 mph was reinstated. Because of kinetic energy, the amount of damage in an automobile accident goes up with the square of the velocity.I am not aware of any auto driver or passenger fatalities occurring as speeds under 35 mph, but we don't want to sacrifice that much time. (We also don't know why in most states when seatbelts were introduced the rate of pedestrian fatalities increased.) You should protect yourself by driving the heaviest car you can, like an SUV, since if you are unfortunate enough to be in an accident, you want the other vehicle to bounce off you, and not to crush you.
15) If you don"t "believe" in sleeping pills, then if you are a woman try OTC Benadryl 25 or 50 mg at bedtime. It is so safe that we give it to pregnant women. A future blog will address medical belief systems. And if you husband doesn't believe in them, hide them from him. It's your body.
16) There has been no study to show that if you post the number of calories next to food that people will lose weight.
17) The FDA does not have the authority to clear or license any new surgical procedure, including robotic surgery. Any surgeon can do any surgical procedure if he/she can convince the patient to permit it. I have read articles that it takes 150 to 250 operations to become proficient, for instance, in robotic prostate surgery. So don't be the first human on whom your surgeon is doing a new procedure.
18) The only way to find out who is a good surgeon, or the ability of any other doctor is to do as I did, and ask the residents who work with them. The residents see it all: in the operating room, post-op care, medical diagnosis and treatment, etc. If you ask your friends, all you get is their opinion. Even the published ratings are a joke, as any doctor will tell you. And hospitals can improve their open heart surgical death rate by not operating on the sickest people. (As I recall, there was an Op-Ed piece in the NY Times about 10 years ago by a columnist who had a very difficult time trying to find a cardiac surgeon who would operate on his mother for this very reason.)
Wednesday, June 23, 2010
Men and Women Think Differently
Hooray for the State of Wyoming, the only state that gave women the right to vote in its original constitution.
My wife says that I tend to overgeneralize, so in all fairness, when I write "men" or "boys" or "women" or "girls" please mentally insert the phrase "the majority of________in my experience". But it is true that men and women view and react to the world in a very different manner, because society trains them differently and imposes different standards and expectations on them. Basically, women think both "micro" as well as "family group", and feel selfish if they think of themselves first. Women usually feel guilty when they leave a drunken, abusive husband. Men, on the other hand, think "macro", and never think they are being selfish if they satisfy their own needs before they think of others. Women buy into the education system and therefore are much more diligent about school and homework than are boys.
We men know we will never understand half of what women are thinking and feeling, but women are determined to try to teach us. I don't think it can be done. As a simple example, girls walk around puddles and boys jump into them. Girls have neat handwriting in school and color within the lines, while boys have extremely sloppy handwriting and don't color within the lines. (And boys never dot their "i's" with circles, let alone little hearts.) Few if any men have said "it's time to redecorate the living room".
It is true that the men "decide" the major issues: should we a-bomb Iraq, should we put a man on Mars, should we trade with Cuba, while women decide the "minor" issues: where should the family live, which school should the children attend, do they need an after-school tutor.
A fundamental problem is that if a girl means to signify thought (A) by action (B), the boy generally means to signal thought (C) by the same action, so the girl misinterprets the boy's action. A simple process that creates a lot of emotional stress in women when dating is the man's ending the evening with the phrase "I'll call you". When a man tells that to another man, it means he will call his friend sometime between today and his deathbed. Since men usually use the telephone to convey information rather than to visit, most men can't remember the last time they spoke on the telephone to a particular friend, or that they promised to call anyone, let alone within a definite time period. Men also talk to other men in a way that would cause instant enmity between two women if one talked to the other in the same fashion.
Men consider errors of omission a minor sin. I have three male friends with whom I grew up and still see regularly. Sometimes one of us will send the other a birthday card or, more rarely, a birthday present, but we don't keep score, and it doesn't matter, and we won't stop being best friends because of a forgotten birthday. In fact, boys may have a "best pal", but never a "best friend" as girls do. Men also always split the dinner bill evenly, without checking who ate what.
On the other hand, society seems to hold wives responsible (or wives think it does, and accept the responsibility) for how their husbands dress when they go out. Every man has heard the phrase "you're wearing THAT???". Men also wish that our wives and girlfriends never ask us if they look different, or if a dress makes them look heavy. We love the way you look most of the time, and usually don't notice details. And we rarely, if ever, look heavy to ourselves: looking face on at a mirror, a woman sees her hips, but a man does not see his protruding stomach that hangs over his belt.
BTL, or tubal ligation for sterilization is abdominal surgery, and a vasectomy is easier surgery, external to the abdomen, and is an office procedure. But somehow, in the majority of marriages, the wife gets the BTL when the couple wants to make birth control permanent. Men shudder at the thought of a knife in that vicinity.
It never occurs to men that we can be physically hurt. So when the plane lands, we don't call home to our girlfriend or mother to say we arrived safely. (Calling the wife comes under the heading of keeping the peace.) On the other hand, most women fax a copy of their itinerary to at least two people, one friend and one relative, a concept that is foreign to most men.
It never occurs to men that they won't be able to get married when they want to.
Married men will never "get it" that they cannot excuse an affair with the statement "but I didn't love her".
BTW, everyone is on his/her best behavior when they are dating, so if there are things you don't like about the other person, they will not improve with time. Albert Einstein (yes, that one) once said: "The tragedy of marriage is that each husband expects his wife never to change, and each wife expects to change her husband, and both are doomed to be disappointed".
Men prefer laws, and women prefer justice. So men will "cheat" within the laws of baseball (remember Alvin Dark of the NY Giants and his running start to tag up?) and think it legal if they win without breaking the letter of the laws of the game. Since women are trained by society to fit in and make no waves, they seem to take some part of all professional criticism personally, and thereby fail to get the maximum benefit from it. In the same vein, I doubt that a man would "throw" a baseball game to let his brother's team win, as Geena Davis did for her sister in "A Game of Their Own".
You will never convince a school-age boy that school is anything but jail (and I was a straight-A student with SP classes in JHS, and valedictorian and all of that). He will never understand why there is any value in writing a book report after he has read it. "But I read it, didn't I?" When, however, he discovers what he wants to do with his life, he will buckle down and study intensively, and society says "he found himself".
It was extremely clever of the men who passed laws against abortion to penalize the doctor heavily, but never indict the pregnant woman as an accessory before or after the fact, because they know that unless you are in a dictatorship such as Romania was, you can't get such a law passed or the women punished. The reverse happens in prostitution. In the the case of the Mayflower Madam, the prosecutor went after the madam and not the important government employees who utilized her services. Why didn't the grand jury expose their names? Society gives much more sexual slack to men than it does to women, because men make the laws. BTW, did Wilt Chamberlain, who confessed (or bragged?) about having slept with over 13,500 women have no problem with "sex addiction" because he wasn't married, unlike Tiger Woods and Spitzer? Whch leads to a separate philosophical-social-moral question: why is it legal for a woman to sleep with a stranger for free, but illegal to charge him money for the same service?
At least pregnant high school seniors no longer have to leave school for home schooling, but they are still being dropped from Arista after they become pregnant, as if pregnancy diminishes and taints their academic accomplishments. The father, of course, is not forced to drop out of any school extra-curricular activity.
And after marriage, the wife is suddenly and magically given social responsibility for remembering all dates. If the husband forgets his mother's birthday, somehow the wife gets blamed. And when women talk to their daughters and daughters-in-law, they are much more conscious of the effect of their words on the listener than men are (cf. the book "Walking on Eggshells"). I always know by the tone in her voice when my wife is talking to our daughter.
Mothers also get more tired than do fathers, because most mothers sleep with one eye and one ear open to hear the children crying, because they are concerned that their husband will not hear them.
Unlike women, men NEVER make eye contact with or talk to another man in a bathroom, especially if he is at the next urinal. But we are allowed to greet a friend in the street with just a small nod of the head, rather than stopping to talk. And if he has his fly open, it is a rare man who will mention it to him.
Men can let a phone ring without answering it, but women at home usually cannot. I have difficulty convincing my female patients to take an hour's vacation by turning their cell phone off for one hour/day.
But remember that without women to civilize us, we would all be living in the society depicted in "Lord of the Flies".
My wife says that I tend to overgeneralize, so in all fairness, when I write "men" or "boys" or "women" or "girls" please mentally insert the phrase "the majority of________in my experience". But it is true that men and women view and react to the world in a very different manner, because society trains them differently and imposes different standards and expectations on them. Basically, women think both "micro" as well as "family group", and feel selfish if they think of themselves first. Women usually feel guilty when they leave a drunken, abusive husband. Men, on the other hand, think "macro", and never think they are being selfish if they satisfy their own needs before they think of others. Women buy into the education system and therefore are much more diligent about school and homework than are boys.
We men know we will never understand half of what women are thinking and feeling, but women are determined to try to teach us. I don't think it can be done. As a simple example, girls walk around puddles and boys jump into them. Girls have neat handwriting in school and color within the lines, while boys have extremely sloppy handwriting and don't color within the lines. (And boys never dot their "i's" with circles, let alone little hearts.) Few if any men have said "it's time to redecorate the living room".
It is true that the men "decide" the major issues: should we a-bomb Iraq, should we put a man on Mars, should we trade with Cuba, while women decide the "minor" issues: where should the family live, which school should the children attend, do they need an after-school tutor.
A fundamental problem is that if a girl means to signify thought (A) by action (B), the boy generally means to signal thought (C) by the same action, so the girl misinterprets the boy's action. A simple process that creates a lot of emotional stress in women when dating is the man's ending the evening with the phrase "I'll call you". When a man tells that to another man, it means he will call his friend sometime between today and his deathbed. Since men usually use the telephone to convey information rather than to visit, most men can't remember the last time they spoke on the telephone to a particular friend, or that they promised to call anyone, let alone within a definite time period. Men also talk to other men in a way that would cause instant enmity between two women if one talked to the other in the same fashion.
Men consider errors of omission a minor sin. I have three male friends with whom I grew up and still see regularly. Sometimes one of us will send the other a birthday card or, more rarely, a birthday present, but we don't keep score, and it doesn't matter, and we won't stop being best friends because of a forgotten birthday. In fact, boys may have a "best pal", but never a "best friend" as girls do. Men also always split the dinner bill evenly, without checking who ate what.
On the other hand, society seems to hold wives responsible (or wives think it does, and accept the responsibility) for how their husbands dress when they go out. Every man has heard the phrase "you're wearing THAT???". Men also wish that our wives and girlfriends never ask us if they look different, or if a dress makes them look heavy. We love the way you look most of the time, and usually don't notice details. And we rarely, if ever, look heavy to ourselves: looking face on at a mirror, a woman sees her hips, but a man does not see his protruding stomach that hangs over his belt.
BTL, or tubal ligation for sterilization is abdominal surgery, and a vasectomy is easier surgery, external to the abdomen, and is an office procedure. But somehow, in the majority of marriages, the wife gets the BTL when the couple wants to make birth control permanent. Men shudder at the thought of a knife in that vicinity.
It never occurs to men that we can be physically hurt. So when the plane lands, we don't call home to our girlfriend or mother to say we arrived safely. (Calling the wife comes under the heading of keeping the peace.) On the other hand, most women fax a copy of their itinerary to at least two people, one friend and one relative, a concept that is foreign to most men.
It never occurs to men that they won't be able to get married when they want to.
Married men will never "get it" that they cannot excuse an affair with the statement "but I didn't love her".
BTW, everyone is on his/her best behavior when they are dating, so if there are things you don't like about the other person, they will not improve with time. Albert Einstein (yes, that one) once said: "The tragedy of marriage is that each husband expects his wife never to change, and each wife expects to change her husband, and both are doomed to be disappointed".
Men prefer laws, and women prefer justice. So men will "cheat" within the laws of baseball (remember Alvin Dark of the NY Giants and his running start to tag up?) and think it legal if they win without breaking the letter of the laws of the game. Since women are trained by society to fit in and make no waves, they seem to take some part of all professional criticism personally, and thereby fail to get the maximum benefit from it. In the same vein, I doubt that a man would "throw" a baseball game to let his brother's team win, as Geena Davis did for her sister in "A Game of Their Own".
You will never convince a school-age boy that school is anything but jail (and I was a straight-A student with SP classes in JHS, and valedictorian and all of that). He will never understand why there is any value in writing a book report after he has read it. "But I read it, didn't I?" When, however, he discovers what he wants to do with his life, he will buckle down and study intensively, and society says "he found himself".
It was extremely clever of the men who passed laws against abortion to penalize the doctor heavily, but never indict the pregnant woman as an accessory before or after the fact, because they know that unless you are in a dictatorship such as Romania was, you can't get such a law passed or the women punished. The reverse happens in prostitution. In the the case of the Mayflower Madam, the prosecutor went after the madam and not the important government employees who utilized her services. Why didn't the grand jury expose their names? Society gives much more sexual slack to men than it does to women, because men make the laws. BTW, did Wilt Chamberlain, who confessed (or bragged?) about having slept with over 13,500 women have no problem with "sex addiction" because he wasn't married, unlike Tiger Woods and Spitzer? Whch leads to a separate philosophical-social-moral question: why is it legal for a woman to sleep with a stranger for free, but illegal to charge him money for the same service?
At least pregnant high school seniors no longer have to leave school for home schooling, but they are still being dropped from Arista after they become pregnant, as if pregnancy diminishes and taints their academic accomplishments. The father, of course, is not forced to drop out of any school extra-curricular activity.
And after marriage, the wife is suddenly and magically given social responsibility for remembering all dates. If the husband forgets his mother's birthday, somehow the wife gets blamed. And when women talk to their daughters and daughters-in-law, they are much more conscious of the effect of their words on the listener than men are (cf. the book "Walking on Eggshells"). I always know by the tone in her voice when my wife is talking to our daughter.
Mothers also get more tired than do fathers, because most mothers sleep with one eye and one ear open to hear the children crying, because they are concerned that their husband will not hear them.
Unlike women, men NEVER make eye contact with or talk to another man in a bathroom, especially if he is at the next urinal. But we are allowed to greet a friend in the street with just a small nod of the head, rather than stopping to talk. And if he has his fly open, it is a rare man who will mention it to him.
Men can let a phone ring without answering it, but women at home usually cannot. I have difficulty convincing my female patients to take an hour's vacation by turning their cell phone off for one hour/day.
But remember that without women to civilize us, we would all be living in the society depicted in "Lord of the Flies".
Wednesday, June 16, 2010
Useless Medical Screening Tests
Let me begin by defining what I mean by useless: the results of the test are of no use to the patient and cannot be used to improve the patient's health. There are four classes of screening tests, and I will discuss them each in turn, as well as discussing how to interpret tests and their basic limitations. Just bear in mind (except for a few tests such a red cell blood count and oxygen saturation) that a negative test proves absolutely nothing, that any abnormal test should be repeated before acting on it or worrying about it, and that NO DOCTOR EVER GOT SUED FOR ORDERING A TEST, but only for not ordering one.
The first consideration is the ability and skill of the interpreter (and in the case of ultrasounds such as cardiac echoes, the skill of the technician) and the skill of the laboratory tech.. There are two different terms to describe the error due to the observer/reader/interpreter: inter-observer variation and intra-observer variation. Recall that at the bottom of all mammogram reports is a statement that they can miss cancer 10% of the time. The inter-observer variation, for X-rays, is the percentage of times that a another radiologist differs from the interpretation of the first radiologist. The intra-observer variation is the percentage of times the first reader will disagree with him/herself when he/she re-reads the X-ray one year from now. Neither percentage is ever reported with the test result (which is usually 5 to 15 %).
Next, we have the standard error of the test. The "normal" range given for a blood test is usually the United States average (?men ?women? ?ethnic group ?age range) for the test in question plus or minus two standard deviations. Therefore at least 5% of patients are "abnormal" in any given test without having an illness. Racial variation is never mentioned, but I know from experience that females of a certain racial group average 3.5K in their white blood cell count, and not 4.5K. For that matter, all Inca Indians are blood type O, which will affect some of their blood tests. However, the standard error of the test itself is never given (hematocrit from the hospital lab = 45% +/- what %?). No blood test is 100% accurate, and the error bars are vital for proper interpretation of the test. I will not even start to discuss the diurnal variation (cortisol is higher in the AM, serum iron is higher in the PM), or the fact whether a male gives an AM urine sample standing or lying down can affect the % of protein in the urine, and that many joggers will test positive for blood in their stool (and possibly their urine) on the days that they jog. So when you see a numerical lab test posted, you are told the "normal" range, but never the probable per cent error in the measurement itself, which may be larger than the gap between the patient's value and the "normal" one. And what if a patient's test value has an annual variation? We know that gastric and duodenal ulcer bleedings used to peak in the spring and the fall. What else can vary with time? For that matter, has any one seen a table of the variation in the basic lab tests throughout a female's menstrual cycle? And please remember that the absolute systematic lab error and the interpretation variability of the observer, lab tech or radiologist should be added because these errors are independent of each other.
A screening test is ordered for one of four reasons: (a) you are having surgery, and the anesthesiologist or surgeon insists on it, (b) the doctor thinks it will be of benefit in managing your health, (c) the patient asks for it, either for himself or because a spouse or a friend, or an article suggested it, and (d) a van pulled up to his nursing home or city hall and offered the screening test for a "special" price (usually an ultrasound of your carotid and femoral arteries, and your abdominal aorta.).
The fourth reason seems to me to be morally and ethically wrong on the part of the tester. He/she performs the test, and then takes absolutely no responsibility for applying the results to you, but instead essentially abandons you (after taking your money) and tells you to take the results to your doctor. This is a violation in spirit of the Hippocratic Oath.
When the patient or spouse or friend asks for a test, I used to try to explain why that test might not be indicated (e.g. a cardiac stress test in a young patient who has had chest pain from an anxiety attack). But, since even "healthy" young adults can drop dead suddenly, the better part of valor is to order not one, but two stress tests (echo and thallium) and then refer the patient to a cardiologist as well, thus minimizing the chance of a malpractice suit. As far as Chest CT scans for coronary artery calcification is concerned, why not cut to the chase and do a stress-thallium test, to see dynamically how well the coronary arteries nourish the muscles of the heart?
Almost all screening blood tests for cancer are suspect, with the exception of alpha-fetal protein or beta-HCG in patients with chronic hepatitis or cirrhosis who you are screening for hepatocellular cancer. The other tests: CA-125, CEA, CA-19-, CA-15-, etc, are not useful to test for the presence of the disease, nor is a vaginal ultrasound to look for ovarian cancer. The blood tests are, however, useful after the cancer has been found and operated on, to screen for recurrence of cancer.
I have deliberately omitted any mention of PSA, because there is not yet any conclusive evidence that treating prostate cancer saves lives.
The jury on whether CRP has causative value or is just a marker similar to the elevator arrow in the lobby is still out. The latest study was a meta-analysis; for a general criticism of this type of study I refer you to an earlier blog of mine "Analysis of Meta-Analysis".
TSH, or Thyroid Stimulating Hormone is another useless screening test. The body runs on free T4 (actually free T3, but you need to measure that only if you suspect T3 toxicosis). If the TSH is off, then doctors measure the free T4. But I just start with the free T4---why stick the patient twice? I of course repeat the measurement of free T4 along with TSH before starting treatment. Anyway, historically the TSH was easier and cheaper to measure because free T4 is measured by radioimmunoassay (and Rosalind Yarrow got the Nobel Prize for developing the technique of measuring hormones by radioimmunoassay, but because she was a woman and worked at a VA hospital, she couldn't get her early work published in the Journal of Clinical Investigation). But now both T4 and TSH are same day measurements, so if your doctor screens with only the TSH, he is doing you a disservice. Some doctors will measure the free T4 and the TSH at the same time, which makes perfect clinical sense. There is also no evidence that if the TSH is elevated and the free T4 is normal that you need thyroid supplement. In fact, excess thyroid hormone can lead to osteoporosis.
Periodic chest-Xrays and sputum for cytology every 3 months have not been found to be useful to discover lung cancer at an early, curable stage, according to two studies, one at the Mayo Clinic, and the other at Johns Hopkins. The question of the usefulness of spiral chest CT to detect early lung cancer is being studied right now.
Question: how often should a pap smear, a mammogram, and a stool for blood, all of which are useful in detecting cancer at an early and curable stage, be offered to the patient? Once a year, once every 6 months, once every three months, once every month? No one has ever tried to determine the optimum testing interval for any of these tests.
If an anesthesiologist or surgeon requires a test, then you have no choice, unfortunately, because the surgery will not be done without them. An EKG in the previous 6 months is a reasonable request, because the repeat heart attack rate is elevated during surgery for 6 months after a heart attack. However numerous studies (see the Cochrane reports) have shown that pulmonary problems and bleeding problems can generally be detected by a proper history and interview, and a Chest Xray, and the clotting tests PT and PTT are not routinely needed. On the other hand, if there is unexpected bleeding or pneumonia after surgery, someone might get sued if the tests were not done, even if the USPHS guidelines do not recommend them.
Finally we have the question of how to handle a patient who refuses a test. It would seem logical to just make a note in the chart. However, several years ago, a female who refused pap smears for 5 years in a row developed cervical cancer that was ultimately fatal. Despite the documentation of the patient's refusal, with the note in the chart signed by the patient, the plaintiff lawyer for the estate claimed that if the doctor had really explained the risks of not doing the test, and the patient had really understood them, she never would have refused the test. The California jury found for the plaintiff! Consequently, many doctors will "fire" patients who refuse to do certain tests.
I know of no medical use from the results of analyzing the heavy metals in your hair.
FINGERPRINTS: I know this doesn't quite fit the topic, but this should be checked out. It is absolutely true that fingerprints are unique to a given individual, and even identical twins have different fingerprints. However, that does not translate into 100% accuracy in identifying a "latent" fingerprint on an object as coming from a particular person. Recall how a California lawyer's fingerprint was identified as being on some wrapping paper they found at the deliberate explosion in the Madrid subway station but later on they found the real culprits in Europe? Two fingerprints apparently "agree" if a fingerprint "expert" says they agree, much as a psychiatrist testifies that you are sane or insane. However, if you look further into this problem of identification, there is no agreed upon standard as to what constitutes a match. How many "points" have to agree? 6,7,8? And what if some points disagree? And no fingerprint expert will ever admit that there is no "gold standard", but only a judgment call.
Lie detectors are absolutely forbidden to be used to establish guilt or innocence in US federal or state courts. They are too unreliable and non-reproducible, as well as operator/interpreter dependent. There was an article about this in JAMA 3 to 5 years ago. But the CIA and FBI still use them, and DA's often request them.
Urine screening drug tests. The best book about this is probably still Abbie Hoffman's "Steal This Urine Test". The urine tests usually only test for a chemical fragment of the forbidden chemical, and are therefore not very reliable. Also cutoff values are needed for a test to be positive. If the cutoff is set too low, there will be many false positives. For instance, co-nicotine is a metabolite of ordinary vegetables (especially tomatoes) as well as nicotine. So if your urine tests positive for co-nicotine, are you a cigarette smoker or a vegetarian? And remember when Elaine on the "Seinfeld" show flunked her urine test for opium because she had eaten a poppy seed bagel? That has happened in real life as well.
Finally given the fact that 5% of patients statistically are expected to be abnormal on any given blood test, the odds that you will have one abnormal result from a panel of 20 tests when you are healthy is approximately 50%!
And ask your internist if he/she personally reviews ALL Xrays and ultrasounds taken of his/her patients with the radiologist, whether or not the report is normal. I always do, and the Xray report gets modified 10% of the time. Just as in my intern days, the most common overread is cardiomegaly on a chest Xray because the patient did not take a deep enough breath.
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