YOU’RE DAMNED IF YOU DO, YOU’RE DAMNED IF YOU DON’T

Sometimes, you just can’t win!  In medicine, sometimes is way too often!  “Doc, do I need that test?” published in February 2011, reviewed the issues surrounding screening colonoscopy exams.  The dilemma is always the same.  Do I order a test or don’t I?

If I order a test, there are consequences.  Some are obvious; some are not.  Tests cost money and money is in short supply.  One consequence of ordering a test is that my patient may be held responsible for a big bill.  Having to pay for the test may well stress my patient and his/her family.

A second consequence is that the test may not prove anything or help make a diagnosis.  In this case, not only have I wasted hard earned money, but I have frustrated my patient.  Ordering too many tests that turn out normal shakes your patient’s confidence in your abilities as a doctor.  It may also lead to the accusation of profiteering or practicing defensive medicine.  In reality, a negative test helps remove items from the “Differential Diagnosis” list and helps make an accurate diagnosis.

A third consequence is that a positive result may lead to more testing, more expensive and more risky procedures.  PSA testing is used to screen for and diagnose prostate cancer.  A positive PSA test is suggestive of a problem but certainly is not definitive.  If your PSA is elevated and your digital rectal exam is normal, your doctor may simply repeat the test in a few months to monitor the situation.  If there is any question of malignancy, your doctor will probably refer you to a urologist for further testing.  Further testing often entails multiple biopsies of your prostate, painful and expensive procedures.

As a physician, you are really damned when the positive blood test leads to a biopsy and the biopsy is negative!  Rather than being happy that he does not have prostate cancer, your patient is pissed that he had to have a biopsy and even more pissed that he has to pay for everything.

You are also damned if you don’t order a test!  Fail to order a test that might have revealed a disease at an earlier date and your patient will be even more pissed!  

“Cyberchondria,” a relatively new phenomena, is a disease in which patients read about illnesses on the internet and then convince themselves that they have those illnesses.  They often come in requesting an assortment of tests, some expensive and some invasive in nature.  While making your patient happy is preferable, ordering a barrage of tests without clinical reason is both wasteful and inappropriate.  The patient who thinks they have “XYZ” disease wants an MRI of his/her brain.  “XYZ” is extremely rare and present only in people of Asian origin and your patient’s family is from Hoboken, New Jersey, having come over on the Mayflower.  Do you order the MRI? No!  You explain that you see neither signs nor symptoms of “XYZ” and look for another cause for the patient’s ailment.  The patient eventually finds   a “real” doc who orders an MRI and is pleased to find that they don’t have “XYZ.”  They tell everyone you are a “quack”, don’t listen to your patients, and don’t care.

You are really, really damned when the MRI verifies that your ex-patient is the first non-Asian in medical history to have “XYZ.”  

So, as a physician, what do you do?  How do you win?  You partner with your patients.  You make your patients responsible members of the medical team.  You help educate your patients to the benefits, risks, limitations, and costs of testing and treatments.  You listen to your patients and offer your best advice.  You write a nightly column.  Then you say a little prayer!  May you be so blessed as to never know the disease you prevented.

ED

If you watch TV or use the internet, you’ve probably have seen commercials for ED (erectile dysfunction).  I’ve seen three different commercials for ED.  The message is a simple one; men, you have to be ready at a moment’s notice, so take a pill.  ED is common.  Fifty two percent of men between the ages of 40 – 70 have ED.

Recently, I was at a lecture on ED and impressed by a quote from Tiefer and Melman, “Erection is truly at least a sensory-motor-neuro-hormonal-vascular-psycho-social-cultural-interpersonal event.”  Yes, the male erection is much more complex than just taking a pill.  Being ready at a moment’s notice relies on many things coming together all at once.  Is it any wonder 52% of men between 40 – 70 years old have ED?

So, is the pill the answer?  Not really.  There are multiple risk factors for ED including high blood pressure, high cholesterol, diabetes, smoking, low T (testosterone), alcohol abuse, drug abuse, anemia, coronary artery disease, Peyronie’s disease, vascular surgery, depression, and obesity.  With such an impressive list of possible causes, a medical work-up should be performed and associated causes should be appropriately treated.

“Erection is truly at least a sensory-motor-neuro-hormonal-vascular-psycho-social-cultural-interpersonal event.”  Note that psycho, social, and interpersonal relationships can be significant factors in ED.  Trying to over-ride psycho, social, and interpersonal issues with a pill can be perilous.  Facing psycho, social, and interpersonal issues can be difficult but rewarding in the end.

The most interesting material addressed during the lecture was the effects of lifestyle changes on ED.  Exercise had the ability to improve ED in the studies quoted.  As exercise also improves high blood pressure, high cholesterol, diabetes, coronary artery disease, and obesity, as well as improves ED, EXERCISE!

Over the last few years, I have written many articles extolling the benefits of exercise.  Convincing patients to exercise is difficult at best.  Now I have one more reason why men should exercise!

So, men, if you want to optimize your erection, exercise!  Women, if your husband’s ED is a problem, get him a membership at the local gym and workout with him.

If all else fails, chill and take a pill.  First, make sure your doc agrees that it is safe to take a pill and you have reviewed its risk with your pharmacist.

PREDICTING STORMS

Published on February 17, 2015, this concept is still relevant and understanding it may save your life.

While I would like to believe that I am better at predicting storms than the weather- man, unfortunately, I am not.  If you are wondering if I’ve lost it, I haven’t.  Yesterday, my first patient of the morning left the office by ambulance.  After taking a careful history and performing a thorough exam, my assessment was that he was in imminent danger, much the way the weatherman declares a tornado/storm alert.

Yes, a major storm was in the making, one we docs call sepsis.  Calling in the paramedics is the equivalent of calling up the National Guard.  As always, they responded quickly and efficient, securing my patient against what could have proven to be a major tempest.  Today, my patient is much better.  The storm has blown over and, thanks to G-d, was nowhere near as devastating as I had predicted.

Unfortunately, there are times when medical storms strike fast and appear from nowhere.  No matter how good my patient and I are at practicing preventative care, there are many occasions when medical twisters touchdown in our lives wreaking havoc.

So, what can we do?  In the case of a severe weather alert, most of us get busy securing our homes, checking on our flashlights, making sure we have gas for our generators and snow blowers and fill our pantry.  We check on our loved ones and neighbors and then hunker down for the night.

In the case of a medical alert called by your doc, respond promptly, heeding his advice.  If the doc says, “Call 911,” call 911.  Take proper precautions.  If your doc warns of an approaching storm in the form of a future heart attack/stroke/diabetes, take action by improving your lifestyle, complying with medication and seeing the specialist when recommended.

Yes, my predictions are often wrong.  When I warn of impending doom and it fails to develop either due to your precautions or not, I’m one happy camper.  Now, if I can only figure out how to predict those sudden acts of terror that occur when illness is lurking in the wings but invisible to the modern medical eye.

PEELING AN ONION

Often, I use the analogy of peeling an onion to help my patients visualize their illnesses and health.  An onion has many layers, each unique yet looking similar to the ones next to it.  Each layer of an onion affects all the other layers.  

When you buy an onion at your local supermarket, the outside layer is often thickened and discolored.  In order to assess the quality of an onion, you often have to peel away the outside layers until you reach the healthy core. 

When dealing with humans, physicians often have to get past the thickened, discolored outside layers of a person’s life in order to reach the healthy, vital core of their patient’s existence. 

“Doc, I don’t feel good.  Do you think it’s stress related?”

“Doc, I’m having problems maintaining an erection.  Do you think I have low T?”

“Doc, I have . . .  Do you think it’s  .  . .?”

Solving my patient’s problems often means peeling back the layers of his life, carefully, one at a time.  Rarely is there a simple cause for human suffering.  Most of the time, the bad layers adversely affect the good layers; and, sometimes, it is impossible to discern which layer is the culprit.

When something is bothering you or making you sick, carefully peel back the onion and explore what is under the surface.  Share your findings with your doc; it will help him help you.

DIVORCE

This article was published in March of 2014.  It is even more relevant now:

Happy Anniversary, Renee. Forty one years of marital bliss! It seems like just yesterday that we said, “I do.” It’s been a great 41 years. Of course there’s been both good and bad times but we’ve weathered them together.

I think the secret to a good marriage is “WORK.” Yesterday’s article addressed divorce. Marriage is like a house a couple buys and settles into. Imagine living in a house which has never been kept up, repaired or cleaned. After 37 years of neglect, it would be uninhabitable.

Unfortunately, many of my patients take their marriage for granted, never bothering to tidy up little messes or simply sweeping them under the carpet. I’ve often imagined that each of us has a large steamer trunk in which we shove little tidbits of unaddressed problems into. After years of accumulating junk, the contents of the chest begin to rot; and, when we open it to shove in the latest junk, the trunk threatens to explode its rank contents onto us and those we love. So, we try to seal the trunk and move on or we try to empty the trunk ourselves.

Think about it for a minute. Many of you own just such a trunk and those tiny tidbits of garbage have grown into monsters over the years they have sat, rotting in that trunk. Do you really want to open it on your own? I think not.

Marriage counselors are trained professional whose job is to carefully open your marital steamer trunk of neglected problems and, one by one, disarm them. Let me give you an example. The following is a true story.

I once had a couple whose marriage was disintegrating rapidly. While talking with them in the office, I challenged the wife by noting that her anger appeared to be markedly out of proportion to anything her spouse had done. Surprisingly, she responded, that 27 years ago, her husband had insulted her mother’s cooking by criticizing her meatloaf and that she would never forget the hurt look on her mother’s face. The husband’s dumbfounded look on his face was accompanied by the emphatic statement, “But I loved your mother’s meatloaf and everything she cooked!” He had no recollection of ever insulting his mother-in-law’s cooking. The other fact you need to know is this gentlemen was a 300 pounder and obviously enjoyed eating!

A minor misunderstanding 27 years ago had been left to rot at the bottom of a trunk in this woman’s mental closet and had ended in the threat of divorce. Why hadn’t she said something 27 years ago? Probably it was just easier to sweep it under the rug and go to bed.

The moral of the story is simple! If your marriage has been neglected, is stale or worn and dirty, don’t throw it out. Get some help. Talk to your doc and find a good counselor and get to work restoring it to its original luster.

From a strictly personal point of view, watching my patients go through the misery of separation and divorce drains my energy and you don’t want to do that, do you? So get to work and fix it now. Spring cleaning can be more than just fixing up the house and working in the yard!

(Renee’s addendum: Happy Anniversary, Stewart! When both of us have to ask each other how many years we have been married and then actually mathematically calculate the number of years, I’d call that a good sign.  It takes communication, even when it’s hard. As you said, marriage is work and is always a work in progress as we change with age and the stages of our life. We’ve always tried to remember that, in the end, it was going to be the two of us left after we had raised our children and cared for our parents. We are finally there. Here’s to us and our future! Thank you for a great 41 years!)

FOLLOW UP

I have a new job!  Yep, my new full-time job is seeing my assortment of docs and following up on their orders.  I just saw my urologist who prescribed a new medication and a lab test to be done in 2 weeks to monitor the new medication.  I’ve already made an appointment to have blood drawn and will follow up as directed.  Don’t worry, I’m ok.  I’m just an old man who stops at every bathroom he walks by.

Below is an article I wrote about this subject:

Please, don’t get mad at me! When I last examined you, I gave you instructions on when to follow up with me. I gave you prescriptions for enough pills to last you until our next visit. I told you to see me before you ran out. Now you are running out and being seen in the office doesn’t fit with your schedule.

Medications are prescribed for very specific reasons. Each medication comes with its own benefits and its own risks. Monitoring your medications for both effectiveness and harmful side effects is my responsibility. You are supposed to be my partner in this endeavor. I need your help!

Making me the bad guy is not in anyone’s best interest. I don’t like holding your refills as hostage to your next visit; but, over the last many years, I have come to the conclusion that putting off your doctor’s visit is a universal human trait. Everything is more important than following up with your doctor!

After all, you feel fine. I’m happy you feel fine. My job is to keep you feeling fine. If the medicine I prescribed for you is injuring your liver, there are two ways of finding the problem. My preferred method is to monitor you for liver injury on an appropriate schedule. The second way is to wait for you to turn yellow. Appropriate follow up and monitoring of potential side effects makes more sense than treating rare but serious side effects, doesn’t it?

Unfortunately, the electronic medical record and the “portal” make it too easy to dodge your follow up visit. Sending me an electronic request for a refill or having the pharmacy contact my office for a refill means never having to talk to my staff or your doc. In the end, you get mad at me. Your expectation is I will refill your medication without question and you will eventually see me.

While I’d like to be your friend and play the role of the good guy, I have to be your doc. I have to make sure any treatment I give you is as safe and effective as I can make it and that means seeing you for appropriate follow up.

My recommendation is that you take an empty bottle of your medication and put 2 weeks worth of pills in the bottle and put it in your medicine cabinet. When you are down to your last 2 weeks of pills, it’s time to come in. Pretty simple, huh? Help me help you. The life we save may be your own!

10 GIFTS

With the holidays coming up soon, Sara Debbie Gutfreund’s article on Aish.com entitled the “Top 10 Gifts Every Wife Wants,” is excellent and very thought provoking. The ten items she listed are:

  • Appreciation
  • Compliments
  • Empathy
  • Kindness
  • Friendship
  • Affection
  • Respect
  • Acceptance
  • Authenticity
  • Laughter

At first glance, I thought this was an excellent article and should be shared with my patients. As my readers know, I have written about the surge in divorce I was seeing in my practice. Gutfreund’s article might be an antidote to the sickness afflicting my patients’ marriages.

Then it dawned on me. Should this not be a two-way street? Gutfreund’s article should have been entitled “Top 10 Gifts Every Spouse Wants.” Then I realized that the husband’s list needs to have an eleventh item listed: sex. Now where do you think that goes on the above list?

While we are on the topic, I’m sure you’ve heard the saying, “If momma’s not happy, ain’t nobody happy.” Why haven’t you heard, “If daddy’s not happy, ain’t nobody happy?” I suspect that the answer is that momma controls the eleventh item on the list.

MY FAVORITE BLESSING

There are some things in life that, at first glance, you fall in love with. Once On Saint Patrick’s Day, one of my specialists sent a greetings card that said:

“May your troubles be Less, Your Blessings be More and nothing but Happiness Come through your Door.”

This Irish blessing will join the following blessing on my all-time greatest blessings list:

“May you be so blessed as to never know what disease you prevented.”

And so, to each and every one of you, have a blessed day and be happy and healthy.

I JUST DON’T GET IT

Sometimes, I just don’t get it! Let me give you an example. My patient is 60 years old. He lives in an older section of Lake Zurich in a house that is 50 years old. His lawn is beautifully manicured and landscaped. His house is freshly painted. The roof has recently been upgraded; the windows caulked.

The inside of his house is immaculate. Anything that breaks gets immediately repaired or replaced. The 50+ year-old kitchen functions just as good today as it did when it was new. The plumbing was updated two years ago.

In his two-car garage sits two beautiful cars. The 1998 Oldsmobile is in pristine shape. The 2006 Ford still purrs. Oil changes are done on a regular basis. Brakes and tires are checked on a schedule. As you can see, my patient believes in keeping his belongings in tip top shape.

So why am I confused? What’s not to understand? Let me share some more facts with you. My patient is in lousy shape! His frame has spread in all directions and he weighs in at 240 pounds. His chassis (back) is full of arthritis and the muscles that are supposed to support it have been neglected for decades.

He has heart disease (plumbing), diabetes, high blood pressure and high cholesterol. He has an irregular heart rate called atrial fibrillation (electrical system) caused by his alcohol intake. While he puts only the best gas in his cars, he puts fast food crap in his belly.

I get that it is important to take good care of your house. You live in it! I get that it makes good sense to take care of your car. You drive around in it. What I don’t get is how you can totally ignore and abuse your body. After all, your soul lives in it!

Unfortunately, my patients don’t get it. One day, my patient’s beautiful home will have a hospital bed in it. One day his family will wheel him in a wheelchair to the kitchen to eat. One day, his family will mourn his loss in an immaculate, well kept, old house.

Take better care of yourself than you take of your property or pay the price! By the way, this patient profile is all too common in my practice!

ARTHUR ITIS

One of my octogenarians stated that the “Itis” family was a problematic bunch and Arthur Itis (arthritis) was the worst of the bunch. After I stopped laughing and regained my composure, I realized that he was right and that I should share her wisdom with you.

The Itises are many. This time of year we see rhinitis, sinusitis, and bronchitis just to name a few. Of course, my patient’s arthritis is seen year-round and tends to become more problematic with age.  Frankly, all of the Itis family can be nasty and most need to be dealt with sooner rather than later.

Unfortunately, most of my patients put up with the Itises too long and allow them to entrench themselves in the body where many of them proceed in wreaking havoc. If you are plagued by Arthur or any of his extended family, see your doc and learn how to get rid of them and stop them from coming back. Arthur Itis indeed may be the nastiest of the bunch, and, while we may not be able remove him, at least we can contain him and limit the damage he is likely to cause.

Out of the mouth of octogenarians comes great wisdom.