#10: Do You Even Need to See Me?

Dear Dr. Tumoriffic,

Why do I need to have an appointment with my PCP to get a referral to see a specialist? If I have a skin condition, for example, why do I need to go through the time and trouble of an appointment with my doctor BEFORE I can go see a dermatologist?

Signed,
Ruprect

Dear Ruprect,

You have to see your PCP because your PCP is needy. Be kind to your PCP. Clearly, he or she is just insecure and wants to be loved. Bring them candy, and they'll refer you to a special specialist.

OR

The reasons I often bring in patients before I refer them out (or order testing) are:

1.  Often, I can diagnose and treat you myself, and I can almost always see you more quickly than a specialist can. That nasty rash you have between your legs is just jock itch. I can fix it with a good, strong antifungal cream.

2. In addition, if I cannot treat you, the information I get from seeing you gives me the ammunition I need to call the specialist and get you seen immediately instead of waiting for weeks the way you normally would. *

3. Also, you might be asking for the wrong specialist, and I may need to see you to pick the right one. For instance, your rash may be caused by Lyme disease, in which case, you don't need a specialist, you need a doxycycline prescription. Or, "why no, Mr. Smithers. That's not where your pancreas is. You actually need to see a urologist."

4. My healthcare organization does not get paid when I don't see patients. I am not like a lawyer who bills by the hour. Although I will refer a patient directly to a specialist if I am absolutely sure they won't benefit from seeing me, when I do that, the time I spend making the referral (which involves some thinking and writing) comes out of my own free time. Not all doctors have the time to do that, and some organizations may actively discourage it.

This last part is a shame. In a sane world, there would be an incentive for doctors to get their patients wherever they need to go as efficiently as possible. But our system is not based on efficient patient care. It is based on efficient money-harvesting from insurance companies.

Be well,

Dr. Tumoriffic




* For example, at my job, I can take a photo of your rash with my iPhone and get an electronic dermatology consult. The dermatologist looks at the picture and, if they can make the diagnosis based on the photo and my description of what is going on, they can treat you without bringing you in, or they can get you a faster appointment.

The Dog will see you now.

#9 Screen for Everything! Every Day!

Welcome to my new blog! After much internecine struggle, the staff at Dr Tumoriffic's Inappropriate Guide got fed up with staff at tumoriffic.blogspot.com and left in a huff. On the way out the door, they copied all of the old posts and they built this new blog.

(Most of the above is a complete lie. I have no staff for either blog. I started this one because it made sense to put the advice posts in a different place than the updates on my own health. Hopefully, it will be a long time before I have to write one of those.)



Dear Dr. Tumorific, 

Why can't I be screened for all cancers?

Signed,
Z

Dear Z,

You can! Get every lab test anyone ever heard of and more! Get a head-to-toe CT (a.k.a CAT) scan! Get more mammographies that you have boobs! Have an entire gastroenterology department climb down your throat and up your colon! Get ultrasounds in all your most awkward places! And do all of them all over again every year! *

These and more are available if you have the bucks. For instance, do a quick Google of "executive physical" paired with the name of nearly any prominent medical center, and you can find a program on which the world's worried wealthy can blow big bucks. These come with all sorts of non-medical luxuries, so, if you want something less fancy but just as medically extravagant, find a functional medicine clinic! There, you will get all sorts of tests and all sorts of expensive remedies!

So, are miserly death panels and insurance companies withholding state-of-the-art prevention from the masses? Are in-the-know doctors sneaking off to exclusive clinics for a yearly inspection? Are you missing out? No. No. NO.

These testing programs are like buying a thousand lottery tickets where the second through hundredth prizes are pointless surgeries with possible complications, radiation-induced cancers, and a whole lot of uncomfortable tests and unnecessary anxiety. Worse, when you win first prize--an early, curable cancer--it may have been harmless in the first place. But you will never know for sure. The one thing you can be sure of is that your wallet will be a lot emptier.

"But Dr. Tumoriffic," you say, "isn't screening and prevention good all the time? Don't you want to know in advance and treat early?" Ah, now there's the rub. Not all tests are good screening tests, and not all screening tests are appropriate for all people.


What is screening?

To screen is to test a patient for a condition for which they have no signs or symptoms. For instance, a routine colonoscopy is a screening test. Doing the same test once there is a problem is not screening. So doing a colonoscopy to look for why a patient who has blood in their stool is a diagnostic test, not a screening test.


Problems with overscreening:

To understand why your doctor should not overscreen you, the first thing that you must admit is that you are abnormal. For instance, the definition of 'normal' for any single lab test is that 95% of patients tested have a value within the 'normal' range. That means that 5% of healthy patients will have a value that is 'abnormal.' If I do enough lab tests on you, it is all but inevitable that one of those tests will be abnormal.** Only occasionally will one of those 'abnormal'' tests have any importance at all.***

False Positives: Unfortunately, at the current state of medical technology, most of our tests are liable to ring alarm bells when their is nothing really wrong. What's important is the context. If I do a chest CT scan on a 3 pack-a-day smoker with weight loss who is coughing up blood and struggling to breath, whatever abnormality shows up in their lung is probably worth worrying about.

If I do a whole body CT on healthy 24-year-old with no history of bad habits, I can guarantee you that there will be something strange there. And the older the patient, the more of those strange things there will be.*** Very occasionally, there may be something meaningful. But the overwhelming majority of the time, I'll just scare the heck out of the patient. Very likely, I will expose the patient to unnecessary and potentially cancer-causing radiation following a meaningless abnormality with subsequent scans, and, sometimes the patient will have dangerous and useless surgery to evaluate what turns out to be nothing. And I will make my healthcare system lots of money

Overdiagnosis: This one is really thorny. As we have done more and more screening for cancer, we have discovered that not all cancers are created equal. For instance, an article in the October 13, 2016 issue of the New England Journal of Medicine noted that, after the advent of regular screening mammography, the incidence (number of cases detected per 100,000 patients) of large breast cancers (> 2cm) decreased by 30 per 100,000. That means that, presumably, in a group of 100,000 patients, those 30 cancers were detected and cured as small cancers. Sounds pretty good, right?

Yes and no. During the same period, the number of small (< 2cm) breast cancers increased by 162 per 100,000. If mammography were perfect, you would expect the increase to be 30 per hundred thousand. Instead, there are 132 extra cases of small breast cancer per 100,000. The most likely explanation is that those 132 cancers would disappear by themselves had those patients never had mammograms!

That is not to say that mammograms are useless. They may be accountable for the 2/3 of the substantial reduction in breast cancer mortality since testing began. (The other 1/3 comes from improved treatment.) On balance, mammograms may do more good than harm. But for every 30 large tumors avoided, there are still probably 132 out of 100,000 women who had breast surgery and sometimes worse even when they didn't need it. All of them and their doctors probably consider those surgeries lifesaving, but there may be no way to tell for sure. *****

The worst of both worlds: The prostate specific antigen (PSA) test is the most troubling of common cancer screening tests. There are 26,100 prostate cancer deaths per year in the United States. A good prostate cancer screening test would be a great thing. However, the test we have is very flawed.

On average, if I tested 1000 men for PSA levels, I would find about 150 whose PSAs were high. Of those, between 40 and 50 would actually have prostate cancer. Of those, I might or might not (the two leading studies disagree on this) prevent a single (!!!) death from prostate cancer. Meanwhile, by treating those 40 or 50 prostate cancers, I will have caused a lot of men to be forever impotent, forever incontinent, or both. I will also have caused other painful complications.

But how can this be? Why did 150 of those men have high PSAs? What happened to all those guys whom I didn't save?

1. Most men with high PSAs do not have prostate cancer. They have benign prostatic hypertrophy. That is a nonmalignant enlargement of the prostate that eventually affects all men and may or may not raise the PSA.****** 
2. Most prostate cancers grow so slowly, men with prostate cancer are much more likely to grow old and die of something else. Prostate cancer is incredibly common. Most of the time, though, it grows very very slowly. Autopsies of men over 55 who die of other causes show that 30% of them had prostate cancer. Autopsies of men over 80 show that 2/3 of them have prostate cancer.*******

Is the PSA a useless test? Far from it. The PSA is very useful in watching men who have had prostate cancer to see if they are having a recurrence. It also is useful in men at high risk for developing dangerous prostate cancer. Otherwise, I skip it.


Also, there are other tests which are completely useless, many of which are offered by various quacks. But that is a topic for another time.


So what should Tumoriffic readers take away from this? Medicine is always getting better, but it's not perfect. Doctors promising to screen for everything are likely more concerned with your money than your health.

Oh, boy. Next post should be something less complicated!

Be well,

Dr. Tumoriffic





* And cancer screening is just the beginning. You can get stress tests and coronary calcium CT scans for your heart, ultrasounds for your carotid arteries, and more!

** Thus, every single person who reads this blog is a weirdo in some way or other. Even if all your lab values are normal, that's weird too.

*** If you do an MRI scan of MY head and see something suspicious that is new, chances are pretty high that it's cancer. Even so, not always. (See tumoriffic.org and, more recently, the post starting with http://tumoriffic.blogspot.com/2016/07/tumoriffic-rides-again.html)

**** Generally, a functional medicine doc will tell you these 'abnormal' tests are causing your back pain, your headaches, your dizziness, your fatigue, your angst, etc. with all sorts of useless nostrums that relieve you of nothing but your money. If you don't feel better, there must be more things wrong, and you win another round of testing and so on. If no remedies work, then you're doing it wrong, but the functional medicine doctor is never wrong. (See https://sciencebasedmedicine.org/functional-medicine-in-practice/) (And if you get better, chances are that had nothing to do with the 'treatment.' Minor problems tend to get better on their own. But that's fodder for a whole other post.)

***** http://www.nejm.org/doi/full/10.1056/NEJMoa1600249http://www.nejm.org/doi/full/10.1056/NEJMoa1600249

****** I tell my male patients that the only things that grow for your entire life are your ears, your nose, your feet, and your prostate. If men live to be 200 years old, we'll all be walking around with basketballs between our legs.

******* All stats come from an UptoDate Prostate Cancer Screening article. Unfortunately, it's behind a paywall, so you can't have it!

The only kind of CAT scan everyone should get:

#8: Your Special Specialist

Dear Dr Tumorific, 

How can I know which doctor at the specialist practice to see?

Jay

Dear Jay,

This is a very special question. There are many ways to do this.

For instance, if you would like to use the guidance of the spirits, print out pictures of all the specialists in the specialist practice. Then paste them to a Ouija board. As the paste dries, burn some incense and douse yourself in patchouli oil (at least 5 feet away from the burning incense so as not to light yourself on fire). Clear your mind, and let the spirits of the medico-industrial complex guide the planchette (Ouija piece) to the answer.

If you're less spiritually minded, you could tack that Ouija board to the wall and throw a dart to pick your specialist. Why did you even have a Ouija board in the first place?

Finally, there's the superficial method. If looks can kill, they can also save your life. Peruse the photos. Which one looks most doctorly? Do you prefer red-headed doctors? Are you more comfortable if your cardiologist is ugly? It's all a matter of taste.

But, if you want my real opinion, it's complicated. There are a lot of factors. I am going to interpret the question broadly. I'm not going to talk not just about how to choose a specialist within a given practice, but how to choose any specialist anywhere.

1. This is the most aggravating, but, for many, the most important question to answer: which specialists take your health insurance? More and more, insurance companies are making deals with specific groups of doctors, and if you go to someone outside those groups, you have to pay a higher price, or in some cases, you won't be covered at all. 

Sometimes, your primary care doctor can get special exceptions, but the insurance company will then penalize the primary care doctor's organization financially. This puts primary care docs like me in a tough situation. We would like our patients to go wherever they want to go, but if we ask for too many exceptions, we will get in trouble with our employers. But when we don't think an exception is warranted, we end up being the bad guys by telling our patients they can't get what they want, because, let's face it. almost no one reads their insurance contracts, so the fact they can't see their friends' 'great specialist' comes as a nasty surprise.

2. Next, where is the specialist located? Assuming you're not a medical oddball like me, convenience may be a good way to find a specialist. Especially if you are elderly and have a hard time going places, Dr. Nearby may be the best for the job.

3. Also, which specialist works best with your primary care doctor? Like all primary care docs, I have a few people in each specialty who see almost all of my patient referrals. I know them, like them, and trust them, and I can get ahold of them easily. There are some who will call me within 5 minutes if I text them. I even bug them about random questions when I'm not sending them patients. And if I am sending them a complicated case, I will call and talk to them about the details instead of just sending them a brief written referral request. All else being equal, ease of communication goes a long way towards quality of care.

4. Finally, how special do you need your specialist to be? Aside from intelligence and conscientiousness, the quality of a specialist for a given problem depends largely on how often they see and deal with the problem.

You don't need to go to a medical Mecca to find a gastroenterologist who is an absolute wizard with a colonoscope, and you do not need to go looking far afield for the world's greatest hip replacement surgeon. There are doctors all over the place who do dozens upon dozens of these procedures all the time.

But on the other extreme, you could be like me and have a type of radiation-induced tumor that is rare even among radiation-induced tumors and in a very difficult to reach spot in the bone under my right eye. In 2005, I could have gone to the highly prestigious Wicked Famous Cancer Hospital in my home town and been operated on by very eminent surgeons who had never before worked as a team, much less done my operation ever before. (No kidding! I was going to be their very first case together!) Instead, I chose to go 215 miles away from home to a team of the F'in' Famous Cancer Hospital who did 50 of those surgeries a year. As a result, I still have my right eye. (See http://www.tumoriffic.org/Part%20II.htm, April 17, 2005, The Clash of the Surgeons, or The Eyes Have It!)

The most common way to locate one of these super-specialists is to know somebody who knows somebody, or to ask your doctors, who hopefully will know somebody who knows somebody; I call this the Medical Mafia.

You or your doctor could also look up who is getting NIH grants in that area (https://projectreporter.nih.gov/reporter.cfm), or research who is publishing articles about their work on similar cases by searching in pubmed (https://www.ncbi.nlm.nih.gov/pubmed/).

So, how to find the right specialist is a very special question. Thanks, Jay, for another good one.

Be well,

Dr. Tumoriffic

#7: The Never Ending Prescription

Dear Dr. Tumoriffic,

Why does it take so long to update my med list in the EMR? I haven't taken that med for 5 years.

Liz




Dear Liz,

The reason is that your medical record is constipated. Clearly, it has not been eating enough fiber. Now, it's paying the price. I recommend you give your medical record prune juice. If that does not work, try giving it Colace. If that does not work, Miralax.

If it's still holding back, desperate measures may be called for. The next step is an soap suds enema. Giving an enema to a medical record is really unpleasant. They tend to struggle, and, if you are successful, it's really ugly. I would wear an apron and put lots of newspaper on the floor.

Finally, you may have to institute the measure of last resort, the manual disimpaction. This is one of the most unpleasant procedures you can perform, both for you and your medical record. You should definitely wear gloves and hold your breath for as long as possible. However, the result is likely to be cathartic for both you and the medical record.

Once your medical record has become regular, it should be able to update itself just fine.

Of course, if your medical record is already regular, there are other explanations. Some systems, like my dearly beloved Epic, do not automatically discontinue medications that obviously should be discontinued. For instance, the short course of azithromycin (after a buttock injection of ceftriaxone) for gonorrhea should, clearly, automatically stop. If the patient needs it again (and I have had patients like that), the patient should at least come in for a stern talking to about condoms before getting a refill. If your doctor is not rushed and thinks of it, they can write in a discontinuation date for the medication, but the fact that they have to do that for obviously short term medications is ridiculous.

Another possibility is that your medication was discontinued by a doctor who uses a different electronic medical record system. As of right now, there is no automatic way for your pharmacy and your other providers to know when a medication has been discontinued by another doctor. As a primary care provider, theoretically, I get all specialist notes, and I try hard to look through them for important details like discontinuations, but it's time consuming.

It's also very dangerous that pharmacies are not automatically notified when a doctor wants a patient to stop taking a medication. Especially with men and older patients, the patient may not know exactly which pill they are supposed to stop. So, unless the doctor's office calls the pharmacy and tells them not to refill, the patient may continue taking that medication and continue to get that painful genital rash that it causes.

In the end, it often falls to the patient to know which medication to stop taking and to remember to ask your physician to update the EMR manually. You need to keep careful track of your own (and maybe your parents' and grandparents') medications. That's not how it should be. It's highly dangerous, but that's how our messed-up system works. Sorry for the bad news.

Be well,

Dr. Tumoriffic

Getting Your Ducks in a Row

#6: Pills, Pills, and More Pills!

Dear Dr. Tumorific, 

I can't remember the name of the medication I take, it's round and white. Do you know the one I'm talking about?

D

Dear D,

Take this to heart:

One pill makes you larger, and one pill makes you small,
And the ones that mother gives you don't do anything at all.

--Jefferson Airplane


Pills, pills, and more pills. A round, white pill has the blandest of all shapes and colors. I need more information.

Is it a big pill, or a little pill? Is it tasty, or gross? What happens if you give your husband five or six of them? If they're sildenafil (Viagra), you should know right away. If it's a water pill, like furosemide (Lasix), that should be pretty easy to identify this way, too. Still don't know? Give him more! Of course, he may end up in the emergency room getting his stomach pumped, but, sometimes, that is the price of knowledge.

Okay, okay, just kidding. Do not, under any circumstances, take a whole bunch of pills you can't identify, or give them to someone else!*

The sad truth is that most of the time, we doctors have no idea what the pills we prescribe look like.** It's not our fault. Even for a single type of medicine, different manufacturers make pills that don't resemble each other at all. Sometimes, different doses from the same manufacturer don't look similar and may be nearly identical to entirely different medicines.

This can lead to dangerous or amusing situations. For instance, one friend of mine was on vacation and mistook his sleeping pills for his blood pressure pills. He then went to after-dinner cocktails and had a couple of very delicious margaritas. Even though they were small and did not taste strong, he quickly found himself quite soused.

Manufacturers could, theoretically, have some uniform standards for pill appearance (antidepressants could be blue, water pills could be yellow, and so on), but they don't. So I have no clue what your pills look like. But I do get asked questions like yours quite frequently. It happened last week. Especially as they get older and have more medical conditions, patients often don't know what it is they are taking. The complexity of the names of the drugs makes it harder. ***

A couple of weeks ago, I stayed at work quite late, taking 45 minutes to explain a patient's asthma meds to him over and over again. I then called his daughter and explained them again, because the patient seemed a little demented. The patient then came in last week and complained that I didn't bother to explain his medications. There's no pleasing some people. Another patient had been taking a medication I meant for him to stop, but actually stopped taking a medication I only wanted to change the dose on. I think I explained it pretty well, but it didn't sink in.

Try to remember what it is you are taking and why. If you can't remember the names of all of your medicines, bring the bottles in whenever you go to the doctor. Better yet, bring someone you trust with you to write them down and make a master list of the names, doses, and what they are for, including vitamins and supplements. And if you have a family member who has complicated medical problems, maybe you should volunteer to go with them to the doctor.

Digression: This is part of a larger point I plan to repeat a lot. Try NEVER go to a doctor for a complicated problem without a helper you trust. This is true if you are 93 and having memory problems, or if you are young and have a great memory. It has been true for me during my various Tumoriffic adventures. My wife is always at my side, writing things down and coming up with questions or remembering ones I forget to ask. It can be disorienting and scary to be a patient no matter who you are or how much you know. Here endeth the lesson.

So don't pay too much attention to whether your pills are red, white, or blue. Learn their names, and try to remember what they do. Yes, it is my responsibility to do my best in the limited time I am given to explain them to you. But ultimately, no one can pay as much attention to your own health as you and your family can. Know your pills.

Be well,

Dr. Tumoriffic



* Strangely enough, there is a thing called a pill party. People will come to the party and drop a bunch of pills in a jar and mix them up. Then, party-goers will just take random pills. I'm sure I could break such a party up pretty quickly if I brought a bunch of laxatives.

In other crazy pill lore, there was a rock star in the 70s who would accept random pills from his adoring fans and take them immediately. I don't think it was a member of the Grateful Dead, but it could have been. Please tell me in the comments if you know.

** A major exception would be the occasional generic Adderall pill one might find around the call room during residency.

*** The names of generic drugs are often purposely difficult to pronounce and remember. That way, the doctors and patients will have a comparatively easy time remembering the brand name when the patent runs out, so they are more likely to prescribe the brand rather than the less expensive generics.

Ginny says, "know your pills!"

#5: The Top 10 Reasons to Come Back After Labs

Dear Dr Tumoriffic,

My labs were drawn three weeks ago--why do I need an appointment to know what they report?

Jay

Dear Jay,

Here are the top 10 reasons your doctor is making you come in for an appointment to tell you about your lab results 3 weeks after they were drawn:

10. Your doctor is lonely. See, a good doctor is like the Maytag repairman (Google it, youngsters!). No patients ever come to visit, because he or she does such a good job keeping them healthy.

9. Your labs will reveal that you have an embarrassing disease, and your doctor just wants to see the look on your face and laugh maniacally like some comic book villain.

8. You're their very favorite patient.

7. There is no number 7.

6. Ed McMahon will be waiting to award you the Publishers' Clearinghouse Sweepstakes grand prize.

5. It's a trap! Run away!

4. I'm tired, and it's late, so I'm skipping to the serious ones.

3. The results have not answered the diagnostic question the doctor wants answered, and they want to get you in to examine you again and ask more questions.

2. The results show that something serious is wrong, and your doctor wants to tell you in person.

1. Your doctor's employer is very stingy. Insurance companies don't pay for the time your doctor takes to write a letter or make a phone call. They pay when you come in. This is the least likely answer, but things are getting so cut-throat in the health industry, I wouldn't put it past them. Stay tuned. It may be standard practice in a few years.

Be well,

Dr. Tumoriffic


PS: Addendum for issue #2, about why doctors don't know what things cost.

Jay said: This one needs an addendum: doctors not knowing how much their own visits cost.

This a good question. I don't know. The insurance company pays whatever their contract with the health care organization says they pay, so it's practically unknowable. Out-of-pocket visits are rare and vary from place to place. Kind of sad, really. I don't know whether my patient is paying a ridiculous co-pay for a visit just to hear about their labs 3 weeks after they are drawn.



Another shamelessly cute picture to make you look at my blog:

#4: Why, Oh, Why No MRI?

Dr. Tumorific,

Why are you refusing to order an MRI every time my yoga instructor thinks I need one?

Nina

Dear Nina, 

Clearly, your question was a bit tongue-in-cheek, so I will answer it with the utmost seriousness--but in rhyme. It doesn't scan too well, but dammit Jim, I'm a doctor, not a poet!


Why, Oh, Why No MRI?

Patient:
Why can't I get an MRI?
My back, it hurts! I want to cry!
A nasty pain shoots down my thigh!
I think it's cancer! I might die!

Doctor:
Is it worse at night, or when you wake? 
Is it worse with rest? Do both legs ache?
And is the pain on your back bone?
Or to the side when it makes you groan?

Has your leg gone limp and weak?
Your crotch gone numb? Your anus leak?
Is your pee messed up? No? Then don't freak.
Most times, it's gone within 6 weeks.

Patient:
But can't a surgeon fix my spine?
This one bad disk that's out of line?
I'm in such pain, oh doctor mine.
Just operate and make it fine.

Doctor:
I've seen a thousand painful backs
That have been hacked by surgeon quacks.
And docs with whom I'm  much impressed
Might bat 500 at their best.

Your pain's so bad, it makes you curse,
But surgery might make it worse.
We spend more bucks on aching backs
Than all but diabetes and heart attacks.

We haven't got a treatment yet,
But we might hook you on Percocet.
So unless your story rings a bell,
An MRI has naught to tell.

So though it hurts, it's much more wise
To do some gentle exercise.
And in a month or in a day,
It almost always goes away.

Be well,

Dr. Tumoriffic


PS: Got a question you'd like me to post about? E-mail tom@tumoriffic.org!

Beware of quacks!