#13 Talking About the Elephant in the Room

First of all, I'm rededicating myself to this blog. I got off-track after getting a little behind on paperwork. A nightly (QHS *) post was too ambitious. However, a weekly (Qweek **) post, maybe with a few extras sprinkled in on easy weeks, should be doable. It will just take a few more decades to have enough to make a book and get to the top of the New York Times bestseller list.

So here goes. . .


Dear Dr. Tumoriffic,

How long should I wait before I call you when I, for instance, feel like I have an elephant sitting on my chest for X minutes, can't catch my breath when I walk, etc.?

Signed, 

Ms. Z



Dear Ms. Z,

You are asking a big, and very important question. Basically, what are some really scary symptoms I should call my doctor (or my priest) about really quickly? The answer will not fit in a single post. It deserves several. So, here we go.


How long should I wait before I call you when I feel like I have an elephant on my chest?

Does 'Z' stand for Zookeeper? If so, there is a finite chance that an elephant is literally sitting on on your chest. In that case, I would call immediately. An elephant on your chest is an emergency.

After quickly consulting online textbook, Up-to-Date, I would advise you to give the elephant's wiggly bits a firm pinch. It will stop sitting on you immediately.*** For the root cause, which is a bigger problem, I might refer you to a specialist, say, an animal behaviorist, who will explore important issues such as, "is it an Indian elephant, or an African elephant," and, "why do you dress so much like a chair?"

But, assuming 'Z' does not stand for Zookeeper, don't even call me. Call the ambulance. 'Elephant on my chest' is one of those phrases causes doctors to pee in their panties. ****

'Elephant on chest," especially when paired with 'can't catch my breath' makes us think of a heart attack and other choice horrors, especially when they run with 'nauseated,' 'clammy,' and 'radiating to the left side of my jaw/running down my left arm,' 'feeling of doom,' and so on. And, even if the feeling in your chest is not akin to Jumbo's butt, there may yet be reason to worry. Nearly any kind of chest discomfort may be a reason to call me. 'Elephant on chest' is a textbook description of a the feeling people get when a part of their heart is not getting enough blood, but your body might not have read the textbook. Women, in particular, may have symptoms that are very hard to interpret. 

On the other hand, there are some nonelephantine forms of chest pain that tend not to upset me. I don't get so freaked out when you describe "a sharp, stabbing pain that lasts a couple of seconds at a time."***** I'm fairly unimpressed when you're 21 and just started doing pushups lately and it hurts particularly badly when you move your arm a certain way. I won't get my hair up in a bunch if you have burning chest pain every time you guzzle a bottle of habanero sauce. It all depends on context and who you are. If you're a 75-year-old chain-smoker with diabetes and a history of heart attacks, even a little chest twinge makes me edgy.


Doctor Tumoriffic, how long should I wait to call you when I have a thunderclap headache?

Once again, don't call me. Call the ambulance. Despite what it sounds like, thunderclap headache is not a symptom of severe gonorrhea. It is a horrendous headache that, instead of building slowly, comes on like a 'thunderclap,' It may be that a blood vessel has burst inside your skull, and it is filling said skull with blood. If a surgeon does not put a hole in your head very quickly, the pressure from all that blood will squeeze your brain out through that hole at the bottom of your skull that's really way too small for the average brain. Bad things happen very quickly--like dying. Don't call me. Call the ambulance.

To be continued. . .

Be well,

Dr. Tumoriffic





* 'QHS' is an abbreviation for a Latin phrase that I use to make me look like a smarty pants even if I don't know what it stands for.

** Qweek is an abbreviation for a Latin phrase that lacks a precise English equivalent but roughly translates as an entire week of bad Star Trek: The Next Generation first season reruns.

*** Side effects of this therapy may include being stomped to death by an angry pachyderm.

**** Other such phrases include 'thunderclap headache,' and 'Medicare Access and CHIP Reauthorization Act of 2015.'

****** That can be significantly scarier, though, when you tell me that is that a guy right in front of you who looks like Freddy Kruger, and he's holding a knife.

Happy Springtime!

#12 Antibiotics: Tell Your Doc if They Aren't Working

Dear Dr. Tumoriffic,

I took my entire course of antibiotics, but my pneumonia is still not better. What should I do?

Signed,

Mr. Cofflin


Dear Mr. Cofflin,

Clearly, you were taking your antibiotic  incorrectly. Much like a fine wine, antibiotics must be paired with the right food.

For instance, you should never pair amoxicillin with red meat. The food will overwhelm the flavor. Amoxicillin goes better with subtle flavors such as a buttered white fish like flounder or sole. You would be advised to wash it down with a pinot grigio or sauvignon blanc.

On the other hand, a bold antibiotic, such as levofloxacin (aka, Levaquin) can be paired with a bold flavor such as grilled sirloin or pasta marinara. Here, you should take your tablets with chianti or red zinfandel.

Azithromycin (commonly found in the Z-pack) is a fine every-day pill. You should take with ale and a hamburger.  Whereas doxycycline is for hard alcohol and beef jerky.


No. Scratch all that. Booze and pills don't mix well.

Most of the time, your antibiotic should make you feel mostly better within 3-5 days. If it does not, or if your infection is worse after 2-3 days, you're on the wrong pill. Also, if your antibiotic is making you projectile vomit or is showing up undigested in your poop, those are also a bad signals.

Surprisingly, I and other doctors sometimes get it wrong. For most respiratory infections outside of the hospital, at least, treatment is based on guesswork. *  It's hard to get a proper culture to identify the exact germ responsible for the infection, and we can usually do pretty well just by knowing which bugs are common the area and which antibiotics tend to work for them.

So what to do then? Give up on antibiotic entirely and go to your local faith healer.

No. First of all, don't just stop the antibiotic without talking to your doctor. Call your doctor. Tell them what's going on so they can replace the antibiotic with one that works better.

I have seen this several times in the last few weeks, and it makes me afraid for my patients. They have come to me much sicker weeks after they finished their prescriptions. (I suspect there is an unusual bug in my community.) One of these days, someone is going to wait too long for the antibiotics to work and they'll get really sick. Now, I'm trying harder to explain this to them.

When you take an antibiotic, most of the bacteria should be killed off in the first few days. You shouldn't stop early, because the rest of the course of antibiotic kills off the stragglers. But if the initial attack is unsuccessful, the bugs are just going to get stronger. Talk to your doctor.

Be well,

Dr. Tumoriffic




* For urinary tract infections, we usually get a culture, so even if we guess wrong to begin with, we can quickly correct our course. However, sometimes, even antibiotics that appear to be effective in culture turn out not to be in real life. That's a whole other subject.

Adorable Sea Otters

#11: The Cold War: You're Not Getting Antibiotics!

This one goes to eleven!

Dear Dr. Tumorific, why do you refuse to give me an antibiotic when I have a bad cold?

Signed, 
Nina



Dear Nina,

I hesitate to answer this, because to do so would break a solemn vow of secrecy that all doctors must make. Furthermore, if I do so, I may be targeted by Big Pharma's squad of flying monkeys, because it is an issue of serious liability to them. But I will tell you, because I believe in the truth even at great personal cost:
Every time a doctor gives a patient with a cold a prescription for antibiotics, there is a real chance that the patient will spontaneously combust. There have been a few famous cases of this, like the talented drummer, Peter James Bond, but there are many less famous ones. As Bond's bandmate, David St. Hubbins said, "Dozens of people spontaneously combust every year. It's just not that widely reported." *

Of course, there are other reasons. . .


[Before I go any further, I have to make a few qualifications. If you have asthma, COPD, a long history of heavy smoking, cystic fibrosis, hereditary or acquired immunosuppression (like from chemotherapy), or have a giant piece of dead skull behind your face, this may not apply to you.] 

Newsflash: There are some medical issues I cannot fix. The common cold is one. Let me illustrate with a fictional scenario:

It's January in Massachusetts. The sky darkens at 4 pm, and the waiting room is packed with patients coughing and sneezing on each other. I walk to the door of exam room 1, and on it is a paper with the name of my patient, the 24-year-old Nigel Tufnel. ** 

I vaguely remember Nigel from his last visit 2 years ago, when he came in to get a health clearance for a bungee-jumping stunt for his heavy metal band. Lower down on the paper, I see written, "complaint: cold." My blood runs cold in anticipation of the battle ahead. I knock and slowly open the door. ***

Nigel looks over at me from the exam table. He appears generally healthy, but his eyes are a little bloodshot, and his upper lip is chapped from wiping. He coughs a loud, juicy cough and greets me in hoarse, broken voice. I avoid his extended hand and make a polite elbow bump.

He has been feeling lousy for three days. He has had a little fatigue and a headache. He has  been coughing all night. He can't stop blowing his nose, and his throat hurts. He has had no sweats or chills, is not short of breath, and he is not wheezing. He has no muscle aches. He might be feeling a little better than yesterday, but he's not sure. 

Nigel has tried three different brands of cough syrup. None of them have worked. I smile sadly. Nigel is doomed. He is doomed for maybe the next few days to cough and sniffle and talk like Tom Waits sings, and there is little or nothing I can do about it. Nigel has a cold. 

I tell him to take a day off and rest. I give him some advice about over the counter medications to make it less unpleasant and maybe prescribe codeine cough syrup. That won't make him cough any less, and it certainly won't fix his cold any sooner, but it will help him sleep. (More about symptomatic remedies another time.)

"But wait, " says Nigel. "Why aren't you giving me an antibiotic? My roommate Derek Smalls had the same thing last week. He went to Dr. Strangelove at the McHealth Stop next to DeMoulas, and Dr. Strangelove cured him with an antibiotic. I think it was called Bubbamycin." This is where the visit gets difficult.  

A cold is a viral upper respiratory infection. Unlike bacteria, viruses do not respond to antibiotics. There are antiviral drugs, but they are not useful against cold viruses. A cold is transmitted when a patient touches something touched by a cold sufferer and then touches their own face. **** One to three days later, the patient gets a cough and/or runny nose and/or sore throat, and/or a bunch of other unpleasant stuff we all know. 

Generally, a cold should start to dissipate after a week or ten days. This can cause a lot of confusion. 

Dr. Strangelove cured Derek of nothing at all. Derek would have gotten better all by himself. But since Derek got better after taking the Bubbamycin, Derek and Nigel logically think the Bubbamycin was responsible. *****

Also, Derek has not told my patient about the very irritating jock itch that happened after Bubbamycin killed off Derek's normal skin bacteria, allowing a nasty fungus to grow. Furthermore, Derek does not know it yet, but the Bubbamycin has also killed off many of his normal gut bacteria. Because of that, in a couple of weeks, Derek will come down with a life-threatening case of Clostridium difficil diarrhea. 

More frightening, every time anyone takes an antibiotic for good or bad reasons, bystander bacteria, or incompletely-eradicated disease bacteria, become a little more resistant to antibiotics. As a society, we are creating bacteria that cannot be cured by antibiotics. There have already been some cases, and we may soon face a post-antibiotic world.

I explain all of this to Nigel. He asks me how I know about Derek's jock itch. I prepare myself for a HIPAA lawsuit. He then says, "But I think I have sinusitis! My sinuses hurt!" 

Nigel isn't wrong. Nigel does have sinusitis. It's probably a viral sinusitis. That's what a cold is. There is a small chance that he has bacterial sinusitis, which also usually resolves on its own within 10 days. Statistically speaking, though, the benefits of antibiotics only start to outweigh the risks after about 10 days. I explain all this to Nigel, watching the clock as it ticks further past the time I was supposed to start seeing the next patient.

Finally, Nigel grudgingly relents. He takes a copy of my custom-made handout for over-the-counter upper respiratory infection treatments (See below! ******) and checks out. I spend the next half hour documenting and billing the visit in the electronic medical record.

This is a common scenario. Doctors find it very difficult. If we give the patient antibiotics, the patient leaves happy and gets well (with the help of their own immune system) and thanks us. Saying 'no' tactfully takes precious time, and the patient may still be annoyed with us. It may also detract from our scores on patient satisfaction surveys, which can lower our pay.

But being a good doctor may mean disappointing the patient. So, sorry Nina. No antibiotics for your cold.

Be well,

Dr. Tumoriffic




PS: By the way, Nina, the same basically goes for the flu. Technically, there is medicine for it, but it's not very effective, it's expensive, and has lots of side effects. I would only use it for very sick patients since it does slightly decrease their risk of dying from the flu.

PPS: Don't buy combo cold products. They're overpriced combinations of medications that you can buy more cheaply individually. If you must get one of these combis, look closely at the identity and dosage of each component before you take a different medication, such as acetaminophen (aka Tylenol), that may actually be the same as one those included. Otherwise, you may overdose. (Also, by the way, never take more of a medication that is recommended on the bottle unless your doctor says so. Just because it's over-the-counter does not mean that it's safe to take it like candy. I've seen that, and it can be ugly.)


* http://www.seeker.com/mysterious-death-ruled-spontaneous-combustion-1765446824.html

** I have no patient with the name Nigel Tufnel. In fact, I have never met such a person.

*** Never tell your doctor you are coming in for a 'cold.' It's like announcing that you're going to waste their time. That can be a dangerous distraction when what you thought was a cold turns out to be a pneumonia. That has happened in my experience.

**** So wash your hands, all of you! The flu, on the other hand, is transmitted through the air, so you should try not to breath when you are around other people during the winter.

***** This is why we need statistical analysis in medicine. Without being able to compare at many different cases of patients who have gotten better from a given condition, we have no way of knowing whether the remedy they used had anything to do with their getting better. Eons of worthless remedies have flowered, not because people in the past were stupid, but because there was no way to distinguish between a cause and a coincidence.

****** 

Advice for Allergies, Colds, Coughs, and Sinusitis

Nearly all short-term upper respiratory illnesses are viral or allergic, and not bacterial.  Viruses cause infections, but we have no treatment for them. Therefore, antibiotics are usually more likely to give you diarrhea or put you at risk for a more dangerous infection than make you better. The following nonprescription treatments may make your illness less unpleasant:

1. REST!  Take a day or two off if you can.

2. Neti-Pot or Sinus Rinse:  Use as often as you want and at least twice daily when you are sick. This is very important. Salt water in a teapot-like container or a bottle flows in one nostril and out the other or the mouth, clearing out nasal discharge and preventing serious bacterial infection. (Best to use boiled tap water or distilled. Most places are probably safe, but you never know.) This is not the same as saline nasal sprays, which can help, but not nearly as much.

3. Honey: Spoonfuls of any kind of honey sooth the throat and may help with coughing. You can also gargle with warm water and honey mixed with salt and baking soda. Go easy on the honey if you have diabetes.

4. Cough drops or hard candy: These, especially the ones with lidocaine, may sooth a sore throat and suppress a cough.

5. Humidifier: Useful for all respiratory conditions during cold weather. Clean frequently to avoid fungus, or use a hot water humidifier.

6. Steam: either buy a sinus steamer from the pharmacy or boil pot of water, put on the table and lean over it with a towel over your head and the pot and breath until the water stops steaming. This will moisten your airways and help clear dried mucus.

7. Over-the-counter nasal steroids: Fluticasone (Flonase) and triamcinolone nasal spray (Nasacort) are very helpful for allergies and sinusitis. They are much safer than oral or intravenous steroids. Do not let the spray get into your eyes. Do not use without a doctor's advice if you have glaucoma.

8. Oxymetazoline nasal spray (such as Afrin): This works immediately to stop congestion and open the sinuses. 2 puffs every 12 hours FOR 3 DAYS ONLY.  Longer use can make stuffiness worse! You may use this at the same time as other nasal sprays if your doctor prescribes them. Do not use this if you have glaucoma. 

9. Pseudoephedrine (You have to ask the pharmacist for this directly): This helps dry up mucus, and open sinuses. It may cause insomnia, anxiety, or cardiac arrhythmias. Do not use if you have severe hypertension.  Elderly men or men with benign prostatic hypertrophy (BPH) should avoid pseudoephedrine as it may worsen urinary symptoms.

10. Antihistamines: These are mostly for allergies. They help dry up nasal secretions and decrease congestion.  Older antihistamines such as diphenhydramine (aka Benadryl) are stronger, but may make you drowsy. Avoid them if you are over 75 as they may cause confusion. The newer antihistamine, fexofenadine (Allegra), is less likely to cause this.  Elderly men or men with BPH should avoid antihistamines as they may worsen urinary symptoms.

Upper respiratory infections usually improve by 10 days or so whether or not you take medicine for them. If you are sick for more than 10 days and are not improving, if have a fever >101 for more than 3 days, if you have difficulty breathing, if you cannot keep down fluids, or if you suddenly become much sicker after mostly recovering, give us a call or visit.

This sneezing marine iguana is not getting antibiotics!

The iguana is actually sneezing. For marine iguanas, sneezing is the equivalent of urinating. They sneeze out extra salty fluid to maintain a proper salt balance in their bodies. So this is also a picture of an iguana taking pee.

#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