Category Archives: Talking to your doctor

Men’s Health

My previous post was about women’s health. In this post I am going to review a couple of aspects of Men’s health. Most of the things men should be doing are things  people of both genders should be doing to stay healthy: stop smoking, exercising, eating a healthy diet, maintaining a healthy weight (or loosing weight if overweight).  Staying up to date with immunizations, such as yearly flu vaccination, is also important. Getting screened yearly for hypertension is important. Skin cancer screening is also important, though this might only need to be done every 2 years depending on whether you have any suspicious moles or lesions, prior history, you and your dermatologist’s comfort levels for yearly vs every other year screening. Cholesterol screening at appropriate intervals is important (a healthy male in his 20’s with no risk factors for heart disease only needs his cholesterol checked every 5 years or so. Older men and those with risk factors require monitoring more frequently and perhaps yearly if risk factors are present or if on treatment to lower cholesterol). I won’t get into more details about screening or other issues covered already in other posts.

Perhaps the biggest controversy in mens health is prostate cancer screening. The U.S. Preventive Services Task Force actually recommends against routine screening for prostate cancer in healthy men of all ages. Even the American Urological association recommends against screening for prostate under the age of 64 and in men with life expectancy of less than 10 years. For screening, a conversation with your primary care doctor is warranted before getting the test. The main reason it is controversial is that one runs the risk of finding a prostate cancer which is indolent (slow growing), non aggressive that one is likely to die with than of – meaning one is likely to die of some other disease before the prostate cancer becomes a problem. At this time we don’t have enough information to know what low grade/early prostate tumors are going to become aggressive and turn into problems. One therefor runs the risk of over treating something that would not be a problem.

Occasionally I’ve had patients ask for testosterone levels and had to talk to patients about testosterone replacement. Testosterone levels are not something  routinely checked unless there is a clinical reason (if there is loss of libido, erectile dysfunction, and so forth, then it’s worth getting). Testosterone replacement has been associated with an increased risk of heart disease so replacement benefits needs to be worth the increased risk.

Although I probably run the risk of repeating myself by saying this, but reducing the risk of heart disease, lung cancer, colorectal cancer by exercising, watching what one eats and getting appropriate screening applies to men’s health as well.

Evaluating health care claims

In some ways this post is a continuation of my previous one titled “…because it’s natural”. In a lot of diseases such as DM-2, Alzheimer’s, and heart disease, there are multiple mechanisms that contribute to either the disease itself or to it’s complications. Two mechanisms of disease that seem to get a lot of space on TV, print and on the internet is that of inflammation and oxidation. Whether it is someone promoting a “super food” that has a lot of antioxidants in it (or a lot of anti-inflammatory activity), or a pill that has plant extracts in it that reduce oxidation or inflammation, the claims should be  taken with a grain of salt. For example in some cases, there may be multiple good studies that show taking said supplement does act as good antioxidant. However this doesn’t mean that the supplement will improve one’s health or lengthen lives. This is a problem with using what’s called a surrogate endpoint. Don’t get me wrong, using surrogate endpoints can be useful when the more significant and relevant endpoints are things to be avoided (death or disability for example) or might not happen for years  – I don’t think a study that would take 30 years to start showing something works would get funding – or finding enough people to study would be practical. It helps if a change in the surrogate endpoint has already been shown to be related to reduction in a particular disease’s morbidity or mortality.There are also observational studies that show certain things (high vitamin A levels, higher beta-carotene intake) are associated with lower levels of a particular disease state. Sometimes using a surrogate endpoint  (or  noticing an association between two things such as high levels of vitamin A and lower rates of a particular disease) ends up leading to people doing negative studies. For example, many deaths after a heart attack are related to arrhythmias. A study called the CAST (short for Cardiac Arrhythmia Suppression Trial) showed  higher mortality in people who were on anti arrhythmia drugs. It doesn’t mean that the drugs didn’t have a role in other disorders. I have a feeling it means that we were just asking the wrong question (even though it needed to be asked and answered) about treating arrhythmias after heart attacks. I use the example of the CAST study to make the point that showing something changes the level of something (either up or down) that is thought to be involved in causing disease – be it inflammation, oxidation, arrhythmia or otherwise – doesn’t mean it affects the disease it is said to. It may be that to treat a disease with anti-inflammatory medications (or substances), one also needs to block other pathways of that disease as a well for any to be effective. This is why most cancers are treated with more than one drug. This is why people are often on more than one blood pressure medication. As I mentioned in my last post, any claims should have data supporting that they work. The results should be reproducible, hopefully other by other researchers. Getting back to my original assertion from the start of this particular blog post, if someone is touting a “superfood” for health, It is appropriate to ask if it actually improves health, decreases complications, etc. In my opinion, just to say something is a “super food”  because it is a ‘super anti oxidant’ is blowing smoke.  That isn’t to say that anti-oxidant rich foods don’t promote good health. There are too many studies that are negative that to look at one thing and say “this is the holy grail of food”. This also undersimplifies things too greatly. It’s better, in my opinion, to say “these are the types of foods/eating (or habits if one is talking about other aspects of lifestyle) that are associated with good health. For examples, many of the studies that show that olive oil intake is inversely related to cognitive decline are more agnostic about what role each component in olive oil plays, despite showing benefits. Is it the kinds of fatty acids in olive oil? Is it the polyphenols that act as antioxidants?  Is it the anti-inflammatory chemicals in olive oil? I suspect the answer is yes, it is all three. Is it the answer to everything: just have olive oil and you’ll live to 100? I doubt it. My bottom line on health care claims:

Be critical but open minded: ask the following questions: “Does it actually affect or prevent disease? Does it decrease complications of the disease and not just something thought to be associated with disease or complications thereof?”. If the answer is “yes, it does reduce _fill in the blank_ and there is a proportional reduction in the amount of deaths/strokes/people going on dialysis/etc then you have a winner. IF the answer is “it does reduce _fill in the blank_” but there is no reduction in _fill in this blank as well_” it may mean that the answer is more complicated than we think. It may mean that the wrong question(s) were asked, or the right ones hadn’t been asked.

Also be wary of claims that make a product or procedure seem that it’s THE ANSWER for a particular disease. It may be a piece in the puzzle, but in order to be considered as such, the answer to the question ‘where’s the proof’ should be along the lines of “here are the studies…”

If the person makes statements like “doctors are in the pockets of ‘big pharma’ and aren’t interested in curing disease”, then be wary. I think most doctors get into this business to make people better. If there was a pill that taken once or twice cured someone of his or her type 2 diabetes (and did not cause some other severe life threatening disease), I think most doctors would use that pill.

Also ask if this the first study of something? Often a treatment is found in a study to be helpful. The numbers of people may be small. Due to the nature of studies, the participants are typically more homogenous than the population as a whole. Once larger studies are done, the benefits of a medication/procedure, etc may not be as large as initially thought.

Another question ot ask is this better than what we have now? Though it could be asked of a new medication, I’m primarily thinking here of new surgical procedures (eg, robotic surgery for certain things). If offered ask: is the rate of complications less with the new procedure? Is mortality less? Is the recovery time quicker with the new procedure?

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Talking with your doctor.

As this is my first blog post I’d like to start of by saying a few of things. One is thank you for visiting my blog. The other is that I won’t be responding to specific questions on this blog, except perhaps in a relatively generic way. In other words, talk with your primary care physician before you act on anything you read in this blog. For that matter, it’s probably a good idea no matter where you get your medical information from. Lastly, I have yet to decide on a schedule for posting. I don’t know whether it will be once a week, once a month, something in between or even less frequently.

And now to the subject of today: suggestions for talking with your doctor and getting the most out of your visits.

As a practicing physician there are times when I think my patients and I speak different languages even when English the first (and sometimes only) language either of us knows. For example there are times when I’ll be seeing a patient for the first time and I’ll ask what medications he or she is on and the response I get is along the lines of “a heart pill” or “a blue pill, for my heart”.  Other times the patient will know the medication name but not doses so I’ll get the response, for example “metoprolol twice a day”.  This is somewhat better but as medications often comes in multiple doses, knowing the dose is important especially if there is a need to change doses or when a patient calls in for a refill.  This leads me to my first suggestion: make a list of all your medications and include the dose of the medication and frequency. As some medications have more than one use, adding the condition can be useful. For example, some anti seizure medications and a class of blood pressure pills called beta blockers are sometimes used to prevent migraine headaches in people who have them frequently. It also can clue your physician into medications that other physicians you see are prescribing.

A list might look something like this:

Metformin     500 mg twice daily      diabetes

lisinopril    10 mg once daily  high blood pressure, to protect renal function

gabapentin    300 mg three times daily for neuropathic pain

Well, you get the idea. It is also helpful if, heaven forbid, you get sick and need to visit an emergency room on a weekend (your regular doctor might not be covering) or out of state. You might not even be in a position to talk and give information. This last possibility brings up the idea that having a “file of life” – a small document that also lists your name, doctor’s name, health problems, etc – on you in case you can’t speak for yourself.

Another thing that can help you communicate with your doctor is to actually bring a list of written questions/concerns you have to your visit. This is especially important for a few reasons when you have a number of medical problems. One is that even if you’re at a routine office visit, a symptom that you bring up might alert the physician something new is going on, a known condition could be getting worse (or better so now you’re over medicated), or medications might be interacting. Realize however, that if the list is long, your physician might choose to focus on what he or she feels is the most one or two important items on your list (or the one or two that you both agree are the most important). Yes, the knee pain may be making life miserable for you, but if you’re also getting chest discomfort or winded just walking down a hallway or up a flight of stairs, your doctor might feel that focusing more on your heart and lungs might be more important this visit as this could indicate problems with those two organ systems. It also avoids making your visit longer than it needs to be. Often if someone has a lot of issues, a physician will have a patient come back to go over the other issues at a future visit. There are cynics out there that might say we do this to make more money. To counter this I would say that I would not want to miss diagnosing severe heart disease or a potential cancer because someone was coming in for something unrelated. Though I like to believe that all doctors give each patient the time they need to address every issue at each, we also need to keep in mind that there are usually other patients waiting as well!

Having a family member with you can help if you feel overwhelmed by the number of health issues you have, or if you have memory problems. The family member might remember something you forget, for example. I think in general physicians don’t mind when a family member accompanies their patients. There may be some circumstances/questions a patient doesn’t want a family member to know about, this is one of the reasons we shy away from having family (especially young family members) act as translators when a patient has limited – or even no – proficiency in English. For this reason, don’t be surprised if the doctor asks the family member to leave the room for a few moments or chooses/requires the services of a professional translator.

Try not to make a diagnosis yourself. There is a reason that the maxim “doctors who treat themselves have a fool for a patient”. It’s commonly taught that if we listen to our patients, they’ll tell us what they have. However, I know I’d prefer someone saying “I think I have _fill in the blank_ because I have the following symptoms….” than to say “I have _fill in the diagnosis_”. Many disorders have similar symptoms and might be easy to confuse, though many times a patient will be correct, at least with more common or well known disorders. Often I’ll ask a patient why they think they have a particular disorder, as on occasion they will dismiss a symptom that might indicate a different disorder, or be so focused on the diagnosis and the need for particular treatment that it can be a challenge to convince them that something else is wrong or they don’t need treatment. A good example is someone coming in saying that they have “strep throat” and “need an antibiotic” when only a minority of people with a sore throat will have strep throat and a minority of those (I believe it’s only about 1-5%) of adults get complications and all antibiotics are doing is shortening the course of symptoms.

On the other hand there is nothing wrong with looking things up before you go into see your doctor and asking questions.

Anyhow, I hope some of this is helpful to people. Some of the recommendations have been written about elsewhere. If I could recall where I’d be glad to attribute them. If there are other things that come to mind that fit the description of this post, I’ll put them in a part II.

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