Doctor: would you mind saying that again, but in English?

It will come as no surprise to most of you that what doctors think they say and what patients hear are frequently not the same.

Every field has its own jargon, understood by the practitioners but not “outsiders.” Be honest: if you bring your car in for service and the service advisor says you have a bad solenoid, would you understand what this means? [engineers excepted]

A recent study published in JAMA Network Open described what researchers found when they asked a group of adults attending the Minnesota State Fair last year their understanding of common medical expressions used by doctors talking to patients.

Despite the fact that this was an educated group (90% had at least an associate degree and 65% a bachelor’s degree or higher), less than 10% correctly understood the question “Have you been febrile?” and 2% understood the statement “I am concerned the patient has an occult infection.” 11% knew what it meant when they were told “You will need to be NPO at 8 AM.”

A common cause of confusion is the frequent difference between common usage and medical meaning. In most circumstances, “positive” has a good connotation, but in “your lymph nodes were positive,” the opposite is true. Being told “your performance on the test was impressive” would make a student happy, but if your doctor says “your Xray findings were very impressive,” you had better worry.

Even doctors may miscommunicate if an abbreviation is used out of context. If one doctor says to another “the patient has MS,” does this mean they have multiple sclerosis or mitral stenosis? If it is one neurologist talking to another, the meaning will usually be clear, but if the neurologist is talking to a cardiologist, all bets are off.

How should this affect your behavior?

A good medical interaction should end with the doctor asking the patient to tell the doctor what they understood of the conversation, but this rarely happens in today’s frantic environment. You should take the initiative and tell the doctor what you believe they just told you. Do not be surprised if they say “no, that is not what I intended to tell you.” You can then hopefully get a clarification.

Remember: the only dumb question is the one you should have asked but did not. Do not leave a medical visit without being sure you know what you were told and understand all its implications.

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Out from the valley of the shadow of death

It has been a while since I last wrote, but there was good reason. On Sept 23, I went in to one of the country's "top ten" hospitals for a “minor procedure” that was supposed to let me out in 3-4 days. My surgeon was very well-respected. On the second post-op day I told the staff there was a problem but was reassured my recovery was normal. Late on the third day my blood pressure disappeared, a fever developed and I was rushed back to the operating room, where 2 quarts of blood were found in the abdomen, indicating a post-operative hemorrhage, and then I was admitted to the ICU in “guarded condition.” [Translation: may not make it.]

After 10 days in the ICU, I went to the surgical floor for a week and then a rehab hospital where I could not get out of bed without help. Two weeks of rehab, followed by home PT for a month and I am well on the way to recovery.

What lessons should you take from this experience?

First, let me remind you of my definition of “minor surgery:” surgery done on someone else. Something can always go wrong, so be very sure there are not non-surgical alternatives before agreeing to an operation.

Second, be your own advocate or have someone close assume that role. I was probably not insistent enough that studies were needed the day before everything went sour.

Third, be sure you have a written health care proxy and have reviewed it with your surrogate. Do you want to be on a ventilator? In what circumstances? This should be made explicit.

Fortunately, my tale has a happy ending, but that was far from guaranteed.

On another note, the newest Alzheimer’s drug has been reported to great fanfare, but I urge caution. As is all-too-often true with new drugs, the benefit was "statistically significant" but I was not impressed with the clinical benefit, and the two deaths in the trial remain to be explained. More when I have a chance to read the full paper.

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The new Covid boosters

As you must be aware, the U.S. FDA recently approved (on August 31) a new booster shot against Covid-19, The bivalent vaccines, which are updated boosters, contain two messenger RNA (mRNA) components of the virus: one of the original strain of SARS-CoV-2 and the other, one that is common between the BA.4 and BA.5 lineages of the omicron variant of SARS-CoV-2, the most recent strains of the virus that are circulating.

Should you get one? Some facts:

The first is that the mRNA vaccines have been remarkably effective. While they do not necessarily mean you will not catch the virus, they dramatically reduce your chances of getting very sick or dying from it. Hospitalization rates were over 10 times commoner in unvaccinated people. Vaccinated people who are sick enough to require hospital care are overwhelmingly the elderly and those with multiple other medical illnesses.

While any vaccination helps, the best protection is offered by having the original two shots plus 1 or 2 boosters.

If you have not had your 3rd or 4th shot, the new vaccines will now be the only ones offered.

While the new vaccines have been shown in mice to produce good antibodies against the current Omicron strains, their effectiveness at preventing disease in humans has not been fully studied.

My take: if you have been fully vaccinated – 4 shots – I would be in no rush and would wait for more human studies to be reported. If you have not yet had your boosters, get one!

Also: everything we know tells us that this winter is likely to be a bad flu season. There was severe influenza in the southern hemisphere during their just-finishing winter and that is often an early warning about what we will experience.

The much-discussed mask wearing of last winter had a spin-off benefit: much less respiratory illness in general, including influenza. As people have begun to stop wearing masks, this extra layer of protection will be gone.

Get your flu vaccine before the end of October.

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Foods as medicine

As you know from reading earlier posts, the effects of different foods on health can be difficult to interpret. Rarely do studies get to compare people who are exactly alike except for their consumption of the substance of interest. Avocados may be good for your heart, or it may simply be that people who eat avocados eat a healthier diet overall. Hence the often contradictory headlines - coffee is good for you/coffee is bad for you – that populate the press.

I have thus been very interested to find several recent studies with robust data behind the health claims.

First bananas. A British group treated almost 1000 people with a hereditary tendency to colon cancer (Lynch syndrome) with a “resistant starch” powder made from bananas or a placebo for 4 years and followed them for at least 10 years. The supplement group had a similar rate of colon cancer but dramatically fewer cancers of the pancreas and upper GI organs: 5 vs. 21.

Another study looked at the value of cocoa-based chocolate compared to white chocolate and placebo in elderly patients with advanced cancer in palliative care. After 4 weeks, the group given dark chocolate had better calorie and protein intake and overall better nutritional status than either the white chocolate or no chocolate groups. They also had improved functional status.

Finally: prunes. Prunes are known to contain large amounts of antioxidant compounds. Researchers at Penn State gave post-menopausal women 55 to 75 either 6 prunes/day, 12 prunes/day or no prunes for 12 months. All 3 groups were given daily calcium and Vitamin D. Not surprisingly, the group assigned to 12 prunes/day had a high (41%) drop-out rate, presumably because of excess bowel movements, but only 10% of the 6-prune group and 15% of the no-prunes group left the study.

After a year, the groups taking prunes had much lower levels of inflammatory markers in their blood. More important to the women in the study, the placebo group had a significant fall in their bone mineral density while the group who took 6 prunes/day had no drop.

So, good data showing that bananas, dark chocolate and prunes have proven health benefits. Enjoy!

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Do I really need that test?

A 2019 study estimated that overtreatment and “low value” testing costs the U.S. between $75 and $100 Billion annually. Why should you care? You should care because this means that the cost of your health insurance and your out-of-pocket costs go up to pay for this unnecessary treatment and testing.

We will leave treatment to another post and focus on over-testing. Unnecessary or low-value tests are those which are very unlikely to make you live longer or feel better.

Such over-testing is ubiquitous, but one area is “routine” pre-operative testing. Clearly if you have evidence of bad heart or lungs and are being asked to have a risky surgery, your doctor may need tests to determine if you can safely undergo surgery. That, however, accounts for only a tiny fraction of pre-op testing.

The vast majority of pre-operative testing is done on relatively healthy people who are about to have low-risk surgery such as hernia repairs or cataract extractions. Decades ago, the American College of Cardiology and the American Heart Association, in conjunction with the anesthesiology societies, published guidelines recommending against pre-op stress testing for most patients, and even advised against routine ECGs. While some hospitals have tried to reduce such testing, the overall impact of these recommendations has been minor.

In many cases, asking a few questions, such as “can you walk up 2 flights of stairs without problems” will avoid the need for most heart and lung testing before surgery.

Why do so many unnecessary tests continue to be ordered? Some of the incentive is financial. Doctors and hospitals are paid more when they do more. As long as this perverse incentive continues, there will be pressure to do more. Research has demonstrated that doctors who own MRI machines order many more MRI studies. If I were paid by the word to write, you can bet this post would be much longer.

The other factor is cultural. Doctors have been conditioned to believe that “It cannot hurt to get more information.” While an occasional extra blood test may not cost much or harm you, some invasive tests carry risk, and the added cost and inconvenience of any test is not trivial if you take off time from work or drive a distance. Another under-appreciated factor is that many “routine” tests turn up unexpected minor abnormalities that are not significant, but which require other tests to prove this.

What can you do? Before agreeing to any test, ask how the results will change your treatment.

For anything but blood tests or plain X-rays, ask if there is any risk to the test.

Ask if there are simpler alternatives.

Ask if there is any harm in waiting a bit. Many illnesses are self-limited, and the doctor will often be certain you have nothing serious but orders tests “to be sure.”

If the recommended test is invasive, such as cardiac catheterization, consider asking for a second opinion before you agree to have it.

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Protect your brain!

Dementia is probably the most feared illness to which older adults are prone. While we cannot do anything about the biggest risk factor, aging, there are many other risk factors that are under our control.

I mention aging because the likelihood of dementia rises rapidly as we get into our 70’s and beyond, and the only way I know of to prevent getting older is to die young, which I do not recommend.

So-called “mind games” have been much touted but there is little evidence they do any good.

The “modifiable” factors that increase the odds of dementia include physical inactivity, cigarette smoking, depression, low education, obesity, diabetes, high blood pressure and hearing loss. It has been said that anything which is good for the heart is good for the brain, and that certainly applies to many of these factors.

Stopping smoking if you are a smoker will add years to your life and improve the quality of your life. Treating hypertension and diabetes will lower your risk of both heart attack and dementia. Losing weight obviously helps numerous health issues, from heart disease to arthritis, as well as dementia. If only I had a magic bullet to make this easy.

Depression and hearing loss share the common factor of increasing isolation. Treating depression and getting hearing aids both allow more social participation, which in turn decreases the risk of dementia.

I have saved the best (studied) for last. Innumerable scientific studies have shown that regular physical activity lowers the risk of dementia and pushes it out later if it occurs. This does not mean you have to run marathons. Walking, gardening, pickleball or line dancing are all helpful.

How exercise works is becoming clearer. Studies in mice have shown that exercise creates more neurons and synapses (the connections between neurons). There is also evidence in mice that exercise reduces the inflammation that harms brain cells. More recently, a study of older Chicago residents followed closely over decades has found similar benefits in the human brain. There was a strong correlation between being more active physically and healthier brains with less inflammation. None of these seniors formally “exercised,” but activity monitors were used to see how often they moved versus sat.

Bottom line: get off the couch and walk, do housework or play with the grandchildren. Move that body for at least an hour a day. Your brain will thank you.

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Monkeypox

Does it appear as if we are beginning the plagues that struck Egypt in the Bible? Just as we seem to be learning to live with COVID (though that virus may not be done with us just yet), along comes monkeypox. What is it? How worried should you be?

The most notable poxvirus is the life-threatening smallpox, which has been vanquished after millennia in which it was a leading cause of death. Related viruses are the cowpox virus that Jenner used to make the first vaccines and the vaccinia virus used to make modern smallpox vaccines.

Monkeypox is a similar virus, and has probably been around for a long time, but was largely confined to central and western Africa, so was not studied by western scientists. It is so-called because it was first detected in laboratory monkeys (in Denmark), but its usual hosts are small African rodents and other small mammals. There are two forms of the virus; the one seen in the Congo basin causes more severe illness, with about a 1-2% death rate in humans, and is more transmissible. The current outbreak appears to be of the less severe West Africa strain. No deaths have yet been reported in the current outbreak.

Before this year, cases outside Africa were rare, and usually seen in returning travelers. The U.S. had an outbreak in 2003. A shipment of Gambian pouched rats infected prairie dogs housed in the same facility, and these were then bought as pets and infected their owners.

2022 is different. As of this writing, some 1500 confirmed cases have been reported from 31 countries around the world, with 60% of these in Spain, Portugal and the United Kingdom. Most of these have been traced to large gatherings such as raves, where people mingled closely. Some 50 cases have been verified in the U.S. and over 110 in Canada (most in Quebec). The virus is primarily spread by direct contact with skin lesions but can also be spread by contact with sheets or clothing that have been in contact with skin lesions. While still debated, it may be spread by large respiratory droplets.

The usual illness is fever, chills, muscle aches, sore throat and swollen lymph glands, and then comes the rash. The rash begins as flat moles, which then form blisters and then pustules. It can be all over or confined to a small area.

In the current outbreak, most cases have been in men who have sex with men, and the rash has been in the genital and rectal area. Unless the doctor treating such a patient thinks of monkeypox, they are more likely to diagnose a more common sexually transmitted disease such as herpes.

Should you be worried? Probably not yet. Unlike Covid-19, which spreads primarily through small respiratory droplets and can easily be spread even when the carrier is not sick, monkeypox is mostly spread by direct contact with a sick person, so you do not need to worry about catching it in stores or concerts. Casual contact is not a high risk.

Treatment is focused on treating symptoms. Some vaccines and antiviral medicines are available that help, but these can only be obtained from the CDC.

My biggest concern is that if private doctors and public health officials are not vigilant, the virus may become established world-wide and no longer be confined to Africa.

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