Getting the most out of a doctor visit

By now, most of us are all too aware that the doctor visit is becoming shorter and that the doctor seems to interact more with the computer than with you. It is frustrating to leave a visit that may have been made months in advance with your questions unanswered.

How can you get the most out of a medical appointment? The key is preparation.

Before you set out, you should have made sure that you have the correct date and time, that the doctor is on your insurance plan, and that if you need a referral, you have it.

Leave enough time to get there even if traffic backs up. Yes, you will probably have to wait, so bring a magazine.

If this is a new doctor, bring a list of all medicines you are taking, any medication allergies you have, major family history, recent test results and surgeries and hospitalizations you have had.

Key to a satisfactory visit is to know what you want from it. If you are scheduled for a follow-up of chronic health problems but you have a new symptom that worries you, get that out up front and not when the doctor has their hand on the door.

Bring notes and take notes. Have a written list of things you want to discuss in the order of priority you want to cover them.

It has been repeatedly found that most of what a doctor tells you is forgotten by the time you get to your car, so take notes of what you are being told. Doctors tend to slip into medical jargon, so do not hesitate to ask that they repeat something you do not fully understand.

It is very helpful to have a close friend or family member with you to act as a second set of eyes and ears, but be sure they understand what you want them to do and do not let them take over the visit. (Speaking of ears, if you need hearing aids, be sure to have them in for the visit!)

Be honest with your doctor. They have seen and heard it all, so any habits you have of which you are not proud, be upfront. Keeping secrets is not going to get you optimal care.

At the end of a visit, tell the doctor what you understood them to say and what is planned. It is rare that a problem is solved at one visit, so be clear in your mind if further testing is needed as well as what you should do if things do not go as expected. Be sure you know what to do before you leave.

If you are not comfortable with what you are told, do not hesitate to ask for a second opinion. This should not be threatening to a good doctor. In the case of a serious diagnosis, second opinions often change the diagnosis and/or the treatment.


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A new test for colon cancer

Late in July, the FDA approved a blood test to detect colon cancer. What does this mean for you?

Colon cancer is the second most common cause of cancer deaths in adults, behind only lung, and an estimated 53,000 people will die of colon cancer in the U.S. this year. At the same time, colon cancer should be almost completely curable if found very early and surgically removed.

Finding cancers in people without symptoms is called “screening,” and good screening tests are only available for a small number of cancers. Good screening tests should pick up cancers early, should be negative in people without the disease and should be proven to reduce death rates in screened populations.

For colon cancer, the gold standard screening test is the colonoscopy. It will detect both cancer and pre-cancerous polyps, most of which can be removed during the procedure. It is very sensitive – if the person has done a good clean-out “prep,” very few polyps or early cancers will be missed. It does not give false alarms – if your colon is normal, the endoscopist sees this and you can generally go 8-10 years before your next test.

The downsides are cost and the “ick” factor.

A recent report on the cost of cancer screening showed that fully 60% of the cost of all cancer screenings was spent on colonoscopies. The test requires a whole team, a special room like an operating room, anesthesia for most people having the test and costs thousands of dollars.

As Dave Barry so colorfully described, ((https://www.miamiherald.com/living/liv-columns-blogs/dave-barry/article1928847.html) the thought of a colonoscopy is repulsive to many of us, and the dietary and laxative preparation required is a turn-off for many.

The alternative has been to check the stool for hidden bleeding, the so-called FIT test. If done every year, this has a reasonably good pick-up if positive tests are followed by colonoscopy. More recently, a stool test looking at cancer DNA markers has been approved. It picks up about 85-90% of colon cancers but only about 40% of large polyps.

The newly approved blood test looks for circulating cancer DNA and was shown to detect about 83% of cancers found on colonoscopies. It had a “false positive” rate of 10%, meaning 10% of people with a positive blood test had no cancer. And it was poor at finding pre-cancerous polyps. Only some 13% of people with such polyps had a positive test.

The big advantage of the new test is ease – most of us are used to having blood drawn at a medical visit and do not mind having this done. No preparation is needed. The cost is dramatically lower than a colonoscopy. The biggest disadvantage is that it is not as good as a colonoscopy. It will miss most pre-cancerous polyps.

My take: if you have insurance that covers colonoscopy, gather up your courage and just have it done.

If the alternative is not getting screened, do the blood test.


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Shingles: more than just a rash

Some 95% of U.S. adults had chickenpox when they were children. Chickenpox, scientifically called varicella, is usually an annoying but not dangerous illness in children.

What makes the illness treacherous is that the causative varicella-zoster virus can go into a dormant phase, hiding out mostly in nerve roots near the spinal cord. When our immune system is weakened by stress, illness, medications or simply aging, the virus can spread out from the nerve root along the nerve.

This recurrence of virus along the course of a nerve is shingles.

The clinical course of shingles is usually very stereotyped. With a patient who is a good observer, I can usually diagnose it over the phone.

Stage one is an itching or burning pain localized to a band around one area of the body with nothing visible. To many, it feels as if they burned themselves when they did not.

The next phase sees them break out with blisters in the same area. It can be on any part of the body, head to toe, but is virtually always only on one side, right or left.

The blisters scab over and eventually dry up, but this may take weeks. Particularly in older people, the pain may linger for months or years after the rash has gone. This is called post-herpetic neuralgia and is very distressing.

If the involved nerve is one of the nerves of the face, the eye may be affected, and this can be a sight-threatening issue.

To fight back, we have treatment and prevention.

Two anti-viral drugs, acyclovir and famciclovir, are useful in shortening the course of the illness and in preventing post-herpetic neuralgia. To be effective, they should be given early, ideally within a day of the rash appearing. If you break out with what may be shingles on Friday, do not wait until Monday to seek help.

Vaccines are available that reduce the likelihood of getting shingles. The older one, Zostavax, is about 65% effective and the newer one, Shingrix, is over 90% effective. While Zostavax is easy to get: one shot, minimal side-effects, the more effective Shingrix requires two shots and is more likely to give you a day or two of flu-like symptoms.

There have been recent studies suggesting that vaccination reduces the risk of dementia, possibly by preventing the re-emergence of the varicella-zoster virus dormant in the brain.

Since most children are now vaccinated against chickenpox – the vaccine came out in 1995 – we can hope that shingles will follow polio and smallpox into “mostly of historical interest.”

In the meantime, most older adults should get the shingles vaccine. If getting Shingrix, don’t schedule your shot the day or two before an important event.


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Cannabis - good or bad for your health?

Cannabis (marijuana) products are widely used. Cannabis is now fully legal in 24 states, legal if medically prescribed in 15 and partially legal (depending on the composition) in 7. In only 4 states is it still completely illegal.

Among 176,000 primary care patients in a Los Angeles clinic, 17% reported regular use. Not surprisingly, use was commoner in younger people than older ones: 31% of those 18-29 used cannabis, while only 8.5% of those 60 and older reported use.

A large percentage of cannabis users say they do so to treat symptoms, largely stress, insomnia and pain.

Cannabis can be inhaled or eaten. Smoking gets the active ingredients into you faster, but the effects of edible (“gummies”) products is similar.

Do cannabis products help? Our evidence base is flimsy. The fact that cannabis is still classified at the federal level as “Class 1,” with no approved medical use, means funding for large well-done studies is limited.

Many of the studies of the benefits rely on self-reported use and are uncontrolled. An analysis of the use of cannabis for chronic pain found 7 large studies, including 13,000 patients, that were “observational” (uncontrolled) and 18 randomized placebo-controlled trials – but these were very small, averaging fewer than 100 subjects in each trial.

What we can gather from studies to date is that some cannabis products do help with insomnia, but this is countered by deterioration in sleep if use is stopped.

The evidence seems to show that cannabis has moderate effectiveness for chronic pain, but the benefit is countered by sedation and a marked increase in dizziness and falls.

What about the risks? Cannabis use by women during pregnancy results in increased likelihood of low birthweight, preterm birth and need for intensive care by the newborns.

Regular long-term use starting in adolescence and continued into middle age was accompanied by a fall in IQ and evidence of shrinkage of the part of the brain known as the hippocampus.

Participants in the United Kingdom Biobank (a large respected observational trial) who were regular heavy cannabis users, followed for an average of 12 years, had a higher mortality, both overall and from cancer and heart disease.

Older people should be particularly cautious, as side-effects such as dizziness and sedation are more likely. After cannabis was legalized in Ontario, Canada, the number of older adults treated in emergency departments for cannabis side-effects rose four-fold.

My take-aways? First, cannabis should be strongly discouraged in adolescents and young adults, whose brains are still developing, and in pregnant women.

It should be discouraged in older adults, where side-effects are more common and more likely to lead to falls and injury.

In the middle? Be cautious and minimize your use.

Finally, I do support the removal of cannabis from Class 1 to a lower class, so that proper studies can be done with federal funding. Only large, randomized, placebo-controlled trials can determine whether cannabis has a role in treating symptoms.


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Why do my feet tingle?

Peripheral neuropathy is a common condition, affecting some 6% of adults 45 or older.

What is it, what causes it and what can you do about it?

Our nervous system consists of the central nervous system (CNS) – the brain and spinal cord – and the nerves that carry sensation to and commands back from the CNS. These nerves are the peripheral nervous system.

The peripheral nerves can be thought of as the body’s wiring system. There are sensory nerves that bring sensations of touch, temperature and pain to the CNS, motor nerves that carry commands from the CNS to our muscles, and autonomic nerves, that regulate bodily functions not usually under conscious control such as heart rate, breathing and gastrointestinal function.

Many things can damage nerves, some of which happen no matter what we do while others are under our control.

If sensory nerves are damaged, we may be unable to feel hot or cold or where our feet are, or we may feel numbness or tingling, or we may feel pain for no reason.

If motor nerves are involved, you will notice muscle weakness.

Autonomic neuropathy can have many effects, including drop in blood pressure when you stand up.

Because the nerves to the feet are the longest peripheral nerves, they are most susceptible to damage and usually the first to suffer. Hence, we usually notice abnormal sensation in the feet rather than higher up. The fingers may be next.

What causes peripheral neuropathy? The commonest known cause is diabetes; the longer and more poorly controlled is the diabetes, the more likely to result in neuropathy. Another common cause is excess alcohol. Vitamin deficiency, particularly of B12 and other B vitamins, is a very treatable cause. (Oddly enough, excess B6 can also cause neuropathy!) Chemotherapy often results in neuropathy.

There are numerous diseases, too many to list, that have peripheral neuropathy as one of their symptoms.

Finally, there is that great wastebasket of “we do not know.” One of the commoner causes of peripheral neuropathy is simply aging, with no specific disease found after thorough testing.

What can you do? If you notice any of the symptoms listed above, bring it to your doctor’s attention. Verifying the presence of neuropathy is usually easily done by physical exam. If it appears likely, you should probably see a neurologist for a more thorough exam and testing.

To minimize the likelihood of developing neuropathy, eat a healthy diet with lots of fruits and veggies to get your B vitamins and minimize your alcohol intake. If you have diabetes, work with your doctors and nurses to keep it under good control.

Do not dismiss it (or let your doctor dismiss it) as simply aging. Only after treatable causes are excluded is this an acceptable conclusion.


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Are you taking a daily aspirin?

Should you be taking a daily aspirin?

First, a little bit of (easy) basic science: we cut ourselves all the time, and nature has given us protection against bleeding to death every time this happens.

The first line of defense is our platelets, small blood particles that go to the site of disrupted blood vessels and plug any small holes, like the little Dutch boy at the dike.

The second and more permanent way bleeding is stopped is that proteins in our blood form clots.

These protective forces can cause harm. Platelets attracted not to a hole in an artery but to an irregular surface such as a cholesterol plaque can block off the artery, causing a heart attack or stroke.

(Unneeded clots can also cause problems – we will discuss that another day.)

Aspirin works to prevent platelets from clumping together. This effect is rapid and effective: a single dose of 81 or 162 mg (“low dose”) aspirin paralyzes all the circulating platelets. Platelets turn over rapidly; you get an entirely new set every 7 days, so a single dose will be effective for a few days only.

Many decades ago, it was shown that daily low dose aspirin started within 24 hours of a heart attack dramatically reduced the risk of another heart attack and stroke. This effect is called “secondary prevention:” preventing a recurrence, and nothing has changed this benefit. If you have coronary disease, you should be on aspirin unless you are at very high bleeding risk.

The problem comes when the prescription of aspirin moves from this valid use to broader use. It seems logical that if aspirin taken after a heart attack prevents another one, taking aspirin before a heart attack should prevent a first one, so-called “primary prevention.”

Aspirin taken this way DOES decrease a first heart attack or stroke, but only by a very small amount. This benefit is typically outweighed by the increased risk of bleeding that comes with aspirin use.

The higher your risk of heart attack or stroke and the lower your risk of bleeding, the more the evidence says to take aspirin. If you have multiple risk factors such as hypertension, high cholesterol, smoke and have a positive family history, and particularly if you have a high coronary calcium score, the more likely you would benefit from daily low dose aspirin.

If your coronary risk is only moderate and if you have had a bleeding ulcer or other serious bleeding, you are better avoiding aspirin.

In between? The old fallback: talk to your doctor!

No known major coronary risk? The risks almost certainly outweigh the benefits.


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How much water do you need?

It depends!

Water truly is life – we can go without eating for weeks and survive but get very sick if we do not get adequate water for a few days.

You are doubtless familiar with “rules” such as the need to drink 8 glasses of water a day. The problem with relying on such simple rules is that the real answer truly is “it depends.”

A man who is 6’5” and weighs 205 lbs. needs more water than a woman who is 5’4” and weighs 110.

It is currently sunny and pushing 90 degrees F. Walking up to get the mail left me sweating. We clearly need more water under these conditions than we do when it is 65 and shady.

People doing physical work outdoors in the heat need more water than those sitting at desks in air-conditioned offices.

“Water” includes most other liquids such as herbal tea and fruit juice – but not caffeinated drinks or alcohol, which tend to pull water out of the body.

Finally, and perhaps less obvious, we do not get water only by drinking. Many foods, particularly fruits and vegetables, contain significant amounts of water. Our habitual diet will change the amount of water we need.

Then how do you know how much water to drink? A simple reliable way to assess this is to look at your urine. If your urine is dilute – clear to pale yellow in color – you are adequately hydrated. If your urine is closer to apple juice than lemonade in color, you are dehydrated and need to drink more.

If your urine is very dark, you ought to seek medical attention, as you may need intravenous fluids.

Do not depend on thirst as your sole indicator. If you are thirsty, you are probably somewhat dehydrated, but lack of thirst is not as reliable as the color of your urine.

So: drink up!


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