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Wednesday, April 22, 2015

Preventive Medicine: on being a "bad patient" (Readers beware: this is the rant of a curmudgeon. Take with at least one grain of salt.)

I am, or will be, a "bad patient." The "good patient" accepts advice gracefully. The "bad patient" may not be a bad person, but does not play the part of the patient well. The word patient comes from the Latin word root pati, to suffer. The "good patient" suffers well, and accepts help from a physician,who Merriam Webster defines as someone skilled in the art of healing. This relationship is one in which the roles are well defined. When the patient is not actually suffering and is even more confusingly "skilled in the art of healing" the roles get really wonky. I will be this kind of "bad patient."

One way in which I do not play the part of the patient well regards preventive medicine. I am getting to an age at which various things are recommended in order to reduce my risk of developing some dread disease. When it comes to these recommendations, I find that I have become quite the picky consumer. I would dearly love not to get a preventable disease, but after more than 2 decades of practicing primary care medicine, I have seen too many undesirable consequences of perfectly benign sounding medical tests.

Breast Cancer Screening:
I don't avail myself of mammograms. I did once, and that was fine. Starting age 50 I was supposed to get mammogams every other year, according to the US Preventive Services Task Force (USPSTF). Maybe I'll get another one sometime if the data gets better. A Canadian study showed no significant effect of regular mammography on breast cancer mortality in average risk patients, though women who get regular screening do get more treatment for breast cancers, including mastectomies and radiation therapy.

Colon Cancer Screening:
I haven't had a colonoscopy. In this test, a fiberoptic scope would be introduced into my lower intestine by way of the rectum and the whole colon would be visualized with the expectation of finding and removing polyps before they become cancers, or seeing cancers before they become incurable. USPSTF said I should have started those at age 50, but the data for women without suggestive family histories of colon cancer is not convincing and the potential for something to go wrong definitely exists. An inadequately sterilized colonoscope could introduce some unfriendly bacterium into my gut. I think I like my flora as it is, thank you. The procedure to clean out my gut, drinking a half gallon of polyethylene glycol solution until my bowels run clear, which is required before the procedure, may be fine, but I'm not entirely sure that a day of rapid intestinal transit is good for me. Intravenous sedation, which is usually given in order to make this procedure tolerable, has a small risk of killing me and will make me goofy, though possibly in a pleasant way. I will watch for updates, but I'm thinking I may have this procedure when I'm 60. Maybe. I prefer to reduce my risk of colon cancer by maintaining a healthy weight and eating a diet rich in fruits and vegetables.

Cervical Cancer Screening:
Pap smears. The recommendations have changed and the schedule is less onerous, but since I had regular yearly pap smears until several years after becoming monogamous, my chance of having a new human papillomavirus infection is vanishingly small, and it is that infection that leads to cervical cancer, which is the only cancer that a pap smear reliably detects. I think I may be done with pap smears.

Hypertension:
Blood pressure screening is another story. Detection of hypertension and treatment of high blood pressure saves lives, prevents strokes, heart attacks and kidney failure. I can do it myself, and if my blood pressure is persistently high, I will actually see a doctor and start medications. Let that not happen, because I will not submit gracefully to someone else's opinion on which medication I should take. Unless, of course, they are right. Often I see patients started on some medication which just came out and is available in the doctors free sample cabinet. That one I don't want. It will be expensive to refill and we will know very little about how well it works in the long run. Don't I sound annoying?

Osteoporosis:
Bone density testing. There are machines that will shoot photons at my bones and tell me if I am developing osteoporosis. I should get this done at age 65. Mostly I should avoid breaking bones, though, since that is the real problem. It matters not a bit if my bones are as fragile as dry corn stalks so long as they never break. Staying strong and agile is the best way to avoid falls and fractures. If I find out that my bones are thinning, the main option for bone strenthening are the bisphosphonates, such as alendronate (Fosamax). These are medications which, if they don't get caught in the esophagus and cause a terrible ulcer, which they are known to do, and they don't get entirely eliminated, unabsorbed, due to having taken food with them to avoid getting the esophageal ulcer, will enter my bones to reduce the natural breakdown of bone by my osteoclasts, thus messing up the delicate balance of osteoblasts and osteoclasts that creates normal bone architecture. This will reduce my risk of breaking a hip or vertebra if I fall, but will put me at risk for a rare but horrific breakdown of bone in the jaw called osteonecrosis. So I will work hard on my strength and balance, eat a good diet and encourage the effects of gravity on my bones via weight bearing exercise. Luckily I am not yet 65, so I can decide on this test later. I'm leaning toward not.

But what about taking estrogen for my bones? It is primarily the loss of natural estrogen at menopause that will lead to osteoporosis. Will I take estrogen, then, since I am in menopause? The drawbacks are a slight increase in breast cancer, but without a convincing increase in breast cancer deaths, so this is a wash as far as I'm concerned. There is a slight increased risk of developing blood clots to the legs and lungs, but I didn't get those when I made estrogen with my natural ovaries so I doubt I'll get them with a small dose of exogenous estrogen. There is a slight risk of developing endometrial cancer when taking estrogen if progesterone is not taken as well to maintain a thin endometrium. Birth control pills, which are about 6 times the estrogen dose of a standard estrogen replacement pill, have a progesterone agent in them, and that may well be adequate to maintain a thin and healthy endometrium. I can also check my endometrium regularly with a quick transabdominal bedside ultrasound and make sure everything is looking hunky dory. Will I get a stroke or heart attack with estrogen? The results from the Women's Health Initiative suggested that this might be a risk, but further study has suggested that it may have been the relatively high dose of medroxyprogesterone that caused that problem, and there was no actual survival disadvantage in long term estrogen users. Will estrogen help me avoid hot flashes and vaginal dryness? Yes, it will. Perhaps I shall take one sixth of a birth control pill daily, since that is cheap and generic and will avoid wallet toxicity.

Vaccines:
What about vaccinations? Yes, with no hesitation. Yearly flu shots, though I recognize my potential benefit from these is low, pneumonia shots when the time comes, tetanus and acellular pertussis, yes, and appropriate travel vaccinations with the possible exception of yellow fever. (There is a longer discussion of that here.)

Lipids:
How about obsessing about my cholesterol? The present recommendations about cholesterol lowering are to treat patients with a 10 year risk of cardiovascular events of 7.5% or higher. The calculator for this has recently been shown to overestimate this risk, but I have always been in the vanishingly unlikely range, which means that I need not know my numbers. I have checked them occasionally and they are not pristine, but it is not clear to me what intervention would be most likely to lower my already low risk of cardiovascular disease. Certainly there is no indication for medications. I might become primarily vegetarian and eat fish when I can get it, embracing the Mediterranean diet. There is no good data to tell me which fats I should eat, but it seems wise to be moderate and avoid trans-fats which don't naturally occur in the foods I love anyway. 

Moving my body:
How about exercise? Exercise seems to play an important part in preventing all kinds of things I don't want, from diabetes to dementia. It will control my weight, which will help me avoid hypertension and cancer. It will improve my balance so I will avoid falling and breaking bones. I will be more likely to be nimble enough to jump out of the way of an oncoming bus or bicycle. Yes to exercise. Long walks in the woods, cross country skiing, visits to the gym, bicycling, swimming, canoeing. 

The yearly physical:
How about a regular physical exam? Not sure. So far it's been no for me, but yes for my patients. A physical exam is no longer really recommended, though there are many pieces of the physical exam that are part of what we recommend to patients as prevention. I think a physical exam is actually a good idea, but more as a prolonged discussion of preventive testing recommendations and to develop shared goals. Examining the body is not a bad idea, either. As we age, our bodies do weird things. A toe will point in the wrong direction, there will be a lump or a pain or a vague dysfunction, none of them severe enough to warrant a visit to the doctor, but each one deserving attention and maybe explanation. In total, these little irritations may paint a picture of a whole organism which needs some kind of intervention in order to be as healthy and vital as possible. If this kind of an evaluation and discussion is a physical, then yes, definitely, and I might even want one. 

So am I actually a bad patient? Since I am not a patient, it is still a moot point. They say doctors make terrible patients. We will just have to see, when the time comes.

4 comments:

Anonymous said...

This is really funny. Are all female physicians like us? After having a painful breast cyst aspirated, I stopped wearing tight fitting sports bras all weekend and stopped getting cysts. I will never do a mammogram.I stopped doing pap smears years ago. I take generic yasmin for unrelenting menopausal symptoms which is a fraction of the cost of prempro; quality of life bearable only while on them. I exercise and eat healthy and will never do a bone density. Rather than sending our older patients for bone densities, I'd rather enroll them in exercise classes to build their muscle tone,improve their balance and widen their social circles. Yes, the goal is to avoid fractures not just focus on what the bones look like under the microscope. I will not be doing a colonoscopy, but I will do the Cologuard test and feel that patients should be able to order than own rather than wasting time and dollars for an appt and a script. There is no cancer in the family, I lead a healthy lifestyle and did a DNA test that has shed some light on what I should be worried about. Of course risk stratification is important, but doing more does not always lead to better outcomes. Maybe one day the rest of America will catch on.

Janice Boughton said...

It's funny how little we want of the product that we offer. Nice to hear that I'm one of many who feel this way.

herbert said...

AMEN to all this! For the 'drills' here that relate to both sexes, my gut sense is affirmed by all you've written here. Thank you.

About the absence of "good data" regarding desirable vs undesirable fats, I'm happy doing without trans-fats (and I read labels!) and beef products (which isn't simply about content, but even more about the 'beef' I have with the way that industry is managed & promoted). After decades w/o pork, I've given in to the occasional side of the 'clean' bacon we get from Canada... and butter (often organic, always from rBST-free sources). Being in the low-mid range of Americans re cholesterol I take a red yeast rice supplement, which seems to have neutralized any ill effects from the occasional bacon. Now that I'm over 70 I have been to see MDs more in the last 5 years than the previous 35, partly the result of an industrial accident, and being eligible for Medicare... which, perhaps rightly, costs more than any 'health insurance' I had previously... and I'm waiting for Someone to tell the world how the insurance companies,via "Medicare Advantage" plans (with the apparent cooperation of clinics & physicians) have usurped Medicare coverage as I once understood it.

Exercise, Si! I wish the DHHS would send every Medicare recipient a 'birthday present' of one of those partially-inflated discs which one uses to practice keeping one's balance... & maybe a pilates ball, too.

Again, thanks for keeping it real! ^..^

Thaniel said...

Love your comments on Pap smears. However the insurance companies still pressure women to have them. I've been married for 24 years and we are very close and very manganous. In fact we have never had sex with anyone else. Ever. Not before we were married and most defiantly not after. But there it is every direction recommendations for regular Pap smears. I find it offensive. It's like they think all women are sluts. Its disgusting.