How is this done and what can you really learn?
Do I worry that the genetic classification of diagnosis and treatment will make me obsolete?
To the contrary, I think it can make me better at what I do. I already strive to get to know my patients, understand how health or lack thereof fits in the rest of their life. We discuss risk for future disease, concerns about hereditary and what medicines are best for them. That is personalized medicine. Getting to know my patients at the genetic level can only strengthen that bond. Using the information we get from genetic testing and putting it in the context of the person sitting across from me is how we put the Personal in Personalized Medicine.
The path to wellness begins with a proper diagnosis
It was a typical Monday for an Internist – lots of phone calls, catching up on results that came in over the weekend, a full office schedule. I was about to go see my next patient when my assistant said that Dr. X was on the phone about a patient, could I take the call. I popped into my next patient’s room and told them I’d be 2 minutes – they said no problem and I went to my office to take the call.
The call was from a sports medicine fellow working with a specialist that I’d sent Mr. Smith to (name changed). I met Mr. Smith about 2 months ago, he had new onset high blood pressure and complained of back pain. We’d started some blood pressure medication and he was seeing the sports medicine specialist to design an exercise program for his back. He’d gotten an MRI as part of his evaluation, and instead of showing the expected herniated disc, it showed metastatic cancer – from where, we did not know. We called Mr. Smith and had him come in the next day to review his scan.
I met with Mr. Smith and his wife the next day. I took them through the scan findings, explaining what we could and couldn’t tell. He told me his back wasn’t too painful, and the specialist was helping manage it. We talked about a plan – blood tests and CT scans to find the source of the cancer. I told them I’d speak to an oncologist – and arranged his appointment with him.
Two days later, I had the blood work and his CT results, and we met again. The news was not good – there were extensive metastases in his spine and it looked like lung cancer – though we still couldn’t be sure. I sat with the Smiths, and we discussed a plan. They’d be seeing the oncologist in a couple of days, I’d already sent there results over. We discussed the next steps, what the oncologist would likely do next. We talked about how he hadn’t been sleeping well, and that I could help with that.
The Smiths left – and I was drained. It was very emotional telling someone who felt fine they have metastatic cancer. Yet we both left the encounter optimistic. The Smiths understood they have an uphill battle, but together they felt informed, guided and supported.
How Mr. Smith does is mostly out of my hands – yet I know I played a huge roll in getting them ready. I did all the things I love about medicine – bonded with a patient, made a diagnosis, educated them and got them ready for the next steps. This is Internal Medicine, and why I do what I do.
Are e-cigarettes safer?
Do e-cigarettes help you quit?
How does this affect us?
The path to wellness begins with a proper diagnosis
So many people start the New Year stating what they wish to accomplish, without reflecting on the past year. So for my first post of 2015 I’d like to reflect back on the first year of TheDiagnosisMD.com – and a challenge I undertook.
In the first year of my blog, I posted 34 times – with over 3400 views from 76 countries! Reflecting on what I posted, and the responses I got will help me shape 2015.
My goal for 2015 with TheDiagnosisMD is to make it educational, useful and fun!
In January of 2014, I ran the PF Chang’s Rock n Roll Half Marathon, with my running partner, Dr. Craig Primack. After the race, he suggested we try to run one half marathon a month for 2014. I accepted the fitness challenge. Two weeks later, on a cold morning in Sedona, we ran our 2nd half marathon of the year. It was a fun race, but we had not trained for the hills in Sedona!
After another organized race in March, schedules and races became difficult to match up, so we mapped out several 13.1 mile courses near our homes, and, on December 20, 2014 we completed our 12th Half Marathon in 2014.
Training for this, I ran over 545 miles and 83.5 hours. I went through 4 pairs of running shoes, several minor injuries and 4 toenails. The injuries have healed, and 3 out of 4 toenails are normal again.
So what did I learn?
Consistent long distance running is great for cardiovascular endurance. I have no doubt that at any time I could go run 13 or so miles without worry. However, from an overall fitness perspective I’m the same as I was in January of 2014. Same weight and non-running strength!
When I knew I was running long distances on the weekend – I found it mentally difficult to go for a 3 or 4 mile run during the week – it didn’t seem worth it if I couldn’t run 6 miles – so I ended up stacking the runs and concentrating things on the weekends. So there was less balance to my overall activities.
I’ve always told my patients that moderation was the key to success for health. So it’s time for this physician to heal himself. My goal for 2015 is to be more balanced in my fitness and in life. Challenge accepted.
I look forward to writing more about the topics you are interested in – so let me know what you’d like to learn about!
Wishing you health and happiness in 2015.
The path to wellness begins with a proper diagnosis.
It’s October and that means post-season baseball, (sorry Yankees), football season is in full swing and it is Breast Cancer Awareness month. Many athletes, celebrities and people affected by breast cancer in some way are sporting pink clothes or accessories and advocating for breast cancer screening. Why has breast cancer gotten such universal recognition in the US?
Breast Cancer Statistics
- 1 in 8 women will get breast cancer in the US
- About 300,000 women will be diagnosed this year
- About 2300 men will be diagnosed as well
- 40,000 women will die from their cancer this year – a death rate that is decreasing due to early diagnosis and treatment advances
- Breast cancer is the 2nd most common cancer in women – the first is skin cancer
- Breast cancer is the 2nd leading cause of cancer death in women – the first is lung cancer
- 2.8 million women in the US are either living with breast cancer or post treatment
- having a 1st degree relative with breast cancer doubles breast cancer risk
- 85% of women diagnosed have no family history
- 8-10% of breast cancers are linked to a genetic risk such as the BRCA gene
- BRCA-1 carries a 55-65% risk
- BRCA-2 carries a 45% risk as well as an increase in ovarian cancer risk
Breast Cancer Screening Guidelines
Given the number of women affected by breast cancer, as well as the high death rates and the fact that early detection and treatment have improved survival, one would think there would be little debate about the value of breast cancer screening. However, there are conflicting guidelines regarding screening – what age to start, when to stop, and how often to test.
The American Cancer Society (ACS) recommends yearly mammograms beginning at age 40 and continuing as long as a woman’s health and activity level make it feasible to continue.
In 2009 the US Preventive Services Task Force (USPSTF), a key driver of guidelines in the US, changed its recommendation from the ACS guideline to mammograms starting at age 50 and repeating them every other year, stopping after age 74, and eliminating self breast exams.
This change caused a lot of confusion and backlash, and later the USPSTF “softened” its recommendation to include a section stating that all women should discuss the risks and benefits of breast cancer screening with their doctors and make a decision based on their individual concerns.
So there are somewhat conflicting guidelines, but a decision about breast cancer screening should be based on your preference, your doctor’s assessment of your risks and likely your insurance company’s willingness to pay. As of now, there have not been any major changes to the reimbursement of mammograms.
So how do we screen for breast cancer?
The main screening tool we use is a history!
- What age did you start menstruating
- Do you have a family history of breast cancer
- Have you had breast surgery
- Have you ever been pregnant
The answer to these questions add context to the next part of screening – a mammogram. A mammogram is an x-ray of the breast taken from 2 angles with the breast pressed against the machine to give a standard view. That image is evaluated for irregularities that suggest cancer.
There are many variables that go into a mammogram – size of the breast, age, and density are several. Density describes the ambient of breast tissue and fat in a breast. Denser breast make it harder to detect abnormalities on a mammogram. Denser breasts tend to be found in younger women, those who never had children, and athletic women. When this occurs, adding an ultrasound of the breasts can improve the reliability of the results.
MRI has been looked at recently as a screening tool – attractive because it does not use radiation, and can create very detailed images. Therefore, it can detect much smaller abnormalities. Currently this is only recommended for very high risk women.
Another technology recently developed is called Digital Tomosynthesis. Similar to a mammogram, the breast is pressed into position but 11 x-rays are taken instead of two. The images are fed into a computer and a 3-D image of the breast is created and evaluated for abnormalities.
MRI and tomosynthesis are not currently recommended for routine screening.
What do I tell my patients?
- Every patient is unique, and needs their risk factors evaluated
- Based on the risk assessment, a mammogram and possibly an ultrasound will be ordered
- I reserve MRI and tomosynthesis to those women with very high risk
- Breast implants do not change the need for a mammogram – the implants can be maneuvered out of the image so the breast can be assessed
After the study is done, we will decide when to repeat it – usually yearly based on the ACS guidelines.
One important aspect of breast cancer screening that is overlooked is communication – any test, especially one looking for cancer will provoke anxiety, and I try to get results to my patients as soon as possible. In fact, reducing test anxiety was one of the reasons the USPSTF recommended less testing!
Often there will be an area that was not well seen on the mammogram. In this situation, close up views of the area need to be done – called spot compression views. This does not mean you have cancer – it means a closer look is needed.
Regardless of which screening guideline one follows, one thing must be stressed – if you feel something that does not seem normal to you – bring it to your doctor’s attention! Breast tissue does change and often develops cysts (tender lumps) throughout the menstrual cycle, and where you are in your cycle as well as caffeine intake can influence cysts. These changes tend to go away at the end of a period. When there is a lump – especially if it persists through a complete menstrual cycle – it is not considered screening and all guidelines stress the need to further diagnose a lump – regardless of age. When discussing self breast exams with my patients I tell them to learn what is normal for them – all breast tissue has some irregularities. If something is different from your normal, see your doctor. It may be nothing but all evidence shows early detection improves outcomes – and ignoring a lump will delay things – either peace of mind that everything is ok or the opportunity to find a cancer early.
The path to wellness begins with a proper diagnosis
For the past month or so we have all seen ice bucket challenge videos of friends, family and celebrities dumping buckets of ice water on their heads, making donations to ALS foundations, and asking others to do the same. In addition to giving us some good laughs, the campaign has raised over $70 million. And that is the point. There are many diseases we don’t have all the answers to, they range the spectrum from infectious, cancerous, autoimmune and idiopathic (a fancy way of saying “we don’t know” and still sound smart.)
For the record, just as the ice bucket challenge was going viral, I was interviewed on the Phoenix NBC affiliate about the health affects of cold water shocks and any health consequences. Unless you have a predisposition to heart rhythm irregularities it should be a safe activity – just be sure not to fall or have someone drop a heavy bucket of ice on you.
For people diagnosed with a life long illness, lives are altered. Some diagnoses bring more change than others – depending on how day-to-day life changes come from the diagnosis or treatment. This emphasizes how important it is to get a diagnosis correct. The only way to improve the outcome of a diagnosis is through research – for better and earlier diagnostic tests, treatments with better results and less side effects. Research for clinical treatments is time-consuming and expensive. There is not enough money available for all the diseases that need more research – leaving many underfunded diseases.
Most medical research in the US is funded by the National Institutes of Health. Over $30 billion in grant funding is scheduled for this year. The competition for funding is fierce and complex. Most universities have entire departments to help researchers with the process of applying for grants. Private industry can choose the diseases they invest in, and have improved the lives of millions of people, however, as private businesses they also need to develop products that will be used by many. It doesn’t make business sense to invest millions of dollars in a product that won’t generate sales to cover the cost of development.
What has filled the gap between highly prevalent diseases and NIH funding are patient organizations. These groups have, for several decades, brought together people who share a connection to diagnosis, raised awareness and money for research – with direct benefit to those in need. 30 years ago people would whisper the words “Breast Cancer” or “HIV” – today there are huge organizations that have taken these “taboo” diagnoses into the mainstream. They have raised huge sums of money and affected government policy. The result: more and better treatments which have resulted in longer, healthier lives for those diagnosed with these conditions.
Many of the non-profits hold events – dinners, fundraising parties and athletic training programs – a personal favorite of mine. I became involved with the Crohn’s and Colitis Foundation of America in 2010, and joined Team Challenge, their Half Marathon training program. Together, the NYC team raised over $250,000 and the entire event raised $3.7 million for the CCFA. For more of my thoughts on exercising for a cause, click here.
Besides the direct money these races or other events raise, there is media attention given to a cause that might not get it otherwise, as well as the stories of the people participating. Stories of how a diagnosis has affected their life or the life of a loved one, and how being part of an organization dedicated to improving the lives of those affected can bring change.
We can laugh at our videos of cold water drenching (see mine here – Ice Bucket Challenge), cry at some of the stories behind the videos and get annoyed that our Facebook/Twitter/Instagram feeds are being clogged by them, but to those affected by ALS this campaign is life altering, just as the diagnosis of ALS was in the first place. Just like my work with the CCFA was for me. Remember, the work done today can mean that the person diagnosed tomorrow has hope and options, not fear and shame.
The path to wellness begins with a proper diagnosis
Every culture has its own lingo, a shorthand that allows those in the know to gather information quickly and process it efficiently. I think the first language of medicine I remember is from the 70’s TV show Emergency – “get me an amp of bicarb and D50 STAT!”
The language of medicine makes sense to those in it – and sometimes we sometimes forget that others may not speak it fluently. I was reminded of this when my daughter shared a text message with me and I needed to Google half of the “words” until I found a very helpful text translation website!
There are two occasions that I find I use lingo in front of patients.
- When speaking to another doctor in front of the patient. Sometimes this is necessary to give or receive information quickly. I try to remember to tell the patient what I am doing and apologize if it seems like I am ignoring them, but it is important in that moment for their care.
- Out of habit. Since lingo is so familiar to me, I slip into it even when speaking to someone who is not – just like saying LOL instead of actually laughing.
Language has the power to frame how a patient interprets the information I give them. If I present a diagnosis or therapy in a calm voice with familiar words it sends a very different message than information given urgently with very technical language. The language and tone I use deliver confidence or panic, trust or suspicion. It is part of the bedside manner that influences my relationship with a patient, and at different times needs to bed differently. Some patients want to be told what to do, others need to be led to a decision but have the final say. Most people are somewhere in between.
Another aspect of this is how the vocabulary we choose can change a patient’s outlook. I have a choice when discussing treatment options for a diagnosis – you can take this medicine or do a treatment. One is passive and one is active, which impacts how both I and a patient perceive their diagnosis and options. We tend to reserve active language for more serious diagnoses – you take medicine for strep throat, but you do a treatment for cancer. While not life threatening, any diagnosis impacts the person with it. Remember the difference between major and minor surgery – minor surgery happens to someone else, major surgery to you.
How a patient interprets their diagnosis has a huge impact on its outcome. It effects their understanding of its severity, their role in its management, their likelihood of completing therapy and their trust in their physician. Attitude about a diagnosis affects the body’s immune system and multiple studies have shown engaged patients have better outcomes.
Done well, good communication is a low-cost, high-value therapy, and when done right does not take any longer than poor communication – and it has benefits down the line for both doctor and patient. I’d like to think I get this right all the time, but I know I don’t – some patients you don’t connect with at all, sometimes you can’t find the right words. Much has recently been written about the need for doctors to be good listeners, but we need to be good speakers as well!
Earlier today a plane landed in the US carrying a very sick person. They are being transported to Emory Hospital to be treated for one of the scariest infections that exists – Ebola Virus. This person contracted the virus in West Africa caring for other victims of the same infection, and is now being brought to a special infection control room for treatment. Ebola has been featured in many books and movies – usually as a weapon or shown in a widespread epidemic of plague-like proportions. But what is Ebola, and what is more accurate – truth or fiction?
What is Ebola?
What is happening in Africa?
What does this mean for us?
The average person should not be concerned with catching Ebola, even if you are in the vicinity of Emory Hospital. Ebola is not an airborne virus – meaning you need to have direct contact with infected droplets to be infected. You can not catch Ebola by breathing the same air as someone who has Ebola. In addition, the plane the patient travelled on was not a commercial flight and was set up to prevent the spread of droplets. Same for the ambulance that took the patient to the hospital. So I do not think there is a high contagion risk in the US. The CDC has issued a travel advisory, recommending non-essential travelers leave the affected areas in West Africa, and for those in the US to avoid travel there. They are also implementing screening and reporting systems to identify and isolate potentially sick people boarding planes from the area, as well as decontamination procedures for the airlines, as they have done with other infections like SARS. So as frightening as Ebola is, and no matter what happened in that movie you saw, there is little risk of infection to the average person.
The path to wellness begins with a proper diagnosis
Last weekend we dropped our daughter off in a mall parking lot to take the bus to camp for the next 7 weeks. Of course, the night before, while thinking about summer, the movie Meatballs was on television, and I laughed and envied her the summer she was about to have. So, on the way to the bus, between obscure movie jokes I tried to give my daughter some summer health tips, and thought I would share them.
I had the chance to be the camp doctor for a couple of weeks for the past 2 summers, and therefore had a first hand look at some of the summer health issues we forget about when summer is otherwise just a hotter day at the office. Summer health threats come in several categories – bugs, weather and accidents.
Most bugs that bite people are harmless, other than typical itching/swelling – unless you are allergic to that particular bug. Mosquitoes, bees and ticks are the majority of insects that come out in the summer. Depending on your location, different diseases can come with them.
Mosquitoes bite and cause skin reactions that swell or itch. For centuries, mosquitoes have carried illness – Yellow Fever, Malaria, Dengue, and West Nile are several types of infections spread by mosquitoes. You can not tell which mosquitoes may be carrying infections, so efforts have focused on prevention – spraying areas with standing water where mosquitoes breed, using insect repellent and clothing to avoid bites, and vaccines for those illnesses where available.
The biggest risk to bee stings is an allergic reaction. If you have a history of severe reactions such as trouble breathing or mouth or throat swelling, then you should carry an Epipen. An epipen is an emergency injection of epinephrine which can stop the difficulty breathing.
Ticks are another potential source of infection. On the East Coast, some tick species carry Lyme Disease, Babesia and Ehrlichia, and in the West, Rocky Mountain Spotted Fever. These infections can be treated with antibiotics, especially when found early. Of course, the best defense is to not get bit by a tick. The good news about tick borne illnesses is that a tick needs to be on a person for 24 hours to transmit disease – so regular checking after coming indoors can prevent many infections.
The other bugs that people worry about, especially at camp, are bed bugs and lice. Neither of these cause illness, but the bites can be itchy and uncomfortable! Most cases of lice and bedbugs are brought in from the outside – whether it is camp or a 5 star hotel! Heat kills both lice and bed bugs, so putting all bedding and clothing in the dryer on high for an hour before sending them to camp can reduce the likelihood of bringing it in. Also, in my experience as camp doctor, I’ve seen an increase in the detail of lice checks – with outside companies with magnifying lights and fine tooth combs being brought in to help check the kids on arrival!
The next risk in summertime is weather – mostly heat. When you spend more time outdoors, being active you run the risk of dehydration – not just kids playing, but adults and pets too. I can’t stress enough how important it is to drink plenty of water. It doesn’t take much to get overwhelmed by heat. I ran in NYC last weekend when it was 65 degrees, did 8 miles with a small water break half way through. This morning, I ran 8 miles in Arizona – 87 degrees at 6am, drank a full bottle of water after 4 miles and had to walk parts of mile 7 & 8! I needed more than one bottle of water spaced through my run. My general rule is if you will be outside for more than 30 minutes, bring a water bottle.
Summer is also a time for thunderstorms. Common sense says to stay indoors during a thunderstorm. Lightning tends to strike water before land, and higher structures before the ground, so if you are stuck outside during a storm, do your best to get indoors and away from trees and water. And listen to those weather alerts on your phone – I got stuck driving in a dust storm last week – and the wind was so intense that branches were torn from trees and flying around. I was happy to get home safe!
My last weather related summer health tip – use sunscreen! The burns from summer sun – intense short exposure – dramatically increase the risk of skin cancer – not to mention wrinkles!
With summer activities will certainly increase the rate of getting hurt – bike falls, sports and water activities all carry some risk. Again, common sense can reduce the risk of severe injury. Helmets save lives and prevent concussions. Don’t ride a bike without one.
Never swim alone, and be sure your yard and pool are fenced in – different areas have different laws regarding home swimming pools based on the age of the people/children living there – follow them! If you are on a boat, use a life-preserver – the name says it all!
My last safety summer tip is simple – leave the fireworks to the professionals. Too many people end up in the emergency room with burns or missing fingers and toes.
Nothing can completely prevent accidents – they will happen, but you can minimize their impact. While I was camp doctor we had several campers with cuts, head bumps and even broken bones. Fortunately, with good planning and training of staff, potential disasters can become another summer memory!
The path to wellness begins with a proper diagnosis