Annual Physical Exam vs Personal Health Assessment

I read a piece in the New York Times this week questioning the usefulness of a yearly checkup with your doctor.  It cited a study from 2012 that said that people who went for an annual exam did not live longer, avoid the hospital more or visit the doctor less.  A similarly themed Op-Ed piece was written by Ezekiel Emanuel earlier this year.  With all due respect to Dr. Emanuel and the New York Times, I will disagree, although with a caveat.
The usefulness of anything depends on how you define it and the what you seek to accomplish.  A checkup that ticks off boxes on a form for an insurance discount – maybe checking blood pressure, weight, blood sugar and cholesterol may identify some people with a health issue.  A fuller exam that looks at when recommended screening exams and vaccines were last done may increase health care usage, but no one argues that a colonoscopy at the right time in one’s life can be life saving and cost-effective.  Medicare covers an annual wellness exam, designed to identify those things that cost medicare money and increase health expenses – dementia, falls and depression.  It also requires a discussion about advanced directives – what a person does or doesn’t want done if they get too sick to make decisions for themselves.  It does not cover lab work, blood pressure checks or other “problems”.  In fact, there is no “laying of hands” at all.
The argument often cited for the yearly exam is relationship building.  If you see your physician when you are well, it is a chance to know what your baseline is, and later you are not trying to establish a relationship in a crisis.  There are pros and cons to this argument – in a mobile society, when you are young, will you have the same doctor when you get ill?  Or do you view your relationship as an insurance policy?  You have the relationship, and hope not to use it.  If there wasn’t precedence for this, wouldn’t we only buy auto insurance after the accident?  Or do you view your physician as a trusted advisor, investing in your health like you might your financial portfolio, with regular review to try to optimize things?

So what do I think of an Annual Exam?

The issue with studies on physical exams are multiple – inconsistent definitions, goals and outcomes make it hard to compare results from various studies.  Besides the studies the NY Times quoted, there are several studies that show recommended screening occurs more in people who come for annual physicals, and that there are health benefits – such as identification of high blood pressure – which has no symptoms and won’t be found until it is too late.
I believe in a yearly checkup.  However, I think the definition needs to change, and it has a very specific goal.  Personal Health Risk Assessment.  All the studies are based on large populations, and when I am with a patient, the most important thing is that person across from me.  We can use population data for a discussion, but what really matters is your risk.  So I like to use the opportunity of an annual exam to go through a person’s history, family history, social history and medical concerns.  Using that information, we can use population studies and decide what studies are appropriate for you!  We can look for the things you are at highest risk for and are most concerned about.  We can decide on a risk reduction plan once we have testing data back.  Can I guarantee you will be healthier for it? No, life does not come with guarantees.  We will be able to say that we identified your risks and did our best to reduce them.  We come away with information and recommendations that are specific to you.  I know your health risks, fears and concerns, and can provide advice that addresses them.
Will you live longer for our time together?  I don’t know.  Can you live better for it – absolutely!
 The path to wellness begins with a proper diagnosis
 

Something personal

For the past year and change, I’ve used this forum to educate and demystify medicine, and to introduce myself as a physician to everyone.   Today is a little different.

I have been involved with the Crohn’s and Colitis Foundation of America for the past 5 years. Now I am proud to say my daughter is getting involved too!

She has organized Team EmGo in honor of her Bat Mitzvah/ 13th Birthday for the Take Steps walk to raise money to support research for Crohns Disease and Ulcerative Colitis.  To learn more about her team:

online.ccfa.org/goto/teamemgo

 

Stop Counting Cholesterol? New Dietary Guidelines say so

At the end of 2014, The Dietary Guidelines for Americans Council issued its 2015 guidelines and analysis of what we should eat, what we do eat, and what the consequences of what we eat are.  Many of the recommendations and observations are what we expected – we eat too much sodium and sugar, not enough fruits, and are overweight.  What was surprising is that they do not recommend watching cholesterol intake any longer – saturated fat yes, but cholesterol, no.

What did the report say?

The main thrust of the report emphasizes a diet with lots of fruits and vegetables, whole grains, low in saturated fat.  Limiting processed meats, refined grains (white bread) and drinks with added sugar is also recommeded.  Good food such as seafoods, nuts and legumes, as well as low-fat dairy are emphasized.
Notably, the report for the first time removed the recommendation to limit cholesterol intake.  Prior recommendations were to limit cholesterol intake to under 300mg daily.  Instead, it is recommended to limit saturated fat and empty calories such as processed sugars.  It is these foods that are contributing to obesity and its consequences much more that dietary cholesterol.  Added sugars and saturated fat should be < 10% of total calories in a day.
Saturated fat has 9 calories per gram.  So in a 2000 calorie diet, saturated fat should be limitied to 22 grams daily.  Sugar has 4 calories per gram.  In the same diet, sugar should be limited to 50 grams daily.
For a real world example, a Snickers bar has 250 calories.  That is over 10% of a 2000 calories diet.  It has 4.5 grams of saturated fat, which is 20% of daily recommendation, and 27 grams of sugar, which is 54% of the daily recommendation!  By contrast, 2 scrambled eggs has about 200 calories and the same amount of saturated fat, but only 2.1 grams of sugar, or about 4% of the daily recommendation.

So what does this mean?

The report brings dietary guidelines more in line with current research.  We have seen several studies showing the benefits of a Mediterranean style diet – high in fish, nuts, vegetables and good fats such as olive oil.  The guidelines now support those findings.  It means a heart healthy diet can include some fats, and should limit the empty starches – those made with refined flour that add little nutrition but many calories.  It means that moderate intake of eggs and lean meats is healthier than meals based on breads, rice and pasta.
Perhaps the best news in the report (at least for me) is that up to 5 cups of coffee a day does not seem to be harmful!!!

The path to wellness begins with a proper diagnosis 

Challenge Completed

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.

Got Milk? Too much of a good thing?

The USDA recommends 3 cups of milk or dairy a day.  This is mostly to promote bone health.  However, it has also been linked to increased cancer risk in some studies, others have supported health benefits.  A recent study tried to sort out these conflicting results by separating milk from other dairy products and looking at death rates, heart disease, cancer rates and fractures.
What they found was surprising – adults who drank 3 or more glasses of milk a day died sooner, had more fractures as well as heart disease and cancer.  Those with similar dairy intake, but from fermented dairy like yogurt, cheese, sour milk, etc. had a lower incidence of death and disease.  The difference?  Lactose content.

What is lactose?

Lactose is a sugar found in milk.  When digested, it is broken down into glucose and galactose.  Galactose has been linked to oxidation and inflammation – triggers for disease.  The study authors hypothesized that the difference in lactose, therefore galactose intake with milk versus other dairy products is the cause of the difference if death and disease

What did they do?

The researches used 2 health registries of residents in Sweden where records are centralized, totaling over 61,000 women and 45,000 men and sent them questionnaires that looked at milk and dairy intake.  They then followed their records from the early 1990’s until now, looking at death and disease rates.  What they found was that women who drank 3 or more glasses of milk daily were:
  • 1.9x more likely to die
  • 1.4x more likely to get cancer
  • 1.6x more likely to fracture a hip
In men, the effects were less pronounced:
  • 1.1x more likely to die, mostly from cardiovascular disease
  • no increase in fractures
They also messed marks of inflammation and oxidation in the blood of participants and found higher levels of both in those with higher milk intake.

So what does this mean?

There are some interesting associations based on this study.
  • ingestion of milk, with it’s higher lactose content, may be linked to increase risk of disease
  • ingestion of low lactose dairy products (yogurt, cheese) is associated with a decrease of disease
  • moderate intake of milk is not associated with increased disease risk

There are some limits to this study

  • the data is based on 1 or 2 food surveys, and subject to people’s memory and answers
  • the population studied was very uniform – 2 or 3 counties in Sweden – which may limit generalizing to the population at large
  • All subjects were over 39 years old so no conclusions can be made about children and young adults
  • Lactose free milk was not evaluated

What can we take away from this?

  • High amounts of lactose may contribute to disease based on its breakdown into oxidation and inflammation promoting compounds
  • Dairy foods with low lactose contents are associated with lower death rates and illness
  • Moderation again seem to be the word of the day – it is possible to have too much of a good thing!

The path to wellness begins with a proper diagnosis

Breast Cancer Screening – In October We Wear Pink

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

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