The Daily Dose with Dr. Spence: October 2008

Questions on MRSA

Dear Dr. Spence, I am concerned about the supposed "super bug" they call MRSA. Am I at risk? Signed, Concerned to the point of complete panic

Dear Concerned,

MRSA, or methicillin resistant Staphylococcus aureus, refers to a particular strain of bacteria that has developed a resistance to standard penicillin products. This may be a result of physician overprescribing of antibiotics and the gradual trend towards bacteria developing resistant genes. It has been in the press quite a bit lately secondary to its prevalence among athletic teams. Several members of an area football team, in fact, have been plagued with skin abscesses directly attributable to MRSA. Most commonly, MRSA affects the skin and causes large, often painful abscesses that often need formal drainage in order to heal. More virulent strains may affect immune compromised patients resulting in possible severe pneumonia or infections of the bloodstream. Generally, MRSA is spread via direct contact with a lesion, but many patients are nasal carriers who risk spreading it to others in close quarters. Nationally, most strains appear to be sensitive to antibiotic treatment with either sulfa drugs or clindamycin. I usually suggest treatment of the nostrils to eradicate a potential carrier state. Oftentimes, I treat family members as well. Recurrences are not uncommon and usually demand further intervention. Dear Dr. Spence, My friends have suggested B12 injections to "cure" my fatigue. What do you think? Signed, Sick and tired Dear Sick and Tired, Older physicians still utilize B12 injections as a way to boost energy. The reality is that no study has ever shown a confirmed benefit from B12 unless the patient has a true deficiency. I regularly check patients for B12 problems regardless of age. I have been shocked at how prevalent the condition is, especially in those with complaints of fatigue. Studies suggest 15 % of the population has a low B12 level. We are grossly undertreating this condition in my opinion. Of those I screen, close to 80% have a deficiency. B12 deficiency can result in fatigue, anemia, neurologic change resembling dementia, and general nerve damage. It is suspected that the deficiency stems from problems of malabsorption in the gut, a condition that becomes more demonstrable as one ages. For this reason, most physicians have relied on 1000 microgram injections each month in order to bypass the gut altogether. A reasonable alternative is to supplement with daily 1000 microgram pills (available over the counter). It appears that equivalent levels can be achieved with either the oral or injectable form; many may opt for pills to avoid a painful injection. I suggest close follow-up with B12 monitoring to ensure an adequate dosing regimen. Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on Strokes

Dear Dr. Spence,
I had a stroke last year and I am terrified at the thought of having another, more severe one? What can I do to prevent this from happening?

Signed,
Terrified Joe

Dear Joe,
There are approximately 700,000 strokes per year in the United States of which nearly 1/3 are recurrent. Fourteen percent of those with a new stroke will go on to have another and 270,000 people die annually from stroke and its complications.

The most important initial step is a basic evaluation for possible risks and causes. Most patients will undergo heart ultrasounds (echocardiograms), EKGs (electrocardiograms) to rule out abnormal heart rhythms and carotid ultrasounds to evaluate for blockages. Assuming these have all been done and are normal, the next step is modifying those risks that you may have. Though I cannot comment on your individual risks, I generally assess five potential problem areas.

(1) Hypertension – Studies have consistently shown a decreased risk of stroke with improvement in blood pressure. A goal of 140/90 or less is recommended but I strive for 120-130/60-80 if possible. The best medication appears to be an ACE inhibitor like lisinopril combined with simple diuretics like HCTZ or chlorthalidone

(2) Diabetes – Control of blood sugars has never truly been proven to reduce the risk of stroke but diabetics do need close monitoring and aggressive treatment. Not to overemphasize the blood pressure issue, diabetics are encouraged to maintain pressures less than 130/80.

(3) Cholesterol – High cholesterol remains a very modifiable risk factor. Bad cholesterol (LDL) should be decreased to below 100 in most, or less than 80 if the patient has cardiovascular disease. I tend to use statins (lipitor, zocor, etc.) even when patients have reasonably normal LDL readings as the data suggests additional benefits from these medications beyond LDL lowering. Recent studies with lipitor have shown that 52 patients would need to be treated for five years to prevent one stroke or 29 to prevent one heart attack.

(4) Lifestyle – Smokers need to quit, alcohol use needs to decrease and exercise needs to be implemented to assist with weight loss and general health. Enough said!

(5) Blood thinners – I recommend aspirin at a dose of 81 mg per day for most patients. Other drugs are on the market but most do not provide any additional protection when compared to their potential adverse effects and cost. Aggrenox may be a better overall agent but can be cost prohibitive.

Of course, strokes are not entirely preventable regardless of our interventions, but we certainly can intervene to decrease the overall likelihood.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on Prostate Cancer & Carpal Tunnel Syndrome

Dear Dr. Spence,

I have been having problems with urination and I am concerned about prostate cancer. How do I know if I have it?

Signed, Concerned in Marianna

Dear Concerned,

First, prostatic symptoms correlate poorly with disease state. At least fifty percent of men over the age of fifty will have some symptoms of prostatic enlargement, also referred to as BPH (benign prostatic hyperplasia), but few will actually have cancer. Symptoms of BPH include frequent urination (especially at night), dribbling, hesitancy and urgency, and a generally weakened stream. Of course, medications are available to treat this condition.

Prostate cancer screening consists of checking the blood prostate specific antigen (PSA) and performing a digital rectal exam. Neither is particularly sensitive nor specific at detecting cancer. PSA velocity, the rate at which the PSA rises over time, may also be an important clinical indicator in deciding when a biopsy should be considered. At present, there is insufficient evidence to determine whether screening for prostate cancer reduces mortality or impacts quality of life. Only forty percent of patients with an elevated PSA will have cancer but most will have undergone expensive and painful prostatic biopsies. Prostate cancers are also notoriously slow growing. Autopsy data suggests that perhaps greater than 50% of patients older than 85 years of age have prostate cancer. Rarely is this the cause of death, however, What do we do with this information? Prostate cancer still claims an estimated 27,050 lives annually and 1 in 34 men will die from the disease. I generally recommend starting screening around age 50 unless family history warrants earlier testing. Though not a perfect science, it is the best screening tool currently available.

Dear Dr. Spence,

My doctor has sent me to an orthopedic surgeon for carpal tunnel syndrome. Are there any other options besides going under the knife?

Signed, Wrist pain in Sneads

Dear Wrist pain,

Two randomized trials have demonstrated that oral steroids like prednisone can be effective in treating the symptoms of carpal tunnel syndrome (CTS). Perhaps even more efficacious are localized injections at the carpal tunnel itself. I have personally had great success with the latter and have helped many patients prolong or even prevent surgery. The medical literature is divided on the efficacy of night splints, but given the relative lack of overall risk, they remain a reasonable and inexpensive first option if not tried previously.

Questions on Why? Part 3

If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions through his weekly column.

Last but not least, this is the third in a series of articles globally entitled: Medicine Demystified. I have attempted to break down some of the inherent barriers that frequently disable good doctor-patient relationships. I will finish with a word about the so-called "god complex" and then address several difficult issues encountered in an office setting..

God complex: I have a real problem with physicians who purvey an attitude of invincibility. We are all human. I just happen to be good at what I do and went to school a long time to get there. We can all be good at whatever we’re trained to do. Ask me to fix your car – it won’t happen. The so-called "god-complex" disables good doctor-patient interactions, destroys autonomy and has no place in medicine. Confidence does not equal arrogance and arrogance does not guarantee better care. Find a doctor without the ego.

Difficult Issues: Physicians dislike narcotics (at least most do!) Too many habitual drug users manipulate their MD for pain medications through doctor shopping, faking injury or milking their own misfortunes. Patients who abuse or divert medications for secondary gain have burned us all. The sad truth is that it is extremely difficult to weed these folks out.

I generally try to give my patient the benefit of the doubt when it comes to pain management. Unfortunately, not all physicians are the same – they refuse to manage pain syndromes at all and treat these individuals with suspicion and contempt. They fear lawsuits, DEA disapproval and have a general concern about being manipulated. Until there is a universal computerized tracking system for prescriptions, this narcotic dilemma will persist.

Another pet peeve of mine is the failure to treat pain. I have multiple geriatric patients who suffer miserably from severe intractable pain as a consequence of a chronic medical condition such as osteoarthritis or restless legs syndrome. They have seen other doctors who have refused to prescribe pain medications stating, "I don’t want you to get addicted" or "you’re getting older; you should expect some pain at your age"

This logic is ridiculous and near-sighted. Any good doc knows that dependence does not equal addiction. Why should my 92-year-old patient suffer from severe pain when a simple twice a day pain med could alleviate their symptoms? Don’t let your doctor use the above arguments to discourage your quest for pain relief! They are obligated to improve your quality of life!

I am not perfect, but I value my patients’ time, feelings and autonomy. I am not your boss; I work for you and with you. If you are uncomfortable with what you are getting out of your doctor’s visits, look around. Word of mouth speaks volumes. You deserve the best.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on Why? Part 2

This is the second part of a series entitled: Medicine Demystified. I am attempting to break down the barriers that may exist between patient and physician. Previously, I discussed the nuances of appointment scheduling. Here I will tackle wait times, rooms and reps.

Waiting times: The scourge of our existence, long waits is my biggest stressor. I pride myself on being punctual with a goal of only one hour spent in the office, from check-in to checkout. Understand the unpredictability of scheduling. A visit for a cold may take eight minutes whereas an 85-year-old patient with diabetes, Alzheimer’s dementia and frequent falls may take greater than the aforementioned fifteen minutes. It only takes one walk-in or emergent care visit per day to slow my schedule down considerably. Do not allow your physician to rush you out the door! Again, you deserve 10-15 minutes of his/her undivided attention. If I am behind, my patients still know I will hear their complaints in full without exception. For those who absolutely cannot wait to be seen, I recommend seeking early morning appointments or those just after lunch. Wait times are obviously minimized with this strategy. A 10:30 appointment time is a set-up for potential delays.

In the Room: I don’t mind covering multiple issues, but be sensible. Unraveling the Dead Sea Scrolls of complaints is a recipe for disaster. Remember that fifteen-minute timeframe. Though you are important and have waited patiently, there are many more behind you. Often due to the inherent medical costs and the inconvenience of office visits, patients will present with dozens of problems. Rome wasn’t built in a day. I will try to accomplish as much as possible in that 15 minute to make your visit complete. If you expect ten complaints to be addressed in their entirety, you will undoubtedly leave dissatisfied. In this case, a more reasonable lowering of expectations will improve perceived quality of care. If you are a patient with a long history office visits with multiple complaints, your physician may label you as a nuisance or hypochondriac. This will only further serve to erode your doctor-patient relationship and may adversely affect your health in the long run.

Drug Reps: Many of my patients hate pharmaceutical reps. They view them as mere salesmen who waste my time, slow me down and do nothing more than provide free lunches, golf trips and a plethora of fancy pens that are later sold on e-bay. I disagree. I provide drug rep samples to patients on a regular basis to assist with cost and allow them to "test drive" a new medication before paying a large co-payment to obtain it. The reps do serve a purpose. They occasionally provide valuable information regarding novel agents that can be used to improve a patient’s life.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on WHY? Part 1

The medical field often to the layman seems cloaked in a shroud of mystery. Why does my doctor do what he does? Why can’t I get an appointment? Why do I have to wait three hours to be seen? Why won’t my doctor listen to me?

As a small town doc, I have attempted here to unravel some of these mysteries and perhaps improve your doctor-patient relationship and overall impression of the medical field. This is the first of a three part series.

Overview: I would like to presume that all patients are ultimately satisfied with their medical care. The reality, however, is that many remain frustrated with long waits, poor communication with their physician and growing expense. Data suggests the average doctor sees 20-25 patients per day, but my experience is otherwise. Many physicians feel overworked, underpaid and under appreciated – there is a growing trend away from primary care. When asked whether they would again choose medicine as a career given the opportunity, many physicians suggest that they would not. Is there any way we can coordinate our efforts as patients and doctor so that we can both live harmoniously and without disdain.

Appointment Scheduling: My pet peeve is poor scheduling. I demand my patients be seen in a timely fashion whenever necessary and with minimal wait. With increasing demand, it is nearly impossible to provide either. Sadly, many patients must wait weeks or months to see their physician. There is no proven method to solve this dilemma. I prefer at least fifteen minutes per visit. There are numerous factors however that prevent this from becoming a reality. There is always demand. Certainly, patients with severe chest pain need more immediate assistance and this can bog down the system. My costs, as your own, rarely decrease. With inflation, medical costs continue to rise at an astronomical rate. I am forced to spend tens of thousands of dollars every month on office mortgage, staff medical insurance, employee wages, liability and disability insurance, malpractice, supplies etc. Medicaid reimbursement is poor at best and Medicare continues to threaten cuts in reimbursement each year. How do physicians’ offset these changes? Obviously, to maintain if not increase revenue, more patients must be seen.

For those of us in large groups with fixed salaries, bonuses may be based on the total number of patients seen or on total revenue, not on quality of care. We are forced to see more than is reasonable or comfortable in order to "get ahead". The reality is that most physicians seek careers in medicine to help and serve patients. But like anyone else, they want financial security and all the benefits that derive from it, general practitioners on average train for eleven years past high school. There is great animosity when physicians earn less than some pharmaceutical reps or car salesmen. Does higher education not equal higher pay? We are not money hungry as many may suggest; but we are driven to achieve financial and academic success.

I suggest that patients find a doctor who spends 10-15 minutes with them on average. We owe it to our patients – there is no excuse!!

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by filling out the form on the webiste or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on CT Scans

I recently commented on the potential dangers associated with CT scanning and the feedback has been impressive. Given the apparent interest, I decided to use this space to elaborate on the risks of medical imaging.

In the United States, it is estimated that 62 million CT scans are performed yearly as compared to 3 million in 1980. Recent data from the New England Journal of Medicine suggests that CT scans may cause breaks in our DNA that results in genetic mutations and possible cancer. Over 20 million adults are unnecessarily exposed to potentially harmful radiation each year. Some even submit themselves to full body CT scans in hopes of "catching disease" early as a preventative (though unproven) measure. Physicians often order unnecessary scans in a so-called "shotgun approach" manner that allows for less likelihood of a missed diagnosis or potential resultant lawsuit.

CT scans are not benign. A single CT scan of the abdomen exposes patients to the radiation equivalent of 500 chest x-rays. X-rays have been linked to cancers of the lung, breast and thyroid as well as leukemias. An article in the New York Times indicated that Americans lifetime per-capita dose of ionizing radiation increased 600% between 1980 and 2006 with the bulk of the increase attributed to diagnostic imaging procedures.

Here are some truly scary statistics. The risk of developing a fatal cancer after one chest x-ray is 1 per one million. The risk increases to 1 in 2000 after just one CT scan of the abdomen. These exposures are nearly equivalent to those unintentionally received by survivors of the atomic bomb explosions in Japan during World War II. Furthermore, 1 in 143 women receiving a scan at age 20 will develop cancer (usually breast). The risk for a 40 year old drops to 1 in 284.

The FDA has never approved CT scanning for general screens of the body nor of any part of the body when there are no symptoms of disease. If this is the case, then why are so many done? Mostly, the answer is because we can. Lost is the art of history taking and physical exam skills – we rely on CT scans to make decisions, though they have never been shown to prolong life nor alter behavior (i.e. smoking). One example is cardiac catheterization. Stent placement has come under scrutiny because it does not improve clinical outcomes more than does optimization of medical therapy and modification of lifestyle. Yet, a cardiac cath exposes us to the equivalent of 120 chest x-rays. Caths may be better suited for unstable patients with persistent chest pain despite maximum medical management. There is a fear of missing the "big one". Unfortunately, in a litigious society such as ours, lawsuits (frivolous or otherwise) are commonplace and are a source of financial worry, psychological trauma and contempt for patients, insurance companies and the legal system.

It’s easy to order a test. Awareness of the potential dangers involved with the test is critical. The Hippocratic Oath says, "First, do no harm". Maybe we should listen.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by filling out the contact form provided on this page.

The Daily Dose with Dr. Spence