The price of peace of mind

Priceless, I suppose. But nearly $2,000 is what I just spent to attain it.

I was delighted to be approved by my insurance company for a breast MRI as part of my high risk screening. I've mentioned before that dense breast tissue increases the risk of breast cancer nearly six-fold. First of all, dense breasts are extremely difficult to image by mammography which makes cancer more likely to be missed. Plus, dense breasts are caused by increased amounts of glandular and supporting tissue, all of which is more likely to be stimulated into some sort of unwanted, carcinogenic DNA mutation.

Recent information confirms that MRI imaging is much more likely to catch a cancer in a set of dense breasts. Since I happen to own a pair, and I also have a family history of ovarian cancer, I definitely fall into the high risk category.

I was relieved to get the all clear notice from Rose Medical Center's radiology department. I was not so pleased to get the bill from Anthem--$3,682 for the undertaking, over half of it mine to pay. As my medical partner pointed out, Anthem's stance was "Sure get a breast MRI. Get two. We don't pay much of anything on those."

Another less expensive screening test which is useful for dense breasts or really any kind of breast is thermography. Whereas mammograms and ultrasounds rely on differences in density of breast tissue (thus not so good a test for the 'all dense all the time' set), thermograms use infrared technology to find temperature differences in breast tissue.

On average, breasts hang off your chest in a cooler sort of way, showing up in shades of greens to blues on thermograms. Cancers recruit blood vessels early on to fuel their nefarious growth and show up orange to red. Breasts remain thermographically stable over time, so yearly thermograms are one more way to screen for cancer.

One more reasonably-priced way that is. I have gotten thermograms at Pristine Health in the Denver Tech Center for a mere $195. I picked up a price list from Colorado Heart & Body Imaging in Cherry Creek on Friday--thermography (called a Sentinel BreastScan by them) is merely $145!

Coke for breakfast?

I spend a lot of time asking people about their personal health habits, and this one always astounds me. Lots of people drink coffee in the morning, and, fortunately, coffee has been cleared of such awful consequences as pancreatic cancer and heart disease. Instead, recent evidence positively links its consumption with a decreased risk of diabetes, Parkinson's, and Alzheimer's disease.
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Some people don't like the taste of coffee, and I don't entirely trust this group. In place of it, they might start the morning with tea (that's good!) or soda. That's bad, really bad.

Wrapping their hands around a comforting, chilly can of Mountain Dew, these misguided souls get their caffeine hit along with the equivalent of 1/4 cup of sugar. Worse yet, they are setting themselves up for ATHEROGENIC DYSLIPIDEMIA.

Now there's a little something you could live without. A cholesterol profile so destructive that they couldn't just call it high cholesterol, but rather a fancy name meaning deranged blood fats that actively promote atherogenesis or the birth of nasty, cholesterol-rich deposits on the blood vessel walls.

Atherogenic dyslipidemia is a triad of bad actors: high triglycerides, low HDL-cholesterol, and small, dense particles of LDL-cholesterol. While labs do not routinely measure the size of your LDL particles, if you've got the first two, rest assured you've got destructive little LDL particles. (for an explanation of LDL particle size, see Bullets to Beach Balls.

The trouble with soda and many other sweetened drinks is fructose, a corn syrup derived sugar. It's sweeeter and less expensive than sucrose making it an attractive additive to popular drinks. And overweight persons experimentally persuaded to drink a lot of fructose-sweetened drinks took their normal cholesterol profiles to atherogenic dyslipidemia within two weeks of having their way with all that free soda.

Atherogenic dyslipidemia not only raises risk of heart disease, it also promotes central obesity (wearing your weight front and center like an unwanted late life pregnancy), the metabolic syndrome, and diabetes.

I find myself urging patients to drop the pop and brew some coffee instead for their first drink du jour.

This was a big year for coughs. And a big year for big coughs, muscle-straining, sleep-robbing, gagging, back-twisting coughs that went on and on for weeks.

Studies suggest that much of what makes adults cough through the winter season is pertussis or whooping cough, the so-called childhood disease that's not just for children anymore. We now know that the final booster shot administered to teens against diphtheria, tetanus, and pertussis is not a lifelong boost against this disease that causes the cough from hell.

The next time you get a tetanus shot, sign up for the new version that includes protection against pertussis. If you're not so sure whether or not you want to get a shot against a disease that may well rob you of weeks of peaceful sleep and quiet work-days, consider this from Richard Irwin, MD of the University of Massachusetts Medical School:

While kids could die from pertussis, adults feel like they're going to die.

For more info, check out Adacel.

The adenoma-carcinoma sequence

Colorectal cancer is the 2nd most common cancer in developed countries. A person's lifetime risk of ending up with this tumor is 1 in 20. Virtually all colon cancers arise from a pre-existing polyp, a phenomenon known as the adenoma-carcinoma sequence.

So here's the deal on colonoscopies. Much as you do not want to go through the icky prep, and much as you do not want someone touring your colon via a tube stuck up your backend, the fact is that colonoscopies are one of the most effective cancer screening tools we have. If a polyp (aka adenoma) is found during the procedure, it's removed on the spot.

Adenoma snagged, cancer averted. It's that simple. I've had mine, go have yours.
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Check out the fun at Colonoscopy city!

Greetings create a first impression that may extend far beyond what is conventionally seen as 'bedside manner.'
--Gregory Makoul, PhD, Northwestern University

In the 'what-will-they-study-next' category of medical research, this Chicago group set out via telephone to discover how patients would like to open that first appointment with a new physician.

They found that "415 survey respondents reported that they wanted the physician to shake their hand, 50.4% wanted their first name to be used when physicians greeted them, and 56.4% wanted physicians to introduce themselves using their first and last names."

Well score, score, and score. Been there and do that, all that, every time a new patient arrives at the office. My medical partner and I always troop out to the waiting room to meet and greet. And now its medically proven to work!

Smelling like a doctor

Probably smelling like a doctor means not smelling at all. Maybe a touch of lemon, or a soapy clean sort of scent, but certainly not oh de' garlic.

I've mentioned that I love my supplements, and I love www.puritan.com for ordering my dietary substitutes. Right now they're running a 3 for 1 sale. When I accidentally ordered garlic from them, it was buy 2 get 3. So I now have 1,250 capsules of garlic oil, and dear heaven how this stuff reeks. Puritan's Pride supplements generally get thumbs up ratings on Consumer Lab testing, but I knew that WYSIWYG just from the smell and the aftertaste.

While Consumer Lab reviews are a bit lukewarm about the good of garlic, a glance at the medical literature through a MedLine search is almost convincing enough to get me to take this stuff. Garlic promotes the healthy function of blood vessels, inhibits the formation of those pesky nanoplaques (itty bitty deposits of LDL-cholesterol in the arterial walls), and best of all for me because I personally fear dementia worst of all, garlic prevents neuronal apoptosis which is aging brain cell suicide.

But gad, I just can't do it. I suppose I could chuck these smelly capsules and by the scent-free kind, but instead they sit in my cupboard and I save my neurons with crossword puzzles instead.

Dressing like a doctor, Part III: Eyebrows and Exercise

I've mentioned in two previous posts my difficulties in achieving that look of professional insouciance, particularly when I have zero fashion sense whatsoever.

I recently saw an article on the well-groomed brow, not sure where, Good Housekeeping perhaps? This model had impeccably shaped eyebrows, lush and burnished. I neglected to note how she achieved them, but thought perhaps just a touch of brown color would take mine there.

Think Frida Kahlo with a stethoscope. No one actually was so bold as to ask me what the heck happened to my eyebrows, but then again the only two people who actually take notice of my appearance--Jean at my office and my daughter--weren't there to check the look. I've decided to chuck that look.

In a second fashion foray, I sought a new outfit for exercise class, no more wearing my son's cast-off t-shirts. I found the perfect accessory in the Univ. of Northern Colorado bookstore as I whiled away two days at freshman orientation pretending I did not know my son. For his sake.

A perky little Northern Colorado tee, gray with blue lettering, just the match for my sassy, blue exercise capris. Even if my co-exercisers did not mistake me for a co-ed, surely they'd think me a physician in the know.

Damn, I don't know how the college girls fit in these tees. I bought the large size and spent the entire class today tugging it down in front. I'm going to send the shirt to my daughter and resurrect Mike's hand-me-downs out of the ARC bag.

Dietary supplements

If you've been reading my health news for any amount of time, you know that I am a fan of supplements. I've got that came-of-age-in-the-'60's sort of attitude--got pills? I'll take 'em. Actually, I hope that they will counter-balance my somewhat less than perfect diet, as in this a.m. bing cherries, yogurt, and Krispy Kreme doughnuts. I didn't buy the latter, however, they came free from an imaging facility seeking my referrals. Imaging company bribery calories don't count.

If you also like your supplements, and judging from the patients I speak with daily, many of you do, remember that supplements are not a WYSIWYG (pronounced wizzywig and meaning 'what you see is what you get') situation. The FDA has bowed out of supplement supervision, so these companies could put in floor sweepings and call it alpha lipoic acid if they wanted to.

Enter ConsumerLab.com. Their stated mission is "To identify the best quality health and nutrition products through independent testing." Beholden to no one, they sample a myriad of supplements, then 1) tell you the evidence behind the product, and 2) tell you whether or not WYSIWYG, comparing label claims to actual content.

Let's say that you're one of many who fuss about overloading your liver whose job it is to clear the schmutz you put in your mouth before it poisons your body. Mine, right now, is wringing its liver-spotted hands over big globules of Krispy Kreme doughnuts that would have their way with my blood vessels if left to their own fatty ways.
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In support of your ever-loving liver, you might choose to take Milk Thistle supplements. According to Consumer Lab info., the evidence in support of this supplement is full of mights, maybes, and so-so significance. Nevertheless, they tested eleven brands and found that only two delivered the amount of active ingredient (silymarin) listed on the package. One delivered a bit of lead contamination on the side, but what the heck, your liver will probably take care of it.

There is a nominal annual fee for access to this information which is available on their web-site and regularly delivered via e-mail as well.

Bad news skills revisited

I've just received an e-mail from a reader that suggests my that using the telephone to deliver those ghastly diagnoses is quite simply that...bad news. I think I have a lesson or two to learn from those on the other side of the desk or phone line receiving this information.

If you have personal experience in receiving bad news and wish to comment on the way in which it was delivered, please share it! You can reply here or to my e-mail address judy.paley@femailhealthnews.com.

I'd like to include your stories in an article written for other primary care physicians. These would include only your first name. Let me know if I have your permission to do so.

More interesting facts about fingers

A reader noted in response to my item on finger length, specifically the ratio of Ms. Index to Ms. Ring, that she'd heard of a correlation between this ratio and sexual orientation. Indeed, there are several studies to that effect, the latest one published in the July, 2006 issue of Neurobiology.

Doctors in Zurich knew that longer 4th fingers are associated with higher levels of prenatal testosterone. This embryological hormonal climate influences the developing brain with respect to sexual preference. They measured the ratios of finger 2 to finger 4, and found that the higher the ratio, the less likely the Swiss miss to prefer lesbian relationships.

A previous study out of NYU looked at finger lengths in identical female twins with different sexual preferences. They found that the 2:4 ratio was lower in the lesbian twin compared to her heterosexual sister, suggesting some difference in their prenatal environments because their genetic make-up was exactly the same.

Blood clots and cancer

My grandmother developed phlebitis (blood clots and inflammation in the veins of the legs) in her mid sixties. She was treated for the clots, however clots were treated in the 1960's, and no further investigations were undertaken. Within a year, she was dead from metastatic ovarian cancer.

So when my very healthy (tanned, fit) fifty-something patient came in with tender, swollen veins in her right calf, I thought of Grandma and alarm bells went off. One week of testing later, the results showed metastatic pancreatic cancer. She too was dead within the year.

My Mom always felt guilty that she hadn't pursued further work-up for her mom after those clots popped up. A study in the Archives of Internal Medicine suggests that prompt follow-up wouldn't have helped Grandma any better than it did my unfortunate patient.

Over half a million cancer cases were culled from the California Cancer Registry to identify cases of common malignancies correlated with spontaneous blood clots. While the incidence of blood clots preceding localized cancer was not significantly elevated, the risk of being diagnosed with metastatic cancer post-phlebitis was more than double.

So no guilt here for cancers discovered after the clot-fact. Per the authors, "Given the timing and advanced stage of the unexpected cases, it is unlikely that earlier diagnosis of these cancers wwould have significantly improved long-term survival.

Trust in God...and tie your camel securely.
--Muhammad of Arabia

Medicine can be likened to the strong rope that tethers the wandering camel.
--Shobi Ahmed, JAMA, 10/19/05

From a public-health perspective, if you can
improve the health of 5% of 50 million people,
that's a lot of people.

Keith Norris, MD on inexpensive vitamin D supplements
to prevent diabetes and obesity.

Data from the National Health and Nutrition Examination Survey (NHANES) was analyzed to correlate serum vitamin D levels with the incidence of diabetes and obesity. Those subjects in the lowest quartile of D levels were twice as likely to develop these high risk medical conditions.

Note to my pasty white D-ficient patients: How many more D-tales do you need?

Bad News Skills

Oh right, my son picked up a lot of those in high school. This particular study, however, did not deal with THOSE kind of skills, but rather the skill with which doctors deliver bad news.

The researchers ran a 4-day communications workshop called Oncotalk for medical oncology fellows. These doctors were in the last phase of their training as oncologists, and soon to be cancer specialists who doubtless would face bad news deliveries on a regular basis.

During the 3-year study, the fellows were observed pre- and post- workshop participation talking with standardized patients, as in "I'm not a patient, but I play one during this study." Postworkshop, participants gained an average of 5.4 bad news skills. The number of doctors mentioning the word cancer in bad news encounters rose from a paltry 16% before the skills practicum to 54% after.*

Being a reluctant bad news deliverer on a regular basis, I've given a lot of thought to this. That "C" word cancer is sitting in on the conversation whether you mention it or not, and I think it becomes a bigger presence if left unmentioned. I used to think that delivering bad news on the phone was wrong, then I saw how people freaked out when called by my office staff to come in to discuss test results. No one is calling anyone to come in and hear that their mammogram was normal.

Equally important is delivering good news the instant it is known. When test results come back to our office, they are immediately reviewed for critical information that needs to be conveyed immediately. But good news or bad, there is one anxious person waiting by the phone to hear about those negative scans and those benign biopsies.

*Can you imagine an oncologist NOT saying the word cancer when they tell a person that they have it or that the tumor is now out of control?

Upright Imaging

A new era in MRI comfort:
Walk in,
Sit down,
Watch TV.
--Ad for Fonar upright imaging system

I've ordered a lot of MRIs for patients. I've watched patients hauled out of the MRI screaming, seizing, and hemorrhaging on the TV show House. This past week, however, was the first time I actually had an MRI. I expected the tiny space, but no one warned me about the noise.

The doctors on House usually discuss their sex lives while monitoring their patients' procedures. In fact, no one would be discussing sex or anything else in the vicinity of an MRI due to the racket of the machine. I'd imagined a coffin, but never knew about the jackhammer working just over my head. The earphones and piped-in music are just a pre-procedure ploy of no use whatsoever during the exam.

So now the Fonar Upright advertises itself for my patients uptight. They note their machine allows "imaging a child without anesthesia because the child can sit on his or her mother's lap, imaging claustrophobic patients, and overweight patients, who fit right in...The patient simply walks in, sits down, and watches TV during the scan."

Best of all, apparently, these upright scans can image the back with the spine fully loaded with the weight of the body which creates real-life pressure on squashy discs as opposed to scans done when the patient is lying flat. This enhances the ability of this MRI imaging technique to pick up pain-producing pathology.

Hmm, watching TV, that implies they've also squelched the noise. Maybe patients can watch reruns of House.

Fun facts about fingers

If you're wondering whether or not your male acquaintances are mathematically inclined and interpersonally challenged, have them give you the finger. No, not that finger, rather two fingers--index and ring--and more specifically, check the length of the former compared with the latter. Now of course if you need to measure finger lengths to figure out whether or not your man friend relates well to others, perhaps you'd better measure your own fingers.

In the 'whoever thinks of these studies' category of studies, researchers theorized that the length of the 4th finger, which apparently correlates well with testosterone levels in a man's remote embryological life when he first came to life in his mother's womb, might predict male traits such as strong visual/spatial talents but weak people skills. They measured a host of 2nd:4th finger ratios, and found that those men whose ratios were less than or equal to .98 (meaning 4th finger looms larger than 2nd) did indeed score high in math but couldn't read non-verbal cues.

The exaggeration of these traits (male intellect to the max) is autism, although the researchers did not measure the digits of autistic persons. Women tend to have 4th fingers equal to 2nd in size, but when they don't, no predictions as to mathematical or relationship skills can be made. This finger length stuff is totally a guy thing.