What should I ask my doctor?

How to handle a medical handoff...advocate for yourself or a family member when heading home from the hospital or off  to a consult for specialty care.

This morning I completed an online continuing medical education course on medical handoffs.  I wasn't even sure of what this meant when I registered and embarked on the course.  Turns out that it's just what it says, namely the handoff of a patient's medical care from one professional to another, say, for example, from me as primary care provider to a specialist consultant, or from a hospitalist to me as one of my patients is discharged from an inpatient admission back into my care.  These handoffs are risky business (and so this course is sponsored by my medical malpractice company) if information is incompletely or inaccurately transferred. 

I can't tell you how many times I've been in this situation--a patient comes to my office for follow-up to hospital care, and the discharge summary is not available.  Sometimes, I've heard the history via phone from the doc in charge at the hospital.  Too often, I did not even know that the admission occurred. More than once, the patient does not know the names of the physicians that were in charge of their inpatient care, and, worse yet, may not even know their final diagnosis! You may be nodding in recognition because this has happened to you or a family member.

This course gave a nice summary of that which a patient should know on leaving the hospital.  With just slight adjustments, many of these items could apply to any handoff situation where more than one professional is in charge of any aspect of your medical care. 

• What are warning signs of a relapse? (I would add that any change that alarms you is worrisome enough to inquire about).
• What are side effects to look out for from new medications?
• Whom should I contact in case of difficulty? (I feel like your primary care doctor should be available to advocate for you in this matter even if they are not fully apprised on the matters at hand)
• Does my primary care doc know that I was in the hospital and that I am leaving?
• Do I understand why I was hospitalized, what was the diagnosis, and what is the treatment plan?
• What results are pending?  Whom do I contact to find out these results? (this is extremely important, and applies as well to outpatient tests ordered by a specialist; find out if the specialist or your PCP will be the one to get the results, and call them if you don't hear from them within a reasonable amount of time).
• Have any new medications been reconciled with my usual medications?  How long must I be on these meds, and who will order refills?
• Where, when, and with whom do I follow-up? 

On average, PCPs only hear back from hospitalists 10% of the time after their patients are discharged from inpatient care.  An estimated 60% of discharges are made before all the in-hospital test results are in.  The hospitalist may assume that the PCP will follow-up; the PCP may not even know that the test has been done. 

Be your own best advocate on behalf of yourself or a loved one; ask these questions and make sure you get answers!

Radiation from medical imaging

Plagued by shoulder pain, especially at night, Jack was not happy with his orthopedist nor improved by physical therapy. Being a tightly wound sort, he'd come to the conclusion that the pain must be from cancer. I was happy to reassure him, as I'd done many times in the past, that he did NOT have cancer. Soothing the worried well (there's actually an ICD-9 diagnostic code for 'worried well') is one of the easiest parts of my day.

But Jack came back the following week, yet again shouldering grave doubts. A second opinion from another orthopedist confirmed the original diagnosis of a torn rotator cuff. So what was on Jack's mind? He was agonizing over the fact that Dr. Two took a repeat set of shoulder films. Not the unwarranted expense that now worried Jack, however, he was near tears over the possibility that this extra radiation would significantly increase his future risk of cancer.

So what's the scoop on medical imaging and cancer risk? Radiation from any source is not only a cancer inducer, turning healthy cells into pre-malignant ones, but also a cancer promoter which can push these compromised cells into a more abnormal state. Radiation danger is compounded through a lifetime of ionizing destruction; years of exposure compounding today's CT with yesterday's tan. If you'd like an estimate on your annual irradiation, check out the interactive quiz at American Nuclear Society's website.

If you're not an internet quiz type, let me inform you that a single CT scan can deliver a radiation dose equal to dozens of shoulder films. And there's no particular standardization here; radiologists can adjust their sets to enhance detail, and the higher the dose, the crisper the image. As a result, concerned specialists have banded together in various self-policing initiatives to rein in the rads, among them Image Gently setting guidelines for testing children and Image Wisely for adults. Nevertheless, the estimated annual number of CT scans in the US rose from 3 million in 1980 to 67 million in 2006 and the numbers continue to climb. Scarcely an ER visit goes by for one of my patients without an accompanying CT procedure. And one CT begets another when "incidentalomas" are found (unexpected abnormal findings of unclear significance) that require future scans to clarify their nature.

Based on data from survivors of the atomic bombings in war-time Japan, biophysicist David Brenner estimated the lifetime risk of cancer for a child undergoing a single abdominal CT as one in 1000. While other experts take issue with both his calculations and his conclusions, all agree that rads must be reduced.

One of the most innovative approaches comes from Mass General Hospital. Docs there created a rather complex program that scores the appropriateness of the choice of a diagnostic CT as compared to other imaging techniques for any particular clinical situation. The software shares this info with the ordering physician who is then offered the opportunity to change their minds and their orders. This software replaces the aggravating insurance pre-authorization procedures that Dr. James Thrall has dubbed "1- 800- may- I- do- a scan." Once this process was in place, CT use at MGH dropped considerably.

There is no doubt that CT technology has been critical to the accuracy of diagnosis since its inception. Pre-CT scanning (back when I was a doc-lette in training), diagnosing brain tumors involved a horrendous procedure wherein air was introduced into the spaces around the brain (as demoed graphically in "The Exorcist"). CT scans are perfectly appropriate even while over-ordered. Ask your doctor, however, what your other choices might be when offered such tests.

The changing face of primary care

I ran into one of my patients today at the grocery. We chatted in the bread dept. about footwear and fiber, then met again in books. I was there considering whether or not I could justify adding yet another book to my 'to read' pile, she was just browsing on her way up one aisle and down the other. By the time we parted, I'd learned that her older son, once my patient, had moved home again and was struggling with depression. Her younger was now in his 7th year battling an HIV infection. Who knew I could learn more about her personal life at King Sooper's then ever I knew from our not infrequent exam room encounters?

This small town sort of intimacy in the middle of a moderately big city represents all that I love about my practice of medicine. Alas, it looks like things will change mightily in the coming year as my partner and I strike out in new directions in order to continue practicing medicine at all.

Strange how primary care is front and center in the middle of health care reform, yet remains undervalued and underfunded in ways that will soon completely preclude the sort of Mom and Mom shop that she and I run. In the face of falling reimbursements and rising expenses, here's what we view as our two choices:

The first is to become employees of a large hospital corporation. Economy of scale and deep pockets will remove the agony of the overhead--buying medical supplies and injectibles in quantities and at per unit prices of which we can only dream in our current situation. Being able to negotiate with insurance companies for contracts that two docs in a 1950's style little medical box could not begin to command. But...no more funky offices adorned with antiques and artwork (and leaky basements!), no more elevator-free hop, skip, and jump from parking lot to office door, January 2011 would find us working out of a medical building reeking of disinfectants and cleaning products instead of coffee and popcorn.

The other option is a gradual shift to a membership practice. Many dollars short of a concierge version which requires an annual fee of $1,000 or more, this concept involves a much smaller cost, say $25/month, which not only brings in the sort of yearly revenue that covers property taxes and hazardous waste disposal, but also benefits members with 24/7 ask-a-nurse access, wellness and nutritional counseling, as well as e-mail access and same-day appts. While there is no requirement to join in order to remain our patients, this nominal-ish sort of fee would be each patient's affirmative vote that small practices reap big satisfaction for all.

Obviously, my language screams of my preference, but we worry, rightly, about 'willingness to pay.' Particularly in light of the new health care legislation, there is increasing belief that health care is a right for which one should not have to pay much at all. Our time frame here is short in terms of decision-making; I'd love to get your opinion--especially from my patients but honestly, from anyone who'd like to chime in--about what you'd like your future relationship to be with us or whomever your PCP may be. Feel free to use my e-mail address or to leave anonymous observations.

Diagnoses at Denny's

I've mentioned before that I tend to diagnose the passers-by that I see around town and on the road. I was eating breakfast at the Denny's in Moab, Utah this past week when a middle-aged couple lumbered to their seats.

They were both quite wide in the middle, carrying way too much visceral fat packed around their waistlines. Doubtless two cases of metabolic syndrome, a high risk constellation of central obesity plus two of the following: high blood pressure, low HDL cholesterol, diabetes or elevated fasting blood sugar, and elevated triglycerides. Of course, I have no idea about their lab findings, but he no sooner sat down but he pulled out a ziplock baggy jammed with pill bottles.

He was unnaturally red in the face contrasting with his pale arms and legs sticking out from t-shirt and shorts. Sunburn? Shoot, that's a med. student's diagnosis. Idiopathic erythema? Rosacea? Polycythemia vera? His legs, however, had none of the swelling or skin changes associated with venous insufficiency which is a good sign, but his calves and thighs were scrawny which may be a bad sign per a recent report that a low thigh circumference is associated with a higher risk for heart disease!

As they sat, unaware of my clinical musings, she leaned forward, grinning, and said something to him in a low voice. His face immediately crinkled with amusement and softened with affection.

My final diagnosis? They were in love!

Fun with the flu

My patient no sooner sat down when she grabbed a Kleenex, said "Hold on!" and quickly turned away, coughing wetly into the tissue.

"Oh gad," I thought unhappily, "She's going to show it to me."

At that moment, my patient dabbed delicately at her lips, looked over her shoulder, and said, "Don't worry, I'm not going to show it to you."

We both burst out laughing.

New Diagnoses, New Behavior

Can't look for what you might find
Once more you're running around in circles just to prove
You knew the answers all the while
Can't figure why no matter what you say or do
Things stay the same you will remain
Day late a dollar short
Day late a dollar short
--The Acro-Brats(1)

There's nothing like a new diagnosis of diabetes to get a patient's attention. Suddenly, all those discussions about diet, exercise, weight loss, soda consumption, etc. make sense. Well better late than never (perhaps The A-B's have a song about that too) but there's also the day late dollar short thing too because this is a condition that you are far better off without.

Yale scientists actually set out to prove what I already knew from years of consultations with the newly diagnosed. They checked out data from the Health and Retirement Study panel on over 20,000 people who were overweight or smokers.(2) The odds of weight loss or smoking cessation were hugely increased among individuals newly diagnosed with serious illnesses such as diabetes, smoking, heart disease, or COPD. Those who'd just learned they had heart disease were 5 times more likely to throw away the smokes than persons just counseled to do so just because it was the right thing to do, and new diabetics sent their BMI's plunging compared to the merely overweight.

Can't figure why no matter what I say or do
Things stay the same patients will remain
Day late a dollar short
Day late a dollar short

_____
(1) I actually listened to this song on You-Tube. Definitely not my thing--the metallic thrum made my amygdala cringe-- but I appreciate the edgy frustration expressed by the Acro-Brats. I feel it myself, everyday, in exam room encounters.
(2) Keenan, PS. Smoking and weight change after new health diagnoses in older adults. Arch Intern Med. 2009 Feb 9;169(3):237-42.

Health care debate

If you live in the Denver area, consider attending the Great Debate on Health Care this Thursday, Sept. 17th at South High School. Conservative talk show host Hugh Hewitt and C.U. law professor Paul Campos, both articulate proponents for their respective sides, will debate current proposals for health care reform. You can order tickets online at 710knus.com or purchase tickets at King Soopers.

Denver Doc now on Twitter

I've made the technological leap to Twitter for those medical pearls of wisdom from me to you that fit in 140 characters or less. No updates on my dentist appt. or the weather here in Denver, just good health-related information from reliable sources. This blog will continue to be published on a regular basis as well.

If you're interested in Twitter updates from Denver Doc Online, you can sign-up at
www.twitter.com/docofages. Thanks!

Of cockatiels and trumpets

Some of my patients are 'difficult' insofar as I am stumped as to what they need and how to improve their health situation. One such customer was a middle-aged lady plagued with pain, poverty, and depression. She was a large lady, and part of each appointment was spent in the slow walk from the waiting to the exam room which she negotiated one tedious step at a time with the help of two canes. She always arrived with copious pencil-written notes about her days spent doing little other than getting by.

What her notes never included, however, were tales of her cockatiels. Who knew she raised birds? I certainly didn't. I'm not sure how it even came up, but once we discussed her birds, everything seemed to change. She still came armed with those torn notebook pages full of complaints, but she was also the person who brought pictures of her birds and their tiny little-finger sized hatchlings. She was now, for me, the bird lover who struggled with pain rather than just the pain.

Yesterday's new patient was a nervous young man who at 23 had an engineering degree and spent his working days making sure that the calculations made by his firm on bridge design were correct. I remember a magazine article on school standards (and their increasing laxity) that asked the reader whether or not they would care to drive across a bridge designed by someone in the lowest quartile of their engineering class. My first impression of this fellow was that he'd be a good one to have beneath the bridge upon which we drive with nary a thought as to its safety.

At the end of the physical, I asked him if he planned to go on to a higher degree in engineering. He answered that he felt that engineering was going to be the job that supports his real loves in life, namely playing the trumpet. I'd like, I thought, to drive across bridges designed by this engineer who plays the trumpet. No need anymore for either of us to be nervous.

Brain centers in charge of voice recognition

In everday life, we automatically and effortlessly decode speech into language independently of who speaks. Similarly, we recognize a speaker's voice independently of what she or he says.(1)

My first call of this holiday weekend was a real jaw-dropper. The youngish man was most put out; he'd been assured that his prescription was called in and, on arriving at the pharmacy, found that they had no record of it. In language worthy of a drunken sailor, he anonymously expressed his deep unhappiness, and concluded that my staff and I were copulating pieces of excrement but in different words.

Now I certainly appreciate his aggravation--been there (at the pharmacy as a customer) done that (felt my blood pressure rising that the pharmacy staff had no knowledge of any script) myself. As often as not, it's an oversight or delay at the pharmacy, but I do know (as do you my patients) that we also have system failures at the office. That said, this tirade was inappropriate done anywhere but in the privacy of one's own brain or car, and I would like to know the identity of the caller so we can discuss whether or not he should continue as our patient if he even cares to do so.

So now we're on the topic du post: voice recognition. I remember a much more pleasant call nearly two decades ago when my front desk assistant announced I had a personal call on line 6. I didn't recognize the name she gave me (remember--we do admit to system failures) but I instantly knew the voice of my freshman college best buddy whom I'd lost track of for 17 years. Now scientists have identified the bit of gray matter that lights up with delight or dismay at the sound of a familiar voice.

Using functional MRI scanning, researchers from the Department of Cognitive Neuroscience at the University of Maastricht located an area of the auditory cortex that hums with activity as test subjects decipher the message and the messenger of spoken stimuli. In order to establish the identity of my anonymous caller, I need to find a staff member whose right anterior superior temporal sulcus (this STS is a brain bit located roughly behind and slightly above the right ear) along with the nearby Heschl's gyrus roars with recognition (and righteous indignation) when the message is replayed.

And Mr. No-Impulse-Control, get this, Pat at the front desk has a highly developed STS, and we will smoke you out. And know that a plainly worded message, even one expressing anger appropriately over lost time and effort, would've resulted in a prompt call by me to your pharmacy!
_____
Formisano et al. "Who" is saying "What"? Brain-based decoding of human voice and speech. Science. 7 November 2008, Vol 322, pps. 970-973.

Lest you think that I don't observe my own health habits, here's the latest. I've developed a juicy head cold since I got back from South Dakota, so perhaps I got in the line of fire of infected droplets from Mr. Sneeze-in-the-hand who passed not five feet away from me at the Rushmore Memorial. On the plus side, however, I logged well over 4,000 steps* at the office today, leaving the exam room every time I needed to sneeze or cough and then, of course, washing my hands. Unfortunately, I joined the chunky mom and child in the Keystone, SD restaurant by snacking through the day on Milky Way bites (dark chocolate covered!) and chips.

My bro', whom regular readers know as a strict grammarian and my sharpest critic, wrote a limerick in response to my previous post:

A very old guy in Custer
Said it's not beer that loses your luster;
Read your own blog,
Be a stick, not a log,
(And drink coffee to make certain, buster.)

Last week, I received an endoscopy report (complete with color pictures) on one of my patients who underwent the test two days prior to evaluate her upper abdominal pain. She had a mass in her duodenum that looked scary, like something you might see growing on the Great Barrier Reef. The comment section of the report said "Pt. should call the office in 7 days for the report."

Seven days waiting for a biopsy report? Sounds like the week from hell as there's nothing worse, I think, than waiting for test results on a mass found where no mass ought to be. An hour later, the path report came over the FAX--no cancer!! I called her to let her know, although I advised her to call the GI doc to find out what the next step should be. Her response reminded me of a line from Dennis Prager's "Happiness is a Serious Problem":

"...ideally, we should awaken every day and be as happy about our good health as if we had just received the wonderful news that a lump was diagnosed as benign."
_____
*I wear a pedometer every day. I'll refund the co-pay of the first person who shows up in my office for their physical wearing one! People tell me all the time that they don't need exercise as they 'run around all day at the office' or 'park at the end of the lot.' I've often wondered how many steps are involved in said running and parking.

My father was a psychiatrist. When my friends came to visit, they would ask me--half-joking--if he thought they were crazy. I know for a fact that he passed no judgments on our crazy adolescent antics, but I'm here to tell you that the internist in me is always on alert to the health habits of others. Here's several observations from my just-completed trip to South Dakota:

--The young man sneezed mightily into his hand as he walked away from Mt. Rushmore. He looked with distaste at his mucous-slicked hand, then wiped it half-heartedly on his jeans. Remember, this guy (or his cousin) touched that door knob just before you did.

--This fellow (a dead ringer for TweedleDee's silhouette) jockeyed for position at the toaster during the crowded, freebie breakfast service at the Dew Drop Inn in Rapid City. He was reaching for the whole wheat bread when the little serving lady brought in a heaping stack of chocolate muffins. To heck with bread, he nabbed two fresh muffins.

--This chunky young mom walked into the restaurant with her overweight daughter in tow. They placed their orders, and shortly thereafter the waitress brought a plate of onion rings for mom and a platter of fries for the young lady. Hmm, I thought, but oh well, they're on vacation and going for a treat before dinner. Alas, their second course was ice cream parfaits for all.

--A very thin, very old guy sat at the bar in Custer, SD, reading the paper and nursing a beer before dinner. We discovered that he was a World War II veteran, a banker, a cattle rancher, and the jeep tour driver for the lodge. He regaled us with stories from all his various careers.

I'm having whatever he's ordering!

"Why don't we do it in our sleeves?"

I feel an enormous amount of compassion for the sick people in my exam room. But my fountain of understanding abruptly runs dry when some infectious chucklehead lets loose an unrestrained cough or sneeze as we sit together in that tiny space.

So please, one and all, as we pass through this scary, fluish time in close quarters, check out this video . Give your family, your co-workers, and your doctor a break!

How would you have handled this one?

My long-time patient has struggled with alcohol abuse in the last two years. She's been in and out of rehab plus had several hospitalizations with serious illnesses indirectly linked to her addiction. Now she's back to work and looking the best I've seen her in ages. She came in alone yesterday regarding a mild skin ailment--her daughter usually accompanies her-- and walked slowly and a little unsteadily into the exam room due to a 'minor ankle sprain'.

After our pleasant visit, I gave her a hug and realized she smelled of alcohol.

"Studied calm"

I'm still reading Jerome Groopman's book "How Doctors Think", and I still highly recommend it to you. Not only does he illuminate the processes--some good, some ill-considered--that doctors use to arrive at clinical decisions, he recommends various participation strategies to patients that they should use to keep their doctor on an objective path to a diagnosis.

Dr. Harrison Alter is an ER physician that Groopman interviewed for this book. Alter notes that the emergency room atmosphere can be hectic and chaotic, and he personally works on fostering "studied calm, consciously slowing his thinking and his actions with each patient in order not to be distracted or pressed [into a hasty decision]. "

Well, you don't have to practice in an ER these days to feel pressed for time. I too have to make a conscious decision to slow down and forget the schedule, settling into my chair and focusing on the patient and what she's saying. Sometimes, this take-a-deep-breath-and-listen attitude pays off big-time.

I was running nearly 15 minutes late when I called Ms. V in from the waiting room. She's a 70-something dynamo, raising her teen-aged granddaughter and taking care of her ailing spouse. The previous morning, she'd had nothing to eat in preparation for a glucose tolerance test. After two hours at the lab where she drank the hyper-sugary Glucola and had hourly blood draws, she headed home, lightheaded and nauseous. Once there, she proceeded to begin cleaning the kitchen, leaning into those counters with her usual elbow grease. Moments later, she dropped to the floor, hitting her head and not really coming to until the paramedics arrived. While she was cleared for home at the ER, the doc there urged her to follow-up with me.

Ah, that is so you, I said to Mrs. V, cleaning up in lieu of relaxing over a late breakfast. On the other hand, I thought, it is so not you to faint. Groopman warns against making clinical judgments based on what we know or expect about a patient. I checked her goose egg of a lump on her head, took her blood pressure, then asked "So anything else going on?"

Well, she said, she'd been having episodic shoulder pain, did I think perhaps she had strained a muscle? And she'd nearly fainted in the Sears parking lot the week before. Ms. V has hypertension, high cholesterol, pre-diabetes, and her EKG at my office looked vaguely abnormal. I sent her directly to the hospital for admission to the cardiology service, and the following morning they put a stent into her nearly obstructed main coronary.

Here's to studied calm.

Living through cancer

A friend and I are gathering material for a how-to guide for cancer patients. Last week's JAMA had an interesting essay on that subject by Deborah Lewis, a social worker and breast cancer survivor. Titled "Legacy," her comments address her cancer experience as it relates to her father's death from heart disease. In particular, she found herself "playing follow-the-leader behind my father's tough but frail, limping frame" because she discovered that parents teach their children how to handle illnesses, aging, and death. She notes:

Before I got sick I thought people could choose how to confront serious illness. Once could either wallow in self-pity or buck up and move that rubber tree plant. Now that I've had cancer I understand that there is no deliberation and thought. You handle it the way you are going to handle it. Either you have high hopes or you don't; sometimes the ant just can't.

But she proves that she mostly can, living through her treatment in the way she saw her dad manage his own heart disease. Her imagined conversation with him:

Me: One time I threw up while I was running, heaving behind a distant neighbor's bush, my hands braced on my knees while the sweat dripped off my forehead. I wiped my mouth with a leaf and finished my run.
Dad: You're proud of that, aren't you? The vomiting and running thing?
Me: Yes, actually. I am.
Dad: I am too.

Early a.m. calls

Ordinarily I'm up by 6:30 a.m. I recognize, however, that patient problems don't follow my schedule, even my more leisurely Saturday morning agenda. I also know that nagging problems have a way of seeming more urgent through the wee hours of the morning, so that which is not an emergency (say the discomfort of a bladder infection) can move a patient to place a call to me at oh-dark thirty.

That said, here's the gist of my conversation with a patient of one of my call partners at 6:30 yesterday morning:

Pt: I've had an irregular heart beat on and off for two weeks now.

Me: Is it worse this morning? Are you having shortness of breath or chest pain?

Pt: No. It's just been on my mind and I thought I'd run it by someone.

Turns out this fellow is quite the work-out fiend, feels fine when he works out without any sensation of skipped beats (typical of benign premature contractions), and I think he just wanted reassurance before he went off to his early morning work-out. I was tempted to berate him a bit for his timing (I know some people call off-hours because they know they'll get right through to the doctor), but I held my tongue as he was not my patient.

Would I have been justified in schooling him on after-hours etiquette?

"How Doctors Think"

I love highlighters. And I adore those tiny sticky strips with which I mark interesting passages in the books I read. So imagine my delight when a well-known pharmaceutical company via their local sales rep gave me four highlighters, each with scores of matching sticky tabs bursting out the sides. Of course, all these freebie pens bore the branded name of an expensive, widely-advertised anti-depressant.

Before I get to my point here, let me assure you that these gifts in no way influenced my prescribing habits. The pens, in fact, were all dried-up and hopeless for highlighting, but that made me no less likely to dole out the drug. The tabs were all I could hope for, but I promise you I've written not one additional prescription based on my delight. My patients often do well on this med, and that makes me more likely to prescribe it. Many who love the mood boost stop taking it, however, due to intolerable side effects, and that makes me less likely to write for it.

So there's a little insight into how this doctor thinks, but what I'm really plugging here is Dr. Jerome Groopman's must-have book "How Doctors Think." I'm halfway through it, and pages read thus far bristle with my ill-gotten, dirty-drug-money sticky tabs, each one flagging a point I wish I'd made in a book I wish I'd written. Not only should doctors read this book to understand why we think the way we do or to change our cognitive strategies in useful ways, you and I as patients (or as people who love and support patients*) should pay close attention as well.

Regular readers know that I've spent more than a little time these past two years as a designated listener and an advocate for friends and family working their way through the medical maze. I've seen how my colleagues listen or don't, and how they arrive at outrageous conclusions...or good ones, and the ways in which doctor/patient interactions influence the outcomes. Dr. Groopman has lots to say on the subject; more to come in later posts.
_____
*Two other excellent books that will help you become your own best advocate are Sick Girl Speaks and Pursued by a Bear.

Been there, done that? Share your cancer advice

I asked one of my patients years ago about the best advice and the worst advice she'd received during her treatment for breast cancer. I don't even remember what she said was the best so horrified was I to hear that my advice was the worst.

I had told her she should consider quitting her job in order to deal with the upcoming treatment. I meant well; why spend energy on work when you will need all your inner resources to undergo chemotherapy and radiation? Now I know that 1) if you quit work you lose your insurance, and 2) ongoing work may provide a measure of satisfaction and normalcy to a life that has been transformed by a cancer diagnosis. I currently advise newly diagnosed patients to consider filling out paperwork to activate the Family Medical Leave Act so absences for treatment or side effects won't jeopardize their job.

I am collaborating with my friend and colleague Gail Harrison (who has been there/done that cancer journey) on a book for newly diagnosed cancer patients. Please consider sharing your stories if you have been down that road as well, or pass this questionnaire on to a friend or family member who has been through this experience.

Getting a call back from the doc!

Just finished a week of testing for my nearest and dearest. Getting the results was a bit of a challenge, even when I pulled rank with the "This is Dr. Paley calling Dr. R. for test results" which presumably pushed pushy me to the head of the phone call line.

Here's an article I wrote several years ago on the subject. I'd love to hear your stories about getting through (or not) to your physician.