Conquering Fear

So much to blog about and so little time....
A patient of mine turned me onto the television series Doc Martin years ago, and I wondered why the good doctor never did a repetitive exposure protocol to reduce his blood phobia. 
If anyone out there is not getting medical care or blood draws for good preventive care because they are afraid of needles, there are great ways to help yourself. 
I highly recommend a workbook which a patient of mine introduced me to called 
Mastering Your Fears and Phobias.  
http://www.amazon.com/Mastering-Your-Fears-Phobias-Treatments/dp/0195189183
This book is meant to be used in conjunction with a therapist who is using this book:
Mastering Your Fears and Phobias: Therapist Guide
http://www.amazon.com/Mastering-Your-Fears-Phobias-Treatments-ebook/dp/B00192LYRG
This is the link to the Kindle edition but you can also find it in hard copy from Barnes and Noble and other places online. 
Unlike with most books, I found that the authors' blurb on the cover of the therapists' guide delivered exactly what it said and that the two books together are an extremely effective system. So I will reproduce the blurb on the therapists' guide here:

"Specific Phobia is the most commonly occurring anxiety disorder with approximately 12.5% of the general population reporting at least one specific phobia during their lives. People may fear heights, flying, spiders, blood, water, and any other number of circumscribed objects or situations. Research has shown the most effective treatment for these fears and phobias is an exposure-based, cognitive-behavioral program.  Written by renowned researchers, this Therapist Guide provides you with all the information you need to help your clients ease their anxiety and conquer their fears. Whether they are afraid of dentists, dogs, or driving, you can teach your clients the necessary skills to overcome their phobia in as little as a few weeks. The strategies outlined in this book include exposure exercises and cognitive restructuring techniques. The corresponding Workbook includes blank forms and records for tracking progress and allows the client to extend the therapeutic experience outside of the office. Together, both books form a comprehensive package that has proven to be the most effective and successful treatment available for specific phobia. TreatmentsThatWorkTM represents the gold standard of behavioral healthcare interventions! All programs have been rigorously tested in clinical trials and are backed by years of research A prestigious scientific advisory board, led by series Editor-In-Chief David H. Barlow, reviews and evaluates each intervention to ensure that it meets the highest standard of evidence so you can be confident that you are using the most effective treatment available to date.  Our books are reliable and effective and make it easy for you to provide your clients with the best care available Our corresponding workbooks contain psychoeducational information, forms and worksheets, and homework assignments to keep clients engaged and motivated."
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Unlike other phobias, it is hard for a regular psychotherapist to provide the exposure needed if you are afraid of needles or blood.  Your therapist will need to work with a doctor who can expose you to needles and blood.  Or, like my client did, you can buy your doctor the Therapists' Guide and convince them to help provide you with the needed exposures. Be prepared to spend some money on this as it would not be surprising, given the sorry state of our insurance system, if your insurance plan did not cover the doctor visits needed for this type of treatment. 

So, if you have nothing to fear but fear itself, take heart and buy these books and enlist your doctor in helping you get rid of this disabling phobia which is preventing you from taking care of yourself.

Ode to the Bedpan

   Having taken a few years off to begin and run a primary care practice, it's time to start blogging again. Erstwhile followers have clucked disapprovingly about the sparsity, nay absence, of posts since 2011, while flattering me that they used to enjoy them. Today, finally out of activities to distract me from my tax return or writing the website content for my new medical aesthetics practice (www.skinlifemedical.com), I feel compelled to write a blog post.
    On telephone coverage today for myself and several other physicians, I got an amusing call from a hospital nurse confronted with an order to remove a Foley catheter (a catheter used to collect urine from the bladder during and after surgery to collect the urine)  The nurse noted that the patient could not yet walk steadily after hip surgery, and asked "What should I do? Should I just leave the Foley catheter in another day or should I let her be incontinent?"  Puzzled, I asked whether because of the hip surgery the patient was unable to raise herself for a bedpan,  Or was she was unable to control her bladder perhaps until the bedpan came? Or were they understaffed on the floor and unable to come in time to bring a bedpan when people called? "Oh, a bedpan!" the nurse exclaimed, "that's a good idea! I'm so glad I talked to you!"
   Some of you may be laughing as much as I was, and some of you may be wondering what was amusing. Regrettably perhaps, my reluctance to dampen your fun has ceded to the desire to express the sadness which followed my initial amusement. Writing about it will improve my mood, because it is so much more pleasant, as anyone in the word of quality improvement can tell you, to point out others' failings than to do one's own work. Taxes, anyone?  I think not!  And, my inattention will ensure that myown  failings will remain to provide an endless source of pleasure to my teenage daughter. And, to you, Gentle Reader, should you wish to elevate your own mood after reading the sad things I write herein.  Yes, instead of doing my taxes, or writing my website content for my new medical spa (www.skinlifemedical.com) I will spend a most pleasant half hour writing this post and shaking my head once again about how far our hospital staff will go to avoid doing the simple task of answering a call bell and bringing a patient a bedpan when needed. My mussar teachers will (oh, so gently) point out how mistaken this course of action is, and I am delighted to allow them that great pleasure too.
   Is it right to keep in a foreign object with the potential to damage our urethra and bladder and muscles which control continence, and with a great potential to introduce infection, rather than to arrange for the patient to ring a call bell when she has to go and then bring her a bedpan? When someone is unconscious for surgery or can't move at all, there is no option. But once she is even slightly mobile after surgery, and can't walk, isn't it better to use a bedpan than to leave in a Foley catheter?  Yet the bedpan is so out of use that this nurse had completely forgotten the option existed!
   Bringing a bedpan rather than leaving in a Foley catheter creates many other opportunities that improve a hospitalized person's health care. Since the patient will need more frequent encounters with staff for bedpans than to change a Foley bag, it offers more opportunities to introduce ourselves with a smile. These personal encounters with staff make some people feel secure when they are hospitalized and vulnerable, whereas others feel their privacy has been invaded. Regardless of which type of person we are treating, and I believe the former are more prevalent in the great majority of hospitals, the encounters offer many other opportunities for improving health care. For example, after removing the bedpan and wiping, a nurse or aide can examine the backside for pressure ulcers (bedsores), reposition to avoid causing bedsores with prolonged immobility, evaluate if the mental status is OK (cognitive issues such as hallucinations or confusion may indicate overmedication or onset of infection postoperatively), ask if the person needs water, and check that the call bell and telephone are within reach.  In addition, removing the Foley catheter makes it easier for hospital staff to try to help someone begin to walk (have you tried walking with a large plastic tube sticking out your urethra and a bag of urine hanging from your leg?) How sad that the nurse didn't even think of this option before calling.
  Bedpans do have some downside. As mentioned above, we invade patient's privacy more frequently with bedpans than with Foleys where our postoperative care is limited to emptying the bag. And, nurses or nurses' aides can spread infection when bringing bedpans too if they don't wash their hands.  Because bedpans require more patient encounters with staff, they require more nurses' aides in hospitals.  As administrators try to reduce hospital costs, I am sure there are pluses and minuses to the equation of more Foley catheters and fewer people interactions. These are things which can be studied. My hunch is that the humble bedpan and the equally humble aides who bring and empty it probably are cost-effective given the complications they prevent. Or, maybe Americans should just spend more money on new versions of the iPhone.  Or let Comcast make another $1 billion dollars per year by charging each American household $10 more a month for what they said was included in the package to begin with when they sold it to us.  Or perhaps each doctor and hospital should pay for yet another electronic health record because the one we have isn't working and doesn't talk to anybody else's and we should spend a good portion of our societal and healthcare budget on health IT.  Our society seems to be fine with all that waste, but Heaven forbid there should be a nurse's aide to bring a bedpan.
  Alas, the taxes beckon.  Perhaps I can clean out my refrigerator...

US life expectancy drops

According to the U.S. Centers for Disease Control (CDC), for the first time in 25 years there was an actual drop in overall life expectancy in the US, calculated in the year 2008 (since the data take some time to calculate, the CDC usually puts things out a couple of years after the fact, and 2008 is the most recent year for which data were released). This is not very good news. The bright spots were infant mortality and death from stroke.

This stands as an indictment of our health care system as well as what we do as a society to prevent illness and promote wellness. We can only hope that more Americans will be adequately insured and receive more appropriate health care in the future, and that our health care system will turn more towards prevention, where its bang is likely to be much bigger for the buck.

Sublingual allergy tablets effective in preventing seasonal nasal allergy

A new meta-analysis (synthesis of all available clinical trials) in the Cochrane Library has found that under-the-tongue immune treatment (which can be done at home) is effective without the side effects of weekly allergy shots. This advance in allergy treatment is particularly good for kids, and of course whether for children or adults reduces the major hassle of driving to the allergist's office, not to mention the pain and not infrequent reactions experienced with allergy injections. Very good news for allergy sufferers.

Getting doctors to follow our wishes with advance directives

People of all faiths and atheists should be interested in doctors ignoring patients' wishes about life support. Whether or not you are predisposed to a particular religious point of view about life support, whether your wish is to be on life support, or not to be on life support, or something in between depending on the circumstances, we need a way to make sure doctors are paying attention to what our wishes are.

Three things are particularly important for everyone: 1) filling out an advance health care directive to indicate your wishes and your desired medical agent (durable power of attorney for health care), 2) having a knowledgeable health care advocate; in addition to designating the person who cares about you most as your agent, this person if they do not have a lot of experience from the medical care system may need help from someone more knowledgeable, and 3) the importance of registering your advance directive with an organization such as US Living Will Registry so that hospitals and health care facilities can check to see if one is present when you are admitted.

Great info about how to make sure your meds don't cause you harm

http://www.ahrq.gov/consumer/cc/cc120710.htm

Getting tested for BRCA genes

I have been asked many times whether to be tested for the gene mutations which increase risks of breast cancer, also known as BRCA genes. There are a few such gene forms identified, which together account for a large percentage of hereditary breast cancers, as discussed in this National Cancer Institute fact sheet. These genetic mutations code for faulty enzymes responsible for repairing damage to DNA that causes cancer.

The first question in deciding whether or not to get tested is whether you have had breast cancer!! If so, get tested!! If you are positive for one of the BRCA mutations, it should have a big impact on whether you decide to have a prophylactic, that is, preventive mastectomy of the other breast. Women without BRCA mutations do not survive longer if they have second mastectomies. It also affects how frequently you screen the other breast with a mammogram. I am always surprised by how many people (yes, men get it too) who have had breast cancer have not had these genetic tests! This is a situation in which the downsides are much fewer. Specifically, the documentation of increased risk which might make it hard to get health insurance, is besides the point, since the history of breast cancer already confers that risk.

If you haven't had breast cancer yourself, the next question is if you know the medical history of your first degree female relatives, your mother and your sisters, or your father's sisters and mother. If you do not, consider whether you are in one of the ethnic groups at higher risk of the genetic mutations which increase the risk of breast cancer (Ashkenazi Jews, Icelanders, Norwegians, and Dutch). If you are in one of these ethnic groups, and you don't know your personal family history, you are likely to benefit from being tested.

If you do know your mother's, your sisters', both of your grandmothers' and your father's sisters' medical histories, and know what they died of, and they lived into their older years (70s or 80s, say) without developing breast cancer, then there is little chance that you have an extra genetic risk of breast cancer. Your lifetime risk is then like the risk in the general population without a family history of breast cancer, or about 12%, and there is no special reason to be tested.

Now, if your mother or sister did get breast cancer, is there any additional advantage in getting tested for BRCA genes?

The first step is, if the person who had breast cancer is still alive, to ask that person if they were tested for these gene mutations. If they were not, you could ask if that person is willing to be tested. The reason is that if they are negative for one of the gene mutations, then you are unlikely to have an increased risk on that basis too, and testing is much less helpful and not recommended. The second reason is that if they are positive, and you then get tested and test negative, you can set aside worrying about increased risk due to your family history as you have probably not inherited that risk.

If the person in your family who has breast cancer has died or refuses to be tested, the pros of getting tested are that if you test negative, you can get screened less often than if you are positive. If you are positive, you can get screened more frequently, and using different forms of screening such as ultrasound. Also, if you are positive, you can get screened for ovarian cancer, which is not normally done otherwise, because women with BRCA genes have increased risk of ovarian cancer. You may also wish to have prophylactic bilateral mastectomies, or if you develop cancer, to get the other breast removed at the same time. The lifetime risk of developing breast cancer when one is identified as being at genetic risk is extremely high, and many women opt for this solution, even some without BRCA genes. Finally, as above, if you do develop breast cancer, evidence has shown that if you do not have a BRCA mutation, having a prophylactic second mastectomy does not improve your survival.

The biggest downside of testing for breast cancer risk genes is being identified by insurers as being at increased risk. While there is now a federal law against insurers discriminating against women on this basis, this is totally unenforceable. Women can be denied by insurers for a host of spurious reasons (one woman I know was denied because she had had a urinary tract infection treated with antibiotics in the last year!) which may be cover-ups for other risk factors. We also have no assurance that health care reforms banning exclusion of pre-existing conditions or refusal to insure people with those conditions, will remain after future changes in the political landscape. Many women will feel with some justification that it is simply better not to have this risk recorded.

The solution to this downside, of course, is to get tested anonymously outside the insurance system. Then, at least, you will not be classified as being at extra risk unless you divulge this information to a physician because you wish to do something about it (such as bilateral mastectomies). Most labs will send specimens anonymously as long as you are paying for it and not the insurance company. Now that the patent on the BRCA1 gene has been struck down, other companies besides Myriad Genetics will spring into the marketplace and testing is likely to become less expensive. This brings up a new downside: the cost of testing, which depending on how many genes are tested for, can be anywhere from a few hundred to a few thousand dollars. See this discussion in the National Cancer Institute's factsheet

Getting tested may cause other harm worth mentioning. The increased screening for breast cancer which you are likely to have if you test positive carries risk. If you get screened more, you are more likely to have a false positive mammogram, or ultrasound, or breast MRI, with unnecessary biopsies, etc. Radiation from mammography and MRIs may also cause some increased risk. There has been a lot of recent publicity around why one might want to avoid mammography and screening despite a family history of breast cancer such as this recent column in Health Affairs.

The organization Facing Our Risk of Cancer Empowered (FORCE) runs a hotline to help answer questions about breast cancer risk and screening for breast cancer genes. Local communities often have support networks as well. In Palo Alto, there is also an organization called Breast Cancer Connections which specializes in helping newly diagnosed women, but also provides a lot of information to women about risks for breast cancer.

For additional information, ask your doctor to refer you to a genetic counselor. You can check with your insurance about whether they cover a visit like this. They may only do so if you have a family history of breast cancer.