Till We Meet Again...A Special Note to my WLFP Patients

To my wonderful patients from West Lake Family Practice,
This note is a month overdue, not from neglect, but from the inadequacy of my words each time I sat down to write. I simply cannot express what a privilege it has been to care for you and your families. Many of you have been trusting your healthcare to me for almost two decades- first at my practice on 38th street and then in Westlake. I truly cherish our friendships and shared experiences- through occasionally bewildering medical challenges and with your "real life" experiences, both the joyous and the sorrowful. When I think about the practice of medicine, it's not about cancer, diabetes, weight, heart attacks, depression or sore throats- it's about the complete person dealing with these challenges, and his or her stories and relationships. That is why I love family medicine.

When I took what I had hoped to be a six month leave of absence last year to finish up two writing projects, I had every intention of returning to WLFP. Unfortunately, publishing world turnover created chaos in one project, extending my leave to a full year. Meanwhile, medical care is obviously in the midst of upheaval and evolution, and primary care practices in particular have been swept up in these changes. WLFP is no exception, as I am sure you are aware. Like any business, our practice both gained and lost personnel as the ownership changed hands.  I believe many of these changes in healthcare will push the practice of medicine in the right direction (such as electronic medical records)  but patience is required, as the growing process can be challenging for all of us. With all of these changes, however, the timing is right for me to make another transition in my career.

Although I miss the patients, co-workers and staff at WLFP, I am truly enjoying being back at the University of Texas, seeing students in the urgent care area of the health center. (The reflection from my Aggie ring makes all that burnt orange look maroon...) Seriously, though, please make sure your current Longhorn students know I am available for them! Additionally, many of you know that I have been working with our Bishop Emeritus, John McCarthy, on his book (very near publication), and I am excited to bring my life full circle soon by joining the team at Seton's McCarthy Clinic (named in his honor.)

A special thank you to Cary Douglass, MD, for inviting me to work at WLFP a decade ago, and always supporting my editing, writing, publishing, and media adventures. To Scott Gaertner, MD, & Kristyn Fagerberg, MD, I miss you both and wish you success at West Hills Family Health Center.
To Mary Sue and the front office staff, thanks for juggling my schedule without complaint. To Deana and Lorie, I know you will keep taking great care of our patients, thank you! To Virginia, all the best...until we meet again.

BOTTOM LINE: My dear patients, I will not say goodbye, but only "till we meet again"...and many thanks for your trust and friendship. 

Does Your Sinus Infection Need Antibiotics?

Item number two on the “Choosing Wisely” campaign to educate doctors and patients on unnecessary tests is the toughest one of all- “Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.”

For years doctors have known that the majority of sinusitis infections are caused by viruses. We know that antibiotics do NOT cure viral infections, only bacterial ones. Why, then, do many doctors continue to prescribe antibiotics for this problem? Why do patients ask for an antibiotic even when the doctor takes the time to explain that an antibiotic is unlikely to help? Americans spend over $5.8 BILLION health care dollars on this common diagnosis via 16 MILLION office visits and medication costs.

Have I ever prescribed antibiotics for this? You bet- especially on a Friday, or when a patient is headed out of town! BUT…let me explain why and how. As a busy mom, I understand the exasperation of a lingering runny, stuffy nose and headache, and the desire for a simple cure to “fix it”- whether those symptoms are mine or my husband’s or kid’s. If I take the time to schedule an appointment, show up, and wait because the doctor is running late, I want to get my money and time’s worth and be handed a cure. The doctor wants to be able to give you this cure. Both parties can feel like they are “doing something” when the doctor prescribes the antibiotics. And sometimes it seems that once we take that antibiotic, then, indeed the symptoms go right away. However, from good research, we know this is the exception, and not the rule.

Given all these factors, here is my approach. If I examine a patient and believe they have a mild to moderate sinus infection that has lasted only a few days, I frequently offer them two prescriptions: one for something to help with the symptoms (such as a drying antihistamine, if a runny nose is a major complaint, or a decongestant and something to break up mucus if they are stuffy with thick nasal discharge); and the second one a prescription for an antibiotic. BUT- I ask them not to fill the antibiotic prescription for a couple days, explaining why it is unlikely to help unless their symptoms drag on or they get signs of a secondary infection such as fevers or local pain in their teeth or forehead. I encourage them to hydrate till they float, and to use old -fashioned topical vapor rubs or sip spicy soups to open nasal passages. I have found that the vast majority of the time, when we follow up with our patient, they report they never needed to fill that second prescription (for the antibiotic) and we all feel as though we’ve done something productive.

BOTTOM LINE: Most sinus infections will resolve without antibiotics- talk with your doctor about treatment options that will help your symptoms, but don’t insist on an antibiotic.

An Xray for Your Aching Back?

Last week, the “Choosing Wisely” campaign was unveiled to physicians and patients alike. The concept was for each major specialty to identify five interventions that traditionally, physicians have ordered (and patients have expected) yet now evidenced-based medicine is telling us that these are simply unnecessary, not truly beneficial, and/or costly in dollars or health. For the next week, I would like to add my two cents worth for each of the five interventions highlighted by my academy- the American Academy of Family Physicians.

The first recommendation is to AVOID IMAGING (x-rays, CT or MRI scans) for LOW BACK PAIN that has been present less than six weeks
Did you know that low back pain is the 5th most common reason that people head to their doctor? We “throw out” our backs at an amazing rate, and it’s usually just from bending over or vacuuming more than moving baby grand pianos. The vast majority of low back pain is muscular, and a combination of anti-inflammatory medications (like ibuprofen), topical modalities (heat & massage) and judicious use of muscle relaxants-plus TIME measured in days, not hours- will take care of the problem. Ergonomic evaluations and physical therapy can also do wonders for low back pain, especially if it is recurrent. Insisting on an x-ray or fancy scan will certainly reduce the thickness of your wallet, but is unlikely to reduce your pain.

BOTTOM LINE: Hold off on x-rays or other scans for low back pain unless your pain has persisted more than six weeks, or your doctor sees “red flags” that suggest less common, more serious underlying issues.

Why Don't Doctors Talk about Weight?

I have often heard people complain that their doctor did not tell their spouse to lose weight. (While I could do a side blog on why it is that people have this complaint more about their spouse than themselves, I will pass on that aspect today.) The CDC reported that in a recent Disease Control and Prevention survey, only 42% of obese patients were advised by their health care providers to lose weight. Interestingly, those who WERE counseled to lose weight were more likely to be actively trying to do so.

Why don't doctors tackle this more often? Obviously, there are many reasons, but let me list the top ones that immediately come to mind.

1. TIME- Doctors are all frustrated with less and less time with our patients. Weight loss conversations are rarely brief (and often loaded with emotional baggage) so doctors may avoid the topic purely from lack of time.

2. FEELINGS- Doctors are human (mostly) too, and we don't want to insult or hurt people's feelings. No one seems to be offended by high cholesterol or blood pressure, but universally people are defensive and/or hurt when say they are overweight or obese. Certainly, our society has made fat a four letter word.

3. MIRRORS- If your doctor is overweight, he or she may consciously avoid discussions of weight (why can't you lose your weight, doc?) or subconsciously avoid the topic because of their own frustration with the issue.

4. EXPERTISE- Not all physicians receive equal training in nutrition, so we have different comfort levels in direct counseling. Having said that, know that we can refer to our wonderful colleagues- our registered dietitians- who specialize in nutrition.

So, on your next office visit, why not ask your doctor about your weight? I think the least stigmatized way is to ask about your BMI- your body mass index. What's a BMI? More on that tomorrow...

BOTTOM LINE: Obesity should not fall into the "don't ask, don't tell" category- ask your doctor if you are at a healthy weight!