October 1st, 2007 by Dr. Val Jones in Health Tips
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A dear friend of mine sent me a panicked, cryptic email late on a Friday night: “call me immediately” (followed by her cell phone). As a doctor, I usually know that these kinds of requests are triggered my medical emergencies, so I anxiously picked up the phone and called my friend, hoping that I wasn’t going to hear some alarming story about a tragic accident.
And low and behold the story was this: “I got home from work late and picked up the mail. There was a letter in there from the radiologist’s office. It said that my mammogram was abnormal. Do you think I have breast cancer? Am I going to die?”
Remaining calm, I asked what sort of abnormality was described. She read the letter to me over the phone:
“Dear [patient],
Your recent mammogram and/or breast ultrasound examination showed a finding that requires additional studies. This does not mean that you have cancer, but that an area needs further evaluation. Your doctor has received the report of your examination. Please call us at XXX to schedule the additional examinations.”
I knew immediately that this was a form letter (heck the letter didn’t even distinguish between whether or not my friend had had a mammogram or an ultrasound) and it made me angry that it had frightened her unnecessarily. I knew that as many as 40% of women who have mammograms have some sort of “finding” that requires further testing. Usually it’s because the films are too dark or too light, the breasts are particularly large or dense, or there is some cyst, calcification, lymph node, or shadow that the radiologist picks up. And in a litigious society, a hint of anything out of the ordinary must be reported as an abnormal “finding” until proven otherwise.
I did my very best to reassure my friend – to tell her that if the radiologist were truly concerned about what he or she saw on the mammogram s/he would have called the physician who ordered the test right away. Receiving a vague letter like this is reassuring, because it’s an indication of a low index of suspicion for a malignancy. I also told my friend that if a true mass were found on the mammogram, that a biopsy of that mass still has an 80% chance of being normal tissue.
But even though I did my very best to reassure her, my poor friend didn’t sleep well that night, and worried all weekend until she could speak to her physician on Monday. As I thought about her experience, and the unnecessary fright that she was given… I began to wonder about how common this experience must be. How many other women out there have lived through such anxiety?
Personally, I think that women who get mammograms should be warned up front that there is a high chance that the radiologist will find something “abnormal” on the test, and that these abnormalities usually turn out to be any number of typical breast characteristics. They should be told not to worry when they receive a letter about the abnormality, but come back for further testing in the rare event that the finding is concerning.
I decided to do a little research about this phenomenon (women receiving scary letters out of the blue about their mammogram results) and interviewed Dr. Iffath Hoskins (Senior Vice President, Chairman and Residency Director in the Department of Obstetrics and Gynecology at Lutheran Medical Center in Brooklyn, N.Y.) about her experiences.
Please listen to the audio file for the full conversation. I will summarize her opinions here:
Q: How common are abnormal mammograms?
Mammograms are considered “abnormal” in some way in up to 40% of cases.
Q: What sorts of things are picked up as abnormal without being true pathology?
Overlapping tissues in women with larger or heavier breasts, fibrocystic breast tissue, calcium deposits or the radiologist doesn’t have the last mammogram to compare the new one to and sees some potential densities.
Q: What happens next when a woman has an abnormal mammogram?
It may take a week or two for the patient to get scheduled for follow up tests. Usually the physician will choose to either repeat the mammogram with targeted views of the area in question, request a breast ultrasound, biopsy the mass, or remove the concerning portion of the breast tissue surgically.
Q: When would a physician choose a biopsy?
A biopsy is indicated if the mammogram and follow up tests all are consistent with the appearance of a concerning lesion. Sometimes the physician will do a biopsy on a lump if a woman says that it’s unusual, new, or tender and the mammogram result is equivocal.
Q: What percent of biopsies confirm a malignancy?
It varies from physician to physician because some have a lower threshold for performing biopsies (so therefore the percent of biopsies that are malignant is lower). But on average only 10% of biopsies pick up an actual cancer.
Q: What does a radiologist do when he or she finds an abnormality on a mammogram?
First of all, the patient must be notified of the abnormality. Secondly, the radiologist reports the abnormality to the referring physician, usually by fax. They do it either in batches, or one at a time. If the person reading the film has a serious concern about the breast tissue – or if it appears to have the characteristics of a malignancy, the radiologist will personally call the referring physician right away.
Q: What advice would you give to a woman who receives a letter in the mail indicating that she’s had an abnormal finding on her mammogram?
Please try not to be concerned yet. Wait for the doctor to fully evaluate the mammogram and do further testing before you make any assumptions about the diagnosis. Although it’s almost impossible not to feel anxious, you must understand that the vast majority of “abnormal findings” on a mammogram are NOT cancer.
Listen to the full interview here.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 30th, 2007 by Dr. Val Jones in Medblogger Shout Outs
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Less than a year ago, I didn’t even know what a blog was. Many physicians still don’t know about them, and yet (according to Wikipedia’s September ’07 figures) there are over 106 million blogs currently online. A recent article about medical blogs suggests that the number of health professionals blogging may be in the order of 100’s. Therefore, medical blogs are only a tiny drop in the blogosphere bucket.
As with IT initiatives in general, the medical world is sorely lagging behind. However, there is a small group of pioneers who are already making a difference in the lives of patients and colleagues around the world. I have witnessed with my own eyes how cancer patients are being directed towards optimal care through blogs like those of Dr. Heinz Josef Lenz. Although he practices in southern California, his blog has been discovered by colon cancer patients across the country – and he has a loyal following who learn about cutting edge research and clinical trial information three times a week. These patients would never have access to this kind of information without his blog – they would have to wait for research to be published in a peer-reviewed journal, and then hope that the media would faithfully translate the findings into consumer language. (Good luck with that.)
Some blogs are being used to educate peers about surgical techniques. Dr. Bates has a wonderful, detailed blog about how to correct cosmetic defects, and a group blog called Inside Surgery has information for surgeons about difficult or unusual cases.
Dr. Rob, our Grand Rounds host this week, does a wonderful job of educating others about primary care, physical exam basics, and the broken healthcare system. He does it with flair – and a whimsical approach that is very entertaining. Where else can you learn about the healthcare system AND the lifestyle habits of llamas, goats, and accordion players?
If you want to keep up with healthcare news – KevinMD is a one-man news feed of all the most interesting goings on. If you need to keep up with advances in the medical device industry, MedGadget is your one stop shop.
Of course there are many other great medical blogs out there as well (and so many nursing blogs, like Emergiblog are outstanding)- but what excites me the most is when I see patients benefiting from the information they receive directly from healthcare professionals. Blogs can truly improve access to the minds of medicine, and even save lives – Medical blogs have the power to:
1. Educate patients about their health
2. Debunk medical myths
3. Cut through the media spin associated with research and health news
4. Influence health policy
5. Instruct other healthcare professionals
6. Expose dishonest medical schemes
7. Increase awareness of clinical trials and important research
8. Provide emotional support
9. Create a networking opportunity for professionals, advocates, and patients
10. Help people navigate the broken healthcare system
If you haven’t already, I hope you’ll add your voice to the medical blogosphere, and be part of a movement to change healthcare – one blog post at a time.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 27th, 2007 by Dr. Val Jones in Health Tips, News
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Heart disease is the number one killer of Americans, and high cholesterol levels are a primary contributor to heart disease. But the cholesterol story is a bit complicated – some of it is damaging to blood vessels (Low Density Lipoproteins or LDL is considered “bad” cholesterol) and some of it is restorative (High Density Lipoproteins or HDL is “good” cholesterol). Most medications are aimed at lowering the “bad” cholesterol, and this strategy has been very helpful in reducing heart disease and atherosclerosis. But what about raising the good cholesterol as part of a heart healthy strategy?
A new study in the New England Journal of Medicine suggests that having low levels of HDL can put people at risk for heart disease and heart attacks, even if the LDL is well controlled. This is the first study to show that low LDL does not erase heart disease risk if the individual’s HDL is also low. In fact, each increase of 1 mg in HDL cholesterol is associated with a decrease of 2 to 3% in the risk of future coronary heart disease. So lowering LDL with statins (if lifestyle measures fail) is only half the battle for those who also have low HDL.So how do you increase your HDL levels?The most effective medicine for raising HDL is a type of Vitamin B called niacin. Taken in the quantities required to have an effect on HDL, though, there are usually unpleasant side effects: flushing (redness or warmth of the face), itching, stomach upset, mild dizziness, and headache.
Perhaps the best way to increase HDL is to lose weight and exercise regularly.? In fact, the list of HDL-raising “to do’s” reads like a healthy living manual:
1. Avoid trans fats
2. Drink alcohol in moderation
3. Add fiber to your diet
4. Use monounsaturated fats like olive oil where possible
5. Stop smoking
6. Lose weight
7. Engage in regular aerobic exercise
So next time you see your doctor, make sure you review your cholesterol levels, and discuss some strategies to get your levels of HDL and LDL in the optimal zones for a healthy heart.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 24th, 2007 by Dr. Val Jones in News
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The oncology community bid farewell to one of its greatest leaders last week, Dr. Marty Abeloff. Marty was a dear colleague of Dr. Avrum Bluming (a guest blogger and friend of Dr. Val & The Voice of Reason) and Av was kind enough to write this obituary to honor him:
On September 14, 2007, Marty Abeloff died.
An intelligent, gracious, caring and supportive human being, he brought all those qualities to his roles as physician, mentor, educator, administrator, and friend.
He was a Phi Beta Kappa graduate of Johns Hopkins and an Alpha Omega Alpha graduate of Johns Hopkins Medical School. He did his house staff/fellowship training at the University of Chicago, the National Cancer Institute, Harvard, the New England Medical Center, and Johns Hopkins. At the time of his death, he was Professor of Medicine and Director of the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University. He was a past President of the American Society of Clinical Oncology, past Chairman of the Oncology Drugs Advisory Committee of the Food and Drug Administration, past Chairman of the Board of Scientific Counselors to the National Cancer Institute’s intramural division of clinical sciences, and past Chairman of the Breast Cancer Committee of the Eastern Cooperative Oncology Group. He was the lead Editor of Clinical Oncology, a comprehensive textbook, now in its third printing, Editor of Current Opinion in Oncology, former Associate Editor of the Journal of Clinical Oncology, and founding Editor in Chief of Oncology News International, a wonderfully informative periodical, a position he established and occupied since 1992.
He was held in high esteem by his peers, and beloved by his colleagues, co-workers, patients, students, family members and friends. Patients held on to his phone number long after they finished treatment, and those of us seeking advise in the management of our own patients never hesitated to call upon his help. He was always available and always helpful.
Any individual looking to fashion a life and career distinguished by accomplishment and filled with love could find no finer role model.
Avrum Z. Bluming, MD, MACP
Clinical Professor of Medicine
University of Southern California
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 18th, 2007 by Dr. Val Jones in True Stories
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Dr. Rob wrote a touching blog post today about death and dying. He contrasts two deaths – one in which the family members were excluded from the room as physicians deliberated about the patient’s heart rhythm (while she was dying), and another one in which a patient was surrounded by family members who sang a hymn and held him in their arms as he passed.
Although the ultimate mortality rate of individuals has been 100% throughout history, physicians are trained to fight death at all costs. When you think about it – we must be the most optimistic profession on the face of the planet. Who else would leap headlong into a battle where others have had a 100% failure rate since the beginning of time?
Instead of thinking of medicine as a means to defeat death, I think we should consider it a tool to celebrate life. Adding life to years is so much more important than adding years to life – and yet we often don’t behave as if we believe that. Unfortunately in my experience, death has not been handled well in hospitals. For every hymn singing departure, there must be 100 cold, lonely, clinical deaths surrounded by a crash cart, CPR and shouting.
I remember my first death as a code team leader in the ER. An obese, elderly man was brought in on a stretcher by EMS to the trauma bay. They were administering CPR and using a bag valve mask to ventilate his lungs. He skin was blueish and there was absolutely no movement in his lifeless body. His eyes were glassy, there was no rhythm on the heart monitor… I knew he was long gone. The attending asked if I’d like to practice placing a central line on him, or if I’d like to intubate him to get further experience with the procedure. She saw that I was hesitant and she responded, “This is a teaching hospital. It is expected that residents learn how to do procedures on patients. You should take this opportunity to practice, since it won’t hurt him and it’s part of the code protocol.”
As I looked down at the man I overheard that his family had arrived and was awaiting news in the waiting area. I sighed and closed his eyes with my gloved hand, gently moving his hair off his forehead. I looked up and told the attending that I was sorry but I couldn’t justify “practicing” on the man while his family waited for news. I took off my gloves, quietly asked the nurses to please prepare the body for viewing, and walked with my head hung to the private waiting room.
The family scanned my face intensely – they could see immediately that their fears were confirmed by my expression. I sat down very close to them and told them that their loved one had died prior to arrival in the Emergency Department, and that he did not appear to have suffered. I told them that we did all we could to revive him, but that there wasn’t any hint of recovery at any point. I explained that his death was quick and likely painless – probably due to a massive heart attack. I told them that they could see him when they were ready, and that I believed that he had passed away with dignity. They burst into tears and thanked me for being with him at the end. I hugged his wife and walked the family to his bedside and closed the curtains around them so they could say goodbye in their own way. I hoped that they felt some warmth on that very dark night. “Doing nothing” was the best I could do.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
