Take The Bitter Pill? (Drug Side Effects)

From a reader:

"I am so tired of taking medications that seem to cause more problems than my diagnosed disease."

This is one of the trickiest problems in doctoring: all medicines have side effects. Doctors treat diseases, but we unintentionally cause a lot of suffering with our treatments.

Some medicines cause frequent side effects. Some medicines cause them only occasionally. Some patients very rarely get side effects. Some people seem to get a side effect from everything they take. Any one person's reaction to any one medicine is impossible to predict. It gets pretty complicated.

It's important to understand that having a side effect doesn't mean it was a "bad medicine." It may work great for lots of other people. You should also realize that a bad side effect doesn't necessarily mean you had an incompetent doctor. Doctor D can't count how many patients have told him, "I'm never going back to Dr. SoAndSo, because he gave me a prescription for a poison. It made me feel terrible." (Patients have probably said this about Doctor D too.) The doctor who diagnosed you and gave the medicine is often in the best position to help you approach the problem of side effects.

In the end, only you can decide if it is worth taking any particular medicine, but your doctor can help you understand the pros and cons of any medicine or treatment.

A few common situations involving medicines:

• Dangerous Disease, Few Symptoms: Some diseases like Hypertension cause almost no symptoms until it is too late. Lots of people stop blood pressure medicine for mild side effects just because they just cannot feel the pressure destroying their arteries. Low-symptom diseases like Hypertension, Type II Diabetes, and High Cholesterol kill millions even though we have lots of great medicines. People have a hard time taking medicine when they don't feel sick. If you have medicine side effects with one of the "silent killers" you really need to talk to your doctor about switching medicines. Going without any treatment is a bad idea.

• Benign Disease, Miserable Symptoms: A lot of conditions from the Common Cold to Fibromyalgia never kill anyone, but they can make you feel horrible. The symptoms are the disease and therefore if you can handle the disease better than the medicine the choice is obvious. Just be sure your doctor agrees you have a benign condition before making this decision.

• Bad Disease, Bad Medicine: This is always a difficult place to be. A horrible disease that is treated with medicines that make most people miserable. Many cancers fall into this category. Your doctor can help you understand the probable risks of the disease as well as the expected side effects of the medicine, but remember the decision is yours.

• Mixed Diseases: Some diseases cause some difficult symptoms now and often vary in the amount of long-term damage they cause. Rheumatoid Arthritis is an example of such a condition. Treatments are aimed at current symptoms, at long-term damage, or both. Decisions about medicines in such conditions are never as clear cut as the other diseases. If you have trouble tolerating a medicine, you should ask your doctor if stopping it would have any long-term ramifications.

All these decisions belong to you, but doctors are useful for educating you. If a medicine makes you miserable ask you doctor, ""I'd love to stop this med because of side effects, what might I risk by doing this? Are there other medicines that I could try?"

Have you ever quit a treatment that was working because of side effects? Was your doctor helpful in your decision-making process? Doctor D would love to hear your stories.

Who Determines Quality Of Life?

This is an interesting question Doctor D found in a discussion going on at the Serenity Now Hospital blog.

Quality of Life is the concept that medical care should focus not just on the number of days our patients live but the amount of meaningful and fulfilling health within those days. Patients will often sacrifice length of life for improved quality of life. Some patients also decide that in the face of a life-threatening illness they will not have further treatment once their quality of life falls below a certain level.

Reflecting on quality of life helps doctors recognize the humanity of their patients. It helps us realize that that longer life isn't always better. At its best, quality of life allows the patient to decide how they approach illness and disability, while the doctors respectfully relinquish control to the patient's wishes.

Doctor D believes that quality of life cannot be determined apart from the patient's personal values and preferences. Many doctors, however, make quality of life judgements about their patients. Often physicians embrace the concept of quality of life without acknowledging that it is a personal decision that belongs to the patient not them.

On the post "Compassionate Death?" Doc Sensitive relates the story of an attending that decided not to treat an elderly man with dementia due to the attending's belief the man had no quality of life. The attending allowed the patient to die comfortably and untreated without ever trying to find out the old man's desires or contact the man's family. Doc Sensitive wonders if this was the right way to handle this patient?

The discussion after the post is also interesting. (Doctor D threw his 2 cents worth into the conversation too--It's the 3rd comment down.)

What do you think? Would you be comfortable with a doctor making a quality of life decision for you if you couldn't speak for yourself? Do you think Doctors are the right people to be making quality of life decisions? Do accounts like this make you more likely to get a living will or discuss your wishes with your family?

Doctor D will be back soon with more answers to your questions.

Query for Questions (Friday Links)

First of all, thanks to everyone sending in all the great questions. Doctor D has some really interesting questions to discuss over the next several weeks.

Thus far, all the questions on this blog have been from patients. To understand the view from the patient side of the exam room Doctor D is reading some great patient blogs like Queen of Optimism, ∞-itis, and Neo-Conduit.

But Doctor D thought he would use this Friday Links to suggest a few other types of questions he would love to answer:

Dr. D: “Who spends even more time with doctors than patients and often wonders, 'WTF is wrong with these MDs?'”

Student in back raises hand: “Nurses!”

Dr. D: “Right! Nurses have to take crap from annoying doctors all day long! They must have questions about doctors eating at them! Doctor D would love some questions from nurses. He promises not to ignore their questions like the other MD pricks. Hear that, Nurse K? Let Doctor D have it!”

So Doctor D's first Friday Link is a nursing blog. With Nurse K on hiatus, D had to find a new favorite nurse in the blogsphere. Doctor D is really enjoying The Lonely Midwife. D has a special place in his heart for midwifery since a midwife delivered his kid, Little D. Lonely Midwife just passed her boards so go on over there and congratulate her!

Dr. D: “Okay, next question. Who else has lots of questions they're just dying to ask doctors?”

Students shuffle feet and look at the floor.

Dr. D: “Come on! You know this one!”

Students sheepishly avoid eye contact.

Dr D: “Medical Students! You guys are working yourselves ragged trying to become Doctors. I know you've got some wacky doctoring questions you can't ask your attendings. This is your chance to pimp an attending! Doctor D stands ready to assist weary students walking the long road he has traveled before.”

This leads D to our second Friday Link, a really great med student blog he recommends: Journey to MD... and Beyond. Ella must be a frick'n genius to have time to blog during medical school, but we are all the better off for her excellent insights! Doctor D could have never kept up a great blog like that in med school.

Doctor D still loves questions from patients too! He just thought it would be fun to sprinkle a little variety in the questions.

Remember Doctor D doesn't do diagnosis or treatment over the web. But questions about doctors' brains, doctors' mistakes, doctors' behavior, doctors' lives, etc. are all fair game. So keep the questions rolling in!

You can also send your questions to Doctor D via Twitter.
Doctor D also links to great med-blog posts on his Twitter Feed.

Why Is It Hard To Live Healthy?

Doctor D was going to write more about first visits next, but instead he decided to tackle a more interesting follow-up to the last post:

Why is it so hard to live healthy?

The Happy Hospitalist recently pointed out that we could prevent 80% of premature death by following some very basic health rules: don't smoke, eat healthy, exercise often, and don't get fat. He then notes out that only 10% of people do all four. Happy says the other 90% of us are “fat smoking lazy food-junkies,” and he doesn't want to pay for healthcare for such stupid people.

Are Americans really that stupid? No, but we do often ignore the basic rules of healthy living. Why? We learned this stuff in health class as kids, but why is it so hard to actually do?

The answer lies in history. The diseases that kill people now are not the same ones that threatened our ancestors. The human mind comes pre-programed with survival instincts for a completely different world. Up until just a few generations ago humans survived on the edge of starvation. Life involved a lot of work and there was barely enough food to go around. Starvation ended the lives of millions, and the many malnourished were at much higher risk from death when confronted with infection or violence. These things killed our ancestors far more often than heart disease or cancer.

The human body is built to live on low-calorie high-fiber foods while doing a tremendous amount of physical exertion—bodies always need these “healthy” things, but your ancestors never needed to look for them any more than they needed to look for oxygen.

The human mind, however, is finely tuned to constantly search out high calorie foods and ways to avoid strenuous work. Your ancestors didn't find these luxuries often, but they were constantly striving for them. An avoided exertion or a caloric meal could make the difference between life and death.

Only in the last 100 years or so have we reached a point technologically in the US where high-calorie foods are unlimited and a person can go indefinitely without any real exercise. We created the world in the shape of our instinctual desires and now it is killing us.

But our brains did not change quickly like the world around us. Your mind still works like that of a sustenance farmer preparing for a long winter. When millennia of human survival instincts tell you to skip the work-out and eat seconds you cannot help but pay attention. Happy Hospitalist threatening you with cutting you off his insurance plan isn't going to change your behavior much. You don't even really worry about getting heart disease in a few decades either, your brain is much more preoccupied with that famine it keeps expecting to show up.

Doctor D has never found that name-calling or threatening people with premature death does much to motivate them to live healthy. When doctors order people to eat better and slim down patients often go to crazy quick-fix diets that usually do more harm in the long run. It is just difficult for the human mind to accept a healthy lifestyle that runs contrary to our instincts.

Doctor D is not saying lifestyle change is impossible, but that it is difficult. Change requires understanding and respecting the power of instinctual drives. Most people who eat too much and avoid exercise don't even know why they do what they do. Doctors commanding patients to "just live healthy" is about as useful as telling an addict to just stop getting high or a depressed person to just cheer up.

Instincts have a strong influence on us, but they are not irresistible. It takes significant motivation, insight, and encouragement to resist the power of survival instincts. Doctors who understand this will do more for their patients' health than doctors who simply order patients to be healthy.

Have you made a difficult change to a healthy lifestyle? Did a doctor help you? How did you find the motivation? Doctor D would love to hear your experiences in the comments.

Why See A Doctor If You Aren't Sick?

A reader question:

One thing I would like to see answered on your blog is, what do you do on a first visit? Especially if you're not sick?

When someone shows up in Doctor D's exam room with an advanced case of some truly nasty disease D will often ask them, “But why haven't you seen a doctor since the Clinton administration?” They always answer, “Because I haven't been sick, doc.”

Waiting till you get sick to see a doctor is like waiting till you're in the water to get a life jacket.

It is a common misconception that doctors save a lot of sick people. Only rarely do we “save” you after you are sick. Usually we hold off a disease which still gets you in the end, or your body heals itself (and we take the credit). The real lifesaving is in preventing diseases or catching them before you feel the first symptom:

First, we help you prevent or postpone serious illness:

• Your doctor can review your genetic and lifestyle risks. What diseases are you more likely to get in the future? What can we do to prevent them?
• We can help with healthy diet, exercise, weight management, and avoiding things that will kill you (like cigarettes). Of course, everyone knows this stuff from highschool health class, but how many of us are really doing it? Even Doctor D needs his doctor to regularly remind him to eat right and exercise. It just isn't as easy to do it as Happy Hospitalist says.
• Get your shots. Doctors have probably saved more lives with vaccines than any other treatment ever invented. Seriously, at least talk to a doctor about it, even if an Oprah guest told you not to.

Second, preventive visits can find serious problems before they cause trouble. Most people can't feel high sugar, high blood pressure, or high cholesterol until it is too late, but those things will kill ten times as many Americans as H1N1 this year. And some of the most common cancers can be caught with early screening—early enough to make a difference between surviving or not.

Remember these preventative things should still be done even if you already have a disease. People with chronic or frequent illnesses often understandably focus on what is giving them trouble. Don't be that guy that focuses so much on what is hurting, when the real thing that might kill you is hiding in plain sight!

So even if you aren't sick or you are seeing a specialist for something else, you really should see a Primary Care Doctor at least every year or two. We cover a lot in these visits.

Doctor D promises he is not trying to get you into get preventive care just to line his pockets. If he wanted to get rich Doctor D would have chosen just about any specialty other than primary care. He also wouldn't be spending all his off-time on this blog.

What is the longest you ever went without Primary Care? Do you think it affected your health? Doctor D would love to hear your experiences.

Writes and Responsibilities (Friday Links)

So last week we started a new feature on Ask An MD: Doctor D's Friday Links!

• This week Doctor D will point you to a blogger many of you already know: White Coat. Doctor D was late to the party, just discovering this blog recently. White Coat is an ER doctor and an incredibly eloquent writer. He tells the stories of ER patients so poignantly that even crusty Doctor D is moved. For an example of one of his better posts read A Broken Heart. If Doctor D could clone the perfect medblogger he would combine White Coat's literary skill with Nurse K's comic genius. (If such a super blogger existed, however, Doctor D might just have to quit blogging out of shame at his clumsy prose.)

• This week was also Invisible Illness Week. Lots of bloggers with illnesses posted some excellent posts about living with illness. Good reading for all of us in healthcare! One that particular stood out in Doctor D's mind was a post by Kerri at Six Until Me. Type I Diabetes is a particularly difficult invisible disease. Doctor D can think of no other condition in which patients are required to work harder to manage their own disease. Kerri video blogs herself during an hypoglycemic episode, a courageous move for those who know how miserable hypoglycemia can be.

• Over at the typically subdued Kevin MD there was very controversial post: Patient's Bill of Responsibilities. It was posted by an MD who sounds like she has been hurt and disappointed by a lot of patients. She asks the world of her patients. Doctor D could never demand his patients be like that. But an interesting question comes to mind: What should doctors reasonably expect from their patients? A lot of intelligent patients and docs read this blog. Doctor D would love to hear your thoughts in the comments section.

• Lastly, Doctor D wants to thank Dr. Grumpy again for his brilliant and witty consult this week!

Doctor D be back to answer more questions soon.

Misdiagnosis and Regret

A reader who was recently found to have a rare, serious condition sent Doctor D a question about visiting one of several doctors who missed the diagnosis:

It could be terribly awkward to have an appointment with one of them—me with all my new scars and a scary prognosis and them perhaps with their former, incorrect diagnoses of various benign conditions hanging in the air. I'd welcome a chance to let them know that I understand that it's impossible to get these things right instantly every time, and I have no resentment. But would it be better to just see a brand new doctor? Or would my former doctors want to see me? Or would they rather I melt into the ether and just let them forget it all?

Human disease is extremely complex, and doctors sometimes miss the correct answer. Every doctor has had that “Oh crap! It was X? I thought it was Y!” panic after finding out about a misdiagnosis. The unspoken truth is that doctors guess—a lot. Usually we make informed, educated guesses, but even good guesses can be incorrect. Unusual conditions can be hard to discover, and we often make several wrong diagnoses on the way to the right one.

Doctor D has made some diagnoses he wished he could "do over" after using his Retrospectascope (D's only medical instrument that produces the right answer every time.)

So on behalf of all doctors, Doctor D wishes he could fall down and kiss the feet of the reader who sent this question! How gracious you are! We feel all patients demand perfection, and we work with imperfect tools and imperfect knowledge. Even the best care won't always produce the right answer—especially at the beginning. Your understanding and kind feelings towards your doctors makes even cranky Doctor D get misty-eyed!

So to answer your question: Go see your doctor!

I wouldn't advise you start out, “Hey remember me? You told me I had Y, when it was really a bad case of X?” Open with this and your doctor is likely turn sweaty and pale with terror. Doctors don't just fear lawsuits. We really hate letting you down. If your doc thinks you are angry about your care, he or she might suddenly become distant or angry too. (We doctors aren't very creative when it comes to covering our fear.)

But if you say, “I really appreciate what you did for me. I know that X is really hard to diagnose, and it often looks like Y,” your doctor might become so overwhelmed by your understanding that they may just break down and hug you. You could instantly become your doctor's favorite patient and be treated like family for years to come!

Have you ever been misdiagnosed? How did it affect your relationship with your doctor? Doctor D would love to hear your story in the comments!

Crazy Brain Doctors: Why Are Neurologists So Strange?

Doctor D recently got a fascinating question about Neurologists. Rather than make something up, Doctor D decided to use his other strategy for covering his ignorance: consult a specialist. Luckily he was able to beg the finest Neurologist in the blogsphere to answer your question. If you haven't yet discovered Dr. Grumpy and his wacky patients you are missing out!

Question: After many years of seeing neurologists I've come to the conclusion that all neurologists are either A) a tad crazy or B) an asshole. I only continue my Doctor-Patient relationships with the ones that are crazy as I prefer crazy folks to assholes. Why do you think they seem to fall in one of these two categories? I haven't noticed this polarizing break down in any other specialists I've seen.

"I freely admit that it seems more neurologists are 'different', though the degree can vary from slightly eclectic to downright scary. I read years ago that, as a percentage, more neurologists are left-handed than any other branch of medicine. I assume this means something, but I have no idea what. I'd like to think I'm at least on the more benign side of the whole thing, but I have no idea what they say about me outside of here.

I agree that the field seems oddly polarized at times, though not sure I've noticed the extremes you have. In my position, though I don't personally don't see how another doc treats his patients in the office. I wish I had an answer as to why it is so, but I don't.

I could also say the same about patients. The majority of them (who I'm not writing about) are decent people. I wouldn't be doing this if I didn't like them. But there are certainly those who I've had acrimonious relationships with from the first moment. I've had some get up and walk out of my office. The bottom line is that how we-see-you and you-see-us is highly subjective, based on the intangible nature of human chemistry. The same docs that you think are assholes likely have a share of loyal patients, and those you like certainly have other patients who think they're incompetent and/or scum.

And I agree with you on who you choose to see. If the docs are equally competent, then I'd rather see a benign eccentric than an ass."

-Dr. Grumpy

Send Doctor D your question!

Should I Have My PSA Checked? (Friday Links)

Okay so no one sent in this question, but a lot of people have asked Doctor D over the years.

Doctor D is using this question to introduce a new feature of "Ask An MD" Friday Links! There are a lot of great medical blogs by patients, doctors, nurses, and med students , so each Friday Doctor D is going to share some interesting reading from the medical blogsphere with you. I'm still answering a couple reader questions each week so keep emailing them in.

Should I have my PSA checked?

Tricky question! Unfortunately the answer isn't as simple as "Yes" or "No" and there are a lot complicated issues in healthcare tied into the controversy surrounding this simple blood test.

Doctor D wouldn't be brave enough to tackle that question, but Doctor Rob (at Musings Of A Distractable Mind) wrote a fascinating piece on the business of prostate care. The debate in the comments is where it really gets interesting.

Read it Here: An Intuitive Reasoning For Rising Health Care Costs

On a side note: It is a sad day for the medical blogsphere. Nurse K has temporarily closed her blog. She says this is a temporary hiatus. Hopefully she will be back soon, but you can still get a taste of her thoughts on Twitter. Nurse K is the funniest, toughest, most wise-ass ER Nurse on the planet and her blog was always a joy to read. I'm sure the Happy Hospitalist will cry himself to sleep every night until Nurse K is back.

Did you read (or write) a great medical blogging this week? Post the links in the comments!

Doctors and Abuse

An email follow-up question from the Review Of Systems post:

I don't understand why they ask, "Have you ever experienced physical/verbal abuse?" This doesn't have anything to do with establishing a diagnoses. What's the point?

Doctor D doesn't enjoy asking prying personal questions. It makes everyone uncomfortable, but this is a question that doctors should be asking more often.

Medical professionals do a terrible job identifying people in danger from family violence. Statistics show that people who seek more medical attention have higher rates of abuse than the general population. A study found 1 in 3 females who visit emergency rooms have been recently abused. Doctors usually just don't find out. We may do a great job protecting someone from Hypertension, while the biggest threat to their health is the person with whom they live. Doctor D knows he has missed opportunities to help patients in dangerous situations. Sometimes simply discussing abuse can be a step towards connecting to resources that save lives.

Because doctors do such a crappy job at this, we are frequently reminded to ask everyone about domestic violence. Doctor D must admit, he is still pitiful at broaching these questions. It makes people uncomfortable when doctors ask, and doctoring is already an uncomfortable job. You expect us to be friendly and trustworthy while asking about how much you really drink and sticking our fingers in your orifices. It makes for awkward interactions!

Asking such questions in a trusting doctor-patient relationship can be very useful, and usually a patient will understand the doctor has good motives. The reader who emailed Doctor D was asked on a paper questionnaire. Sounds like the doctor was trying to follow the recommendation to ask while avoiding the awkward conversation. Unfortunately it shifted all the awkwardness to the patient and also confused her. I also imagine the paper-based format won't uncover many cases of abuse, because patients may hesitate to disclose this on a form.

I think this reader's doctor had good motives, just an ineffective approach. Doctor D personally apologizes for doctors. We all do a lousy job at discussing these sensitive topics. It is harder than you think. Please be patient with our fumbling attempts at difficult questions.

A question for you:
What is the most uncomfortable question a doctor every asked you? How did you respond? You can comment here or e-mail Doctor D.

Health Info Online (That Isn't BS)

A question from a reader:

I’d like to know where I can go for trustworthy information on a diagnosis when I haven’t got an appointment in the near future.

Fortunately we live in the Information Age and you are sitting in front of a computer right now with an ocean of information at your fingertips. The “trustworthy” part is what poses a problem.

There is some crazy “medical” information on the web. Some suggestions are obvious quackery, such as saying that goji juice cures every illness known to man. Some erroneous advice may not be as obvious. There is a lot of money in healthcare, and you don't need any scientific evidence to get access to the big dollars—just ask a chiropractor! There are also a lot of well-meaning people who want to share advice that may or may not really work, like your grandma who was sure that a teaspoon of castor oil would cure anything.

You can start with asking your doctor. A specialist may have a specific site they recommend for your condition. For general information Doctor D typically sends his patients in the direction of familydoctor.org and UpToDate for Patients.

Tips for sorting through the medical information on the Internet:

• Print out what you find and take it to your doctor who can often tell you if it is reputable. Doctor D has researched some very interesting topics because his patients brought them in.

• If it sounds too good to be true it probably is. The more conditions a treatment supposedly fixes the more likely it actually works for nothing at all. This is particularly true of nutritional supplements and “natural” medicines, whose claims are almost totally unregulated.

• Remember that every individual is different. Patient forums can be an excellent way to connect with others in the same situation as you, but the experience of someone else with your condition cannot always be applied directly to you.

• Remember the placebo effect is powerful. Unproven treatments often appear to “work” due to the placebo effect combined with the body's natural ability to heal itself. If a treatment has never been tested against a placebo it is hard to say if it really works or not.

• Consider the source of your information. Who is it and what is their motivation for giving you this info? Big pharmaceutical companies often create “educational sites” whose purpose is to interest you in their drug. Any very nicely-designed site that reminds you to "Ask your doctor about ___" probably stands to make money off what your doctor might prescribe.
  

• Keep in mind that big news/entertainment names are selling drama which often isn't the same as trustworthy medical information. Don't trust everything you hear from Oprah!

• Never take advice from anonymous sources! I mean, what sort of doctor would blog without using his real name? (Just joking. But this is one reason Doctor D doesn't give treatment or diagnosis advice on this blog!)