“I woke with multiple tiny red dots in my armpit... The dermatology office cant see me for weeks..."

Who to see:

• I would do my best to see a dermatologist, perhaps a different one.
• However, if it doesn’t go away in a few days, then I would see your doctor/general practitioner.
• Obviously, if things get worse quickly then go to the ER right away.

For your apt, be prepared for questions they may ask:

• When did it start?
• Is it getting better or worse?
• Does anything make it better or worse?
• Have you used any new products on your skin? (Lotion, soap, etc?).
• Any new clothing?
• Is it related to shaving there?
• Is it worse when it is hot and humid outside?
• Have you spent any time in a hot tub or heated swimming pool?
• Do you have any other symptoms (fever, chills, lumps/bumps under the skin in your armpits)?
• Were there ever little pustules associated with the red dots (white heads)?
• Has it crusted over?
• Has this ever happened before?
• Is it one side or both?

Also:

• Make a list of all your medications, vitamins, supplements.
• Make a list of any other symptoms even if they seem unrelated.

Diagnosis:

• A doctor would have to see you to provide an accurate diagnosis.  However, from what you’re telling me, I suspect it is folliculitis.

Folliculitis:

• Folliculitis is a general term that means there is the inflammation of hair follicles.
• Anyone can get folliculitis
• Folliculitis starts when hair follicles are damaged
• (Damage can happen from friction with clothing, shaving, blockage of the follicle, excessive perspiration, irritating lotions/creams, etc.)
• After the follicle is damaged it can continue to be irritated by whatever got it upset to begin with. Or it can get infected. Infection is often from bacteria such as staph, but many different things can infect the skin such as other types of bacteria and less commonly fungal infections.

Rx:

• An important goal is to get to the root of the problem and try to figure out what started the problem to begin with, so you can stop it and prevent it from happening again (lotions, shaving etc).
• Since the irritation/follicle damage can lead to infection, this is the most important thing to think about. Some of the most common symptoms of infection at the site of concern are warmth, pain, hardness, and redness. Some common general symptoms of infection are fever, chills, night sweats, feeling tired, irritability, and weakness.
• To avoid infection, keep the area dry and clean.
• Do not over clean the area, b/c over scrubbing and drying soap can further damage follicles leading to more problems. Use a gentle mild soap no more than once a day, (unless instructed otherwise by your doctor).
• Your doctor may put you on an antibiotic. However, different antibiotics are used for different types of infections.  Therefore, they will have to see you for the right medication.
• Sometimes topical lotions are also prescribed to help with the inflammation/redness. These can be over the counter or prescribed. Some have steroids in them to help lower the amount of irritation.  I would caution going out and getting over the counter lotions on your own. The right choice depends on the right diagnosis of what’s going on. The wrong lotion can make things worse.

Hope this helps,

Question: "I recently got the sap of this succulent plant on me and it burns like white hot fire. What do I do?"

Answer: 

• If this is Euphorbia tirucalli then you are in for some pain. However, the following general suggestions would probably work for many different types of toxic plant sap. 
• Of note, this topic really wasn’t covered in medical school and it is not in any of my major textbooks.  Therefore, I am using some common sense here as well as insight from my own personal experience.  
• The best first step is to get the sap off of you as best as you can. The faster the better b/c Euphorbia tirucalli sap dries fast and is harder to remove.
• Removing Euphorbia tirucalli sap is difficult b/c it acts a bit like glue and dries clear.
• Even when you think it is gone, trace invisible residue can cause major symptoms. Therefore wash for at least 15 min... more like 30 min. 
• Soap, water and time.
• Don't wash over dirty dishes in the sink-you don't want to ingest even a tiny amount of residue from this powerful toxin.
• Discard anything that you think might have sap on it.  It can cause problems later even if you don't see it.  
• Throw away whatever you used to clean with when you are done.
• IMPORTANT, if you are in the shower, be careful how the water drains off the area you are washing. You could easily wash the sap residue from one place to another place downstream on your body. You definitely don’t want to damage your extra sensitive body parts.   
• If you get the sap on your skin, or worst, in your eye or ingest it, see your doctor/go to the hospital asap... But don’t drive yourself there because the pain is very distracting-making it unsafe to drive. If the sap is in your eyes it can cause blindness (obviously not good while trying to drive either).
• Benadryl may help with the redness but the main thing is to get the sap off you.

My Story:

• Unfortunately, that was me who asked myself the above question after a rude introduction to this toxic “ornamental” plant.
• Shortly after I just bought a house I noticed a huge succulent bush in my back yard with pencil like stems. It seemed interesting and harmless enough so I cut a branch to grow the cutting.
• Not a good idea.
• When I cut the branch, this white sticky latex sap spurted out. It acted like a bottle of Elmer’s glue under pressure. Most of it missed me but a few drops got on my arm and hand.
• Because I heard that some plant saps can be harmful, I immediately went inside and washed my arm for about 5 min.
• At first nothing happened to me.
• Then at about 2am I awoke to a terrible pain on my arm. It felt like white-hot-fire.
• I immediately washed my arm again and went to the internet.

http://www.plantzafrica.com/

This is what I discovered in my search:

• Many people sell this plant b/c it is easy to grow and looks cool.  However, no every seller will tell you that this plant is dangerous.
• It goes by name different names. (Firestick Plants, Indian Tree Spurge, Naked Lady, Pencil Tree, Rubber-Hedge, Sticks on Fire or Milk Bush)
• But the scientific name is:  Euphorbia tirucalli (you-FOR-bee-uh teer-ooh-KAL-eye)

 

http://www.wikimedia.org/

Where it lives:

• It is originally from Eastern and South Africa but has adapted all over the world.
• In some areas, such as Brazil, it is grown it as a fence. It is very effective as a fence b/c no one wants to touch the thing.
• The plant grows very well in dry environments.
• Some websites discuss how the plant can be trained and shaped. But that requires putting yourself in major danger. My advice is to stay clear and don’t touch it.

Problem:

• The sap is the big problem and is extremely toxic.
• It causes burns, and can cause blindness if it gets in the eyes.
• I have also read some articles implicating the plant as a cause of an aggressive type of lymphoma. This cancer may in part be a result of ingesting the sap as part of folk “herbal remedies.”
• More acutely, many have died after a minimal amount of sap ingestion.

Where is it now?:

• I never really noticed the plant before, but now I see it everywhere.
• I have seen smaller potted Euphorbia tirucalli plants for sale at most major home improvement/garden stores. However, I have not seen a warning label on any of the plants. In fact, in one nationwide-chain home improvement a plant pamphlet in the garden center talked about the benefits and care for the plants they sell and not a word about this dangerous plant that was profiled on its own page. Truly amazing and irresponsible.
• So beware, stay away and keep it from kids and animals.
• If you must have it, don’t plant this thing in your yard. It grows fast, is dangerous and hard to get rid of.  Now I have a big Euphorbia tirucalli from a previous home owner and no one wants to remove it.

Here's some more info I found useful/interesting online:
http://en.wikipedia.org/wiki/Euphorbia_tirucalli

http://www.nature.com/bjc/journal/v88/n10/full/6600929a.html

http://www.homegrownevolution.com/2010/04/least-favorite-plant-euphorbia.html

http://www.hort.purdue.edu/newcrop/duke_energy/euphorbia_tirucalli.html

http://plantsarethestrangestpeople.blogspot.com/2009/01/cigarette-smoking-man-euphorbia.html

Question: What are your thoughts on avoiding dairy? do people become intolerant as they grow older? i love it so much but I'm wondering if it is the key to my weight problem? ...

Answer: Yes, but perhaps not in the way you think.


Dairy has a lot of good stuff in it, but it is not good for everyone.

• In fact, we as mammals were only meant to eat it for a very short amount of time in our early youth.
• Yes; people can become intolerant to dairy. But this usually involves indigestion associated with lactose intolerance. This can be a big deal, but you would probably know it if you had it.
• People can also develop allergy to milk products, just like anything else. If you think you have an allergy to any food see your doctor. However, I don’t think this is the issue that you are asking about either.

Yes! Dairy will put on the pounds.

• Think about it. How do you make a little calf into a big cow in a short amount of time? 
• The solution is milk; a highly nutritious and highly caloric drink.  

In general, your weight is all about in's and outs:

• If you are taking in more calories than you are using, your body will store it in the form of fat.
• Some types of food have more calories per bite than others.
• If you are eating a lot of dairy and if you are no longer growing in height... you will grow in width.

Milk and milk products are basically glorified fat. Therefore, your body does not need to do much to it to store it. With dairy, it can be a very efficient transfer from eating to storage.  There is little energy lost in the process of metabolism.

You need to limit dairy products as part of any successful diet and exercise plan to lose weight.

Question “I heard that if I stop smoking that I will gain weight, is this true?”

Answer:  I don't know where to begin.  Don't smoke.  Please read the following. 

Smoking is one of the worst things you can do to yourself. If you want to do one thing to improve your health, the best thing you can do is stop smoking.

In regards to your specific question:

• Although not universal, many have people have reported weight gain with smoking cessation. Reasons for this relate to various potential factors.
• Smoking ruins a lot of your taste buds and ability to smell.  Therefore the joy of eating is diminished.  Less food = less weight.
• If you have a cigarette in your mouth you don’t have food in your mouth, so less food.
• When trying to quit, people replace smoking with snaking.
• Nicotine is an appetite suppressant and stimulant.
• If you get cancer or emphysema from smoking you will definitely lose weight, but probably not the kind of weight loss you are looking for.
• The health benefits of being tobacco free far exceed the problems associated with even moderate weight gain. Smoking is not a viable option for weight control. 
• Overall weight control is a simple equation of, "in's and out's."  If you can control what goes in (food) and counteract that with what goes out (exercise), you are golden.

Please ask yourself why you want to resort to smoking to lose weight/keep from gaining weight:

• In my experience it can generally be broken into two major reasons why people what to lose weight.
• Some want to lose weight for health reasons.
• Others want to lose weight for looks.
• Regardless of your motivation to lose weight, smoking is not a viable strategy.
• Let me elucidate the reasons.

Lose weight for appearance:

• If you are concerned about appearance, smoking is not the way to go. Smoking will decrease your beauty on every level.

Skin: 

• Smoking will accelerate skin ageing. The toxic chemicals in the smoke go throughout your body and damage just about everything it comes in contact with, (this includes your skin).
• The blood vessels that feed your skin (and other organs) are also damaged. No wonder why smokers have prematurely old looking skin.
• Speaking of skin: Smoking is linked to a 2 X increased risk of developing psoriasis.

bupropion-150mg.com

Teeth:

• The yellow/brown stain on your teeth is only part of it.
• Smoking also damages your salivary glands. A major cause of tooth decay is low saliva (xerostomia). One of the many bad things smoking does is that it causes tooth decay by causing xerostomia.
• Smoking also significantly increases risk for many other dental problems: including oral cancer and gum disease.
• It will take longer for your dentist to clean your teeth. Who wants to spend any more time at the dentists than they need to?
• Smokers do not heal as well after surgeries (tooth extractions, and periodontal procedures included).

www.nyc.gov

Breath:

• You may think that others can’t tell you smoke because you cover it up with mints/deodorant/perfume, etc.  Or you think no one will notice because you only smoke at home at night on the back porch. But guess what? You can’t smell as well as others because you smoke. We can smell that nasty.  Even if you are lucky and it is very subtle, we can still tell something is off.

Fingers:

• Got that yellow on your fingernails yet? I guess you can put nail polish on. It is hard to cover up the skin stains though.
• Skin just looks old everywhere.
• In addition, some people will have a change in the shape of their fingers because of smoking. The finger tips get a bulbous look from smoking (digital clubbing).

www.wellsphere.com

Bones:

• Smokers have weaker bones than nonsmokers. Who wants to be shorter and bent looking?

Hair:

• Smoker's are three to six times more likely to go prematurely gray than nonsmokers.
• A smoker's hair is more brittle, older looking.

Cancer:

• I have seen a lot of head and neck cancer and surgery for tobacco related tumors. I have seen a lot of bad things in my career and the nasty head and neck cancer always gets me. Even a small cancer (if you’re hoping for the best) will result in a major scar. You ever worry about a pimple? That is nothing. Head and neck surgery is majorly disfiguring (it is the, 'you don't ever want to ever go out of the house kind-of bad').

tobaccofacts.info

 

http://www.simcoemuskokahealth.org/

http://www.dh.gov.uk/

General:

• Smokers are four times as likely to report feeling unrested after a night's sleep. In regards to appearance, most people look/feel like crap after a bad night’s sleep.

So then you ask yourself, “Why do I want to lose weight-look good.”

• For most it is because they want to have a relationship. Or to be in a position to have/stay in a relationship.
• A 2005 survey of Canadians found that more than half of people surveyed would not date a smoker.
• No one wants to kiss a prematurely ageing, cancer prone, smelly ashtray.
• But if you do get into a relationship beware. Smoking affects circulation; with less blood flow to your genitals, arousal for both men and women can be more difficult. And yes impotence. Bummer.
• Cigarette smoking is a risk factor for developing diabetes. Diabetes causes impotence. Double bummer.

You want to lose weight for health:

• It is almost a joke to explain why smoking is not a healthy way to attempt to lose weight.
• You know tobacco causes lung cancer, emphysema and heart disease.  But there is so much more…

Some more tobacco related health badness you might not know:

• Not just lung and mouth cancer. Also significant increased risk of cancer of the throat, Esophagus, Pancreas, Kidney, Bladder, Cervix, etc.
• Smoking also significantly increases the risk for stroke, hypertension, and spontaneous head bleed.
• Tobacco smoke contains four thousand-plus chemicals… most of them bad (cyanide, lead, ammonia, carbon monoxide, etc).
• What did you say? Smokers have a nearly 70% greater likelihood of developing hearing loss than nonsmokers.
• A study in the Netherlands showed that smokers took an average of 11 more sick days a year than nonsmokers.
• Peninsula Medical School surveyed 10,000 and found that smokers reported below average pleasure and satisfaction with their lives than the nonsmokers.
• Smoking increases the risk of depression.
• Smoking = earlier menopause by several years.
• People are allergic to cigarette smoke. Smoking worsens allergies.
• The Canadian Journal of Public Health reported that smokers got into car accidents 1.5x more often than nonsmokers.
• Cigarette smoke doubles your risk of macular degeneration, which is a leading cause of blindness.
• The journal Neurology studied 7,000 people and found that smoking also increases the risk of dementia. What is going on?
• Women who smoke take longer to become pregnant and are more likely to miscarry.
• And by the way: if you're on the Pill and smoke beware. Mixing the two is an extra major risk for acute blood clots, pulmonary embolism, heart attacks, and strokes.
• If you were to take a medical school test and the question was: “what is the one best thing you can do to improve your health” the answer will always be Quit smoking. It doesn’t matter what the other options are.
• Smoking is estimated to be the single largest cause of preventable deaths in the United States.

The health benefits of being tobacco-free far exceed the problems associated with even moderate weight gain. Lung damage and heart disease are irreversible — weight gain is not.

American Cancer Society

Quit smoking: Every cell in your body will benefit.

Question "…He loses his balance, I was thinking because of his failing eyesight or there is more to it?"

Answer: There are many possible causes of balance problems, but yes the eyes play a big part.

 

• As was mentioned in the last blog entry (for someone else with vertigo). The system that gives you balance is a complicated one. Many different sensory factors are taken into account by your brain and interpreted to let you know where you are in the world. The last blog entry concentrated on the middle ear part of balance. That is a big part. However, the two other big parts are your vision and nerves in your limbs, especially your feet and legs (proprioception).  
• As you know, uncontrolled diabetes ruins your eyes. Unfortunately, diabetes also ruins the peripheral (nerves in your feet). So with bad diabetes, you are only working with 2/3 or the normal balance system. Working with 1/3 is hard enough. For example, as a normal person, try keeping your balance on one leg with your eyes closed. It’s hard. That is only removing one part of your balance system (your eyes). In this scenario your leg nerves and your semicircular canals are trying to figure it out on their own. Now imagine you take away another factor… No eyes and no feet nerves... very hard to keep balance.  
• Of course there are other potential causes for balance problems. However, for this person I would think that diabetes is a big factor.
• Regardless, see your doctor to make sure that there is nothing else going on.

 

Question: “A friend of mine has been housebound for 2 months with Vertigo… Do you know anything about a virus that can cause Vertigo?”

Answer: Yes vertigo can be very debilitating and can be caused by a virus. However, there are other potential causes of vertigo, each with different implications.

I recommend going to an ENT specialist or neurologist to help determine the specific cause and therefore the appropriate treatment.  

Definition:

• Vertigo is a term that is sometimes inappropriately used as a synonym for dizziness. In reality vertigo is a relatively specific symptom that refers to the sensation of spinning and/or rotation (vertigo is from the Latin verto which means to turn).
• Dizziness on the other hand is an imprecise term that is often used by patients an attempt to describe a variety of symptoms including light-headedness, faintness, confusion, tingling, unsteadiness, trouble walking, giddiness as well as a spinning sensation. Each of these potential symptoms have dizzying list of far reaching implications. Because of the lack of specificity and potential associated diagnostic confusion, doctors generally don’t use the term dizziness. As you can imagine, interchanging the term vertigo and dizziness can lead to erroneous conclusions and treatments.

Overview:

• There is a complicated series of parts in your head that work together to give you balance and self orientation. This set of parts is known as the vestibular system. When a part of this system is damaged or disturbed it can give you the symptom of vertigo.

Vestibular system:

• There are many parts to this complicated system, but I think it is easiest to think of it as two major parts: Let’s call it the 'inside part' and the 'outside part.'
• The more 'outside part' is a labyrinth of tiny tubes in your middle ear that include the semicircular canals.
• The 'inside part' includes the nerves that carry the sensory information from the labyrinth to the brain, and the brain itself.
• Each part of this system can be damaged in different ways.

What it looks like:

• I did some medical art of the labyrinth recently for a friend’s text book. I guess since I created the image, it is safe for me to put it up here in order to help with the description (see picture below).
• The whole thing is really tiny and imbedded in the skull bone.
• Most people have two of them; one set in each middle ear.
• The semicircular canals are the three different long loop looking things in the picture.
• The curly thing is the cochlea which is the hearing part of the middle ear.
• The whole labyrinth is hollow and filled with fluid. The fluid is called endolymph.
• The inside walls are covered with millions of tiny sensory hairs.

Artwork by Thomas Osborne, MD.

In the next edition of "Head and Neck Imaging" by Peter M. Som and Hugh D. Curtin

How it works:

• When you move your head the fluid moves around inside the labyrinth.  This fluid motion triggers the tiny sensory hairs inside. Moving your head right to left will cause fluid to move in one area more than another area. Front to back movement will cause other areas to have more fluid movement. Etc.  
• Now looking back at the image (above) you can see that the semicircular canals are set up at right angles to each other. This orientation is the most efficient design to decipher 3D spatial angulations.
• Fluid motion triggers the sensory hairs in the different parts of the labyrinth. That information is sent to the brain via a specific nerve (the eighth cranial nerve aka the vestibulocochlear cranial nerve).
• The eighth cranial nerve then plugs into the brainstem where a lot of other vital information is processed. Additional nerves connect back and forth from the brainstem for additional processing and verification with other sensory input.

Problems:

• An injury to any part of this system can cause vertigo. There is a long list of potential causes each with subtle and profound differences.  I will address some of the more common causes.

Infection:

• Many different types of infections can target the labyrinth; a general term for infection or inflammation of the labyrinth is called labyrinthitis. However, most causes are thought to be viral.
• An infection can cause abnormal activation of the nerve hairs in the labyrinth. This haphazard activation will be interpreted by the brain as motion when there is no motion.
• This can further confuse the brain when sensory input from the eyes do not verify that spinning is actually occurring. To this end, vertigo can be worse when you close your eyes and there is less correct sensory input from the eyes to combat the incorrect input coming from the labyrinth.

Benign paroxysmal positional vertigo (BPPV):

• This is a common problem which is typically made worse by a particular head position.
• There are tiny calcium crystals known as otoconia (stones) in a part of the labyrinth known as the utricle. In patients with BPPV, the crystals migrate into one of the semicircular canals and cause problems when they abnormally trigger the sensory hairs in their new abnormal location.
• Specific movements of the head can diagnose the problem (Dix-Hallpike maneuver).
• Other specific head maneuvers can guide the stones away from locations in the labyrinth that cause problems (Epley maneuver, and the liberatory or Semont maneuver).
• These maneuvers can be taught to the patient or patient’s spouse/partner/friend so it can be done at home if/when symptoms come back.

Drugs:

• Some toxins such as drugs or alcohol can target the labyrinth. One common class of drug are aminoglycoside antibiotics.

Injury:

• A fracture that goes through the temporal bone and labyrinth can disturb the delicate balance and cause vertigo. However, if you did something to fracture that hard bone, the diagnosis should not be a dilemma.

Ménière disease:

• Although there is some controversy as the exact cause of Ménière disease, most believe it is caused abnormal/impaired drainage of endolymph.
• Symptoms are somewhat variable but classic symptoms include vertigo, symptoms of ringing in the ear, hearing loss and a sensation of fullness in the ear.
• Attacks of vertigo can be severe, incapacitating, and unpredictable.  However, with Ménière disease symptoms of vertigo rarely last up to 24 hours.
• Ménière disease is usually a diagnosis of exclusion (only diagnosed when all other causes have been ruled out).

Tullio phenomenon:

• Tullio phenomenon is sound induced vertigo.
• This is caused by a bony defect that results in abnormal flow of endolymph.
• Loud noises causes pressure changes in the labyrinth and when there is a bony defect, fluid moves more than it should. Abnormal endolymph motion = vertigo.

Schwannoma:

• A schwannoma is a specific type of slow growing tumor that can press on the eighth cranial nerve and therefore cause nerve malfunction. This process usually causes a slower onset of more mild vertigo, often with additional symptoms of hearing problems.

Brian injury:

• Injury to the brainstem or cerebellum (where the sensory information is processed) can also cause vertigo. A stroke will result in acute systems which needs to be treated as an emergency. Other diseases such as multiple sclerosis, Lyme disease and tumors can cause acute or slower onset of symptoms.

Vertebrobasilar insufficiency:

• Decreased blood flow to the brainstem and/or cerebellum without a stroke can also cause vertigo. This can be a warning sign of a potential future stroke.

Psychogenic vertigo:

• Psychogenic vertigo is vertigo in public places. This is often associated with Agoraphobia (fear of open spaces, crowds, leaving home).

Treatment:

• Treatment depends on the specific type of problem causing the vertigo. Example: BPPV can be treated with specific head maneuvers, Lyme disease is treated with antibiotics, schwannoma can be treated surgically, etc.
• The right diagnosis will lead to the right treatment. A through neurologic exam from a qualified doctor is essential. I recommend going to an ENT specialist or neurologist. Additional testing may also be needed to confirm suspicions or rule out other possibilities.
• Obviously the ideal goal is to fix the root cause; however, sometimes this is not possible. 
• Medications that treat the symptoms of vertigo can help patients cope during and after the medical evaluation. The following medications may help.
• -Antihistamines: Meclizine, dimenhydrinate, promethazine
• -Anticholinergics: Scopolamine
• -Tranquilizer: Diazepam

Question: “I've come to understand that not all doctors are created equal. What are some things I can do to pick a good general physician for myself?”

Answer: This is a very important question, but not an easy one to answer for many reasons.

   

There is some good news and some bad news for you in your quest:

• The good news is that all medical doctors in the US must meet rigid qualifying criteria to be able to practice.
• The bad news is, as you said, not all doctors are created equal. As in any profession, there are some people who are better at their job than others.
• So how do you separate the wheat from the chaff? Unfortunately, I do not have a magic formula; however, I do have some thoughts that may help.
• There are some things that you can work out before you see a physician but other things will have to wait until you actually step foot in the doctors office.

Before you step foot in the office:

Medical insurance:

• Many health insurance plans will require that you choose a primary care physician from their approved list of providers. Start with this list and save yourself some time.

Minimal requirements:

• I would recommend that your physician has at least met the basic residency requirements of an ACGME certified medical specialty and is board certified.

Ask around:

• Ask other people you know about their PCP. If a trusted friend likes their doctor, then that is definitely something to explore. Be sure to ask them why they like their doctor because their reasoning may not apply to your needs. This admittedly is not a perfect solution; what some people perceive as good is not necessarily going to work for you, but this is a great start.
• If you like your current doctor, but can’t see them anymore for geographic or insurance reasons, then ask your doctor if they can recommend a referral.

Background search:

• Some people believe that the prestige of a physicians medical training will reflect the quality of the doctor. The rational being that the better the medical school/internship/residency/fellowship, the better the doctor that is produced.
• Another perspective is that high level medical training programs will select for the best candidates.
• It is hard to prove if this is a legitimate argument and I don’t think that this method has ever been tested to be a valid strategy for selecting the best physician. In addition, I have known some great physicians from little known medical programs. I have also heard stories of subpar physicians form the most prestigious medical institutions.

Seek a specifically trained physician for a specific situation:

• Some primary care physicians are more experienced in some medical situations than others and will therefore be in a position to provide better care for that specific circumstance.
• As we all know, the more someone (anyone) does something the better they will be at that task. Some of these are obvious; you don’t go to your kid's pediatrician to have your gallbladder removed, and you shouldn’t go the ER for a routine mole check. Etc.
• To this end, consider that some doctors may have additional training in a medical field specific to your needs. This additional training may not always be designated with a certificate of merit or fellowship but may just be an area of particular physician interest.
• If you are an athlete/weekend warrior, then a doctor with additional training in Sports Medicine might be a big plus.
• If you are older, then additional training in Geriatrics will help.
• If you are often sick or have an immune disease then you would be lucky to find a PCP with additional Infectious Disease training.
• Additional Women’s Health training can provide a physician with insight into problems that a general trained physician may not have experience with.

Physician age:

• Some people think that an older doctor will be a better doctor because they have more experience.
• However, others believe that a younger doctor will be better equipped because they have more experience with the latest medical advances.
• I don’t think there is a good answer here. The quality of a doctor in my opinion can’t be determined by their age.

Look around: 

• There are several online physician rating sights out there. However, I wonder who is writing the opinion on the websites or if anyone is policing the entries. I am skeptical about the usefulness of these sights.

Logistics:

• Beyond a doctor’s medical talents, you will need one that works for you schedule.  Consider:
• Office location
• Office hours
• Emergency availability
• How long does it take to get an appointment
• Average wait during appointments
• Number of patients booked per hour
• Is the doctor affiliated with a local hospital? If you prefer a specific hospital, is your doctor associated with it?

After you step foot in the medical office:

Physician personality:

• Some people will think their doctor is the best because they are nice. While, I would expect all doctors to be personable, I would not say that this automatically equates to good medical care. None the less, you definitely want a physician that:
• Listens to you, doesn’t interrupt you, and seems to be paying attention.
• Does not make you feel rushed.
• Is willing to listen to your theories on what's going on and is open to you getting a second opinion without making you feel guilty or ashamed.
• Perhaps most importantly, I would caution against an arrogant physician. Ego can and has clouded judgment. I have seen many unfortunate cases where a self-righteous physician has not allowed themselves to see significant medical issues because someone else proposed an alternative diagnosis or treatment.
• In my opinion, a great physician is one who does everything they can to be at the top of their field and at the same time is open to alternative explanations/care.
• The paternalistic (doctor tells patient) model of medicine needs to change to a more productive partnership between patient and physician.

Medical office:

• Beware if the office/exam rooms are not clean. Cleanliness is a necessity in medicine and may be a reflection of the quality of care in general.
• The doctor’s office and nursing staff should be courteous and respectful of your privacy.

The bottom line, if something doesn’t feel right, don’t hesitate to move on or get a second opinion.