Question: “Every time I leave my doctor I have all of these questions. He talks so fast and I feel like I am being pushed out the door. What can I do?”

Answer: Unfortunately, this problem is becoming more and more common (details below).

Why it happens:

• There are many reasons why this happens and detailing all of the issues would take many volumes. However, for the most part it comes down to economics.
• Health insurance companies and the government (Medicare/Medicaid) continue to cut reimbursements and malpractice insurance premiums are always increasing.
• As a result, doctors are taking an economic hit on both ends; less money coming in and more money going out. As with any business, this squeeze means less money to keep the lights on, pay employees, etc.
• The problem has gotten so bad that some doctors have found that it is more economical not to work.
• The other alternative for a physician is to work more efficiently. That means a physician needs to see more patients in a shorter amount of time to get the same or less reimbursement.

What can you do?

• Learn more about the problem and become politically active… Ok, so no one seems to have time for that.

What can you do to help yourself?

• Knowing that your doctor only has a limited amount of time to see you, make the best of it. Be efficient yourself. Be clear about all of your concerns and problems.

How can I be more efficient?

• Be ready to answer questions about the what, where, why and when of your problem/illness. What makes it better or worse?
• Everyone does a better job at remembering things in a relaxed environment. Therefore, make a written list of your symptoms at home and bring it with you. Keep a medical diary of symptoms if it is an ongoing problem. In addition, the more time you prepare before your visit, the more accurate and complete you will be.
• More accurate patient information = more accurate medical diagnosis.
• Don’t rush in the doctor’s office, just be prepared.

“I never seem to get all my questions answered”

• Being more efficient/prepared will leave more time for you to ask questions at the end of your doctor’s visit.
• However, if you are like me, you often leave a situation such as this and think, ‘Ahh, I forgot to ask about XYZ.’ The solution is simple, bring a list of your questions with you and go through them one by one.
• Do some research beforehand so you can make the most of the time you have with your physician-medical expert. However, be warned, the internet is filled with all kinds of misinformation. Therefore, doing this type of research before your visit will give you an opportunity to have things confirmed/clarified by your physician.

I strongly believe that patient care should be a team approach between physician and patient. The older model of a passive patient with a dictatorial physician telling the patient what to do is becoming less viable, and was probably not the best approach to begin with. Do your part, be organized and educate yourself. Understanding a problem will lessen the fear/anxiety of uncertainty and will allow yourself to make more intelligent-informed decisions.

Question/Statement: "I saw the internist yesterday. She has ordered an ultrasound of the thyroid just for good measure..."

The "just for good measure" part kind of concerns me.

• In general, there should be a good reason to order any test. Just ordering a test or an exam without a significant indication can get you down the wrong path and can lead to additional tests or unnecessary complications.

Every test has it’s +/-

• No test is perfect and therefore it can’t be interpreted in a vacuum.
• Every test has different degrees of sensitivity and specificity.
• Sensitivity refers to how good a test is at finding something subtle.
• Specificity refers to how much you can rely on a positive result being real.

So what’s the problem?

• A positive test result has more meaning if the disease was suspected to begin with. However, if the same test came back positive on someone healthy, then you got to ask yourself, is it a real result or a false positive?
• A better question would be, why order a test that is not indicated, because then you will not know what to do if the result comes back positive.
• Or worse, if you ignored everything else about the healthy patient except the positive test result, you might inappropriately treat them for something they don’t have.

Thyroid ultrasound:

• Unfortunately, thyroid ultrasound is one of those tests that is rather nonspecific. A thyroid ultrasound is nonspecific because you often can't tell what lesions are begin (good) or malignant (bad) just by the ultrasound appearance. Don’t get me wrong, I am not saying that thyroid ultrasound it a bad test. This is just one type of tool that works well for a particular job. You dont use a hammer when you need a screwdriver (unless you are going to make a mess of things).  Thyroid ultrasound, needs to be used appropriately to be relevant.
• So be warned, most people have abnormal looking thyroids on ultrasound. However, a few years back a bunch of doctors got together and created a consensus guideline to help sort out who should get a biopsy.
• Depending on what things look like on ultrasound, a biopsy may be recommended. This happens quite a bit.
• I use to do ultrasound guided thyroid biopsies all the time. Ill fill you in more if it comes to that.

Question/Statement: “My internist stated that the 'gold standard' for sarcoidosis is a bronchosomething or other--a biopsy.”

Answer: Although I am sure your internist has good intentions, the statement is not true. (see below).

Gold Standard Definition:

• In medicine, a 'gold standard test' is the diagnostic test that is regarded as definitive in determining whether an individual has a particular disease process. To meet this definition, the test must have the ability to definitively determine the presence or absence of a disease. The ‘gold standard’ is the single test that other tests are compared to.
• Of note, the term ‘gold standard’ is being replaced by ‘criterion standard test’ to mean the same thing. However, for the sake of the specific question/statement above, I will continue to use the older term.

Reasons for the answer:

• The definition of ‘gold standard’ refers to a single superior test. As you know, you can only have one best of anything. Therefore, stating that there is more than one gold standard for any disease (bronchoscopy or biopsy) is not compatible with the definition. For you Highlander (1986) fans out there, “There can be only one.”
• Secondly, there is no gold standard for Sarcoidosis. The definition of ‘gold standard’ requires that the test can definitively determine the presence or absence of a disease on its own. There are no tests for sarcoidosis that meets this criteria.
• Some people will inappropriately use the term ‘gold standard” to refer to the perceived best test. However, I would defer from this distorted definition because it is misleading. Following this erroneous rational gives a test more credit than it deserves and can lead to inaccurate conclusions.

Why is there no gold standard for Sarcoidosis?

• There is no single test to date that can definitively diagnose the disease. This is not too surprising given that the etiology remains unidentified. Even pathology samples, which are considered by many to be the best diagnostic option, are fraught with error.

Then how do you diagnose Sarcoidosis?

• Because there is no one single definitive test for sarcoidosis, the diagnosis is achieved via a combination of clinical, radiographic and histological findings.  Not every patient suspected of having sarcoidosis will need undergo risky invasive procedures. When noninvasive data is convincing enough, the diagnosis can be achieved. Obviously, this is not always the case and therefore more invasive procedures may be necessary to realize the diagnosis. I would recommend non invasive options first.

Here are a few references I found on a quick search (in regard to the specific question in red above):

“There is no “gold standard” of diagnosis but only support for the diagnosis”
http://www.baylorhealth.edu/proceedings/14_1/14_1_pierce.html

“There currently exists no gold standard to confirm the diagnosis of sarcoidosis.”
http://jem.rupress.org/cgi/content/full/203/2/359

“Owing to the absence of a diagnostic gold standard, sarcoidosis is a diagnosis of exclusion”
http://jada.ada.org/cgi/content/full/137/1/54

No single test can be relied on for a correct diagnosis of sarcoidosis.
http://www.medhelp.org/lib/sarcoid.htm

Sarcoidosis remains a diagnosis based on exclusion... A “gold standard” test to identify which patients require treatment when noncritical organs are involved would be useful.
http://www.nhlbi.nih.gov/meetings/workshops/sarcoid-wkgp.htm

Although there is no single gold standard test…
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1891789/

As there is no definitive “gold standard” for the diagnosis, sarcoidosis is essentially a diagnosis of exclusion.
http://medind.nic.in/jac/t04/i1/jact04i1p12.pdf

Question “What’s the difference between a heart attack and an MI...?”

Answer:

• They are different names for the same thing.

What is a heart attack/MI?

• Everyone has heard the term, but what is it really?
• MI stands for Myocardial Infarction.
• The term is derived from both Greek and Latin.  This is can be rather descriptive if you take the words apart.
• Myocardial: Greek. μῦς (mys) muscle + καρδία (kardiā) heart.
• Infarction: Latin. infarctus = stuffed into (apparently stuffing an artery to clog it).  This artery clogging will cause tissue death.
• Put it together and you have dead heart muscle.
• An MI is caused by a blocked artery that supplies the heart with nutrients. There are many potential reasons for a blocked artery, but most of them are a result of lifestyle and genetics. A common scenario is that the artery wall becomes damaged after years of cholesterol/fat buildup. The chronic high sugar level in the blood from diabetes will also do some major damage to arteries.  Smoking wreaks havoc on the arteries throughout your body.  Risk factors for heart attack are also risk factors for stroke, though the diseases are treated differently.
• Depending on what part of the heart is affected, a heart attack can lead to chronic symptoms or sudden death.

Analogy:

Chronic:

• An artery is like a pipe. If the gunk in an old pipe is bad enough, than the flow out of the pipe will diminish.
• If this gunked up pipe is irrigating the plants in your garden, your plants will get little water. They may not die right away, but they won’t do well.
• Your heart is the same way; reduced flow = unhappy heart. A narrowed heart artery (coronary artery) can cause chronic symptoms and will predispose to acute problems.

Acute:

• The more gunk in the artery the more unstable it is. If the gunk in the pipe becomes unstable and breaks off, the material can go down stream and completely block (occlude) the pipe. As you can imagine, this could be a problem for your prized tomatoes. No water= dead plants.
• Likewise, if the gunk (plaque) in the artery to your heart becomes unstable, it can occlude (completely block) blood flow to that part of the heart. This is a heart attack/MI.
• Dead heart tissue does not come back. However, if the blockage is removed before the tissue dies, then the problem can be reversed. But you have to get to the hospital quickly so this can be done before it is too late.  Time is heart!

Think you are having a heart attack?

• If you think you are having a heart attack, call 911 and go to the ER right away. Minutes count!
• If you know that aspirin is safe for you, I also recommend that you take an aspirin on the way to the hospital.
• Taking an aspirin can be the single most important thing you can do to save your life from a heart attack. But you must also go to the hospital quickly. Don’t delay going to the hospital by shopping around for aspirin. If you are at risk for a heart attack, carry some aspirin with you.
• The fastest way to get aspirin in your system is to chew and swallow a non-enteric coated tablet. The recommendation is to chew a single 325 mg (regular strength) tablet on the way to the hospital. Let the personal at the hospital know you took aspirin so they can act accordingly.

What are heart attack symptoms?

• Symptoms are different for different people and the degree/area of the artery blockage.
• Classical symptoms of acute myocardial infarction include sudden chest pain (typically radiating to the left arm or left side of the neck), shortness of breath, nausea, vomiting, palpitations, sweating, and anxiety (often described as a sense of impending doom).
• Not everyone has the classic symptoms. Some of these symptoms are nonspecific and may indicate that something else is going on. Women may experience fewer typical symptoms than men; most commonly shortness of breath, weakness, a feeling of indigestion, and fatigue. Some heart attacks happen without acute symptoms.
• The American Heart Association covers some of this. http://www.americanheart.org/presenter.jhtml?identifier=3053

Prevention is the best cure:

• An additional preventive measure for many people who are at risk is an 81 mg aspirin tablet a day. Aspirin keeps your platelets from sticking together and therefore keeps potential blockage to a minimum. 
• However, there are also potential side effects and contraindications to the use of aspirin. Talk to your doctor about your specific situation before starting this type of daily prevention.  There are many other medications that can be taken as prevention (most prescription). Each has their own inherit risks and benefits.  Talk to your doctor about what is right for you.

What's the best thing you can do to prevent a heart attack? (This also applies to stroke prevention)

• Depends on who you are.
• However, no matter who you are, if you smoke, stop!
• In addition, reasonable diet (more veggies and less processed food) and daily exercise is very effective and has little side effects (Most common side effect: feeling better in general). Stress reduction/management techniques have also been shown to be very effective. 
• If you are at risk for heart attack or stroke, a combination of positive lifestyle habits and medications may be your best option. Talk to your doctor.
• Since the buildup of deadly artery plaque occurs throughout everyone's life, it is never too early to start positive lifestyle changes.

Question: “I recently had a chest CT and the report said I might have sarcoidosis. What is this?”

Answer:

Some background:

• Trying to understand sarcoidosis is challenging.
• Most definitions start with a statement such as, “… a chronic systemic granulomatous disease of unknown cause.” This is not too enlightening, even for physicians. This is especially unfortunate because sarcoidosis is a relatively common disease.
• Basically there are some things we know about sarcoidosis and some things we don’t know.

What is the cause of sarcoidosis?

• A single causative agent has not yet been found.  There are probably many different factors (genetic & environmental) that lead to sarcoidosis.
• Evidence suggests that sarcoidosis is caused by a heightened immune response to a yet undiscovered stimulus. Many researchers believe that this stimulus is a antigen (antigen =tiny particle of something) or a virus.
• Regardless of the causative factor, something kick starts your T-helper lymphocytes (immune cells) to get over excited. The T-cells then attract other immune cells such as mononuclear phagocytes to accumulate in specific areas and create a mass known as a noncaseating granuloma. This granuloma is the sine qua non of sarcoidosis.
• I suspect that this triggering stimulus is different in different people. Some people have an immune system that is put together in such a way that they are predisposed to an overreaction to something that is otherwise benign.  Sometimes an otherwise normal immune system will work improperly because of different factors (environment, chemicals, stress, bad luck, etc).

What does it affect?

• Being a systemic disease sarcoidosis can affect any organ. However, the lungs are the most common location. The lymph nodes, skin and eyes are also commonly affected.  Sometimes the nervous system, heart, etc is also involved.  

What are the symptoms of sarcoidosis?

• In mild cases, the disease may be asymptomatic. There is a significant amount of redundancy in most organs, and many organs will continue to work without apparent problems until the volume of disease reaches a critical mass.
• The type and degree of symptoms depends on the extent and organs affected. Usually in the sarcoidosis the organ dysfunction is caused by local tissue distortion from the mass of abnormal immune cells. If the disease resolves, then things can return to normal with little residual damage. However, if the inflammation is sufficiently high or for an extended period of time, the disease may cause permanent fibroses and loss of organ function.
• Since sarcoidosis primarily affects the lungs, the most common symptoms are related to the chest, such as dyspnea (shortness of breath), dry cough and retrosternal discomfort.
• More generalized but nonspecific symptoms include fever, malaise, anorexia, weight loss and polyarthritis. From what I hear, this may apply to you (regarding the person who asked the question). However, there many other causes of these nonspecific symptoms.
• The disease can affect any organ in subtle and profound ways. Therefore, many of the symptoms can be overlooked or lead to misdiagnosis for years before sarcoidosis is discovered as the cause.

How do you diagnose sarcoidosis?

• Because many of the symptoms of sarcoidosis are nonspecific, diagnosis is not always straightforward. The diagnosis is generally via a combination of clinical, radiographic and histological findings.
• No blood findings are specific for sarcoidosis. However, the angiotensin-converting enzyme is elevated in 2/3 of patients. 5% of positive angiotensin-converting enzyme tests are false-positives for sarcoidosis.
• Chest x-ray and Chest CT can show typical findings, but similar findings can also be seen with other diseases.
• Gallium 67 nuclear medicine lung scan can show characteristic findings but it is also not perfect.
• Biopsy and bronchial lavage is sometimes used to help diagnose.

Prognosis?

• Sarcoidosis can be acute, subacute, self limiting (goes away on its own) or be chronic.
• Most people who present with acute disease are left with no lasting problems.
• A little less than ½ are left with permanent damage, but most of the time those lasting problems are minor.
• 15-20% of cases remain active or recur intermittently.  

Treatment?

• Since the disease goes away on its own in about 50% of patients, the question is when to treat, if at all. Treatment is usually reserved for severe cases.
• Therapies include immunosuppressants such as glucocorticoids (prednisone) for 4-6 weeks with a slow 2-3 month taper.
• Steroids are not without significant side effects and the decision to treat should be thought through carefully.

Question: “A few days after I left the hospital, I started to get diarrhea that is getting worse. I am on the toilet all the time, it is like water. This has been going on for about a week. I have no energy and I feel dizzy. What should I do?”

Answer:

• See your doctor or go back to the hospital as soon as possible. Have someone else drive you or call 911. Sounds like you are not save to drive ("no energy... feel dizzy")
• Diarrhea is a serious condition.
• Diarrhea can lead to dehydration and electrolyte imbalances.  This is likely the cause of your weakness/dizzyness.
• Severe diarrhea can lead perforation of the colon, which is a real big problem.
• Thousands of people die every year just from diarrhea.
• Different types of diarrhea are treated differently.
• Regardless of the etiology (cause), keep hydrated. With severe diarrhea, your electrolites are likely out of wack. Some sort of sport drink with help with your electrolytes.
• Call/see your doctor today!

What is the cause?

• There are many different causes of diarrhea. However, given your type of symptoms and recent hospital visit, Clostridium difficile colitis would be at the top of my list.

Background terms:

• Colitis: Any time you add –itis to the name of something it means that body part is irritated, inflamed or infected. Therefore, col-itis = colon- irritated/inflamed/infected.
• Clostridium difficile is a species of bacteria. This bacterium, like many other bacteria, can be found all over the place. However, when conditions are right, it can cause a nasty infection.  
• Clostridium difficile colitis is also known by a few other names. You can see the name shortened to c-diff colitis or C. difficile. However, sometimes the disease is called pseudomembranous colitis because of how the colon looks when it is infected by it.  Antibiotic-associated colitis is another name given to the same disease because of how you get it.

How do you get Clostridium difficile colitis?

• Some places have more C. difficile than others. High volume areas are hospitals and nursing homes. However, many people carry it in their colon already.
• Oftentimes C. difficile is living in balance with millions of other species of bacteria in your colon without apparent symptoms. Your colon has its own ecosystem of bacteria. Each species has its own way of living. They share/compete for space and generally live in balance. This ecosystem is known as your flora. (Flora seems like a bit of a misnomer to me because in botany, flora refers to the plant life occurring in a particular region. Bacteria are not plants. None the less this is the term used).
• As you know from looking at our planet, if you dramatically disturb an established ecosystem, all kinds of bad things can happen. For your colon, dramatic things happen when you take antibiotics. Some antibiotics can kill just about everything.
• However, C. difficile has a super tough spore stage of its life cycle and therefore it is sometimes the last survivor after an environmental catastrophe from antibiotics. After the other bacteria have been killed off, there is no competition for space and resources and C. difficile multiplies unchecked. In a short amount of time, the entire colon is overpowered by this one bug. C. difficile produces a toxin that inflames and damages the colon.
• C. difficile can occur after the use of any antibiotic, although clindamycin and cephalosporin's are among the most common offenders.  
• Most cases of C. difficile colitis in the US are caused by antibiotics. However, C. difficile colitis can also occur in patients without exposure to antibiotics. Patients with ulcerative colitis and Crohn's are particularly susceptible.
• Of note, antibiotics can sometimes cause diarrhea that is not due to C. difficile infection.

How do you know C. difficile is the cause of the diarrhea?

• See your doctor. There are specific tests that can be done to confirm my suspicions. Specifically there is a test for the C. difficile toxin A and B.

How do you treat C. difficile colitis?

• There are several treatments. Generally the first line treatment is 10 days of the antibiotic metronidozole taken orally.

Question: "How do you tell if someone is having a stroke vs a hypoglycemic attack?"

Answer:
First a few Definitions:

• Hypoglycemia = Low blood sugar.
• Ischemic stroke = Artery blockage leading to decreased blood flow to the brain.

Stroke vs hypoglycemia:

• This is a really good question and one that ER doctors struggle with all the time. Both conditions can present with similar/same symptoms. In addition, they are both medical emergencies and treated very differently. The easiest way to start to figure out what is going on is to check your blood sugar. This is what is done at the ER and you can do it yourself too. But you should first call 911.

Why are there same/similar symptoms?:

• Since the brain uses glucose as energy and does not store any, low glucose levels quickly lead to impaired brain function. On the other hand, an ischemic stroke is caused by a blocked artery that supplies nutrients to the brain. Blocked flow quickly leads to impaired brain function. Depending on the individual patient and the degree of the problem, someone may have one or many different symptoms.

Some common symptoms of stroke:

• Sudden numbness/ or weakness; face, arm or leg, especially on one side of the body
• Sudden confusion, trouble speaking or understanding
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden, severe headache with no known cause
• Seizures
• Loss of consciousness
• Confusion, abnormal behavior or both

Some common symptoms of hypoglycemia:

• Nervousness
• Sweating
• Intense hunger
• Trembling
• Weakness
• Palpations
• Trouble speaking
• Numbness
• Confusion, abnormal behavior or both
• Inability to complete routine tasks
• Visual disturbances, such as double vision and blurred vision
• Seizures
• Loss of consciousness

If you think you are having a stroke, go to the ER:

• Time is brain; the longer an artery is blocked, the more the brain is destroyed. Infarcted (dead) brain does not come back; it is hard enough to remember birthdays.
• Ischemic stroke is treatable; however, the time window to treat a stroke is limited. The major treatment for acute ischemic stroke is via a medication given intravenously known as TPA. This should be available at every ER in the USA. However this medication can only be given intravenously within the first 3 hr of symptoms to be safe & effective (the time starts at the onset of symptoms). That does not leave a lot of time after traveling to the ER, going through admititng, lab tests, CT and exam.
• There are other ways to treat stroke acutely but these more advanced treatments are not available at all institutions. Even if you missed the time window, you still need to go to the hospital as soon as possible because there are other things that can be done to prevent things from getting worse and to prevent future strokes.
• In addition other medical problems can also present with symptoms similar to stroke/ hypoglycemia. Many of the other medical problems that can mimic stroke or hypoglycemia need to be addressed immediately as well.

If you think you are having a hypoglycemic attack, go to the ER:

• Hypoglycemia is potentially life threatening. Treating hypoglycemia is fairly straightforward. However, it is important to get to the bottom of the problem to find out why it has happened and to prevent it from happening again.

What you can do on the way to the hospital:

• If you are diabetic you should carry a glucose monitor. If you have had hypoglycemia before, you should carry a glucose monitor. There are many glucose monitor models out there that are small and easy to carry. I don’t endorse any; just get one that works for you, you’re worth it. If you discover you have low blood sugar, drink or eat something sweet. Obviously, sugar free items are useless as a treatment in this situation.
• (A list of your medical conditions in your wallet or on a bracelet/necklace is also a good idea).

Question: "I have a friend with ... medical problem. There is a language barrier and they have trouble understanding what is going on. Can you as a doctor call the hospital directly and ask for the info rather than us going to get the records ourselves?"

Answer:
HIPPA: Health Insurance Portability and Accountability Act
As far as accessing the medical record: Any patient has the right to access to their own medical records. As a patient, you can request copies of any of your medical documents, and the hospital will give it to you at little or no additional charge. The only other people who have access to this information are people who are involved in direct clinical care. Nothing can be released from your medical file without your (the patient) written consent. HIPPA was designed for your protection. Therefore, I have no ability to get to your friends medical information, just because I am a doctor. However, your friend has every ability and right to get their own medical information.