Health Care

To Test or Not to Test: of PSAs and Pap Smears

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The United States Task Force on Preventative Services (USTFPS) creates guidelines for providers to help them determine which preventative tests to do when, for which patients and if at all. We in community health rely on this task force perhaps more than other providers due to its global perspective. Basically their mandate is to decide, through a rigorous review of the research, whether certain tests or counseling interactions actually save lives in the long run, whether the benefits outweigh potential harm, and whether they are cost-effective. You can find out more at https://www.uspreventiveservicestaskforce.org/.

To make things more complicated, there are other specialty physician organizations with their own guidelines and the recommendations are often conflicting.  So what to do and how to decide?

If you have a good relationship with your health care provider, that is the best place to start. Discuss your risk factors for certain diseases, your age and state of health, your family history and your state of mind when it comes to medical tests and results. Personally, I am as conservative with tests as I am with prescribing medication.  There are potential downsides to every medical intervention, even tests.

Many people are surprised about this last notion.  They believe testing is good and want every test available, all for the assurance that they are healthy. But tests can have false positives – meaning they might indicate you have a condition when you don’t and thus lead to further testing or unnecessary interventions.  False negatives happen too, when the test says you’re fine but you are not.  Your provider will be able to tell you the false negative and false positive rates of most tests, as well as potential side effects, to help you make an informed decision.

An example is the PSA test, which is a blood test for a protein called prostate specific antigen, which is elevated in men with prostate cancer.  It can also be elevated in men who ride bicycles a lot, or who have an enlarged prostate, or have had a recent infection. Before 2012, we routinely tested men 50 and over, and younger men with family histories, risk factors or symptoms. If the PSA number was above a certain range, the test was repeated and if still high, they were referred to a urologist for a prostate biopsy.

Biopsies are never pleasant but prostate biopsies are particularly unpleasant given the location of the gland. Urologists try to take samples from many locations on the prostate, often guided by ultrasound or MRI, to find the cancer cells. Sometimes they do.  And sometimes they don’t.  As you can imagine, this is anxiety-provoking either way.  To compound the dilemma, many prostate cancers are very slow-growing and may not require treatment. But currently it is impossible to ascertain this definitively so depending on their age, most men are advised to, or want to, get treated.

Because of all this, in 2012 the USTFPS recommended against screening most men. A new guideline that came out just this week amended this slightly, recommending discussing screening with men aged 55-69, and then making an individualized decision.  I think that’s what most of us were doing anyway. A lot of times a man in his 50s would come in for a physical (pushed by his wife or girlfriend), and ask for the PSA test. We would discuss it and he would decide against it and with his permission, I would offer to talk with his significant other as well. Lots of times this would be a relief. The “man on a mission” did not want to go home, as it were “empty-handed,” having failed to get the test she requested.

Now on to the Pap smear, the screening test for cervical cancer. We actually call it a Pap test now because it is no longer a “smear” collected on a slide and preserved with a fixative.  It is liquid-based, collected with two tools usually: a small plastic “spatula” and a small brush. It is a better test because it requires fewer cells (so less repeat Pap tests for an inadequate sample), it can be done on days of light menstruation, and it can also be used to test for HPV, the human papilloma virus.  This is huge because HPV, a sexually-transmitted virus, is the cause of most cervical cancers, and the presence or absence of HPV in an abnormal Pap test guides our treatment and follow-up.  HPV can occur without symptoms and there is no cure or treatment for the virus itself.  Sometimes it manifests as genital warts “the HPV you can see,” and these can be treated, but eliminating the warts does not eliminate the virus.

The efficacy of this liquid test along with the ability to test for HPV is the reason behind the latest USTFPS guidelines on Pap tests: basically less is more, and later is better. This is welcome news to women, who never look forward to getting this test.

Now we don’t do Pap tests on women younger than 21, regardless of sexual activity. (We do of course test for sexually transmitted infections (STIs) and give safe-sex and contraceptive advice.)  This is because most young women have a low-risk strain of the HPV virus, which clears on its own. Before the guidelines, we were getting lots of abnormal pap smears for women under 21 which required other, more invasive tests and interventions, all of which could have been prevented by waiting. The jury is still out on how the new generation of women vaccinated against HPV will influence future guidelines.

Currently we test every 3 years from 21 until age 30. At age 30, women have the option of having the Pap test every 5 years along with an HPV test, or every 3 years without. Women older than 65 don’t need further testing if they have had regular screening in the past and do not have risk factors. This has taken a lot of getting used to, both for providers and patients. Women, as much as they dread the test, wonder if it’s okay to wait that long, is it safe? Rigorous research has proven that it is.  Some providers were still testing every year and some women wanted the assurance. As insurance companies adjusted their re-imbursement to the guidelines, this has changed. Go to this link for the particulars: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cervical-cancer-screening?ds=1&s=cervical cancer

The bottom line though (no pun intended) is that medicine is both art and science and patients are individuals.  There is no “one-size-fits-all.”  If I have a women who wants the test even though it isn’t due yet and is not warranted clinically by the presence of symptoms or past personal or family history, we will discuss it.  Sometimes, I find out she thinks the Pap tests for all STIs and she has had a recent risky sexual encounter.  Lots to discuss including other STI testing and possibly emergency contraception in that case.  Other times there is a nebulous family history, “my great aunt died of cancer ‘down there,” or she is worried after a friend had a bad diagnosis.  As a provider, I value my patients’ mental health as much as the physical.  In some cases, I will do the test to ease anxiety, after discussing cost in case her insurance won’t pay.

The takeaway message to this rather long post is that medical tests are complicated, imperfect, at times invaluable tools to maintaining good health.  Team up with your provider to get informed, be conservative and make sure you understand what you are getting into.

Healthy Thoughts: What This Blog is All About

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There are a lot of health-related blogs out there, so what makes this one different?  Imagine if you will that you have a close relative or friend who is a nurse practitioner.  You would probably feel free to ask her or him anything about your current state of health as a matter of course. Off the cuff, spur of the moment,  things you might not ask your doctor because of embarrassment or time constraints or fear of seeming silly.

My patients often tell me nurse practitioners are easy to talk to because they listen. And I do make it a point to give my full attention when a patient is describing symptoms or as we say in the biz – complaints. That word may have a negative connotation outside of health care but it’s a simple way to describe what brought you in to see a health care provider.

Even nurse practitioners have restricted time-slots (alas!) so there are questions that you might not get to ask during an office visit. Unless you have a relative or friend who’s an NP. Then you can send emails to that person with the subject line “eye” or “kidney” or “weird symptoms.” And you will get answers.

Now before you get the wrong idea – this blog is not going to be a forum for your specific health questions.  Rather, I will discuss all the kinds of questions patients, relatives, friends, and yes, even strangers, have asked me about their health. Chances are, some of these topics will speak to you personally.  I will share with you my health practices — what I do to stay healthy, what I advise my family to do, as well as share my thoughts about health care today, including how to utilize the system to optimize your health. My goal is to improve health through knowledge, from a nurse practitioner’s perspective.

But that is not my only motivation.  The URL for the website is www.mynursepractitionerwrites.com because, well. I was a writer before I was a nurse practitioner.  And sometimes, certain patient encounters resonate with me, becoming almost lyrical in the truths they reveal about both the patient and provider. It happens when the humanity of each person comes through despite the trappings, time constraints and mechanisms of modern-day healthcare.  It’s the reason  I renamed my site, “Tales From the Clinic.”  Some of the content is clinical, for sure, and some of it reflects the meaning I find in patient stories.

Please take a look at the menu bar to find content that interests you, and if you find it helpful, or just fun to read, please subscribe to my blog at the bottom of the menu drop-down. Thank you.

© 2016-2020 Eileen Healy Carlsen, FNP-BC (board certified nurse practitioner in Family Health)

A Bad Diagnosis

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Sometimes it’s in an email, with a worrying subject line. I’ve found the most worrying subject line is just someone’s name. Other times it’s a phone call, the seriousness of which is immediately revealed in the tone of the caller’s voice. There are times when it just comes up in a random run-in with a friend or acquaintance. A bad diagnosis.

It doesn’t have to be life or death but it has consumed this person’s every waking thought. And of course, they’ve been on the internet, reading everything from “survivor” blogs, alternative health sites and mainstream sites such as WebMd.com and Mayoclinic.com. It’s made them crazy, confused and panicky.

Many times, off the top of my head, I can’t give them an immediate answer. It’s out of my field of expertise.  Or I just want to make sure I am aware of the latest developments in that particular field. I tell them to take a deep breath, that they have some time to make a decision, no matter how serious the issue.  Yes, they should get a second opinion, and they should check with their insurance company about how to go about that.

If the diagnosis is cancer, I tell them to check if they’ll be able to go to the top cancer center in their area (and I tell them the name of the center) for treatment or at least for that second opinion.

No matter the diagnosis, a lot of research needs to be done before that second-opinion visit. I am happy to do this for them but for many people, knowledge bestows a measure of control. So usually we do the research together. Not only is it vital to understand the diagnosis, but being as well-informed as possible will maximize the benefits of that second-opinion visit. They will know where the gray areas lie (and there are always gray areas), the latest promising but perhaps controversial treatments being researched, and the ramifications of not treating. The last is always a very important question to ask – what if I decide to do nothing?

In terms of research, I recommend http://www.webmd.com and http://www.mayoclinic.org/ for very preliminary understanding. Beyond that, it’s best to go to the source most health care providers use, including myself. It’s non-biased and has the very latest research. In the past, it was extremely expensive for an individual. Providers have access through their electronic medical record software or as a standalone through a group practice subscription. There is a free basic patient information option and you can start there, but for the kind of research I recommend, you will need to subscribe. Luckily, now you can subscribe for a week for $20.00 or a month for $53. http://www.uptodate.com/home/uptodate-subscription-options-patients  (Note: I currently have no affiliation or financial dealings with any of the websites mentioned.)

Then it’s always a waiting game, and that’s the worst part. For the appointment, for new tests, for test results. I don’t make decisions for anyone but I hope my input helps them make the best decisions possible with the current state of knowledge. And that’s really all anyone can do.

Painful Encounters, Part 2

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“Foot pain” was the reason listed for the appointment. A new patient, male, age 31. I had now been in the clinic long enough to prepare myself mentally for just about anything. A year ago a young women with the same complaint, also a new patient, had presented with an infected foot wound open to the bone emitting an odor so strong, that when she took off her shoe it made the medical assistant have to leave the room in a hurry. Turned out she had spina bifida, and got this often. Her decreased lack of sensation and frequent hospitalizations made her blasé. As we waited for the ambulance, I asked “Why didn’t you just go to the ER?” “I didn’t think it was that bad, and I don’t have my insurance yet.” She was later transported to a trauma center where she remained on IV antibiotics for 3 weeks.

The man was tall and thin with longish straight brown hair. He was wearing a gray tank top and jeans and the prison tattoo on his upper arm was displayed for all to see.  I took that as a conversation starter and made a guess. “Were you recently incarcerated?” It was a universal term, no matter a person’s first language or education level.

“Yes, got out two days ago.” I suppressed the urge to ask what he had been in for.

“Have you had a TB and HIV test?” I asked. It was pretty standard.

“Yeah, all that, I was negative.”

“We can test you again 6 weeks from now to be sure.”

“Yeah, okay whatever, but that’s not why I’m here.”

“So tell me,” I encouraged.

“Five years ago, I was working as a roofer and fell off a roof. Broke both my feet. Was in casts, the whole deal.” He grimaced at the memory. “But the docs said I needed surgery to really repair things and I didn’t have insurance.”

“Are you in pain?”

“All the time. That’s why I’m here.”

Now was the time to ask about why he had been in jail.

He looked sheepish. “Um, narcotics, a little dealing. It was all because of my foot, though.”

I was surprised at his honesty.

“Let’s do an exam first and then we’ll talk.”

He was meek as a lamb.

The exam was pretty normal. The soles of his feet were painful to the touch but there was nothing really to see. He had full range of motion, good pulses.

I took a complete family history and got ready to order some blood tests. “Oh, no, doc, I hate needles,” said the man with the crude prison tattoo.

We compromised. A urine test this time, including a tox screen and a return in two weeks for blood work and a complete physical exam. I gave him a prescription for high dose naproxen for his pain, with the appropriate caveats.

Surprisingly, he came back and became a model patient. He said he was not using and his tox screen was negative. He was depressed, not surprisingly, and I started treating that with medication. We were helping him with insurance so that he could see a specialist for his foot pain. I continued to write him scripts for the naproxen since he was having no ill effects and his labs were normal. This was during the early days of electronic prescribing and not all pharmacies were equipped for this. He told me his wasn’t and I gave him paper scripts.

Six months went by. The clinic was always swamped so it took me a while to realize he was coming less frequently. I placed a call to ask him to come in to monitor his depression meds. Left a message but no response. Next time I called, the phone was not in service. I sent a letter to the last known address. And then forgot about him.

Until two years later, when I noticed he was on my schedule again. The complaint this time was “medication check.”

After the initial greeting, I asked where he’d been, thinking he’d moved.

He had been in jail again. This time, I asked straight out.

He seemed to wrestle with how to respond. “You’re not gonna like it,” he finally said. I was sure I wasn’t. And waited.

“Prescription tampering. Well, not really, but those scripts you wrote for that medication—“

“The naproxen?”

He nodded, and added “And the other.”

“The medication for depression?” I thought I couldn’t be surprised anymore but I was. Shocked actually.

“But wouldn’t I have been notified?”

“Well, there were drugs in the car, they cared more about that. And I was never able to use any of the doctored-up prescriptions – guess my forgery skills weren’t up to par. And the way you wrote them made it hard.“ He chuckled a bit until he noticed my stony-faced expression.

“So what brings you here today?” I finally managed a neutral tone.

“Well this time, I do want help to see the bone doctor. What I told you about my feet – that was true. And um — nurse?” (patients always struggled as to what to call me.)

“Yes.”

“I’m sorry. I know you really tried to help me and I took advantage and screwed up.”

What do you say to that? I just nodded and began the exam.

 

Painful Encounters, Part 1

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I just completed the new mandated continuing education for prescribers on controlled substances in New York State. It’s part of a nationwide effort to stem the opioid abuse problem in this country, which is growing exponentially. The program was very well executed with many suggestions on how to prevent opioid abuse while still treating a patient’s chronic pain. There was also information on state-specific guidelines on prescribing, many of which have become more stringent in light of the opioid epidemic. A month ago, I also completed a similar program for the state of Massachusetts where I also hold a license, and this was through Massachusetts General Hospital. This presentation featured re-enactments of typical patient encounters. They brought back some painful memories.

It was probably my second week at the community health center. A new patient (in this particular scenario it’s always a new patient), a clean-cut while male in his late 20’s, sat on the exam table. I had noticed that he had walked in stiffly past my office door, lagging behind the medical assistant and holding the small of his back. He was with his girlfriend. He said he was visiting from Florida and his back was acting up. He had been in an MVA (car accident) 5 years ago which “broke my back” and resulted in excruciating back pain which came and went. His girlfriend held an envelope which contained an xray film. His last name was written on the corner with marker. He was disappointed when I informed him we didn’t have a light table to read the xray.

His vital signs and reflexes were normal. His lower back appeared normal without bruising or redness or swelling, but was hypersensitive to the touch. He denied fever or urinary symptoms which could signal a kidney infection. He denied loss of bowel or bladder function – a red flag which would indicate an emergent condition called cauda equina syndrome, requiring quick surgical intervention. He denied prior use of IV drugs which would make him more susceptible to a bone infection called osteomyelitis.

He did say that the pain radiated down both legs suggesting sciatica. Every motion I instructed him to do hurt – bending forward, backward, twisting. Any manipulation of his leg while he was supine was painful. Even pushing down on his head while he was sitting was painful.

He said surgery was suggested for his condition, described as “many herniated discs” but he didn’t have insurance. His doctor in Florida gave him Vicodin – the generic didn’t work. Yes he tried physical therapy but it made the condition worse. He was extremely polite and kept calling me “ma’am.”

I held up my hand and began my spiel about how opioids were not the most effective drugs for pain management. I talked about how NSAID/acetaminophen in combination had more efficacy. Suggested we start such a regimen in addition to a muscle relaxant for 5 nights. I talked about alternative therapies such as heating packs or topical lidocaine. I encouraged him to speak with our advocate to start the process of acquiring insurance so that he could get his problem re-evaluated by orthopedics and perhaps start physical therapy again. I spoke about referral to a pain management doctor if all else failed.

He listened politely and then asked, “So you can’t give me any Vicodin?” I told him I was not comfortable doing that. “Well they told me you could help me when I made the appointment.” His voice started getting louder. His girlfriend started to look anxious. “Let’s get out of here, baby” she whispered. She was too thin.

“I’m not f-ing paying for this appointment.” He continued, almost shouting. “I wanted to see a real doctor.”

“They told you I was a nurse practitioner when you made the appointment. Do you still want your prescription for the muscle relaxant? If so, which pharmacy?” I kept my tone level and neutral.

He reluctantly named one and I sent it off. I got up and said I would bring back the instructions for taking the ibuprofen and acetaminophen in rotation and a referral to our patient advocate.

When I returned to the exam room a few minutes later, it was empty. The exam table paper appeared to give one last rustle in the abandoned room, like tumbleweed. 30 minutes spent on a visit allotted 15 and I still had to write the note.

The Dreaded UTI

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You notice in retrospect that you’ve been peeing more than usual. You tell yourself you’ve just been drinking more water lately. Then you notice a little twinge in your lower abdomen (what we call the supra-pubic region). You begin to suspect (okay, reluctantly admit) you are getting a urinary tract infection (UTI). (Note, this post is about UTIs in women.)

What to do? It depends a bit on your age, but everyone should drink lots of water, at least 20 oz. an hour. Recently the long-held belief that cranberry juice has a bacteriostatic effect and can nip a UTI in the bud has been disputed due to lack of scientific evidence. But it doesn’t do any harm so I do start drinking a cup of pure cranberry juice (not sweetened cocktail) an hour.

Women up to perimenopause (so teens to 40-ish) should see a health care provider if the symptoms persist more than a day, or worsen. The reason is that an annoying UTI can more easily turn into a serious kidney infection (pyelonephritis) if left untreated, and is especially common in younger women. Symptoms of pyelonephritis include lower back pain (bilateral or one-sided), pelvic pain, fever and chills. Any of these symptoms require prompt medical attention. It is very important that a urine sample is collected. Your provider will do a quick “dipstick” test that can indicate if you have an infection, and then, send your urine specimen out to the lab for a culture and sensitivities test. This second step is vital because UTIs can be caused by a variety of bacteria that require different antibiotics. (This is the reason I rarely will prescribe an antibiotic for a UTI over the phone. It’s is in the patient’s best interest to come in, if only to submit a urine sample.) Also if your infection is just getting started, the dipstick might be negative or inconclusive but the culture will usually demonstrate an infection if you have one.

Seeing a health care provider is important because the physical exam dictates the care. If I see a young women with all the symptoms of a UTI, including suprapubic tenderness, I will rule out pelvic inflammatory disease (PID) with a quick pelvic exam and send some tests out for STIs (sexually transmitted infections) like chlamydia and gonorrhea which can mimic the symptoms of a UTI. (I always do a pregnancy test too and a positive result will dictate further treatment.) I am going to treat her for a UTI, regardless of what the dipstick says. And if the pelvic exam is suspicious, I will treat for those STIs separately as well while we await lab results. It’s called treating empirically. If I suspect a possible kidney infection, I’ll use a certain type of antibiotic called a fluoroquinolone. If not, I’ll use a medication called nitrofurantoin because of the problem of bacterial resistance to some commonly-used drugs. If the culture and sensitivities test I ordered indicates a different antibiotic is needed, I will call the patient and change it. I always tell my patients to call if they are not much better in three days or if they feel worse, and to go to the ER if the symptoms of a kidney infection develop.

For women entering perimenopause, or if they are menopausal or post-menopausal, fluctuation in estrogen can make them more susceptible to cystitis which is inflammation of the bladder. Cystitis may or may not be caused by a bacterial infection. These women can try the water and cranberry juice for a few days as long as the symptoms don’t worsen and there is no fever or back pain involved. Ibuprofen also helps with the inflammation. It’s never a mistake however, to go to your health care provider at the first sign of a UTI at any age.

There are some things all women can do to prevent UTIs:

  • Keep hydrated and don’t hold urine in when you feel the need to urinate. (‘Holding it’ for too long can definitely cause a UTI.)
  • Wipe from front to back after a bowel movement
  • Urinate ASAP before and after sexual intercourse.

Hope this helps the next time you have an “uh oh” moment.

An Exercise Prescription

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As a health care provider, I often advise my patients to exercise. It does not make me popular. People who aren’t regularly exercising have their reasons. “No time” is a big one, and I get that. But there are ways to work in 15 minutes at a time throughout the day if you can’t devote a half hour to it.

When I promote exercise, I’m not usually focusing on a patient’s need to lose weight. I’m thinking about keeping his heart healthy, her body (especially muscles and bones) in good enough shape to support her in living an active, independent life well into old age. I’m also focused on his mental health.

When a patient comes to me with depression. I always prescribe exercise, in addition to therapy and medication (if warranted).  Regular exercise, even just brisk walking, changes your brain chemistry. The endorphins released when exercising treat depression and anxiety in the most natural way possible.

Exercise is not one size fits all. You have to find something you enjoy doing enough to incorporate into your day at least five times a week. Walking is a great place to start, gradually increasing distance and speed as tolerated. Take time to observe your environment and how it stimulates your senses.  Appreciate the whirring of insects, the birdsong, the laughter of children playing, snippets of overheard conversation.  Enjoy the cool clean air, the fragrances of flowers or evergreens,  or the energy and bustle of the city.

If you have  heart issues, always check with your provider before embarking on any exercise program, and also report back if you are having trouble when walking, including leg pains, shortness of breath, and extreme fatigue. Chest pain when exercising is a red flag which requires prompt medical attention.

People often ask me which is best – cardio or weight training. First, depending on how you work out, weight training is also a cardio exercise because it elevates your heart rate. You should be doing both.  As we age, we lose bone strength and muscle mass. Strength training helps build muscle and strengthen bone. Cardio machines, running, spinning, boot-camp type classes all serve to exercise your heart muscle, making it more efficient and stronger. Your large muscles, mostly in your legs, also benefit.

Pilates and yoga build core strength and, yoga especially, promotes balance. Having good balance is important to prevent falls and maintain mobility. One of the first tests we do during a “Welcome to Medicare” exam is time how long it takes for a person to get up from a chair, walk a few steps and sit down again. It is easy to tell who is going to do well just by observing the patient walking with me to the exam room. The people who exercise regularly ace this part and often get competitive, wanting to know what’s the usual time period (we aim for under 8 seconds), and wanting to do it again to improve their time.

Of Flu Shots and Z Packs

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Everybody gets sick but some get sick more often than others.  As health care providers most nurse practitioners enjoy a robust immunity bolstered by constant contact with germs and sometimes people (usually children) coughing or sneezing in our faces. There are preventative measures anyone can take to reduce your changes of getting sick.  Handwashing is key.  I make it a habit to thoroughly wash my hands as soon as I enter my house, in addition to the usual instances. Being up to date on immunizations, including a yearly flu shot is probably the second most important thing you can do. The third is lifestyle — eating healthy food, staying hydrated and well-rested.  Even if you do all these things, you could get sick.  And most of the time, unfortunately, there isn’t a quick fix.  I am amazed at the people who present with a day or 2 of cold symptoms and demand an antibiotic — usually, and specifically a “Z-pack.”  I always take the time to discuss the likelihood of a viral illness, home measures to help you feel better and the healing power of time. Many people will listen politely and repeat their request, citing that the last time they were sick, this did the trick.  I review the potential side effects, sparing no detail.  Then I usually suggest they wait for a few days, sometimes giving them a “prescription to hold” so they don’t have to come back.  We both know they are going to fill it right away but it’s my way of taking a stand for what we call antibiotic stewardship.  What’s particularly curious is these same people who are so quick to put an antibiotic into their system will refuse a flu shot because of potential side effects (very few and benign) or because “the last time I got the flu shot, I came down with the flu.”  Which is of course impossible.  It’s an inactivated vaccine.  They could have been coming down with a cold at the time of the injection (I discourage getting the shot if you are feeling at all under the weather at the time.), or caught some other virus in the waiting room.  The funny thing is, health care providers, for the most part, practice whet we preach.  We get the flu shot every year and we resist taking antibiotics unless we are sure we have a bacterial infection, which is the only kind of infection antibiotics can resolve.