Staying Healthy

When to Start and When to Stop

Posted on by writenp

Can you have too much a good thing in health care?  Most definitely. Too many tests is never a good thing, which new providers learn fairly quickly as they struggle to follow up results that likely will have no impact on the patient’s health but now must be dealt with.  Which can lead to more unnecessary tests, invasive procedures, added expense and patient anxiety, which is never benign.   

Many people don’t know when it is recommended to stop certain screenings.  While some screenings for cancer are pretty innocuous in terms of the actual examination, i.e., a PSA blood test or a skin cancer screening, there are others that are well, a bit more unpleasant.  I’m talking about pap tests, colonoscopies and mammograms.   Yet these are the very tests many people faithfully have on a regular basis, without thinking about whether they are still needed.

Before I go further, I must stress that these are decisions that you should be making with your health care provider, based on your individual state of health, family history and attitude towards testing.   More about that later.  But feel free to read on and bring any questions you may have to your next appointment. Or me, if you’d like to engage that way.

The pap smear is a familiar but antiquated term for the screening test for cervical cancer.  Antiquated because cells are no longer smeared onto a slide but instead, mixed into a liquid medium. Pap test is more descriptive.  The Pap test is the poster child of preventative screenings, its use having resulted in a remarkable reduction in the incidence of and death from cervical cancer worldwide. But today the pap, which examines the cells of the cervix, is no longer the only test for cervical cancer. Once the link between the Human Papilloma Virus (HPV) and cervical cancer was clearly established, a test was developed to check for it, and a vaccine (the HPV vaccine) was developed to prevent it in the first place.  OB/GYNs are the providers most people think of as performing pap tests, but so can nurse practitioners, physician assistants, and Family Medicine doctors.  In fact, any practicing doctor can perform it but most non-gyn specialists do not, nor do most internists, I guess by choice and subsequent lack of supplies. I am always intrigued by the unwillingness of internists to do an internal exam.  But I digress.  

First, be aware these guidelines only apply to asymptomatic women without any known risk factors or prior abnormal paps.  In fact any test called a screening is by definition intended for those with no symptoms. Depending on the guidelines used (I tend to use the United States Preventative Services Task Force (USPSTF), which has a community health focus) the tests should be initiated at either age 21 or 25 (the American Cancer Society (ACS)), regardless of sexual activity or vaccination status.  For ages 21-29, pap tests every 3 years.  For age 30 and above, a pap test every 3 years, a pap test/HPV test combo every 5 years, or an HPV alone test every 5 years. The HPV test alone is not widely available yet but can easily be added to the same sample from a pap test, which becomes the combo.  The reason testing for HPV is only initiated after age 30 is because many women under 30 have benign HPV infections which could clear without treatment, and additional testing/biopsies are avoided this way.  When to stop pap/HPV testing?  For asymptomatic women who’ve been tested regularly and the last 2 Pap/HPV tests have been normal and have never been diagnosed with pre-cancerous lesions or cervical cancer, the age is 65.

Continuing with women’s health, the advice about mammograms also varies depending on which guidelines you use. The USPSTF advises, for asymptomatic women without known risk factors or family history, a screening mammogram every 2 years starting at age 50.  The American Cancer Society advises starting at age 45, doing a mammogram every year until age 55 and thereafter every 2 years up through age 74.   The consensus for stopping in asymptomatic women without risk factors is 75, unless the patient has a greater than 10 year life expectancy at age 75.  With all these screenings, they are deemed worth doing if your life expectancy is 10 years or more. As much as people loathe these tests, it’s not easy hearing that you don’t need them anymore.  So cancer could go undetected?  That’s a frightening thought for most people.  It’s more like it’s not the cancer that will kill you so why go through testing and treatment, when you are more likely to die of something else.  Mortality is concept most of us can’t truly grasp or accept, surely a topic for another post.  

For male-specific screening tests, we are talking prostate cancer.  Here, it is all about shared decision-making because there is no clear consensus about the benefits of screening asymptomatic men at average risk for prostate cancer across a population. Most guidelines say if you choose to do it, start at 50 in men without a family history of the disease, and discontinue at age 70.  The dreaded digital rectal exam (DRE) is not recommended for screening because it has not proven to lessen mortality.  What is shared decision-making, exactly?  It’s when you and your provider discuss pros and cons of testing, including false positives (which lead to unnecessary biopsies and other tests and of course anxiety), false negatives (missing a cancer that is present), and overdiagnosis. 

Overdiagnosis is a problem inherent in many cancer screening tests, not just prostate, and most notably mammography.  It occurs when a cancer is detected, but it is so slow growing it will not affect life expectancy if left untreated.  But because it is very difficult (the technology is just not there yet for some cancers) to determine that a cancer is harmless, if you will, once it’s found, the push is to treat it.  With prostate cancer, there is the option of watchful waiting, also called active surveillance for certain men (it depends on age, frailty, comorbidities and life expectancy) whose cancer is found to be, through biopsy, imaging and DRE (the digital rectal exam is employed in risk stratification of the cancer), very low-grade.  Even in this case, many men, knowing they have prostate cancer, will opt for treatment to avoid the anxiety of close follow-up and repeated testing. And with treatment often comes morbidity (illness to the layperson), expense, possible loss of employment, and anxiety. There is no getting around anxiety with a cancer diagnosis no matter what you do.

It could be argued that of all the screening tests, the colonoscopy is the most dreaded.  It takes up at least two days of your life, what with the prep and the actual procedure and post-anesthesia recovery of a few hours. The prep is probably most dreaded, when it’s just you and the awful tasting drink to cleanse your bowels.  Cleansing the bowels, that doesn’t sound too bad, right?  What it means is hours of diarrhea, where it is now just you and the toilet.  And when it’s time for the procedure you are weak, and surprise! – at least mildly dehydrated, which usually makes the placing of the necessary IV line more difficult. But there is a silver lining.  The drugs.  Usually now it’s the same drug, propofol, which Michael Jackson got every night to sleep.  And it works so well, you could almost understand his affinity.  One minute you are in the hospital bed after the difficult IV insertion, the next in some zen paradise you most reluctantly emerge from to find yourself in that same hospital bed with a loved one or close friend staring at you worriedly.  It was nice while it lasted.

Colonoscopy is not the only game in town but it is considered the gold standard because it not only can prevent death from colon cancer but it can prevent the cancer from occurring by removing precancerous polyps.  And if yours is negative, you can wait 10 years to do it all again. Another way to screen is sigmoidoscopy, an office procedure where the most distal portion of the colon (so not the entire colon as in colonoscopy) is visualized and any polyps found can be removed and later biopsied This does not require sedation but does require some bowel prep. It is not a popular or promulgated choice because at that point, why not go for the colonoscopy and at least get the drugs?

The other options are stool-based, that you can do in the um — comfort of your own home.  They are pretty good at detecting cancer but not so good at detecting precancerous polyps.  Depending on the test, the suggested frequency is every one to three years. If any of these tests is positive or abnormal, of course you would need a colonoscopy.  Same is true of the so-called virtual colonoscopy that uses a CT scan, which has fallen out of favor lately. 

Screening for colon cancer is recommended starting at age 45 for asymptomatic individuals without any risk factors, since recently there have been more people under 50 diagnosed with colon cancer for unknown reasons.  The stop point is 75 as long as life expectancy is 10 years or greater.

Lastly, there is skin cancer screening.  And I must tell you I was most surprised that there is insufficient evidence to recommend that asymptomatic individuals get a yearly skin check by a dermatologist, especially to rule out melanoma, a skin cancer that can be deadly.  Different guidelines support that providers counsel patients, especially those most at risk with fair skin, to avoid unprotected sun exposure, and to check their own skin for new or suspicious lesions.  I know that as a health care provider, I do counsel sun protection and look at a patient’s skin for anything glaringly abnormal.  But frankly there is so much to cover during a physical, and so little time. For those who can afford it, I advise a yearly skin check with a dermatologist, who will examine every inch of you under very good light, and I practice what I preach. For those who can’t, I tell them the general guidelines of size, color and change in lesions and if anything seems abnormal, to have it checked.  Skin is an organ that should be checked from birth.  As to when to stop checking, no consensus on that either.  Maybe when you no longer feel the need to look in the mirror?  That says more about life expectancy than anything else.

#healthcoach #knowingwhentostop #prevention

Prepping For Your Yearly Physical

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No, this does not mean, swearing off carbs and beginning a vigorous exercise program in the weeks before your exam in order to appear healthier. First, it’s not possible, and could be dangerous. What I mean by prepping is having the information on hand that will help you and your provider make the most out of your visit.
I have my annual physical this year, with a young doctor I’ve only seen once but liked very much. I want to make sure she has what she needs to collaborate on my health care. While there have been studies that refute the value of a yearly physical, I, as a health care provider, think it’s important. Seeing someone when they are feeling well, getting labs when they are healthy, creates a baseline to refer to when there is an alteration in health, and also establishes a rapport which will help communication in the future. It is also the best time to evaluate the need for preventative health care measures or tests.
Sadly, your provider will not have a lot of time, likely no more than 15 minutes. So it’s up to you to prep for the exam, in order to receive optimum care. Here’s what you can do:
1: Have a list of medications that you might need he or she to refill in the future and ask how best to execute this request. Provide all the medication you take, even ones prescribed by other providers, because medication can alter blood tests. And if you’ve changed pharmacies, let them know.
2: If this is a new provider, or if you have gotten vaccines elsewhere, have a copy of your most recent immunizations. Same goes for any health screenings such as colonoscopies, mammograms, pap smears or bone density tests. Also helpful would be a printout out of your most recent blood tests.
3: Be able to provide the approximate dates and nature of any hospitalizations or surgeries, since your last visit (or ever, if this is a new provider).
4: Be knowledgeable about health problems that run in your family, and offer this information if you are not specifically asked about it. These can include heart problems, cancer, hormonal problems such as thyroid imbalances, and mental health and substance abuse issues.
5: If you have some health concerns, pick the two most important ones and plan to reschedule to address others. Do mention what these concerns are; if specifici lab studies are needed, you can have them done at the same times as the rest of your blood work.
Should go without saying, but you should tell the truth. Your provider will not judge and will appreciate honest information that will benefit your long-term health.
#yearlyphysical#preppingispower#optimizeyourvisit#itsyourhealth#youareinchargeofyourhealth

Look Both Ways: Advice for Before you Visit a Specialist

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I am always happy to give advice to friends and family, particularly on navigating the health care system.  While being underinsured is obviously a problem, having great insurance comes with its own particular challenges.

It would seem liberating and well, just better, to not have a “gatekeeper” policing your use of specialists and expensive medications.  Sometimes, indeed it is, but it depends.  And sometimes, seeing a specialist is the obvious route.  Ideally you are under the care of a primary care provider who will take the time to look at your case holistically and advise you about when to consult a specialist.  But sadly, the system is set up to not give the provider the luxury of time to do this easily in many cases, and a referral to a specialist is sometimes a way of passing the buck, even if that is not the intention.

Okay, I’m going to say it.  Specialists sometimes have tunnel vision, and this is understandable.   A provider sent someone to see them, indicating at least that they suspect the problem is in the specialist’s particular field.  But medicine is at times as much art as science, I’m afraid, and that is not always the case.  It could be more like a best guess, or even a scattershot approach –  fainting spells: neuro or cardio? Let’s do both. 

And while in the end, the specialist may report that the problem is not in his or her specialty —  your heart is fine, or your lungs, or your kidneys —   usually there are a lot of expensive and sometimes invasive tests, involved in coming to this conclusion.

I’d like to spare you this. If you have a new subtle symptom, by all means make note of it, when it began, what makes it worse or better, and simply observe for 2 weeks.  Note – and this should be common sense — fainting, chest pain, signs of a stroke like facial drooping or slurring words, severe pain of any kind, prolonged blurry vision, blood in urine or stool are not subtle and you should see someone right away.  Basically, if the symptom scares you, see someone right away.  But if it’s just a newly observed sensation, you may want to wait a little to see if it goes away on its own.  I’ll give you an example of what I mean.  When I was in nursing school, I developed, or should I say noticed, many new symptoms.   My leg throbbed at odd times.  I felt, if I really dug in, some weird bumps under my skin in certain places.  My knees sometimes made a creaking sound.  If I moved just a certain way, kind of like a cha-cha step, I got their strange pain in my hip for a moment.  My doctor would dutifully take note but also wisely took a wait and see approach.  And the next time I saw her, she’d ask about it and more often than not, I’d forgotten all about it.

There is a reason why the majority of health care providers do not utilize as much health care as non-providers.  Sure, they have more knowledge of the human body, but it’s more than that.  We know that every test we order has to be followed.  And the more tests you order, the more abnormal results you will find, that you may not have even been looking for, have nothing to do with the original problem and may have no effect on the patient’s future health.   But now you have to track every one of these down.  You might never find the answer – art vs science, remember? — but a lot of hours have been spent in its pursuit.  While many people want to have as many tests and imaging studies as possible as an assurance that “everything is okay,”  too often they don’t get this reassurance and in fact, might get more to worry about, whether justified or not.  It’s the reason I am leery of those full body scans that are marketed to the public, but that’s another issue. For now, the message is, don’t run blindly from one specialist to another without “looking both ways.”  Form a relationship with your primary care provider and make those decisions together.    

Asking the Nurse Next Door: What I Tell Family and Friends about Staying Safe During the Pandemic

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I never learned to intubate, only suctioned a dummy, and can’t start an IV. Procedures are not my strong suit. The skills I pride myself on — diagnostics, well visits and health screenings,  follow-up of chronic health conditions, and communication, aren’t particularly useful in the thick of the pandemic. I’m sure they will be again, but for now, I try to use my training to make sense of the science and to advise friends and family when they ask. Or in the case, of my children, even when they don’t.

Before I go on, a caveat: this information should not take the place of consulting with your health care provider. Especially if you are vulnerable due to a compromised immune system, age or other health conditions, you should follow expert advice to the letter and err on the side of caution. The CDC and local department of health websites are excellent sources for timely information about best practices for protecting your health in this changing situation. Think of this as my attempt to share, in layman’s terms, what I believe, and what I am doing currently for my own well-being.  

In terms of the science, there is so much unknown. When I first started hearing about the virus’s infectiousness, I questioned whether it was spread solely via droplets as was being reported.  The way the virus has spread appears more like a hybrid of droplet and airborne contagion. Both tuberculosis and chicken pox spread through the air, which explains why they are so very contagious. We’ve also learned that duration of exposure and dose of virus particles are key to whether you are going to get infected, and perhaps how ill you will become. Of course, age and other health conditions also play a role. But we have seen young, healthy people get very sick and even die, while some nonagenarians survive. And then there are questions about genetic immunity, whether it’s blood type or some other genetic determinant that makes the lungs more susceptible to the havoc Covid !9 can wreak. We will understand so much more of this in time, but for now here’s what I do, and suggest others do to be safe without going crazy.

When you leave your home: Always have a mask that covers your nose and mouth ready, in case you cannot maintain a distance of at least six feet. I am a runner and hate running with a mask on – it makes me gag. But I have one around my neck before I venture out for a run and if there’s a chance I will come closer than 6 feet to someone, I put it on. Always wear a mask when entering an enclosed space. Avoid touching your eyes, nose and mouth. And wash your hands for 20 seconds as soon as you enter your home.

Grocery shopping. From what we think we understand at this point, the risk of contracting the virus is inversely proportional to the amount of time exposed and the dose of the virus – ie, whether you are exposed to copious secretions of an ill person up close. So masked, socially-distanced-grocery shopping is not as risky as we once thought it was, as long as you take precautions. Have a list and be efficient so you can limit your time. Sanitize your cart. Use hand sanitizer once you are back in the car, or when your leave the store, if you are walking.

Taking in mail and packages. While the virus has been said to exist on surfaces up to 72 hours in ideal conditions, keep in mind that conditions outside the lab are not ideal and viruses are notoriously fragile. At the onset of the pandemic, I used to leave the mail and packages on a table for 48 hours. Now I am not as worried so I am just careful to thoroughly wash my hands after handing deliveries.

So far these are all caveats, and isn’t it tiring to always hear what not to do?

Here are activities and routines that help me feel better during this stressful and uncertain time: Maintaining a healthy diet with lots of fruits and vegetables and drinking plenty of water. Sticking to a regular sleep schedule. Not overdoing it with the alcohol. Exercising vigorously 3-5 days a week and getting outside every day.  Plus limiting the times I check news and social media during the day.

These are the health-related items I tell my friends and family to have on hand: A thermometer, acetaminophen, and a pulse oximeter to measure your oxygen level if you get sick. This last item will help your health care provider determine how your lungs are functioning and whether you might need to go to the hospital for breathing assistance. A spirometer is also a good thing to have to exercise your lungs if you are sick. You likely used one if you’ve ever had surgery. All of these items are available on-line and some at drugstores.

Okay, what else? I for one have been trying to live more in the moment, not a natural thing for me. Setting some time aside to meditate, or just breathe slowly and let your mind wander. Just a few minutes will help and is worth it no matter how busy your lock-down life is with work, childcare, school. Plan things for which you can look forward with happy anticipation. A walk in the park, a game or book. And yes, this is the time to binge watch for entertainment. Definitely schedule virtual meetups with friends and relatives even if they feel artificial at first.

Looking ahead. Yes, things are loosening up, for sure. The other day we had our first social event in real life since the lockdown. We sat on our next door neighbors’ open deck at our own table at least 6 feet away from theirs and we brought our own libations. But no masks since we were outdoors. It felt incredibly liberating. We will plan similar gatherings, but at this point, always outside and socially distanced. We might consider sharing food in certain situations but will be especially assiduous about hand disinfecting and not touching ones face. That’s it for now. Stay well.

All rights reserved. © 2020 by Eileen Healy Carlsen

Consumption

Posted on by writenp

I find the magnitude of consumption of health care frightening, and I’m a health care provider. I’m not talking about preventative care, which I think, if anything, more people should consume.  And of course people must seek care for sickness and trauma. I am referring to medical testing and specialty care.

Medical tests such as blood work and imaging studies (x-rays, MRIs, CT scans, and ultrasounds) are overconsumed. Most health care providers, in their personal lives, are quite prudent about their own consumption of medicine in general.  We know that every test has a downside and we want to be sure the information it will provide overcomes the potential risks.

Many people, particularly those with very good insurance, think when it comes to testing, more is better. I understand that some people really want assurance that there is nothing wrong. My Spanish-speaking patients frequently ask me — “favor de chequear todo” — to test for everything – including all cancers, to get a clean bill of health.  Of course that is not possible.

Another type of excess consumption occurs when patients want to consult a specialist for the most minor of complaints, ones that could easily and safely (not to mention more economically) be taken care of by their primary care provider. Specialists are a great resource but if one sees a myriad of specialists more than your primary care provider, sometimes health care suffers. It is very possible no one is stepping back to take a holistic approach to you as a whole person, not just a foot or a heart or a GI tract.  Patients don’t always tell their PCP which specialists they’ve been to and specialists don’t always send a report, especially if the patient has not provided a PCP because they don’t need a referral.  Contrary to popular belief, providers don’t all know each other and records don’t magically get sent to your provider’s office. This is especially problematic when medicines are prescribed and there is not a complete list which would make checking for potential interactions possible.  You as the patient need to be pro-active about this, for your own good health.

While it is true referrals are a pain for all concerned, the concept of a gate-keeper for your health, i.e., the PCP, is a good one. Yes, insurance companies use the referral mandate as a way to cut costs, but the upside is that your PCP knows what is going on with your health. We can help you determine which kind of specialist to see, if warranted. Often this is not as clear-cut as one would imagine.  So even if you don’t need a referral, you might want to talk to or message us about what is going on and why you think you need to see a particular specialist.

That being said, there are some medical offerings I wish my patients would consume more of.  Screening colonoscopies and flu shots come to mind.  I sometimes have to have to push very hard for both.  Hope you got your flu shot this year – it’s still not too late. While it’s true it’s not as effective at preventing the flu as it’s been in past years, the efficacy is still around 30%.  Way better than nothing.  Plus the flu shot mitigates the severity of influenza if you are unlucky enough to still catch it.  I was very grateful for even this level of protection when I was taking care of patients with influenza last week.

Stay healthy, and be mindful of your medical consumption.

©2018 by Eileen Healy Carlsen, FNP-BC.  All rights reserved

Hobbled: Running, Plantar Fasciitis and My Mom

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One of my earliest memories is of my mother instructing me how to propel myself on a swing to soar above the then cement-covered playgrounds of New York City. “Stick your legs out and pump!” she coached three-year-old me. I didn’t know what “pump” meant and she had no understanding of aerodynamics. It didn’t go well.

Like many runners, I did not grow up athletic. In fact, I come from a family of remarkably uncoordinated couch potatoes, particularly on my mother’s side. This did nothing to stop my mother from attempting to teach me physical skills she herself did not possess, such as the afore-mentioned swinging.

One concussion and many skinned knees later, I accepted my lack of athletic prowess. After all, I was in good company. Hardly anyone in my family knew how to swim, let alone skate, ski, or play tennis. You’d think it had to do with lack of money but my father, the lone exception, grew up poorer than anyone, yet knew how to swim and skate. He learned to swim by being thrown by his buddies into New York City’s East River. I know. Amazing he was able to procreate after swimming in that toxic soup.

According to family legend, my mother sank like a stone when thrown into a local pool as a teenager and had to be pulled out ignominiously by the seat of her raggedy bathing suit. I have to assume being thrown into a body of water was a rite of passage back then. Lacking my father’s innate abilities, my mother was unfazed, and determined that I learn how to swim.

When teaching me by the side of the local pool didn’t pan out — “Kick your legs, and alternately stroke with your arms, taking a breath every other stroke!”– my mother scrimped to send me to a day camp specifically to learn to swim. I contracted a bad case of swimmer’s ear on day one and had to sit out pool time for the remaining two weeks.

Cutting her losses, my mother set her sights next on bike riding. Quickly she realized this kind of tutelage required a degree of coordination and strength far beyond her own. This was especially true when the child in question had no sense of balance. Someone was bound to get hurt.

My father finally managed to teach me how to ride without training wheels when I was eight, a feat akin to teaching Koko the gorilla American Sign Language. Soon after, I got bumped by a car when I attempted to cross the street between two parked cars. (Hey that’s how we rolled in the Bronx.) Lacking the self-preserving reflexes possessed by most humans, I failed to put my arms out to break my fall. For weeks I sported a grotesquely fat lip and lost the tooth I hit 10 years later.

Catholic school did not help me improve my athletic skills. The backs of my legs always sported welts from misadventures in jumping rope. Jumping-in eluded me and forget about Double Dutch. The dreaded dodge ball in gym was a little bit “Lord of the Flies” in terms of lax supervision and Piggy, I mean I, knowing neither how to throw nor to dodge, was often the worse for wear.

I found my people when I left the nuns and went to a “special” public high school with a concentration in science. You had to take a test to get in and it had nothing to do with physical fitness. Our most popular team was math team. My dodge ball days were over.

In college, there were two major obstacles for the non-athletic — the dreaded swim test and a gym requirement. The swim test, though well intentioned, was a source of severe anxiety to certain demographics. Namely, the poor, the foreign and the phobic. We had not learned to swim as children and could not believe we had to do so now.

There was no choice but to take the introductory swim class. Yes, it was a bit like that rite of passage my parents endured. But at least it counted toward the mandatory gym credits. I found it was a major advantage not to be phobic and to have English as a first language. I actually learned to swim the required three strokes as well as tread water after jumping off the deep end, a feat never to be repeated.

I’m drawing a blank on how I managed the remaining college gym requirements This might have something to do with repeated head trauma sustained during introductory volleyball — I couldn’t help closing my eyes when the ball was in flight.

I know I tried to be more active during those four years. Inspired by a boyfriend at the time, I even attempted “jogging” for the first time. I barely got to half a mile before I had to sit down on the curb, out of breath and half suspecting I might be having a heart attack.

Fast forward 25 years or so. My daughter joins the cross country team her first year of high school. Inspired by a not well-received wish to show solidarity, I start to run. And I like it. I took it slow and was gratified to find that my prior life of sloth left me pristine knees and hips compared to experienced runners.

I started doing some races. Controverting popular running wisdom, I began with a very hilly 10 K and finished (that alone was my goal) in a little over an hour. The vomiting at mile 3 was just an added bonus. Running became my way to relieve stress, to think, and to keep middle age weight gain under control while still eating (and drinking) what I wanted. This past summer, I toyed with the idea of a half-marathon and upped my distances, getting to 12 miles.

I felt strong and fit. Clearly I was overconfident. Ran perhaps more than I should have one weekend with friends who were marathoners. Or maybe it was the neon Easter-egg colored minimalist shoes that didn’t give enough support but were so cute. The next time I ran, I felt this searing pain in my heel about 2 miles in that would not permit me to continue my run. I hobbled home.

Plantar fasciitis (PF). Once thought to be an inflammatory condition, currently the etiology was being debated. There was no consensus on best treatments. It depended somewhat on whether you consulted a podiatrist or sports medicine orthopedist, how far you were willing to go (injections of platelet rich plasma, anyone?), and how much you were willing to pay.

As a health care provider, I tried what the literature suggested and what I in turn had suggested to my patients. Non-steroidal anti-inflammatories and prednisone, an oral steroid, didn’t help, which gave credence to the latest thinking that PF might not be an inflammatory response to injury. I did all the proscribed stretching exercises daily. I took up yoga again. (Downward dog is the perfect stretch for plantar fasciitis.) Decided to eschew steroid injections based on my research and orthotics based on prior bad experience.

I believed the cause in my case was a sprained ankle about six weeks prior that I ran on too soon. The ankle was weak and threw off my gait. So I started cross training at the gym to build up strength. Faithfully stretched, used a foam roller and massaged my foot with a frozen rubber ball daily. Wore the snazzy Strasburg sock at night (https://www.amazon.com/strassburg-sock).  Got fitted for more supportive (albeit slightly less cute) shoes at a running store.

Almost six months later, it is definitely getting better. Some days I have no pain at all. I can run four miles outdoors, five on the treadmill with minimal discomfort. I’m back, baby.

I often wonder what my mother would have made of this newfound running obsession and my recent struggles. She wouldn’t have understood it but she would have put her two cents in. “Propel yourself forward while swinging your arms,” she might have called out, undeterred as always by her lack of personal experience. “Shorten your stride and increase your cadence. And don’t forget to stretch.”

Thanks, Mom. I think I got this.

#plantarfasciitis #RunningInjuries, #unathletic, #HobbledNoMore #RockingThatStrassburg Sock

 

Skin Stuff: or, Yellow Salve Revisited

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This is one of my more clinical posts, addressing common skin disorders. If you are interested, feel free to suggest more topics in the comments section.

Cold Sores

As a small child, I developed what our local GP called impetigo on my lips. My mother put this yellow salve on it. I still remember its slightly sweet taste and grainy consistency. I couldn’t stop licking it off.  Salve – it’s such a medieval-sounding name. I’ve not sure if she got it by RX or if it was something the pharmacist just whipped up.  As I remember, it did nothing but dry out the lesions which took about a week to go away. (If you look online for yellow salve, it seems to be making a comeback as an alternative treatment, but I’m not sure it’s targeted towards cold sores or even whether it is indeed the same yellow salve.) Trouble was, this wasn’t impetigo, it was herpes labialis, or your common cold sore.  Kids can develop this in infancy, often by being kissed by someone infected, or contact with the lesions of a playmate. It’s caused by a virus related to chicken pox and shingles, hence the blisters, and has cycles of dormancy and recurrence. It can be brought on by illness, i.e., a cold, stress, or too much sun. If you’ve had it, you become hypervigilant about the first sign of a tingle, the harbinger or “prodrome,” as we say in the biz, of an outbreak.  Best way to diagnose it is through a viral culture. If the clinical presentation is not obvious, I do both a bacterial and viral culture and see what grows out. Treatment has come a long way, and if begun at that first tingle, goes a long way towards stopping a full-blown outbreak which can be very painful, disfiguring, and embarrassing.

For adults, I prescribe valacyclovir (generic Valtrex), the huge 1000 mg lozenge-shaped pills. Take two of them at the first sign and then another two 12 hours later.  So four should treat an outbreak, which is a good thing because they are very expensive, over $10 per pill. Insurers prefer the cheaper anti-viral, acyclovir, which does not work nearly as well.   I also recommend OTC Abreva (www.abreva.com), a cream that can be applied as often as you like. Since it is white, you might want to save this for when you are not out in public.  You can also buy an OTC clear lysine gel which you can use when you are out and about.  Why would you want these extra measures?  If you are already a cold sore sufferer, you know. Those lesions hurt and are unsightly, and you just want to do everything you can to make them go away.   Health care providers are not immune to this desire to overtreat their own outbreaks.  A dermatologist once told me she herself used a topical steroid cream to reduce inflammation.  This is controversial because a steroid can decrease immunological response. Her point was that a lot of the pain and swelling is caused by inflammation and the steroid addressed that.  If you are unlucky enough to suffer from cold sores, make sure you have your provider write you a script for the 1000 mg valacyclovir pills, maybe eight, with a lot of refills. And always carry two pills around with you.

Preventing Skin Cancer and the Problem of Vitamin D

What I (often) tell my kids about skin care is wear sunscreen every day, at least 30 SPF, limit exposure from 12-3pm, wear a hat and sunglasses when in bright sun, and get a yearly full body check by a dermatologist.  Some posit that this kind of vigilance against skin cancer – a good thing – has led to a widespread Vitamin D deficiency – a bad thing.

Vitamin D is a fat-soluble nutrient essential for calcium absorption, bone health, heart health and especially important for those with autoimmune diseases.  It has been advised to get at least 10 minutes of unprotected sunlight daily so your body can make vitamin D.  This is controversial because of the association of sun exposure with skin cancer. Medicine is seldom black and white. We don’t know how much sunlight is safe, and most dermatologists will tell you, no amount is safe.  I always advise it’s best to get your vitamins through food in most cases, although that’s difficult with vitamin D. Web MD lists food sources of vitamin D: http://www.webmd.com/osteoporosis/features/the-truth-about-vitamin-d-vitamin-d-food-sources), some of which include fortified foods (where the vitamin is added). For a while, most primary care providers were checking vitamin D levels as part of regular screening blood work. You might recall lots of people were deemed deficient and were advised to take megadoses for a period of time. (I was shown to be mildly deficient but chose not to do this. Not a fan of megadoses of anything.)  Now the USPSTF (United States Preventative Services Task Force) recommends against this screening, citing there is not enough information to assess benefits vs harm in testing of adults without symptoms.

Acne

When teens are just breaking out a little bit, simple solutions are the best.  I tell them: don’t overwash, and use a mild cleanser like Cetaphil (www.cetaphil.com). Don’t scrub or use harsh astringents. First try benzoyl peroxide cream (Clearasil: www.clearasil.com) applied to the zits at night. Takes about six weeks to see results, so be patient.  Next step is adding a prescription antibiotic cream, like clindamycin, and mixing the two together. There are premixed creams such as Duac and Benzaclin but insurers are getting less inclined to pay for them.  Some people do well with Differin (www.differin.com) which is a retinoid, similar in the way it works to Accutane or Retin A, but milder, and with fewer side effects. Now you can buy it over the counter. After topical creams, providers try six-week courses of oral antibiotics such as doxycycline, minocycline, or azithromycin. These can work well, but like all antibiotics, they have potential side effects. If the RX topical treatments are not working after six weeks, I recommend seeing a dermatologist.

Diaper Rash

Diaper dermatitis happens to all babies at one time or another, usually after a bout of diarrhea.  At home, treatment is frequent diaper changes, using a diaper balm, allowing the area to air-dry when feasible.  Sometimes, though, the rash is severe, beefy-red, causing obvious discomfort. This is when your child should be seen by a provider. Often, when it gets this severe, there is a fungal component. Usually I can see the rash is deep red, with small affected areas in addition to the main one, called “satellite lesions”.  I prescribe the anti-fungal nystatin cream, and sometimes a steroid cream as well if there is particular discomfort. I advise using the nystatin after each diaper change for 3 days, cleaning with warm water instead of wipes, exposing the diaper area to air as much as is possible.  Not too often, but sometimes, the problem is a bacterial infection, the impetigo I mentioned in the beginning of this post.  In the diaper area, it can manifest with rather large blisters and is called bullous impetigo (which can also appear in other places).  The treatment is antibiotics, usually oral if a large area is affected.

Eczema

Eczema or atopic dermatitis, usually starts in infancy, manifesting as rough dry, reddish patches which can be itchy. It can be mild or severe and is an allergic response to the environment or food and linked to other allergic disorders, such as asthma.  Severe cases are very itchy and can result in secondary bacterial infections from scratching.  Steroid creams are used to treat the outbreak but prevention is best and here’s why: steroids can adversely change the appearance and texture of the skin, making it thinner and at times, darker, which can be permanent, if used for more than two weeks, twice a day.  At times parents need to be educated about this because the steroid cream works so well, they want to use it all the time to keep their child comfortable. If the steroids aren’t helping, there are newer topical meds, such as Elidel and others in this class, approved for children over two years old. At this point, though, I advise having the child seen by a dermatologist. There have been some safety concerns about these newer drugs, including a possible link to certain cancers, but nothing has been proven at this point.

For prevention, I advise only using mild unscented soap, such as Dove for sensitive skin (www.Dove.com), every other day, washing with only water on the days in between. Moisturizing is key. A&D ointment works very well, but some people dislike the rather medicinal smell; others actually prefer it because it makes it seem more like a healing medication. Also good is Aquaphor (www.aquaphorUS.com) or plain old petroleum jelly, which is basically the same thing. The good news is you can use these ointments as much as you want (or can stand, since they can be messy). A little goes a long way. The problem with scented baby oils or lotions is that the scent itself can cause an allergic reaction. Also important is using a detergent for bedding, towels and clothing that is free of perfume and dyes and not using dryer sheets, which can cause a reaction to predisposed people.  If you notice you or your child has an outbreak following a certain food, cut it out. You can get allergy testing down the road but most allergists prefer to wait until children are aged three or older.

There are plenty more skin conditions that could be addressed, but I will stop here. If you have any skin topics you’d like me to cover (or any other clinical topics), put your suggestions for future topics in the comments section below.  No promises, though, and please, no personal medical queries – see your own provider for that.  If you prefer more “Tales From the Clinic” patient stories,  let me know that too.

 

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)

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.