Saying "yes"

One evening a few weeks ago, I attended the local Academy of Medicine meeting.  I was just inside the door taking my coat off when our executive director approached me.

"There's a news team here looking for someone to interview about the flu outbreak.  Could you help them?"

He went on to say that the news crew had been waiting for an Infectious Disease doc to walk through the door, but they were getting impatient.  Feeling my Family Medicine pride swell within me (along with the stage "ham" who can't resist a chance to perform), I said, "yes."

I have some definite workaholic tendencies, so I try to think about most requests for 24 hours before responding.  I've gotten better at saying "no" over the last few years, especially to projects that don't meet my own professional goals.

But the spontaneous "yes" moments in my life - those moments where my limbic system leapt ahead of the rest of my brain and I said "yes" with magnificent joy -  have all led to good things (my husband, my fellowship, my stage experiences).  In those moments, the "yes" erupted from a place so deep inside of me that I may never access it consciously.

Last night's "yes" definitely came from that same inaccessible place. As a family doc, I often feel like I am fighting a war against all of the mis-information that my patients come across.  They didn't go to medical school, and I know it's unfair to expect them to recognize Dr. Oz's propensity to recommend non-evidence based treatments or Jenny McCarthy's insane reasoning regarding vaccines.

Each of us in medicine can be part of the solution.  In my prior city, I contributed a short patient education column about every other month to a neighborhood paper.  I like to write, I like to stand up in front of people, and, most importantly, I like to promote Family Medicine and honest health information every chance I get.

And, if I convinced just one person watching the evening news last night to get a flu shot, it'll have been worth it.

The "annual pap exam" should be a relic

Early in 2012, I took myself to get my pap smear for the first time since moving here.  It was normal.  Yesterday, in the mail, I got a postcard reminding me that I was due for my "annual exam."  This postcard made me most unhappy.

In 2009, the American College of Obstetrics and Gynecology (ACOG) and The United States Preventive Service Task Force (USPSTF) advised docs that yearly screening for pap smears is unnecessary. (1) These recommendations were updated in 2012 to advise that pap smears every 3 years are sufficient to screen for cervical cancer. (2)

These changes are based on sound science.  The overwhelming majority of cervical cancer is caused by the Human Papilloma Virus (HPV).  Pretty much everyone who has sex will, at some point, be infected by this virus.(3) Most people's immune systems clear out the virus before it can damage any cells, though, which is one reason cervical cancer is rare despite HPV's ubiquity.  

Cervical cancer is an extremely slow-growing cancer, which is why the experts now recommend screening just every 3 years. (2)  Heck, if you're over thirty and the doc checks for HPV along with your pap and both are negative - voila! - you get a 5 year pass.

So, what do I do about this postcard?  I don't need another pap smear until 2015.*  There is no evidence-based reason to have a pelvic exam in the interim.  I am not overdue for any other health care needs.

My options at this point seem to be:

1. Ignore the card.  

2. Call the office and say, politely, that I actually don't need another pap smear until 2015.

3. Mail the postcard back along with a copy of the current ACOG and USPSTF guidelines.

In general, I prefer the direct approach, which makes option 1 (passive) and option 3 (passive-aggressive) distasteful.  On the other hand, I'm still pretty new in town, and it's not that big of a town, so I am fearful of igniting trouble with option 2.

I liked this office and doc when I went there, and I don't want to appear impertinent.  I should be willing to hear their side of things.  But science is science, and I want to share my side, too.  Which is that I will not, under any circumstances, submit to another pap smear before 2015.

Hand me the phone.

(1) http://bit.ly/TQApmE

(2) http://bit.ly/cyDcWj

(3) http://www.ashastd.org/std-sti/hpv/what-women-should-know.html

* I should have insisted on getting the HPV testing, too, and then it'd be 2017, but I was trying not to be a typical doctor-patient...

Funeral Homes

I'm always a little anxious during the drive to a funeral home to pay my final respects to a patient.

Last week, I took my first such trip since moving here, and the nerves returned. A paranoid voice inside me wondered, again, if someone at the viewing would blame me for their loved one's death.

Admittedly, this has never happened.  Family members are invariably appreciative of these visits, and I am often introduced proudly to multiple family members as "So-and-so's doctor." These new acquaintances then usually shake my hand or even hug me.  They sometimes express surprise that I am there (which makes me a little sad, since I was taught that attending patient viewings and/or funerals is a natural duty of the family physician and an important opportunity to say goodbye).

When a patient of mine dies unexpectedly, I usually comb through the chart, looking for any mistake I might have made.  It's a ridiculous compulsion based on the impossible idea that I am omnipotent enough to foresee every possible problem that might happen to my patients.  I'm not omnipotent, of course.  And, no matter how good of a doctor I am, all of my patients will eventually die of something.

But I always wonder - did I miss something?  And, I figure, if I'm wondering that, maybe my colleagues are. Or my patient's surviving family.

Overall, I consider myself reasonably comfortable with the end of life as a family doc.  I am disheartened when patients and/or families insist upon invasive, aggressive care that I know to be futile.  I've talked about hospice and end of life wishes with patients and families numerous times.  But, maybe, obsessively sifting through charts and worrying over what others think of me reveals that I'm not really that comfortable with death.  I am, frankly, ashamed of the hubris I must possess to assume that the end of a patient's life has much of anything to do with me at all.

Maybe that discomfort's not so bad, then; it certainly reminds me that I am only human myself.