Tuesday, January 25, 2011

Be Your Own Strongest Patient Advocate

Within the U.S. population, 50% of all Americans have a chronic medical condition, whether that is diabetes, high blood pressure, high cholesterol, obesity, asthma, or another health condition.  Patients need to become their own strongest patient advocate for their own health concerns, if they are to have the highest benefit from their medical provider visits, the medications they take and the lifestyle changes they are trying to incorporate. 

But how do patients do this?  How do they become their own patient advocate?  First they need to become educated about their own disease.  Patients can help themselves by using the internet to acquire health information on their disease and information on how to deal with it, as well as the necessary lifestyle changes that should occur.  But patients need to know which internet websites are reliable and which ones are not.  Not all websites are created equal and have solid medical information on them for patients.  Some of the most reliable ones are: www.webmd.com, www.mayoclinic.org, http://health.nih.gov, or www.clevelandclinic.org. 

Patients also need to know the side effects of the medications they are on.  This will allow them to know and understand what to expect, when to contact their physician about a medication side effect which needs to be addressed and when they can ignore it. 

Patients need to see their primary care provider on a regular basis for the best management of their disease process.  They need to interact, ask questions and become a team member with their provider regarding how to best deal with their chronic condition.  Patients need to be an active participant in the process. 

Another way of becoming your best patient advocate is by acquiring your preventive care on a timely basis.  Is it time for you to receive your colonoscopy, your mammogram, your pap smear, your prostate exam, for instance.  If it is, make that appointment and keep it.  If you need a tool to see what preventive care you are due for do a internet search for ‘preventive health care’ and you will find several websites which will list out for you the recommended preventive health screenings which should be done at the various stages during the adult lifespan. 

Know your family genetic history.  There is important information here.  Did either of your grandparents die of colon cancer, or breast cancer?  Is there heart disease in the family, if so, what kind?  Is there high blood pressure in the family genes?  Is there diabetes or asthma?  All of these you need to know about and tell your primary care provider about.  They can then help you determine whether you need to be screened for them and if so, when. 

Lastly, patients can become their own strongest patient advocate even on a daily basis.  They can do this by caring about themselves and their family members.  Patients can stop smoking, start exercising, lose the excess weight, change their diet to include more fruits and vegetables, decrease their saturated fat intake as well as their red meat intake.  To help yourself lose weight, keep a food journal.  Patients can deal with the stressors in their life, and get the recommended sleep per night. 

Overall, take small steps to change your life and become the strongest patient advocate you can.  Take consistent steps towards a better you, a more healthful you.  Be persistent.  If at first you don’t succeed, don’t give up.  Keep at it, you will make it if you just keep putting one foot in front of the other towards your goal.  Remember, in the end, you and your family will both benefit. 

Saturday, January 22, 2011

Fractured Medical Care



Medical care has become very fractured, as of late.  Patients are not seeing their primary care physicians for treatment of their ailments like they used to.  They are circumventing their primary care physician and going straight to the specialists for care that in some cases the primary care physician is quite capable of handling and at a lower cost to the patient. 
But cost is not the only issue to think about.  Patients need to remember that for them to have an effective patient/physician relationship, these sorts of relationships are not formed overnight.  It takes time to form a comfortable relationship with a primary care physician.  It takes time for the physician to come to know who you are, what you are about, what your preferences are for medical care, what your family is about, or what sort of family genes you could be dealing with which would necessitate a closer follow-up, or preventive care measures.  He/she doesn’t learn this in just one clinic visit, it is typically done over several years. 
And it is this comfort level that lends itself to a patient and their primary care physician feeling at ease and being willing to discuss some hard issues when the time arises, such as end of life decisions, referral for surgery or no surgery, aggressive treatment or comfort care, giving emotional support and encouragement to see a counselor over grief from a miscarriage or loss of a spouse, for instance.  When a patient and a primary care physician have a long standing professional relationship it can lead to less misunderstanding of what they physician is saying, or not saying and an intuitive knowledge that the physician is really on the patient’s side and trying to help.
And if patients would allow their primary care physicians to refer them out to the specialists when needed, this will also facilitate better follow-up care for the patient after they have seen the specialist.  This is due to the primary care physician receiving a follow-up letter from the specialist outlining what needs to be done and by whom. 
Patients need to have an understanding of this when they make their medical appointments with other providers. 
If patients would make their medical appointments and allow their primary care physicians to be involved in their care, over time they are going to find that they are happier with their medical care, as are their physicians.  Primary care physicians truly want to be the person of first contact, the one who provides medical care for acute and chronic medical conditions for their patients.  Patients can help to facilitate this partnership they have with their primary care physician by allowing their primary care to refer them out to specialists when necessary and then they can coordinate this care over the long-term.   
Yes, I realize there are circumstances where patients are unable to make appointments with their primary care physicians for an acute problem.  I also realize that there are women who would prefer having an OB/Gyn see them for their obstetrical and/or gynecology care.  Those are real concerns and real reasons for not seeing the primary care physician.
But what of your chronic condition of high blood pressure, or abnormal blood lipids, or your urinary tract infection, or your needing to lose weight, or your follow-up for diabetes?  Is there a reason to see someone else than your primary care physician for these visits?  Your primary care physician, to be most effective, and most able to help you in your medical care, needs to be involved in your care, needs to be the one that sees you, if at all possible. 
You, as a patient can most help yourself by seeing your primary care physician for almost all of your medical needs, if not all.  Don’t fracture off your care and see an orthopedic surgeon for an ankle sprain, a retail clinic provider for a upper respiratory infection, or a urinary tract infection, an allergist for your seasonal allergies, and a dermatologist for your skin rash.
You, as a patient are not only fracturing your medical care by seeing different providers but you are also taking a risk that these providers could give you different medications which you could have a drug reaction to, or suffer a side effect from.  Your primary care physician will know which medications you are allergic to, which medications you are on and will know which medications to avoid with you. 
Your primary care physician will also know if you come into the clinic with a urinary tract infection (for instance) that it is related to the urinary tract stone you had six months ago and he/she can re-order an urinalysis to assess for fluid status, and urinary calcium.  Fracturing your medical care by seeing different providers would not lend itself to having this work-up done, for instance.
Help yourself, by helping your primary care physician help you.  Facilitate this all so important relationship with your primary care physician, you’ll be glad you did.    



Thursday, January 20, 2011

The Purpose of Wives

I was working as a PA in an internal medicine office seeing out-patients.  One afternoon I was in the clinic hallway when I saw an elderly looking wife in her 60s pushing her husband who had dug his heels into the clinic tile floor and was trying to resist her from getting him into the next open exam room.  She finally won due to her husband’s obvious shortness of breath and noticeable wheezing I heard as they passed by me. 
I proceeded to go into see my next patient, keeping an ear cocked to any sounds coming from the clinic hallway which might portend some trouble coming from the next exam room with the husband’s shortness of breath/wheezing episode.  I quickly took care of my patient who had strep throat, gave them their antibiotics and walked into the adjacent exam room with the wheezing husband. 
The medical assistant gave me his vital signs, his pulse oximetry showed his oxygen saturation was 90, his pulse was 94, blood pressure was normal, respirations were 22.  A quick look at him told me he wasn’t using any of his accessory chest muscles to breath with.  I asked the medical assistant to go and get the nebulizer set up with an albuterol treatment and bring it into the exam room. 
As she left to go retrieve the equipment, I asked the husband, whose name was Bill what brought him into the clinic.  Bill, who was quietly sitting on the exam table told me, “ask her” pointing at his wife who was now sitting in one the exam room chairs. 
I turned to her to see an exasperated, angry stern look on his wife’s face.   She quickly told me, “He’s been wheezing since this morning and he refused to make an appointment to come into be seen.  He was coughing last night.  He has asthma, but he doesn’t always take his medicine for it.  I told him to take his advair this morning, but he said he didn’t need it.  Then he started wheezing about an hour later.  But he still wouldn’t take his inhaler.  At times, he’s too stubborn for his own good.   That’s why I called up this morning and got this appointment for him.  He needs help!”
“I see.”  Turning to Bill I asked him, “how long have you had asthma?”
Bill slowly wheezed out an answer, “About 40 years, I came down with it during college.”  

Asthma is a disease that is caused by chronic inflammation of the airways which causes airway constriction and subsequent problems with breathing.  Patients typically have shortness of breath, coughing, wheezing, and/or chest tightness.  It is a common chronic condition found in 5% of all patients. 
It is caused by a hyperresponsiveness to an allergen, exposure to occupational smoke, viral infections, or can be exercise induced.  It is generally believed to have a genetic basis to it, with multiple genes involved.  Most patients are diagnosed with it when they are a child, although some patients are diagnosed when they are an adult.
 
Just then the medical assistant came back into the exam room with all of the necessary equipment for an albuterol nebulizer treatment.  The two of us quickly set it up and I handed Bill the breathing apparatus end of the tubing, what I commonly called the ‘peace pipe.’
He sat there for a few minutes breathing in the nebulized albuterol as I listened to his lungs through his chest wall with my stethoscope.  His wheezing was slowly becoming becoming less and he was able to breathe a little bit better.  His pulse oximetry showed his pulse to be 96 and his pulse oximetry oxygen level was 92.  I gave him a peak flow meter to breath into a few times so that I could get a result as to how much airway obstruction he had.  The peak flow meter showed he was at 400 when he should have been at 580, due to his tall stature.   
“Okay, when was the last time you used your inhalers?”
“I used my ventolin inhaler last night.  I haven’t needed to use the advair inhaler, so I quit using it about two weeks ago.”
With that, his wife almost came unglued.  Her eyes became fiery and she accusingly said to Bill, “you quit taking your advair inhaler?  No wonder you’re so bad.  When are you going to learn that you don’t stop your maintenance medications just because you’re feeling alright?”
Bill with a look of meekness on his face replied, “I only take the advair when I think I need it, I don’t need to take it every day.”
His wife was not going to let up on him.  “You take the advair every day whether you think you need it or not.  It’s what keeps your airways open and allows you to breathe normally.  It’s what keeps you out of the doctor’s office like today.  When are you finally going to admit that you need that medication?”
Bill didn’t have a reply and he just sat quietly on the exam table. 

Asthma is typically treated with inhalers.  Ventolin is the first medication tried.  It is a short acting albuterol, which dilates the airways.  If patients need additional help then they are started on a long acting bronchodilator and an inhaled steroid.  If they still need additional help above this then they are generally referred to a pulmonary specialist who can assess them for the possibility of being put on the latest medication for asthma, a monoclonal antibody against IgE, which patients who have an allergy component of their disease respond to quite well. 

As this conversation was going on around me I quietly sat at the exam room table and started to type in my clinic note into the electronic medical record.  I asked the medical assistant to go and get one of the pharmaceutical samples of advair out of the closet.  I wanted to give him a treatment of a long acting albuterol and a long acting inhaled steroid.  She came back into the exam room with it and I handed it to Bill to use, which he did. 
“Okay, now that you’re breathing better, I need to ask you a few more questions, Bill.”
“Sure, fire away.”
“Have you had any fevers, or any upper respiratory symptoms during the past week or so that could be making your asthma act up?”
“No.”
“Any change in your exercise tolerance during the past two weeks since stopping your advair?”
With that he looked at his wife and meekly answered, “yes.”
At this point I could well imagine claws beginning to grow out of Bill’s wife’s fingers as she sat there with an angry look on her face. 
“How has your exercise tolerance been affected?”
“I haven’t been able to do my usual 18 rounds of golf and walk besides the caddy, I’ve had to ride in the golf cart instead, from one hole to the next.”
“Okay, well I don’t think I need to go into why you need to stay on your advair medication twice a day, do I?”
“No.”
“Alright, well then let me finish doing my physical exam, I’ll listen to your chest again and your heart.”
With that I completed my physical exam, his lung sounds were clearing up, his wheezing was less. 
“You have a peak flow meter at home, correct?”
“Yes.”
“Am I to assume that you know how to use it and write down your readings every day?”
“I know how to use it.”
“Good. Then what I want you to do is use your peak flow meter at home every day, write down your readings and come back in and be seen in two weeks.  I want you to use your advair every day whether you think you need it or not.  Agreed?”
“Okay.”
I looked over at his wife who was slowly calming down.  I knew once she got Bill home he was going to end up hearing yet another tirade from her about his not taking his medications the way they were prescribed.
“Do you need a refill of your ventolin inhaler?”
“No, I’m fine with that.”
“Then I’ll see you in two weeks.”

There are many ways to assess the severity of asthma.  You can use a pulse oximetry, which is easy to put on the patient’s finger, and it gives you their pulse as well as their oxygen saturation.  You can use a peak flow meter which gives you a reading anywhere from 200 to 650.  Based on the patient’s height you can then correlate this to what the patient should be expiring with each breath.  80% or higher of what is expected is considered the ‘green zone’, 50-79% of the patient’s expected expiratory volume is considered the ‘yellow zone’, and below 50% is considered the ‘red zone’ with the patient typically needing to be hospitalized. 
Physician’s offices also have spirometry machines which the patients can use.  This gives the physician a reading of the patient’ forced expiratory volumes.  Patients can also be tested for potential allergens which is setting off their asthma is the physician thinks that this is playing a role.

Two weeks later Bill kept his appointment.  I walked into the exam room to see a calm appearing wife sitting in the exam room chair and Bill sitting on the exam room table breathing easily with no audible wheezing or shortness of breath.
“Well, I’m glad to see the two of you again.  How’s your asthma been at home, Bill?”
“Much better.  Here’s my peak flow meter readings for you.”
I took at look at his readings and I was impressed.   On day one after seeing us his peak flow meter showed that he was at 400, over the next several days his peak flow meter slowly went from 400 up to 450.  During the last few days his peak flow meter showed that he was at 500 and staying there. 
“I’m impressed by your readings.  You’re staying in the green zone by keeping your peak flow readings above 465.  You must be feeling better and breathing a whole lot easier I would assume.”
“Yes.”
 Okay, well I see here that the medical assistant got your pulse oximetry reading and your oxygen saturation is at 95% and your pulse is at 80.  That’s wonderful, I’m glad to see that.  Let me listen to your chest and make sure there’s no wheezing going on and then I’ll sit down with you and we’ll come up with a workable plan for you to deal with your asthma at home, okay?”
“Alright.”
I listened to his lungs and they were totally clear.  I sat down and explained to him about what the peak flow meter readings told us about the condition of his asthma.  He agreed with me to take his peak flow meter reading once a day and to take or not take his advair medication based on his reading.  If his reading was below 475 or lower he was to take his advair as prescribed for the day.  If his peak flow meter reading was 476 or higher then he could decide whether he wanted to take or not take the advair.  This way he had control over his asthma treatment and could manage it more effectively without asking himself, am I wheezing or not today?  He was to continue to use his albuterol inhaler as a rescue inhaler and only when he needed it for short term relief. 
Bill seemed pleased to be able to self manage his asthma at home with the meter.  It gave him a number to strive for and it would also allow his wife to know what the condition of his asthma was for the day without having to ‘nag’ him into taking his meds. 
Hopefully this would work for him. 
“Alright, if you have any problems at home, you call us, agreed?”
“Agreed.”
“Good, then I’ll see you in two months.  Bring your peak flow readings with you.”

I had seen this scenario played out many times in my years of working in clinical medicine.  It was typically the man who refused to be seen by a physician or admit that he was ill and needed help.  It would be the wife or significant other who would drag their spouse into the clinic office to be seen and taken care of.  I had seen it happen with men who had asthma, rectal bleeding, acid reflux, hypertension, etc (they would stop their blood pressure meds because they didn’t think they needed them, hence the name ‘silent killer.’).  
On the whole, male patients believed that they were ‘okay’ and nothing would happen to them.  They would refuse to admit that they needed help.  And refusing to get help can be a killer, men dying of heart disease because they refuse to admit that they have been having chest discomfort, men dying of colon cancer because they refused to be seen for rectal bleeding, etc. 
If it wasn’t for the wives in the picture, men’s health suffers.  It’s the wives who bring their male companions into to be seen and taken care of.  It’s the wives who make the doctor’s appointments and then make sure their spouses keep them.  It’s generally the wives who keep the men in their lives on track about their health and watch out for what they are eating, whether they are exercising, etc.  Thank goodness for wives!

Sunday, January 16, 2011

A College Student's Freedom


I was doing some locums work in a college student health center, filling in for one of the other providers who was on maternity leave.  I picked up the next patient chart to see that it was a returning patient who had just had a LEEP procedure 4 weeks before by the visiting gynecologist.   
Her chart said that she needed to be seen for a possible urinary tract infection.  I knocked on the door and then went in and introduced myself.
“Hi, I’m Sharon, I’m one of the physician assistants who works in this clinic, and you’re Beth?”
“Yes.”
“You’re 22, is that correct?”
“That’s right.”
“It says here on your intake sheet that you think you have another urinary tract infection. What are your symptoms?”
“Well my boyfriend and I had sex the other night.  I woke up two days ago and started having a feeling of burning when I urinated.  So I knew what that meant and I started drinking cranberry juice.  That helped a little bit, but by this morning I was having to go to the bathroom a lot and my urine now has a strong smell to it.  So I know this means that I probably have another urinary tract infection and I need antibiotics for it.”

Urinary tract infections in women is quite common.  Women usually come down with them after they have had a sexual encounter, or had a gynecology procedure done with instrumentation.  It also occurs in women who are pregnant, or who have diabetes, are immunocompromised (due to receiving cancer chemotherapy for instance), or who are  using a diaphragm or spermicide for their birth control.  Women are at risk for urinary tract infections due to the short length of their urethra and the tendency of E. coli to be able to adhere to the urethral lining. 

Whereas, in men, a urinary tract infection is quite unusual.  They generally get them if they have an anatomical abnormality, or have just received a urological procedure. 

Usual symptoms include increased need to use the restroom, urgency to use the restroom, strong smell to the urine, burning or pain with urination, midline lower pelvic pain, back pain, fevers, or nausea/vomiting. 

“Okay, I see, are you having any fevers, back pain or pelvic pain?”
“No, I’m not having any fevers.  I do have some discomfort over my lower pelvis though, right here.”  As she stated this, she put her hand over her lower pelvis where her bladder would be. 
“Any other symptoms, such as nausea, vomiting, or diarrhea?”
“No.”
“Are you taking any prescriptive medications?”
“Yes, I’m on birth control pills.”
“Okay, well you probably know the routine.  I need you to sit up here on the exam table and let me listen to your lungs, heart and feel your abdomen.  Then I’ll send you off to the lab for a urinalysis.”
“Alright.”
 I listened to Beth’s heart and lung sounds.  They were normal.  I then palpated both sides of her back to see whether she had any costovertebral tenderness, which she did not. 
“Okay, Beth now I need you to lay down for me so I can do an abdominal exam on you.”
“Alright.”
I listened to her bowel sounds and then palpated her abdomen.  As I was palpating over her bladder, Beth spoke up and said, “that’s uncomfortable.”
“Okay, well I’m done.  You can sit up now.”
I gave her the lap slip to have the urinalysis done and sent her down the clinic hallway.
While she was gone it gave me a few minutes to quickly review her chart.  Her problem list included frequent urinary tract infections, having had four in the past year.  The LEEP procedure was done just 4 weeks ago due to cervical changes consistent with CIN (cervical intra-epithelial lesions).  Her pathology had come back as a high grade CIN stage 3.  Her LEEP procedure had removed the better portion of her cervix, as well as the surrounding tissue.  If and when she ever decided to get pregnant she would have to deal with an incompetent cervix, which would mean her OB/Gyn would have to tie it closed until she was ready to deliver her child. 
She would also require close gynecology follow-up after she graduated this semester, so unless she had a position straight out of school with health insurance she was going to end up falling through the cracks. 

Having acquired their freedom from their parent’s restraint while they lived at home, many students find themselves lost in the maze of possibilities while in college.  Not only do they now have time to explore their own sexuality in an unrestrained manner, they have access to alcohol and other mind altering drugs. 

Many students just don’t know what to do with all of this new found freedom.  There are too many tempting items within their view: parties, staying out all night, boozing up, binge drinking, and having sex. 

Due to their unrestrained behaviors at times, even though many students end up leaving their college days behind them, unfortunately they don’t leave the consequences of their behaviors behind them.  They take with them their sexually transmitted diseases (HIV, gonorrhea, chlaymydia for instance).  They take with them their alcoholic tendencies, and what’s worse is that women can also take with them cervical cancer due to acquiring the human papilloma virus.  Based on how their cervical cancer is treated, the women can have obstetrical problems later on, such as an incompetent cervix. 

There are many ways to treat cervical intraepithelial neoplasia (CIN).  Patient’s are first diagnosed with CIN from their pap smear.  Once the pap smear results are known (which typically shows atypical cells, inflammatory cells) then the patient is brought back to have a cervical cone biopsy done.  This is a procedure where a small amount of cervical tissue is stained with vinegar which then turns the abnormal cells white.  The gynecologist then removes these cells by doing a cone biopsy. 
The cells are sent off for the pathologist to look at them under the microscope.  He determines how atypical the cells are and whether there is the presence of human papilloma virus. 
Based on these results the patient is then seen again to determine treatment.  They can either receive ablative therapy (laser or cryotherapy) or excisional therapy (LEEP: loop electro procedure).  After the patient has their definitive treatment, they are then seen every six months for the next year to determine whether there is any evidence of relapse. 
Within the past few years a vaccine has become available for adolescents to receive.  The vaccine is called Gardisil.  It protects against the patient acquiring human papilloma virus.  It has to be given in multiple injections but its benefit are tremendous.  It will end up sparing many, many women from having to undergo cervical cancer treatment because it will treat the root cause: HPV. 

Just about then, Beth knocked on the exam room door and handed me the completed lab slip with her urinalysis results.  
Her urinalysis showed that she did indeed have a urinary tract infection.  She had 3+ leucocytes on it, positive nitrates, small amount of protein, and a moderate amount of red blood cells. 
“Well, Beth you were correct. You do indeed have a urinary tract infection.  What antibiotic have you been put on in the past which has worked for you?”
“I think I was put on Cipro about 3 months ago when I had my last one.  It worked for me.”
“Okay, well seeing that you have quite a few white blood cells present (leucocytes) I’m going to give you a Cipro script which I need you to take for one full week, twice a day, okay?”
“Okay, not a problem.”
“You can also take some azole which comes over the counter and turns your urine orange.  Most women like it because it helps with the discomfort during the first 24 hours until the antibiotic has had time to do it’s work.  You also need to be drinking lots of fluids to flush out your bladder and continue with the cranberry juice, that will help to acidify your urine which the bacteria don’t like.”
“But you probably already know all of this information seeing that you’ve had several urinary tract infections before.”
“Yeah, I know the routine.”

Typically the causative agent for a urinary tract infection is E. coli (80% of the time).  Most women are able to take one of 3 antibiotics for it.  Ciprofloxacin works very well as does Bactrim and Macrobid.  Based on the extent of the infection patients can be treated for 3 days or 7 days. 
Many patients are given antibiotics as a prophylaxis against their acquiring another infection.  They are given instructions on what to look out for and how to take the antibiotics.  If they are trained correctly, this approach can work very well for them.
    
“I see that you’re going to graduate in 2 months.  What are your plans after your leave school?”
“I’ve just been given a contract to teach junior high science out at the Fairfield School District.” 
“Well that’s nice to hear.  So you’ll be able to do your follow-up exams for your cervical cancer I hope?”
“Yes, Dr. Brown told me that I had to have regular exams every 6 months for at least the next year.   He told me that I had to get a copy of my record though so that I can give it to the OB/Gyn whom I decide to see.  How do I go about doing that?”
“All you have to do is go out to the receptionist desk and ask her for the ‘release of information form.’  Fill it out and then give it back to her.  You can then come in tomorrow and she will have copied what portion of your record you will need to take with you.”
“Oh, great, thanks for the information.”
“You’re welcome and I wish you the best.”

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INTRODUCTION/DISCLAIMER

Hello, welcome to my blog about medicine.  I’ve written it for all of the various laypeople out there who need solid information on how to be the best patient advocate they can be for their family members as well as for themselves. 
At no time do I want you (my reader) to assume that the medical information contained in these real patient encounters are meant for you.  Please take the time to discuss any information contained in these stories with your physician or medical provider.  Only with their help can you determine what the best route is for you to take in addressing your own personal health issues.
Please know that I have never used the patient’s real names or given away the locations of the clinics/hospitals I saw them in.  All of the stories are real patients I’ve seen, real scenarios that happened with real endings.   I’ve written about the most interesting, informative patient encounters I’ve been involved in over more than 20 years and counting of being involved in clinical medicine as a physician assistant.  Hopefully this will also allow you to understand what a physician assistant is and what we are capable of doing.  We are as close to being a physician as we can be, without being one, our typical medical training involves an undergraduate degree with 3 additional years of graduate training. 
I hope you enjoy reading the stories, learn from them and use the information contained herein to help you become a better patient advocate for yourself and/or your family members and friends. 
I wish you the best,
Sharon


A College Student's Reticence

I was working in a student health center of an urban university campus when I walked into a exam room and was greeted by a 25 year old male patient and his girlfriend. 
Directing my attention towards the young man, I asked, “So what brings you in?”
The patient, whom I’ll call Rick, stammered and finally spoke, “my girlfriend says that she feels something ‘down there’ and she insisted on my coming in.”
“I see.” 
I turned towards his girlfriend and asked her, “what exactly are you feeling?”
She said, “Rick has something in his testicle on his right side, it’s rather large and round.”
“Okay.  Are you having any symptoms whatsoever, Rick?  In other words, any change in your urination, any pain, any blood in your urine?”
“No, I don’t have any of those symptoms, in fact I wouldn’t  be here if it wasn’t on the account of my girlfriend here.  I’m not having any problems at all.”
‘Alright.  Do you take any medications or have any allergies to medications?”
“No.”
“Anything in your past medical history, such as allergies, asthma or anything else?”
“No, I’m perfectly fine.”
“What’s in your family history, any diabetes, high blood pressure, cancer, heart disease?”
“Yeah, my Dad has high blood pressure and my grandfather died of a heart attack.”
“Okay, well then why don’t you sit up on the exam table and let me listen to your lungs, heart and do an abdominal exam on you first.  Then you’ll have to drop your drawers so that I can do a thorough exam of your testicles.”
With a grumble under his breath, he moved over to the exam table and sat down.
I listened to his lungs, heart and then did a thorough abdominal exam on him.  Everything was normal so far.  I then turned around to the girlfriend and asked her to leave the room while I did Rick’s testicular exam. 
“Okay, now that she’s out of the room, Rick I need you to drop your drawers so that I can feel this mass she says you have.”  While he was complying with my request, I reached for a pair of exam gloves to put on.
I turned back around and with the patient in a standing position I felt both testicles.  The patient definitely had some sort of a mass in his R testicle that didn’t belong there.  It was above his testes below the spermatic cord.  It was round and non-tender. 
“I’m going to switch the exam room light off and then use my penlight to see whether I can make the penlight transilluminate it, in other words, will the light go through it?”
“Okay.”
I switched off the overhead exam room light and turned on my penlight.  Putting it next to his testicles I tried to illuminate the mass, but it wouldn’t allow the light to go through it.  That told me that the mass was solid, not cystic.  I also knew that because the mass was round and not marbled feeling that it wasn’t a conglomeration of blood vessels. 
My next move was to try to reduce it.  So I asked Rick to lie down on the exam table.  I tried to push the mass back up towards the spermatic chord and out of his testicle.  It wasn’t moving, so it was not reducible so that meant most likely that it wasn’t a hernia with incarcerated bowel involved.

Medical providers have been relatively good at teaching their female patients to do breast self-examinations, but were we’ve fallen down in doing appropriate patient education and instruction is with our young male patients.  Very few of them know and understand the importance of inspecting and feeling their own testes, making sure that they don’t have any new masses which have shown up.  Young male patients particularly don’t know they are at risk for testicular cancer as early as 15 years of age. 

It’s taken many, many years to bring breast cancer out of the closet and allow it to be spoken about.  We have Betty Ford and Happy Rockefeller to thank for that.  They brought it out in the open in about 1975.  But who can bring testicular cancer out of the closet?  Currently there is only one, Lance Armstrong.  We need more than just him to move awareness of this disease forward.  For it is a very treatable and curable disease. 
 
“You can get dressed now.  Do you want me to invite your girlfriend back in while I go through the next steps or leave her in the hallway?”
“I guess you can let her back in.”
I opened the exam room door and called for his girlfriend to come back in.  Once she was seated, I turned to Rick and said, ‘your girlfriend has done you a favor.  The round mass in your right testicle could not be illuminated, hence it is not a simple cyst.  I also could not reduce it, so it’s most likely not a hernia.  Additionally, because it lacks a marbling effect to it, it’s not a group of blood vessels.  So the one thing we are left with is that it could be testicular cancer.  You’re of the age range that testicular cancer attacks, between the ages of 15-25 and then again between the ages of 55-65.”
I went on “so with that said I need to refer you over to the University Medical Center and have the urology service see you. They will repeat the physical exam I just did on you as well as do an ultrasound.  After that they will schedule you for surgery. Based on your pathology report, urology will then schedule any necessary follow-ups.”
“Do you have any questions for me before I go out to the scheduling desk and call over to the urology service for your appointment?”
“So I did a good thing by making him come in here like I did?” asked Rick’s girlfriend.
“Yes, you did,”: I replied.
Rick’s face was pale, without words as he looked from his girlfriend and then back at me.  He was trying to digest the fact that he could have cancer which was probably unthinkable to him at the moment. 

Wives/girlfriends are so important to the health of their mates.  Men tend to shy away from seeing physicians for a myriad of reasons.  One of these is denial, another one is pride, and a third one is fear of revealing self to an unknown provider.  And this is where wives come into the picture.  They are the impetus for getting their male partners into be seen by a physician or medical provider.  I’ve seen many a wife drag, push or cajole her spouse into the exam rooms.  Many times it is the wife who tells me what is going on with her spouse, it’s not the husband. 

I left the exam room to schedule his appointment with the urology service over at University Medical Center.  I came back into the room to find Rick with a stoic facial appearance and his girlfriend quietly sitting in the chair.  I advised Rick of his upcoming appointment with the urology service and stressed to him that he couldn’t miss the appointment no matter what his school schedule was. 
I didn’t expect to hear anything further about Rick.  We typically didn’t receive any follow-up information on the patients we referred, but a week later I received a call from the urology resident who was seeing Rick in the clinic.  He wanted to tell me that I had done a bang-up job in working Rick up, sending over all of the clinic information on him and now he was being scheduled for his ultrasound and surgery.  Based on his exam it did indeed look like testicular cancer. 
“Can I ask a favor?”
“Okay, what is it?”
“When the surgical pathology report comes back can you please call me and tell me what it showed?”
“Sure, seeing that you are the referring service and did such a bang-up job, that’s the least I can do.  I’ll keep your phone number with me and when Rick’s pathology comes back I’ll give you a holler.”
“Thanks.”
Ten days later I received a return phone call from the urology resident regarding Rick’s pathology report. 
“You were right on the money, he’s got germ cell cancer, stage 1b, it was fully contained in the testes which we removed, all his nodes were negative.  So he is now cancer free.”
“Oh, that’s great news.  Thanks for calling.”

Cancer, that dreaded word.  But for a man having testicular cancer is unthinkable.  Their manhood is tied up in with their sexual function and size of their given male anatomy.  Yet, testicular cancer has one of the highest cure rates there is.  As with all cancers it is split into 4 stages according to how far it has spread. 

Stage one is where it is contained within the organ of origin.
Stage two is where it has spread to the local surrounding lymph nodes.
Stage three is where the cancer has spread to regional lymph nodes
Stage four is where the cancer has spread to other surrounding structures and generally has invaded major organs.

We as medical providers need to do better in regards to educating our patients about what to look for and when to seek medical care.  Preventive care needs to be at the forefront of our medical care.