Adult Guide: Health Screening and Prevention

Preface

This book was conceived after years of experience practicing medicine. My clinical interactions with patients, nurses, doctors, and medical personnel helped me recognize a need for a concise and informative treatise on disease screening and prevention for the general public. The public has at best only a fair knowledge of disease screening and prevention. This is because the information on screening is not readily available. Information on the internet is confusing and often inaccurate. The vast majority of citizens in our society have no knowledge what disease prevention guidelines have to offer them. Most patients have only a vague, and often an inaccurate knowledge of preventive medicine. Their knowledge, for example, on when to be screened for breast cancer or when to discontinue cervical cancer screening is frequently poor.

This book was designed to rectify the gap in knowledge between the public and the medical community. The work on this book began during my Internal Medicine residency in 1994, and continued throughout my fellowship training in gastroenterology at the Johns Hopkins University School of Medicine. It was conceived in one of the worst economic crisis and the most divisive turmoil in America’s politics and culture. The economy of the United States was in serious crisis. The health care costs in the United States had been rising steadily. The country was in recession. There is always only a finite limit of financial resources, and only a finite availability of professional resources this country can offer its citizens. There is a ceiling to how much health care the United States can offer its population. With losses of jobs and productivity, Americans could not finance health care for themselves and their families. Change had to come. President Barack Obama made it a high priority that all Americans have access to affordable health care. It is within this context that disease screening and preventive health care becomes crucial in saving health care costs.

In this era of steeply rising health care costs, the most effective way for our society to curb costs is to assure that its citizens undergo diligent and careful screening tests. The ultimate benefit of disease screening and early prevention is to the patients themselves. It is very important for everyone to understand that disease must be caught in the early stages. Colon and breast cancer if discovered too late, results in death within three to four years. Both colon and breast cancer caught early results in significantly improved survival, and probably near-normal life expectancy.

In order to help the general public understand the concepts of medicine, many complicated issues and definitions have been simplified in this book. This is to allow those with little knowledge of preventive medicine and screening to understand the principles of basic health care. To medically educated individuals, these may appear to reflect inaccuracies, however, the concepts are intentionally simplified to allow the general public to understand the basic concepts. An example is the concept of "sensitivity and specificity of diseases. These two words have been reduced in this book to mean accuracy" so that the general public will understand the concepts of disease screening. This simplicity relays the message and allows the public to understand their tests. There are many other examples. Many recommendations in this book are based on personal clinical experience and are the opinions of the author. Gun violence screening in this book is a general guide for the public, and is not yet tested by clinical studies.

I would like to thank my professors at Johns Hopkins in encouraging me to write this book. They diligently listened to my ideas and supported me without hesitation. Ms. Molly Tranberg, now in New York, did an excellent job of editing this book. Ms. Naila Abdullah, an aspiring physician, was very helpful in performing background research on disease screening and organizing the bibliographic section of every chapter in this book. She also constructed the excellent tables in this book. I would like to thank Ms. Janel Schultz for drawing the beautiful medically relevant illustrations in this book. My parents’ unconditional faith in my academic projects and education has always been the source of my strength. Finally, and most importantly, I will thank Nargis Jaffer, my wife, and my daughter for allowing me to take time from home to complete this project. My wife computer designed the text of this book. My daughter lost a few months without her dad. They have been a great source of strength to my project.

Salim A. Jaffer, MD, MS

Lansing, Michigan, 2014.

Introduction

This book is written for adults who are interested in their health. It is written for the general public and for those who wish to understand what the disease screening guidelines have to offer them. It educates adults on the basic concepts of preventive medicine, screening, and illnesses that may result in premature death. It is written for fathers and mothers who are concerned about health issues affecting their families. Adults have a natural propensity to worry about diseases and have thoughts about death at many points during their lifetimes. People often die prematurely. This book addresses the preventive measures in health care and its effect on mortality.

Educating adults about heart disease, cancer, obesity, cholesterol, hypertension, diabetes, nutrition, and the prevention of illnesses is the primary aim of this book. Good understanding of diseases allows patients to make better decisions about their health care. It also allows for better choices in health maintenance which helps prevent early and premature deaths. Screening of diseases in a timely fashion prevents premature deaths. This in turn benefits not only the individual and the family but also society. The psychological trauma of death and dying always provokes anxiety and depression not only in the family but also in society. A healthy society is a prosperous society. Society benefits from early detection of fatal illnesses because health care costs are conserved and people are productive. Disease prevention is beneficial to the physical as well as the financial health of individuals, families, and society. The social and psychological benefits of screening are also immense. Consider two examples of preventable diseases easily detected with timely prevention: breast and colon cancers.

Take the example of colon cancer first. Colon cancer is deadly if diagnosed late in the course of the disease. Duke’s Stage D colon cancer is a late malignancy, and has already spread to other tissues and organs of the body. The 5-year survival is only 8 to 12 percent. This means that at the end of 5 years, only 8 to 12 percent of these patients are alive. The rest are dead. This is a dismal survival rate. For a 56-year old man who did not have his screening colonoscopy at age 50, this is depressing news, especially if he has two young children he is going to leave behind. During the few years this patient will survive, he will run up cost of health care services over fifty-thousand dollars. Also during the few years he will survive, the psychological effect of dying will be traumatic to his family. It will drain the spiritual energy of the entire family. However, if colon cancer is diagnosed early in Duke’s Stage A, the 5- year survival exceeds 92 percent. For most patients, this translates to mean cure. Many patients who have been diagnosed with early colon cancer are still alive 25 years later. The aim of disease screening is to diagnose diseases early and prevent premature deaths. Again, this is critically important to parents as they may have to leave behind young children to grow up without a parent.

It is also significantly more cost effective to be screened for colon cancer and catch it early than to find it late. Screening for colon cancer in a 50-year old patient with a removal of a large pre-cancerous polyp by a gastroenterologist costs about $1,700. This includes the doctor’s fee, the pathologist’s fee and the hospital fee. It is the total cost to the patient or the insurance company. On the other hand, the cost of finding late colon cancer in the same patient at the age of 58 (because he did not receive his screening colonoscopy at age 50) will cost the patient and the insurance company in excess of $50,000. This fee includes costs of chemotherapy, radiation therapy, surgery, hospitalization, CT scans, oncology service, gastroenterology consults, hospice care, and a host of laboratory and follow-up costs. If the patient does not have medical insurance, these costs are ultimately paid in most cases by the hospitals, doctors or the tax payers of this country.

Other preventable diseases such as breast cancer have similar financial burdens to the individual and to the society. Breast cancer has dismal survival rates if caught or diagnosed late in the course of the disease. Early detection with effective screening virtually guarantees survival and near-normal life expectancy. If the screening guidelines are not followed religiously, late detection of breast cancer is uniformly fatal within months or a few years of diagnosis. This should be of great concern to mothers. For a mother, the thought of leaving behind young children to care for themselves is depressing. This book allows mothers and fathers to make intelligent choices and set aside time from their busy schedules for appropriate screening, disease preventive measures, and quality time with their physicians. This will allow patients to ask intelligent questions and participate actively in their care. Adults also worry about the health and death of their parents, significant others, children, and siblings. How many times have you called your mother to remind her about her annual breast mammography? Probably many times if you are an educated and conscientious adult. It is natural to think about death and worry about the well-being of loved ones.

Heart disease is another example of an illness that is preventable with proper screening, but it will cost an immense fortune to our society if left without preventive care. Patients generally have screening for hypertension, diabetes, and high cholesterol with their primary care doctors on regular intervals. These screening tests for lipid profile and diabetes costs under $100. Every individual has their blood pressure checked at every clinic visit. However, many patients have not seen their physicians in decades, or do not follow up for these services until too late. A heart attack (myocardial infarct) will cost the patient and the health insurance company over $25,000. The costs include emergency room and ICU care, cardiac catheterization with stent placement, cardiology service costs, and laboratory with follow-up tests. If the patient requires cardiac bypass surgery, the costs will likely exceed $100,000. If the patient does not have medical insurance, this cost is ultimately paid by the tax payers, physicians, and hospitals.

The knowledge of disease-screening guidelines gives adults an understanding of fatal illnesses and allows them to make intelligent decisions that determine the destiny of their own health. A man who turns 50 may not know anything about his clinical options of colon-cancer or prostate-cancer screening programs. His family physicians may not even offer this to him during the routine, short clinical visits that are scheduled for follow-up patients. Take another example of a woman who is 46 years of age and suddenly becomes health-conscious after hearing about disease mortality in the family (cervical cancer) or the newspaper (heart disease). What are her screening options at age 46? Do you know the answer to this question? Her primary care doctor may never have had the time to discuss this issue or to offer the correct screening tests at an appropriate age. The rights of patients to disease screening and prevention are well established. The patients should ask for these screening tests. It is unfortunate that many patients have to demand for such care. A 62-year-old male for whom we recently performed a colonoscopy to find late-stage cancer complained to us that he was never offered this procedure by his physicians earlier. However, it is a basic clinical right. To many patients, a right test could translate into a healthy future.

It is important that citizens of our society receive critically sound health care. Adults should be educated on their clinical rights and options for disease screening and prevention. Knowledge is crucial. A patient is better able to obtain quality health care and appropriate disease screening if he or she is educated on the issues. The educated adults may then guide their children and other members of their family toward making better health-care decisions. This is the knowledge that prevents premature deaths. In clinical practice, many patients are often not offered screening until too late. It is therefore important that patients be educated enough to ask for or even demand screening tests for themselves and for their families. Screening of diseases is not a privilege anymore; it is a right. Prevention of illnesses is vital for your well-being. This knowledge must be sought.

Chapter 1

The Patient and Doctor

Relationship

The medical and social relationship between a patient and doctor is a very important personal bond. In many practices it is a long-term, and, often a lifetime bond. It is within the context of this relationship that patients are able to confide with physicians about their health, past history, sexual patterns, social habits, cultural norms, mental condition, and psychological health without the fear of exposure. This trust results in confidentiality of the patients’ clinical and social histories. It is within this context of confidentiality that doctors are able to deliver objective and excellent care to their patients.

Trust and confidentiality between a doctor and patient is critical to excellent and objective health care.

Routine visits are once every three years between 18 and 40 years; then every year after the age of 40.

In this relationship, the patient’s medical needs are effectively identified and optimally treated. However, it is also often the case that the relationship between the patient and his or her doctor are not favorable for many reasons. In this context, many patients do not receive the best medical care. And in many circumstances, the patient may receive the worst of care. This chapter is written to educate and caution patients on social and cultural issues that may result in receiving poor health care. It is also written to educate patients on the types of behaviors that result in poor health care. This will allow patients to identify points of conflict or anticipate issues that may jeopardize their care. Understanding and rectifying these issues will thus allow for good health-care delivery.

Table 1: Counterproductive Patient Behaviors and Habits

Rudeness: you will receive poor health care, may be discharged from the practice

Arrogance: your complaints will be ignored, resulting in suboptimal care

Tardiness: doctor will spend less time with you

Argumentativeness: will get you suboptimal care at best

Aggressive behavior: you will be discharged from the clinic

Dishonesty: will result in misdiagnosis and mistreatment

Missed appointments: you will be expelled from the clinic

Noncompliance: results in poor health, illness, and early mortality

Poor hygiene: doctors and nurses will avoid you, resulting in poor health care

Lack of medical knowledge: ignorance of your illness results in poor health

This table summarizes the consequences of counterproductive behaviors by the patient. This results in poor health-care delivery to patients.

The behaviors and approaches that patients exhibit in clinic with their doctors are very important determinants of the quality of health care they will receive. Let us first address patient habits and behaviors in the clinic situations that may result in poor health-care delivery. Review Table 1 shown above which lists the most common counter-productive habits and personality types that will result in poor health care to you as a patient.

We will first discuss rudeness and arrogance. Doctors frequently come across rude patients. Patients who are rude or arrogant often do not get good care, whether they are in a doctor’s office or in the hospital. On the extreme end, they may get very poor care. This is unfortunate; it is a negative outcome of a patient-doctor relationship. What makes this situation worse is when a physician is also rude. It is an unfortunate reality in medicine that many physicians are indeed curt and have poor bedside manner. However, adding fuel to the fire will simply exacerbate the situation. Two negatives will not make a positive in a small examination room. Ultimately, when the cloud clears, it is the patient who receives poor care, and so it often falls on the patient to make the most effort.

Neither nurses nor doctors like to deal with rude patients with counterproductive personalities. Do you like people who are rude, arrogant, or obnoxious? You most likely do not. Nurses and doctors are only human, and don’t either. Being ill is not an excuse for rude or arrogant behavior. Many nurses and doctors will not spend as much time with you to make an accurate diagnosis of your illness that is critical to proper medical treatment. In a clinic or the hospital milieu, there appears to be an unconscious tendency among health care workers, including nurses and doctors, to provide the most minimal health care to rude patients and to remove such patients from their care. Thus, at the end of the day the rude patient goes home with suboptimal health care.

A 3-cent United States postage stamp exemplifying the sanctity of patient-physician relationship.

The best example I can give you is from my experience as a physician during residency in a hospital. A middle-aged woman from a wealthy family was admitted to the hospital with vague abdominal pain. She considered her husband very influential. She kept repeating that her family is the mover and the shaker of the city. She had a Cadillac Health Plan. But, she was rude and obnoxious to nurses, and often to resident physicians as well. Her obnoxious personality was so intolerable to the staff of the floor that they just wanted to get rid of her. This is a woman who thought she had clout. However, the only treatment she received during the few days of her hospital stay were IV fluids and a CT scan of her abdomen and pelvis. Doctors and nurses came in and went out of her room every day, spending a few minutes to talk to her and diagnose her illness. She was ultimately discharged from the hospital on Tylenol that she had to buy over the counter. She was told to follow up with her primary doctor.

During the same time, a female in her thirties was admitted to a different room on the same floor. She too complained of lower abdominal pain. She had a history of illicit drug use and was divorced. She was on Medicaid. She came from a very poor background. However, she was very pleasant to the nurses and doctors. She was always smiling, composed and sincere. We took time with her medical problems. We listened to her and talked to her. We considered all her signs and symptoms to arrive at a diagnosis. During the five or so days she was in the hospital, she received not only a CT scan of her abdomen and pelvis, but also numerous laboratory studies to assure she had no life-threatening illnesses like cancer, hepatitis or metabolic illnesses. She received a colonoscopy, an upper endoscopy, an ultrasound of her abdomen, and a barium small bowel study. Think about this for a minute: All these diagnostic tests were done on a young woman with a previous history of cocaine use and a Medicaid card in her purse. Nevertheless, the fact is that she had an immense advantage over the middle-aged wealthy woman. She had a pleasant personality. She was respectful. She was never rude. All the nurses and doctors loved to talk to her. She ultimately received far more comprehensive, and far more superior care than the wealthy lady with a Cadillac Heath Plan.

Honest discussions of your illness and disease are important for accurate diagnosis and treatment.

Have an honest relation with your doctor. Trust your doctor and have faith in his or her clinical treatment plans.

So the main lesson to be learned is not to be rude and arrogant to those providing medical care to you. Your life and health could depend on this relationship. Even if you have money, do not think that your wealth will make the doctors dance. The fact is that doctors do not care how rich or poor you are, or how well you are connected politically. When we dispense health care, we neither consider how wealthy you are nor what type of medical insurance you have. We are interested only in your health, your well-being and your recovery from illness. You can be the mover and shaker of the town with a Cadillac Health Plan and yet end up with poor medical care.

The next thing to address is tardiness and missed appointments. When you come late to a clinic, you push the schedule behind, take a space that may otherwise have gone to a needy patient, and create administrative chaos in the clinic. To make up for the time you are late, the doctors must rush through your clinic time. This results in poor care. Some patients don’t seem to understand this. When time is taken away from your history and physical examination, many important issues are swept aside, including screening and preventive medicine. Even if your time is not infringed upon, then some other patient’s time is used up by your tardiness. Why should another patient sacrifice his or her health because you came late to the clinic? Whether an excuse for lateness is real or fabricated, the result is the same for the physician and his time. Lateness is something physicians hate so much that in many clinics the rule is to cancel the appointment when you are more than 15 minutes late. This is to set a precedent and help ensure people do not receive suboptimal care.

Do not come to the clinic late. If you do, you will get reduced time and poor health care. This is because the doctor will spend less time with you and rush through the assessment of your problems.

Keep your doctor’s appointment. Do not be tardy. Clinical practices do not view tardy patients favorably. It will affect your care adversely.

The same principle applies to missed appointments. When you do not show up for your scheduled appointment, you waste very precious time that may have gone to a needy or urgent patient. Not only do you deny that missed scheduled time to another more responsible patient, but you also take away revenue from the clinic. No physician looks at these issues in a good light. When you miss appointments, you also upset the entire staff, including the physicians, because they have to make phone calls and reschedule your appointment. Your reputation gets tarnished, and you will ultimately receive poor health care. In our clinic, for example, we a have a two-strike rule: If you miss two appointments, the physician sends you a thirty-day letter of discharge. This means that you have one month to find another doctor, and you will not be seen in the clinic after that time. This discharge results in poor patient credibility. When we forward your old records to your new doctor or clinic, the reason for your discharge is clearly stated on this permanent record. Missed appointments can continue to result in poorer health care far into the future.

Do not lie to your doctor about your health. This is extremely important in receiving proper care. Lying to your physician will result in unnecessary testing, misdiagnosis and wrong treatment. Unnecessary testing includes CT scans, blood tests, and other unnecessary interventions that you may not need. These extra tests are performed because lying and deception results in a clinical presentation of illness that does not fit into the logic of medical science. In order to resolve the discrepancies and put together the missing pieces, your doctor has to run additional tests, which increase health-care costs and waste time. This results in poor health care. You are exposed to radiation and needle pricks for unneeded blood tests. You also risk being wrongly diagnosed and treated. Take the example of a young female who has decided to seek medical attention in an emergency room after ingesting 20 large size Tylenol pills in a suicide attempt. This patient cannot lie about her suicide attempt because time is of the essence if she wants to survive. She also cannot lie about using large doses of drugs as a vehicle of attempted suicide. Again, the sooner a diagnosis is made, the faster a treatment plan can be implemented. This delay in making an accurate diagnosis could result in severe liver damage and even death.

Hence, patients who chronically lie do not receive good health care. Patients often lie to protect their reputation and self image. Take another example of an alcoholic priest who develops liver failure. In order to make an accurate diagnosis and manage him effectively, the doctor needs his history of alcohol abuse. If the patient lies, further testing including x-rays, CT scan, and even a liver biopsy will be performed to determine the cause of his liver failure. It is difficult for physicians to prescribe objective care to patients who lie in order to cover their self image. Lying is self-defeating for patients in the long run as well as the short term.

A noncompliant patient has poor health, gets poor treatment, and risks early death. Take your medications as prescribed and on time. Be compliant with your care.

We will now address noncompliance. Patients who are noncompliant with their medications and tests are harmful to themselves. Consider diabetes mellitus as an example. Many diabetic patients do not to take their oral medications or insulin as prescribed. They miss doses, often by forgetfulness, but also very frequently by choice. This type of noncompliant behavior is harmful to the patient. It results in fast and irreversible damage to the kidneys, heart, and blood vessels, including those of the eyes. Doctors view the issue of noncompliance very seriously. Most physicians will give patients second and third chances to correct their irrational behavior. Patients will be educated on the importance of taking their medications regularly and on time.

Missing medications can have serious consequences. Take an example of a 42-year-old business executive who was found unconscious in his car on a highway emergency lane one morning. A 911 call was placed to the ambulance, and he was subsequently taken to the emergency room. His blood pressure was very high. The CT scan of his head showed bleeding in his brain. He had suffered a major stroke, and later died in the ICU. It was learned that he had not filled his prescription for a blood pressure medication for two weeks after he ran out. That fatal morning, he was going to work when he began having a severe headache. He became dizzy. He pulled his car over on the highway and had a stroke. Like this man, you cannot miss taking your medications.

We will now address personal hygiene. There are many patients who have very poor personal hygiene. They may smell of sweat, dirt, old clothing, or even human waste due to unwashed, unhygenic dress. Obese patients may have trouble cleaning or wiping themselves properly after a bowel movement. It is very important to address this, especially before a doctor's visit.

Unhygienic patients cause problems for the entire medical staff, from the secretaries at the front desk to the doctors in the back of the clinic. When patients with poor personal hygiene come to our clinic smelling extremely badly, the nurses have a natural tendency to process them fast in order to get rid of them and move them out of the office quickly. The doctors come to the examination room and do the same thing. They take a quick survey of their problems, perform a brief examination, write a short prescription, and send them out. Doctors and nurses will not spend as much time with them to educate them on important medical issues such as prevention and health screening. Doctors will expedite their clinical visit simply to get rid of them from the office. These patients receive poor care simply because of their unpleasant aroma and hygiene, even if they are otherwise pleasant, polite, and helpful. This is particularly unfortunate because it is something the patient can directly address. Take a shower everyday and use soap. Change clothing and socks every day. Use your common sense. Come to the doctor’s office clean and properly attired. Patients with good personal hygiene receive attention as well as excellent clinical care.

We will next address the issue of patient ignorance. This is a difficult issue to explain in a short chapter, but the point is simple: Be educated on your health and illnesses. Read about your illness from a library book or the internet. Good web sites include Mayo Clinic, WebMD and Cleveland Clinic. Although your physicians will provide the best possible medical care for you, they may inadvertently miss certain management issues that are critical to your care. I will give you an example regarding hepatitis C. Patients with this disease will undergo a full evaluation and be treated with ribavirin and alpha interferon in an attempt to cure the disease. However, your doctor may forget to address the hepatitis B vaccination, something all patients with hepatitis C should receive.

Unhygienic patients upset medical professionals as well as other patients. Doctors and nurses tend to distance themselves from these patients. They want to process them fast. The result is poor health care for such patients.

Buy soap, and shower every day. Go to the doctor’s clinic looking tidy and clean. You will get respect and improve your chances of receiving optimal health care.

If you are educated on your illness, you may want to remind your physician to check your vaccination status. Another example is diabetes type II. Physicians may manage patients with this illness very well with diet, exercise, and medications. However, diabetes is a cardiac equivalent. This means that if you have diabetes, then you are considered to have heart disease. This may be overlooked by your physician. It is up to you to remind him that you are at very high risk for a cardiac event, including a heart attack. This will prompt your physician to take appropriate preventive measures and probably obtain some pertinent laboratory tests. Another example is pancreatitis. Patients who do not have history of alcohol use or gall-stones are often treated for acute pancreatitis in the hospital and sent home. However, there are many other factors that can precipitate pancreatitis apart from alcohol and gallstones. High lipids and calcium levels can also precipitate pancreatitis. You may have to bring this up with your doctor. These should not be overlooked as they are treatable. It is important that you be informed on your illness. This is now expected of you.

We will finally address the issue of high maintenance patients. These are patients who come to their physician’s office with a list of 15 complaints from head to toe. Please do not do this during your regular clinic visit. In the 15 minutes you have with your doctor, spend your time with one or no more than two complaints. These must be the most important complaints clinically. Have these issues addressed in detail with acceptable resolutions. If you have other complaints, bring these up another time during a specific visit. Do not make an infamous exit statement: By the way, I have recently noted severe headaches. If severe headaches are a concern, you should prioritize with a full session, not a 10-second conversation at the last minute. This kind of patient is very difficult for physicians to properly treat, and the numerous symptoms are often swept under the rug as petty complaints. At best, each complaint may be processed in a two-minute advice, even if it is a valid concern. Hence, a very serious underlying illness such as brain cancer or aneurysm may be missed.

Table 2: Physicians’ Poor Bedside Manners

Rudeness: this is unacceptable, file complaint and write a letter to your physician

Arrogance: let the doctor know of his or her arrogant behavior

Tardiness: explain to physician the value of your time

Obnoxious personality: complain and write a letter to the doctor

Insulting: complain to the physician and office manager. Consider changing doctor

Sexual harassment: get a new doctor and file a complaint

Alcohol use: complain to the medical society. Get a new physician

Poor hygiene: write a letter to the physician explaining his hygiene

This table summarizes the poor bedside manners