Optimizing your visit with the doctor
Courtesy: Dr. Zachary Levine, emergency physician at McGill University Health Centre
Average amount of time doctors spend with a patient is less than 15 minutes (this is decreasing)
Female doctors spend a bit longer than male doctors on average
Studies have found an association between shorter doctor visits and increased rate of medication prescription
In order to get the most out of a visit, plan ahead:
You have your agenda (particular concerns), doctor has theirs (screening, preventive health)
- Pick your top 1 or 2 concerns:
- Think about them — description, what brings them on, makes them better
- Research (wisely) if you know your diagnosis. What can you do to help? What don’t you understand? What is the doctor’s experience with this condition, advice
- Ask specific questions
- Be an active partner — what can you do?
- Do you need that test/pill?
- Medication List (DSQ)
- Past medical history
- Past surgical history
If you’re going to the ER
- CTAS — triage — life threatening first, other things wait
- Typically quieter early weekend mornings
- Ambulance doesn’t speed up being seen but if you’re not well don’t drive yourself, ambulance can begin treatment
- Squeaky wheel hard to ignore but doesn’t necessarily get faster or better care
- Care order should be only based on acuity
- Best to go where you’re known
- Consider calling health line (but their threshold has to be low to send you in)
- Think about your goals and what you want done
Almost any symptom can indicate something serious, but it doesn’t mean they are. For example, back pain is from a benign cause 90% of the time, but it can be life threatening. Doctors use clues to give us evidence of whether symptoms are of something serious.
Here is a list of symptoms you should not ignore:
- Chest pain — perhaps this is obvious, but not to everyone. Don’t chalk it up to heartburn unless you know it’s heartburn. If it’s a heart attack, you need to know. Symptoms associated with cardiac chest pain include sweating, shortness of breath, dizziness, and palpitations.
- Shortness of Breath — again, maybe obvious. Don’t decide “it’s just a cold or asthma,” especially if you don’t have asthma! It could be your heart, or your lungs. A blood clot in the lungs, aka a pulmonary embolus, can be deadly.
- Sudden severe headache — sometimes a headache is just a headache. But if you don’t usually get headaches and you get a sudden one that is severe, get it checked out. It could be a bleed in your brain.
- Rapid, unexplained weight loss — If you lose weight for no reason, ie you are not eating less, or exercising more then you need to find out why. It may be that you are not absorbing food properly, or it may be a symptom of cancer.
- Excessive urination — When we drink alot we urinate alot. That’s normal, as the body keeps a balance of fluids. However, urinating frequently may indicate other things, such as infection (usually accompanied by burning on urination), or diabetes, especially if accompanied by unexplained, excessive thirst.
- Bleeding — normally we bleed when injured. And healthy blood makes clots to stop bleeding. However, if you are bleeding for no reason it should be checked out. You may have a blood disorder. Blood in the stool or black, tarry stools, or vomiting blood means bleeding in the gastrointestinal tract. This can be caused by benign entities such as hemorrhoids, but can also be caused by cancer, and the bleeding can sometimes be severe. Blood in the urine needs to be checked. It can be caused by stones and infections, but also by cancer, of the bladder or the kidneys. Coughing up blood may occur with infection (in small amounts) but more serious causes need to be ruled out, such as pulmonary emboli and cancer. Postmenopausal vaginal bleeding needs to be checked out to rule out a serious cause, such as cancer.
- A swollen painful leg (without an injury) — Leg swelling can result from injury, to be sure. But a single swollen painful leg is concerning for a problem with circulation, such as a blood clot. Bilateral swollen legs can result from a heart problem or something blocking the flow of blood back into the pelvis from the legs.
- Severe abdominal pain — Sometimes benign conditions, such as gastroenteritis, can cause severe abdominal pain. However, some life-threatening conditions can cause it as well, such as abdominal aortic aneurysm (swelling of the large blood vessel in the abdomen, potentially bleeding), ischemic colitis (lack of blood to the bowel, which can cause the bowel to die), appendicitis or cholecystitis (gallbladder inflammation, which often requires surgery to treat).
- Severe back pain — Most people experience back pain at some point in their lives, and the majority of back pain is musculoskeletal in nature (due to muscle strain etc), benign, and resolves without any treatment. Severe back pain may be from kidney stones, which are usually benign, but you need to check it out. It may also represent serious infection or cancer. The red flags doctors use to indicate potentially serious back pain include duration of more than 6 weeks, age younger than 18 or older than 50, trauma, a history of cancer, night sweats, fever, chills, weight loss, night pain, IV drug use, and neurological symptoms such as weakness and numbness in the legs or in the saddle area, or urinary retention or incontinence.
- Flashes of light — seeing flashes of light may indicate an oncoming migraine, but they may also be a symptom of retinal detachment, an eye emergency that needs emergency treatment.
All of the symptoms above may result from benign causes, but maybe not. So get them checked out.
Dr. Google — Using the Internet to improve your health
Unlimited information available at the click of a button.
People are getting informed about their health.
One in every 20 Google searches is health related
Pew research ctr: 80% of ppl have looked up health info online
Internet has info about conditions, health maintenance advice, and even programs that will try to diagnose you.
Self-diagnosis? Regarding online symptom checkers – Harvard study reviewed 23 symptom checker sites and found that they are not good at triaging or diagnosing — they err on the side of caution (can’t say it’s nothing if it’s something) and they only got the right diagnosis 34% of the time. 23 websites, 45 vignettes half common.
BMJ 2015;351:h3480 doi: 10.1136/bmj.h3480
Conclusions Symptom checkers had deficits in both triage and diagnosis. Triage advice from symptom checkers is generally risk averse, encouraging users to seek care for conditions where self care is reasonable.
So be careful about symptom checkers. At best they can give you a list of possibilities.
Knowledge is power. Good to be a partner in your healthcare — better to be active than a passive recipient. The doctor has a limited time to explain. More info empowers patients — doctor as guide
Is the information real or “fake news”? Who is writing it? Who is paying for it? What is their motive?
—-Be careful of miracle cures that cost money
Another problem is that we tend to search out things that we agree with or want to believe and dismiss the rest
So where do we go for valid information:
–Governmental (eg/ health Canada, Canadian public health agency), sites that end in.edu, .org
In some countries they’ve curated bona fide health info to pop up with searches eg/ Australia
What about online forums? They are good for support, community (you are not alone) but careful to make sure they relate to you.
I am a 50 year old man who experienced my first kidney stone last week. The pain was excruciating. The doctor sent me home with some pills and a follow-up but I want to know — will the stone pass on its own and will this permanently damage my kidneys?
Kidney stones are very common, with a lifetime prevalence of 12% in men and 7% in women. The risk is higher if you have relatives with kidney stones. They are known to cause very severe pain which often requires a visit to the ER to control.
In general, kidney stones are not considered to be a common cause of kidney failure. The risk of kidney stones causing kidney failure is higher in people with diabetes, only one kidney, pre-existing kidney disease, and polycystic kidneys.
Most kidney stones (85%) pass on their own. The chance of passing depends on the size (less than 6 mm have a better chance of passing), shape, and orientation of the stone. In the ER the doctor gives medication to control the pain and checks to make sure that the kidneys are functioning well and that there is no infection. If the stone cannot pass on its own then a urologist will determine the best way to help it do so. Methods include lithotripsy (using electromagnetic shock waves to break it down), ureteroscopy (using a scope to remove it), or percutaneously (through the skin).
What is important if you have kidney stones is to have follow-up with a doctor after the acute episode, for two reasons: first, the doctor can determine what kind of stone you have and recommend ways to decrease your risk of recurrence. In general it is wise to drink a lot of fluid and, for calcium (the most common type) stones have a low protein and low salt diet. In addition, the doctor can check your risk factors for kidney disease and control them early. This will protect your kidney function for the future.
- Make sure you have medical insurance
- Hopefully you won’t need it but if you don’t have it you’ll probably need it
- Affordable, shop around
- Make a timely Pre travel appointment with your doctor (less than 50% of ppl do)
- You could need vaccinations – routine or otherwise – may need 4-6 weeks for this
- Vaccines are individualized and depend on where you’re going. Available: yellow fever, meningococcal, typhoid, hep A, hep B, rabies, cholera, japanese encephalitis
- Routine vaccinations — influenza, tetanus, diphtheria, pertussis, mmr, polio, varicella
Consider safety while away
- Hand hygiene
- Sun protection for eyes and skin — sunglasses, sunblock, sun shirts, hats, mosquito protection
- Driving — intl license, be careful
- STI’s – bring protection
Top things think of if you’re travelling to Mexico, Caribbean, or southern US this spring break:
- a) Traveller’s Diarrhea
- Most common illness in travelers
- Develops within 10 days of return
- Variety of bacterial (etec most common), viral, parasitic (tend to persist longer) organisms
- Prevention is key — eat only throoughly cooked hot foods, fruits you peel, pasteurized dairy. Bottled drinks without ice, use straw
- Freezing does not kill the diarrhea-causing organisms. Alcohol does not sterilize them. Fruit salads, lettuce, chicken salads unwise
- Water purification — boiling for 3 min then cooling to room temp. Adding 2 drops of 5% bleach to a quart of water will kill most bacteria in 30 min. Adding 5 drops of tincture of iodine to a quart of water will kill bacteria within 30 min.compact water filters can be used
- Chemoprophylaxis not recommended
- b) Chikungunya, Zika viruses – mosquito avoidance
- Avoid feeding time (malaria Japanese encephalitis, west Nile virus between dusk and dawn; for dengue, chikungunya, zika, yellow fever during daytime)
- Wear clothing that covers skin
- Insect repellant. DEET (there are others that work) don’t saturate the skin. Not under clothing. Avoid eyes mouth genitals, wounds
- Treat fabrics with insecticides’
- Screens, tents
- c) Malaria (DR, Haiti) – chemoprophylaxis, mosquito bite avoidance
- Depending on what else you do — diving barotrauma, STIs
2. Staying well en route and coming home:
- risk of VTE (blood clots) on flights of 4+ hours. Consider asa, compression stockings. Get up and walk.
- Decreased paO2 in planes – may cause fatigue, “foggy brain”, headache. Most ppl are fine but if sig heart lung dz, anemia, talk to your doctor
- It’s dry up there — drink
- Air pressure changes can cause ear pain in people with resp tract infections with blocked eustachian tubes — chew, yawn, suck sweets, valsalva, decongestant/antihistamine
- Jet lag — Curtail coffee, stay hydrated, Avoid or limit alcohol inflight, Try to sleep on the plane, Use sleeping pills wisely, Get outside, light, Adjust your clock, exercise
- Sharing germs — wash your hands!
By Dr. Zach Levine, ER physician, MUHC
A postpartum (PP) mood disorder begins within one-year of delivery with most occurring within four to eight weeks and lasts two weeks.
Distinguished by baby blues (BB) which is sadness interspersed with happiness, onset usually two-to-three days with a peak of seven-to-10 days. Subsides within two weeks.
Baby blues affect 75 to 80% of new mothers, while 10-20% of new mothers are affected by postpartum depression.
Note — other postpartum mental health problems may be associated — anxiety disorders (PP Panic disorder, PP OCD), PP psychosis
Symptoms of PPD
- Appetite change
- Difficulty concentrating
- Feelings of worthlessness
- Racing & obsessive thoughts
- Biological – sudden drop in hormones (estrogen progesterone neurotransmitters) at delivery
- Genetic – predisposition to mood disorders
- Psychological – coping mechanisms, myths (below)
Freedom, identity, control, slim figure, feeling of unattractiveness. Usually comes down to a combination of factors.
- Social – lack of support systems
- Infant-related – even healthy infants require regular feedings around the clock and care, along with regular household needs. Unhealthy infants cause extra stress, as well as premature, those with colic.
The problem with myths is they don’t help – not meeting them can lead to guilt and shame. The fairytale image can be problematic: A happy mother, intuitive mothering, unremitting love, perfect baby, fathers being equally involved, being the perfect mother.
Risk Factors for PPD
- First time mother
- ambivalence about the pregnancy
- History of mood disorder
- Lack of social support
- Lack of stable relationship with partner or parents
- Unrealistic expectations about parenthood
- Previous PPD
- Therapy — individual or couple of group
- Support groups
- Practical help (every visitor brings food or does a load of laundry)
It is common and it is treatable and you are not alone.
By Dr. Zach Levine, ER physician, MUHC
Colds and Flu Season
Why are viruses more prevelant in the winter? Beacause we spend more time indoors sharing air and viruses prefer dry air.
Colds are caused by one of several virus’; Symptoms are a runny nose, cough, congestion, low grade fever, sore throat – not caused by being cold.
Flu is caused by the influenza virus. Every year 10-25% of Canadians get flu and 500-1500 die from it.
Virus shedding begins day before symptoms appear and lasts five-to-seven days. Most ineffective on the second and third days after infection. Correlated with fever.
Virus lives longer with low humidity and lack of sunlight. 15 minutes on tissues, five minutes on skin, and one-to-two days on plastic or metal. Mucus protects (it remains up to 17 days on banknotes!)
Symptoms can include fever or feeling feverish/chills, cough, sore throat, runny or stuffy nose, muscle or body aches, headaches and fatigue.
Remember you can infect others, even if you take meds and feel better; see a doctor if sob, chest pain, drowsy, neck stiff, fever in infant less than three months, not urinating.
You can always get the shot! Flu shot (shot is dead virus, nasal is live weakened, only for ages 2-49) is available for everyone six months and older. It takes two weeks to gain immunity. If you have a chicken egg allergy you can get it, unless unless it is severe – if worried, 1/10th the dose and observe 30 min before giving the rest. Some people get soreness, or mild flu-like symptoms. Caregivers should get it.
Heart attacks – They increase in winter with 5-30% increase in heart related deaths in winter, up to 50% more MI’s in winter.
Cold causes vasoconstriction so increased bp. Also blood clots easier in cold.
Caused by cold, shoveling, emotional stress, weight gain, little exercise, more salt, binge drinking and AF. Know the symptoms!
Recommend Vitamin D supplementation, and calcium for:
Bones and teeth
SAD – Seasonal Affective Disorder is caused by a decrease in sunlight
Light therapy (10000 lux, little UV as possible as it is damaging to skin and eyes), 20-30 minutes soon after waking, eyes open but not looking directly; meds & therapy also an option.
Frostbite – An injury to the body caused by freezing. It most commonly affects areas that are extremities and that are uncovered, such as the nose, ears, cheeks, fingers, and toes, especially in those with reduced blood circulation. If recognized early, frostbite can be mild, but if left untreated it can lead to severe damage or loss of the frostbitten body part.
Signs of frostbite include a white or gray skin colour, numbness, and firmness or waxiness of the skin. It is wise to warm or cover any area that begins to feel painful or turn red in the cold because once frostbite sets in the area may be numb and more damage may result without you feeling it.
Frostbite can be associated with hypothermia, another serious condition that is caused by the cold. If you think you might have frostbite, seek medical care. Until you can see a health care professional, the following tips might help: get warm, do not walk on frostbitten toes, put the frostbitten part into warm water or warm the area with body heat. Be careful not to burn the affected area which may well be numb.
As always, prevention is better than treatment. Dress properly
Hypothermia: Abnormally low body temperature – 35ºC or less. Very cold temperatures or less cold temperatures if not well dressed or wet. Very old and very young especially susceptible.
Warning signs of hypothermia include shivering, exhaustion, confusion, problems with coordination, memory loss, and slurred speech. In infants you might note very low energy and bright red, cold skin.
Get warm, get help if bad. Move to a warm place, remove wet clothing and warm the person (such as in a warm blanket). Warm beverages can help the person to warm up as well. Dress warm, wear layers. Be careful about falls.
Shovel, salt, stay active for muscles & balance, slow down, shoes with traction, bring a phone & have a plan.