Should you ever not listen to your doctor?

Since I got married seven years ago and had two kids, I’ve had to shed parts of my life, like the hockey package, going to the movies, and slow-pitch softball. None were hard sacrifices, but the casualty that hurt the most was giving up my doctor of over 20 years. I met him soon after I got out of college and he was early in his career, and while I never needed him for much, I knew he was on top of everything.

Even after my wife and I moved north of Boston, I wanted to believe that I could keep him, that an hour-long drive into town without traffic was possible, because how often did I ever have an emergency? Well, in 2014, one month into our first year of preschool, my son got hand, foot, and mouth disease, and then I got it. After a walk-in clinic visit, the breakup process began.

I got a recommendation and met a new guy. He was nice, competent, and gave ample time on the first appointment. He also wanted to prescribe a low-level statin for some elevated cholesterol. I was 47 years old, active, in good shape, had never had high cholesterol, and had no interest in being on regular medication. He said I could retest. I did several months later and my numbers went back down. I was happy, but also wary. If I had complied, I’d probably still be on the drug. When I asked for his rationale at our second appointment a year later, I wasn’t satisfied. I felt I got lumped into a large group of “what people usually do.” I now had doubt.

And there was another thing that added to it: he wasn’t in the best shape. It was a complete nonissue at first. I wasn’t looking to a doctor for fitness advice, but after the statin conversation, I wondered if I could take long-term health advice from someone who didn’t look so healthy. So, I asked Charles Morris, M.D., associate chief medical officer at Brigham and Women’s Hospital, if I had cause.

Based on the doctor’s apparent shape, no. And I knew that. There’s no correlation between belt size and skill. On being depersonalized, yes, there was a valid concern. “You want to feel like the doctor’s advice was tailored to you and not just people like you,” Morris says.

But this brought up some bigger questions. Medical care feels more restricted, more expensive, and time feels increasingly rushed, so, in this dynamic, what’s reasonable to expect? What should you find out, and what should be in place from the start to let an otherwise healthy person know that this is the right doctor for the long term? Morris has some ideas:

• Family history. It’s routine with the initial exam, but it’s more than checking off boxes. It should involve the doctor asking whether your parents are alive; if not, how old they were when they died; and what conditions your parents and siblings have been treated for on a regular basis. All this information hints at what you’re at higher risk for, and depending on the answers it can set an earlier and more focused timeline for screenings.
• Ask what the doctor’s team looks like. Everyone wants to be able to reach their PCP directly on all occasions, but that’s not happening — there just isn’t time. It is realistic to ask who you should follow up with, and who will be getting back to you and when. Offices have a triage system, and in general, non-urgent matters should get a return call within 24 hours.
• You should be asked something like, “If you had free time, how would you spend it?” The doctor wants to see what, if any, outlets you have and whether you’d rather hit a bar or go skiing. If there’s concern, a doctor should be trying to guide your habits when life is less complicated, so you’re not digging out of a hole in your 40s. And related to that, there’s the issue of…
• Mental health. The free time question touches on how happy or full your life is. Another tool that doctors use is the first two questions from the Patient Health Questionnaire. Over the last two weeks, how often have you been bothered by: 1. having little interest in doing things? 2. feeling down, depressed, or hopeless? It’s not all-encompassing, but it gets at how prevalent depression might be.
• At the beginning of every appointment, there should be an exchange that goes something like, “I have things I want to cover. So do you. Let me hear your list and we’ll prioritize the top eight.” You’re a team. The agenda should be mutual, and ensures you get time to be heard.
• You can push back on anything. If something doesn’t feel right, ask, “How am I different from other people in that category? Is there anything I can do to change that recommendation?” Again, it goes back to getting tailored advice and ultimately feeling like the doctor gets you. If you don’t feel comfortable asking questions, you’re in the wrong office.

The post Should you ever not listen to your doctor? appeared first on Harvard Health Blog.

From: Steve Calechman https://www.health.harvard.edu/blog/should-you-ever-not-listen-to-your-doctor-2017122612959

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Preventing overdose deaths is not one-size-fits-all

By now, we all know that the number of opioid-related deaths in the United States has reached epidemic proportions. Despite the Centers for Disease Control and Prevention declaring an epidemic in 2011, the death rate has continued to increase every year, with more than 30,000 deaths per year now attributed to opioids. Graphs from the CDC show the geographic distribution of the epidemic and demonstrate that nearly the entire United States is involved. This tragic death toll has culminated in many local, state, and federal government initiatives to fix the problem, including President Trump’s recent declaration that the opioid crisis is a nationwide public health emergency.

However, it is important to remember two key facts. The first is that drug overdoses are not all from opioids. It is true that while roughly two-thirds of these deaths are from opioids, the other third are caused by other drugs. For example, in 2015 there were about 52,000 overdose deaths overall, and 33,000 involved an opioid; 19,000 were caused by other substances. The second fact to consider is that despite efforts to reduce gender and racial inequalities in our country, there is still a considerable difference in the life experience between men and women and between different racial and ethnic groups.

With an eye toward these factors — that opioids are not the only cause of overdose death and that inequalities exist in our country — if we want to solve the opioid epidemic we, as a society, must realize that the opioid problem is not the same for everybody.

This point was highlighted in a recent study published in Annals of Internal Medicine. In this research, the authors looked at death certificates of people who died from drug overdose between 2000 and 2015 to determine the exact cause of death. The authors broke up the data into four-year blocks of time (e.g. 2000­–2003, 2004–­2007, etc.) to look at trends. This type of analysis is not new. However, what is new is that they broke up the data based on gender and race, separating non-Hispanic black, Hispanic, and non-Hispanic white people into different groups. (For simplicity in this post, I’ll refer to the first group as “black,” the second as “Hispanic,” and the third as “white,” even though Hispanic is an ethnicity and not a race.)

The results are enlightening. Although there were increases in the death rate among all groups, they were most pronounced for older black men (age 50 and older) and black women (age 45 and older). Also, opioids contributed to the most deaths for white people, but cocaine was the largest contributor to death for black people. In fact, from 2012 to 2015, deaths related to cocaine were almost as common in black men as deaths from natural and semisynthetic opioids were in white men. For Hispanic people, the rates remained lower overall than for white and black people, but there was a large spike in heroin-related deaths in both sexes when comparing the 2012­–2015 period with previous time periods. Finally, the death rate for white males appears to be shifting toward an earlier age, while it is higher for older white women.

We must acknowledge that the authors did separate deaths from the opioids into different categories, such as from heroin, synthetic opioids, methadone, and natural/semisynthetic opioids. If you add all of those categories together, they are still collectively the top cause of death among all ages and sexes.

However, even considering this, evaluating these trends can help us better target interventions. For example, cocaine remains an important cause of death in the black community. With so much attention given to opioids, neglecting the important problem of cocaine can further exacerbate inequality in rates of overdose deaths. Likewise, when developing public service campaigns or increasing resources in a targeted fashion, how the message and care are delivered often depends on the age of the individual. Finally, although rates of overdose death are lower overall among the Hispanic community, they are still significant and too high, which makes the case for culturally appropriate and Spanish-language interventions.

Recent analyses have demonstrated how the response to the opioid epidemic has changed since it has become more of a “white problem.” Whereas in the past drug addiction was commonly handled with criminalization and stigmatization, now there is a call (appropriately) for a gentler war on drugs that recognizes addiction as a medical condition that is treated like any other chronic disease. Recognizing that the epidemic affects different communities in different ways will help us avoid a “one-size-fits-all” approach as we work together to solve the problem.

The post Preventing overdose deaths is not one-size-fits-all appeared first on Harvard Health Blog.

From: Scott Weiner, MD https://www.health.harvard.edu/blog/preventing-overdose-deaths-is-not-one-size-fits-all-2017122212996

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