Medicine For People!

November 2007: How to Talk to Your Doctor, Flu Vaccine, Vitamin D

How to Talk to Your Doctor

The Medical Mystique

When I was a child, I had a great respect for doctors. I viewed them as a slightly different species (What do they eat, anyway?)

Medical school showed me that they were human, but still I sensed they knew much more than I did, not just about medical science, but about life in general. I enjoyed medical school, but I never imagined it would turn me into a higher life form. The last few months I began to get nervous. I counted the weeks, thinking, "My God! I graduate in June, and I don't know squat. The medical school is making a big mistake."

A month later, the first day of internship, five of us began the pediatric rotation. Thankfully, I was not on duty that first night. I looked at the intern who had been chosen. He stood there calmly, and I thought, "This guy is a hero." Now I think the patients were the heroes, for putting up with our bumbling and insecurity. Fortunately, there were real pediatricians backing us up, but I for one was scared to death I wouldn't do a good job and some innocent person would die as a result.

It seemed to me then an amazing thing to be so young and, by virtue of having a medical degree, to be treated with so much respect. As time went on, of course, I settled in as did all of us. What was asked of us was not impossible and, looking back, I knew more than I thought at the time. As the first few years went by, I sometimes wished I could write a book to let people know that underneath it all, a doctor is an ordinary person.

How Doctors Think

So, let me tell you a bit about how this doctor thinks. When you come in with a problem, I don't deal with it using any magical techniques. I gather all the information I can from your story and your physical condition, decide what probably is going on, and then tell you what I think is the best approach.

Even though I'm ahead of the average patient by virtue of spending so much time learning from my medical predecessors and practicing medicine, I'm still an ordinary human being. So there are better and worse ways for you to relay information to me so I can sort out the relevant facts and arrive at a diagnosis.

How Not to Talk to Your Doctor

A patient may come in and tell me something like this: "I've got an infection in my sinuses. It was there for a few days, and then I got bronchitis. So I was telling this to my neighbor, and she said maybe it was pneumonia. Because I had this fever. And then it went to my throat."

The questions that come immediately to my mind from the above story are:

  • What symptoms did you experience that made you think your sinuses were involved? What set it off? Has it changed over time? Did it happen last year this time? What does it feel like? If I know those things, I'm on my way to determining whether it is allergic, bacterial, viral, or fungal.
  • When you say bronchitis, what do you mean? Are you having trouble breathing? Coughing? Sputum coming up?
  • Did you feel hot or did you actually get out your thermometer? If so, what was your temperature?
  • When "it" went to your throat, what was "it"? Pain? Mucous? A tight feeling? Dryness? Itching?

"Just the Facts, Ma'am"

What helps is for you to tell me, as objectively as possible, what you experienced. Here's an example of helpful information: "Ten days ago I developed pain above my right eye with some mucous in my nose on the right. I measured my temperature at 102 degrees. I wasn't feeling too bad otherwise and was busy at work, so I just hoped it would go away. But then I developed this cough, which kept me up at night. And it sounds strange, but I noticed this fruity smell on my breath. Now I'm really tired and need help."

I am still going to ask more questions, but the information you've given me helps me with the detective work. Even something that doesn't seem to make sense, like the "fruity smell", can be a helpful clue. Often we have symptoms that don't match anything you'll find in the medical textbook.

With hard facts about what you feel like from the inside, I'm closer to knowing how to give you proper treatment.

I understand that sometimes we just have to tell our story the way we tell it. We're upset, confused, or not sure what is important. In that case, I definitely want to hear your story, any way you can tell it.

Diagnosing Yourself

Sometimes patients tell me what they think is wrong. They say, "I shouldn't be diagnosing myself." Don't worry; everybody has a go at self-diagnosis. It's natural to try to figure out what's wrong with you. In fact, several surveys have shown that the great majority of the time people analyze and treat their own symptoms, usually correctly. Those surveys covered people dealing with ordinary minor illnesses. My experience is that even with more serious or chronic conditions, your hunches and conclusions can be very useful.

Case Report: Osteoporosis

Here's an example of an ongoing case (I relate with the patient's permission). My patient, a middle-aged woman, has been consulting me about osteoporosis. Osteoporosis can result from low levels of vitamin D, and sure enough, hers were low. She took 5000 units vitamin D daily, but tests showed she was still losing bone. We measured her vitamin D levels and again they were low. That can result from malabsorption, a common cause of which is gluten sensitivity, so we tested for that; she didn't have it.

She took a pancreatic enzyme to help absorb vitamin D, which is a fatty vitamin. Now the latest tests had just returned showing that her vitamin D levels had not improved. I hadn't seen her in several weeks, and as I entered the examining room prepared to suggest a new plan of treatment, I noticed her face appeared much younger, not as puffy as before.

"You know," she said, "even though the test we did for gluten sensitivity was negative, I remembered your saying that I could still have wheat allergy (which is different from gluten sensitivity). So I stopped eating wheat products. Within a couple of weeks I lost four pounds and two inches off my waist, and really feel more clear-minded."

I immediately realized that the wheat intolerance could be preventing her from absorbing nutrients, including the vitamin D. Her self-diagnosis has opened a door. Instead of going forward with the new plan, we will test her bone turnover and vitamin D levels again in a couple of months to see if our collaboration has borne fruit.

So, go ahead. Diagnose yourself. Tell your doctor about it. Just don't let it get in the way of accurately relaying what your feelings and observations to the doctor. Many doctors will interpret "I have sinusitis" as "I want antibiotics." You're paying them to figure out what illness you are suffering from, not just to accept your best diagnosis and write a prescription that may or may not be appropriate. They'll do best when you give them a clear, accurate report of what you have experienced.

Am I a Hypochondriac?

Sometimes people hear or read about a disease and start wondering if they have it. Often people tell me those worst fears followed by "I know I'm being a hypochondriac." Not really! It is normal and very reasonable to ask ourselves what the worst case could be. It is OK to tell the doctor your worst fears, to make sure he or she agrees that they are unrealistic.

Even though your fears may not bear on the diagnosis, expressing them is still valuable. After all, the whole purpose of the office visit is to bring comfort to you - physical comfort through accurate diagnosis and appropriate treatment - and emotional comfort by addressing fears and concerns.

I Do My Job; You Do Your Job

My job is to figure out what's wrong and help you get better. Your job is to care about your health and the health of your family. Your job is to seek help when you need it.

When I was an intern, I remember many times listening with dispassion to a mother describing how her child had been up all night vomiting and crying. I'd ask the proper questions to determine was wrong, but have no real understanding of what this young mother was going through. Today, I know how worried she's been, how tired she is, how many responsibilities she has in addition to this sick child. So now when a mother tells me "I'm sorry to bother you. I know I shouldn't worry." My response is, "If you don't worry about your children, who else on this vast earth is going to? That's your job and I honor you for it."

Winter and Vitamin D

It's winter in Port Townsend, a good time to remind you that living at this latitude leaves you at greater risk of vitamin D deficiency. Vitamin D protects you from osteoporosis, breast cancer, colon cancer, and prostate cancer. A Bulgarian study indicated that vitamin D improves sugar handling in people with adult onset diabetes. And there is considerable evidence that vitamin D lack may contribute to depression and decreased mental function. For more information, see our in-depth articles on vitamin D in our February and March 2004 newsletters.

At this time of year, I recommend you take cod liver oil. Frequently patients ask me whether fish oil contains mercury. The best suppliers of fish oil will test it for mercury, lead, heavy metals, and pesticides. The best quality cod liver oil is safe.

While we are on the subject of mercury, here are government figures of how much mercury you are likely to find in different kinds of fish.

Clinic News - Mercury-free Flu Vaccine

Many vaccines, including the flu vaccine and tetanus, are preserved with thimerosol, a form of mercury. While medical authorities report finding no harm from the thimerosol used to preserve vaccines, debate on the subject continues.

To be on the safe side, we use only vaccines without thimerosol. Such vaccines are packaged in a way as not to require thimerosol preservative, but still retain minute traces of mercury from the manufacturing process.

As of the time of this newsletter, we have some influenza vaccine remaining. I suggest it for anyone who has been hospitalized in the past year, has a chronic disease, cares for someone who is elderly or has chronic disease, or who thinks that their ability to bounce back from the "hard flu" might be impaired. Read more about the flu in the November 2005 newsletter.



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Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.