Breast Pain

Breast pain is a common complain among women of menstruating age.

Susan is no exception. Besides pain, she has lumps in both breasts. Her symptoms are cyclic – associated with menstruation.

Since October is Breast Month, Susan wants her breasts examined. She is worried about cancer.

Susan’s physical examination reveals diffuse lumpy areas in both breasts with one discreet lump (about 3 cm in size) in the right breast. A fine needle aspiration of the lump confirms the presence of clear fluid and the lump disappears.

Susan’s mammogram reveals no suspicious lesions to suggest cancer. She is aware that 15 percent of mammograms fail to detect cancer (false negative).

Therefore, the conclusion is that Susan has fibrocystic changes in her breasts. The old term “Fibrocystic Disease” has now been replaced with fibrocystic changes. It cannot be a disease if the condition is very common, responds to physiological hormonal changes, and disappears later in life.

Women with fibrocystic changes not only suffer from pain but also have significant anxiety about cancer. One can easily miss a malignant lump among the multitude of benign appearing lumps.

Physicians and patients have to be vigilant at all times. The principle of management should be that a breast lump is malignant until proven otherwise.

Dr. B, can you tell me more about the fibrocystic changes of the breasts?

Susan, this condition is known by many different names and encompasses many benign conditions of the breast.

One textbook says that it is virtually impossible to estimate the incidence of benign breast disorders. But it is believed that 50 percent of women experience symptoms of fibrocystic changes at some point in their lifetime.

Usually the symptoms occur in women of menstruating age, with a mean age of 39years and a range of 18 to 67 years.

Solid benign lumps (fibroadenomas) occur in younger women, but cysts occur few years before and after menopause (35 to 60 years).

This condition is associated with a history of premenstrual breast discomfort, irregular menses, and spontaneous abortions; a family history of both benign and malignant breast disease; lack of use of oral contraceptives; a low incidence of obesity; small breasts, and late natural menopause (Breast Diseases by Harris and others).

The cause is unknown. It is likely due to imbalance of the female sex hormones as the condition occurs after the onset of menstruation and rarely appears after menopause.

Dr. B, do fibrocystic changes cause cancer of the breast?

Susan, there is inadequate evidence to suggest that fibrocystic changes lead to cancer of the breasts. Usually the fear is that cancer may be missed in women who have “lumpy” breasts. These women do and get regular breast checkups.

The management of this condition is not easy. We will discuss this next week. In the meantime remember: A breast lump is malignant until proven otherwise.

This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Health and Happiness

Happier we are, the healthier we feel.

The key words are happy, healthy, and feel. It is easy to get these words in one sentence. But is it easy to get them together in life?

Each one of us looks at and feels about life in different ways.

According to E. M. Forster, it is not that the Englishman can’t feel – it is that he is afraid to feel.

Charles Lamb, on the death of his mother said, “I have something more to do than feel.”

But most of us would agree with George Ridding that “I feel a feeling which I feel you all feel”.

Let us look at some examples of healthy and unhealthy feelings.

Some time ago, on a Friday, there was a column in this newspaper titled “Washerwoman’s legacy helps poor students” by Margaret Wente. This is a very inspiring story of a 91 year old lady, who never went past Grade 6, never married, and never owned any book but her Bible. She made her living by washing other people’s clothes.

Dime by dime and dollar by dollar she saved her washerwoman’s money. Then in 1995, she donates $150,000 (US) to fund scholarships for poor students. Wente describes how this 91-year-old is energized to discover what her donation has done for the students.

That must be a great feeling!

Then on a Tuesday, there is Paul Sullivan’s column: More people I meet – more I like my dog. His message is clear – People do suck especially the big ones.

He was discussing the case of Nadia Hama and her daughter with Down’s syndrome, Kaya, who miraculously survived the fall off the Suspension Bridge in Vancouver. Sullivan also explores the methods used by RCMP to investigate this case.

The whole scenario does not inspire healthy feelings.

Compare this to the letter to the editor in Friday’s paper: Heartfelt thanks to a real-life superhero. Leslie Beckman writes: The fact that this man (real-life superhero) could care for a complete stranger, in such an amazing way, is absolutely unbelievable and beyond appreciation.

This superhero is one of the three men who helped a young man survive a near disastrous accident.

So there are people who do things that make us and themselves feel good. Although nobody is perfect.

But life is not about perfection. Life is about what you do with what you have been given, says Globe and Mail in a recent editorial on the new Governor General.

Let us put it this way: Good health is not about perfection. Good health is about what we do with what we have been given and feel good about it!

If that makes us happy then we should feel healthy.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Missing Doctor’s Appointments and No Shows

Dave is angry. He forgets to keep a doctor’s appointment. He receives a bill for not showing up.

Susan is upset. She has to wait for an hour before her doctor sees her.

Doctors and their receptionists struggle all the time to book the right number of patients each day so everybody is seen on time. This helps patients, staff and doctors to get home to their families in time.

In reality, this never happens.

To physicians, the big problem is the “no shows”. Patients make appointments and some do not bother to show up. This happens inspite of being reminded by the physician’s office few days ahead of the scheduled time.

This costs the taxpayers dearly. In the United Kingdom, an estimated US$240 million worth of appointment time is lost each year because of the patients who fail to keep appointments with their GPs, according to a survey by the Doctor Patient Partnership (DPP).

In Alberta, the problem must be serious enough for the College of Physicians and Surgeons to provide directions on this subject. The College’s motto is “serving the public and guiding the medical profession”.

The College says: Although generally opposed, College recognizes that, under certain exceptions, physicians may bill patients for missed appointments.

Dr. Bill Taylor follows this policy. He is the only dermatologist in our region. His office gives out a pamphlet to the patients that says: If you miss an appointment without timely notification this becomes a “missed appointment”. This could result in you being billed for this and future missed appointments.

Dr. Stephen Cassar is the only plastic surgeon in our region. It takes a long time to get an appointment with him. Naturally, patients and physicians complain. We want instant service.

Last week, in sheer exasperation, he sent a letter to all the physicians indicating that in the last nine months he has had 80 “no shows”. This happens despite the fact that his office phones patients to remind them of their appointments.

This “no shows” do not include the ones who fail to attend due to inclement weather, family emergencies, or personal illness. Dr. Cassar says that if patients make their scheduled appointments as booked, then his waiting time would be cut be approximately 4-5 weeks!

An article in the Journal of the American Board of Family Practice says that missed appointments can affect patient health, disrupt schedules, and result in poor utilization of resources, and increased workload for staff and physicians.

Why do patients fail to keep clinic appointments? Asks a report in the International Journal of Clinical Practice. The answers are disappointingly predictable, says the BMJ. They forget the appointment, feel too ill to make it, or never receive details of it in the first pace.

Is there a solution to the problem? Like many things in life, it boils down to individual responsibility to use health services responsibly. Unfortunately, that message does not always get through to people who abuse the system.

The sad thing is, reasonable and responsible people pay the price for the delinquent ones.

DPP’s latest campaign – KEEP IT OR CANCEL IT!

This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Annual Physical Check-up

An apple a day keeps the doctor away? Is prevention better than cure? What about an annual physical examination? Is that the best way to stay healthy? Many people think so.

“The truth is that all of us are, to greater or lesser degrees, prisoners of ritual,” says Dr. Richard Goldbloom, MD, in an editorial in the Canadian Medical Association Journal (CMAJ). We perform these illogical practices to reduce our level of anxiety or, at least, to prevent it from rising.

Dr. Goldbloom is a Professor in the Department of Pediatrics, Dalhousie University, Halifax, NS.

In 1980, the Canadian Task Force on the Periodic Health Examination (now called the Canadian Task Force on Preventive Health Care) recommended that the routine annual physical examination should be discarded in favour of a selective plan for prevention to suite individual requirement.

Many physicians disagree with this recommendation.

Currently, physicians are inundated with clinical practice guidelines that are based on sound scientific evidence. But not many physicians buy into these guidelines as they conflict with the percieved needs and expectations of patients and physicians, Says Dr. Marie-Dominique Beaulieu and others in the same issue of the CMAJ.

Dr. Beaulieu is a Professor of Family Medicine at the University of Montreal, Montreal, Quebec.

The study conducted by Dr. Beaulieu and others, show that the majority of the physicians and patients find the annual check-up beneficial for variety of reasons. One important reason is that check-up permits a more thorough evaluation than regular medical visits. It also builds trust.

The authors say that tests play an important role for patients in their personal preventive routine. Patients considered test results more accurate than the history and physical examination.

Physicians value the history and physical examination much more than test results. Since there are very few truly effective screening tests, physicians feel the downgrading of the annual check-up unacceptable.

A screening test should have some effect on the disease process and offer gain in life expectancy to the majority of the people who under go such tests.

But there are many drawbacks to offering the public preventive therapy. It creates unnecessary anxiety. It exposes the public to procedural complications and the risks of false-positive and false-negative results; and it creates an unhealthy preoccupation with disease among the public.

It has a potential to induce fear.

Over use of diagnostic procedures for screening purposes creates long waiting lists. Thus the patients who would most gain from the test may be deprived of the benefit.

“Another attractive concept has been widely promoted is the belief that if more money were spent on prevention, less would have to be spent on treatment – a concept that, with a few exceptions, does not stand up to close scrutiny,” says Dr. Goldbloom.

For physicians and patients, annual check-up and tests relieve anxiety. To them, this is more important then worrying about clinical practice guidelines. For the preventive medicine experts, the biggest challenge is to bridge the gap between science and ritual.

Dr. Goldbloom says, “… physicians, like patients, are just plain folks after all, enslaved to ritual and tradition, reiterating beliefs and practices that both groups believe, logically or not, have served them well.”

So, don’t forget your apple today!

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!