Our privacy is eroding. Some of this erosion is our own fault – we post to Facebook, Twitter, and other social media with reckless abandon. Some is the nature of modern communication – electronic trails are just as easy to find as paper trails (if not easier). Some of the privacy erosion really doesn’t bother me so much – if Target knows that I buy a lot of Cheerios, I’m happy to accept their General Mills coupon for $1.50 off my next breakfast cereal purchase. But there are some places where I expect and demand privacy.

Like in a doctor’s office. Or hospital. Or pharmacy.

But business has so inserted itself into so many aspects of life, including medicine, that my expectation of health-related privacy is being slammed into the wall. Although I really couldn’t care less if Target knows my cereal-buying habits, I certainly do care if they share the information when I purchase a pregnancy test. Or athlete’s foot spray, for that matter. Of course the store has no idea if I’m purchasing health-related items for my own family or for someone else, so it’s unlikely that this information will be used for anything other than targeted coupon offers, but it still really bugs me that people look at this information. And yes, I am aware that I can simply use cash when purchasing over-the-counter wart remover if I want complete privacy on that issue. But the fact that I have to consider it really bothers me.

What price convenience? And what price financial savings? I have a Target Red Card. It gives me 5% off the price of everything I buy at Target. It allows me to return items even if I’ve lost a receipt. It gives me coupons for things I buy. But I read an article a couple years ago that talked about a man finding out that his teenage daughter was pregnant because she started receiving store coupons in the mail for diapers and infant formula after she had purchased a pregnancy test and vitamins. This is a breach of privacy. And it could also cause harm aside from breach-of-privacy with its presumptions. For example, while some couples who purchased a pregnancy kit and then started purchasing vitamins may in fact be delightedly experiencing a pregnancy and happy to receive a coupon for a stroller, a couple experiencing fertility difficulty (or who experienced a miscarriage) might not appreciate receiving constant flyers for baby item sales. It’s one thing if someone actively opts-in or signs up to receive notification of promotions of certain types of items, but quite a different thing to have the automaticity and presumptuousness, and it’s a problem.

There are other financial “incentives” that erode our medical privacy. One that bothers me quite a bit is the extra charge for health insurance that many companies currently impose unless you have a yearly health screening and fill out an online, detailed, personal questionnaire about health-and-safety-related issues. Strange that this bothers me, considering what I do for a living. And considering that I am all about people taking responsibility for their health. And considering that I am all about educating people on health-and-safety-related issues and healthy lifestyles. And that I like when there are resources to help people. And that I understand deeply how addressing certain issues can significantly improve a person’s overall health and well-being (and in so doing, how it can have a positive financial impact as well).

But I figured out what it is that bugs me so much. I actually would have no problem with it if there were the same requirement for a yearly check-up with one’s own physician and if the questionnaire were between each individual and that person’s physician. My problem is with the online, one-size-fits-all survey/questionnaire with detailed, personal questions (many of which have nothing to do with modifiable risk factors) that goes to some random computer algorithm and perhaps some random person (who is not a doctor). Seriously, the lifestyle health coaching company does not need to know when someone’s first menstrual period was – they can simply ask if a woman has discussed breast exams and mammograms with her physician. My issue with the current system of monetarily penalizing those who don’t comply with this invasive questioning is the presumptuousness and the intrusion of someone else into my doctor-patient relationship. There are too many people in the exam room.

By all means, the companies should feel free to offer their support services as an option to those who decide they would like to use them, or to those whose doctors feel they would benefit. But if you are not my patient and you were not invited in by my patient, then get out of my office. And if I did not invite you, then get out of my doctor’s office.

I like a lot of things about Facebook. It allows me to see pictures and video of my nephews and niece and of friends’ children, it quickly lets me know when something big (either happy or sad) is going on in people’s lives, it lets me know what people are thinking about, and it gives me the opportunity to share my own news, thoughts, pictures, or occasional videos with others.

But as much as it allows glimpses into other people’s lives, Facebook doesn’t give complete pictures. Each of us has our own public persona, an image we project to others, which is only part of who we are. On social media that persona is even more deliberate and whittled down. We share the highlights, the good stuff, the proud moments, major life events, perhaps some political thoughts, and when we complain about something we often do so in a humorous light. In our reporting, a lot of us tend to skew positive.

I’ve noticed that people tend to do this in their doctors’ offices as well. Appointments are short. There’s frequently only time to cover a few highlights. People don’t want to be seen as complainers or don’t want to “bother” their doctors. So when coming into the office for a check-up or to address a specific issue, the answer to the doc’s “How are you?” is a smile and a friendly “Fine, thanks!” Not that there’s anything wrong with pleasantries, but if it stops there and concerns aren’t voiced, that can be a problem.

When we’re patients, we cannot assume that our doctor will notice a hesitation in our voice or a look on our face, or experience clairvoyance that will enable her to know that something is bugging us. If something worries us, we need to express it. We need to write down our concerns before our appointments so that we don’t forget them or decide that they’re not really that important.

When we’re doctors, we cannot assume that our patients’ friendly smiles and polite answers to “how are you” questions indicate that they have no concerns. We have to dig deeper. We have to read the review-of-systems questionnaires of 500 symptoms with check boxes that we made our patients fill out before their appointments and address what is checked off as “yes.” We need to specifically ask if there is anything else bothering our patients or if there is any other concern they have about their health. We need to remember the facade that people are used to maintaining.

A visit with a doctor requires, from both sides, more than a glance and a click on a “like” button. It requires human interaction. It requires communication. It requires connection. When a patient is in a doctor’s office, it is because that patient needs something beyond a Google search of a symptom. Even when someone healthy is in for “just a check-up,” that person cares enough about their health to be there, and deserves to be encouraged to share any medical concerns. And a doctor deserves information from his patients so that he can do his job as well as possible.

Appointment slots are brief. They can seem a bit like a Facebook encounter (or in some cases, even a Twitter encounter). But a doctor’s visit is not a social media situation. It needs to be deeper. It needs to address the person behind the post. Interact. Communicate. Connect. I “like” that.

There was a brief scare in our neighborhood this past weekend. Our phone rang. Our friend, who lives nearby, asked if her 12-year-old son was at our house. He wasn’t.

The child had been gone for about 15 minutes. Their family had just returned from a shopping trip with a family friend, and that family friend had forgotten one of his items at our neighbors’ house. The child said, “I’ll run it out to him, Mom.” His mother said, “I think he’s already pulled away,” and the kid replied, “I can still catch him.” As the mother was putting away groceries, she realized it had been about 10 minutes, and she hadn’t heard her son come back inside. She called through her house, went outside and looked around, called her family friend (who had not seen the child since he left her house), and then called us. Her husband jumped in his car to look for their son.

All five of us headed outside while the mom called the police. My husband took one car and left to drive an east-west pattern, and our eldest son took another car to drive a north-south pattern. Our two younger sons went on foot to check local parks. Each of us had a cell phone. I walked to our neighbors’ house, and asked my friend for details of everything that had transpired in the past 15 minutes. Their family friend had returned to their house, and he and I went inside to search the house carefully as our friend spoke to the police officers who had just arrived (small city, quick response time).

I did not think that the boy was in the house. But I looked anyway. It’s a doctor thing. Listen carefully to the story. Figure out the most likely cause. Think of the potential life-or-limb-threatening causes. Respond in a systematic way so as not to miss anything important. Being methodical and systematic also helps keep panic from taking over.

From listening to my friend and knowing the child, my assumption was that the kid had just gone to the family friend’s house. My friend did not think so – it was a mile-and-a-half away, and she said he wouldn’t have any idea how to get there. I still thought it was the most likely explanation. The police thought it was most likely that or perhaps he saw a friend and went to hang out with the friend and forgot to call home. My friend was terrified that her son had slipped on ice and was lying unconscious somewhere or that he had been abducted. I’m a mom – I get it. Same thoughts went through my own head.

The first of her fears was not overly likely, since it was the first warm day in a while, lots of people were outside, and someone would have seen him lying unconscious and called the police. The second fear was statistically very improbable. But those were the possibilities that were most threatening, so people started searching immediately. Why search inside the house? I certainly didn’t think he was hiding, but what if our friend hadn’t heard him come back inside and he had fallen on the basement stairs or been reaching for something on a shelf and had something fall on his head? Not super likely, but you wouldn’t want to have a dozen people searching outside while he’s lying unconscious inside. So you’re systematic. You look. Even when you think someone’s chest pain is likely to be benign and coming from his esophagus, you still check an EKG because you don’t want to miss a heart attack. The kid was not inside the house.

I stayed with our friend, reassuring her that she would probably be scolding her child for his disappearance within the next few minutes. The family friend drove back to his house to look – and saw in his mailbox the item the child had run to return to him. He called. And at the same time, one of the police officers swung by to say that another officer had just picked up the kid and that they were on their way back. We called the driving and on-foot searchers, and everyone came home.

The child was missing for less than a half-hour, but it of course felt like hours to us. Our friends’ son learned the importance of telling someone when he’s going somewhere, and of bringing his cell phone with him. Our friends learned that their child could navigate his way around our town a lot better than they had thought. And we all had reinforced the importance of responding quickly, systematically, and appropriately (news crew hadn’t been called, no Amber alerts issued, just as a doctor wouldn’t go straight to a cardiac catheterization for that patient with chest pain without first checking an EKG and some other basic things).

Breathe. Call for help when you need it. Be systematic. Communicate. Ask questions. And remember that the most likely outcome is indeed the most likely outcome, but take necessary steps to address other possibilities.

Our 13-year-old woke up feeling lousy two days ago. He had a sore throat and sinus pressure, and felt really tired and generally icky. He didn’t look toxic – just a little tired. I gave him a Cold-Eeze zinc lozenge and told him to get ready for school – a method that generally can tease out exactly how bad one of my kids feels. He just sat at the table. We generally adhere to the “unless you have a fever, are actively vomiting, or have blood squirting out of your ears, you can go to school” policy, but there’s been a particularly hard-hitting virus going around the neighborhood, so I figured I’d keep him home – no need to infect others if he was in a particularly germ-effusing state.

He had awakened at 6:30, and by 7 he was back in bed. He slept until 11, and then got up, gargled with salt water, ate a little rice, and worked on a math assignment his teacher had e-mailed to him when we told her he would be out sick that day. Back to sleep by 12:30. He woke up again around 3:30, had some chicken noodle soup, was back in bed within an hour, and woke up again around 7, when he was feeling well enough to join the family at the dinner table (where his 16-year-old and 17-and-three-quarter-year-old brothers joked that we never would have let them stay home without a fever, to which my husband and I smilingly responded that that was obviously because we love the 13-year-old more). He went to bed for the night at 9:30, and woke up yesterday morning feeling completely fine.

He doesn’t normally sleep for 18 hours total in a 24-hour period, so my powerful doctor-sense (or “duh”-sense) tells me his body really needed some rest to fight this thing off. Or maybe it was the zinc lozenge. Or the salt water gargle. Or the chicken soup. Or maybe he would have been perfectly fine by yesterday morning even if I had made him go to school the day before. There’s really no way to “know” for sure – I can’t do a prospective, placebo-controlled trial of each of the possibilities on my child, so my medical decision making was not “evidence-based,” nor is my conclusion that I did the correct thing based on rigorous academic study. It is based on common sense. A generally healthy 13-year-old who felt yucky and exhausted stayed home and slept and felt better the next day. No need for antibiotics or any other “big guns.”

Much of the art of medicine lies in knowing when a little time and rest is needed, and when more is needed. Sometimes, as Voltaire said, “the job of the doctor is to amuse the patient whilst nature takes its course.”

This morning I went for my annual mammogram. It’s not something I generally look forward to. In fact, I mildly dread it.

In my personal experience, mammograms have ranged from quite uncomfortable to downright painful. And then there’s the general unpleasantness of standing topless in a cold room. The first time I had this screening imaging study done, the plate pressed so hard into my sternum that I was almost in tears. Other times, the plates have dug into my ribs or my sides, or my skin has been pulled too tight in various directions. A few times, I needed to repeat a shot or two because I was told that the radiologist needed another picture because the first wasn’t compressed enough.

Last year when I went, I wanted to avoid the need for repeat pictures. The tech told me to let her know when I couldn’t take any more squeezing. So I just gritted my teeth and let her keep tightening. And she kept going. My breasts felt bruised and sore for weeks afterward. And one of the views needed to be repeated anyway.

So I really didn’t want to go today. But I did. Although there is some controversy as to the ideal timing between screening mammograms at different ages, my doctors recommend an annual schedule and from the studies I’ve seen, I agree that that’s a reasonable plan for me.

So I went to my appointment. And when I went into the room with the technician, I followed the advice I give my clients and that I’ve always given my patients. I talked. I voiced my concerns. And I was lucky to have a fantastic person taking care of me.

As she led me to the room, she spoke to one of the nurses about what room we were going to and where we would head afterward so that I would be seen efficiently. I commented on how she really had everything streamlined. When we entered the room, rather than keeping my mouth shut and worrying about being seen as “a complainer,” I told her about my past painful experiences, because I didn’t know how to get the appropriate level of squish without being injured (believe it or not, they don’t teach us that in medical school).

She told me that the re-takes that I had done in the past were likely not because of inadequate compression. She said that when the radiologist sees a little something that doesn’t look quite right, they get another picture to make sure, but so as not to alarm people they tend to say something that indicates the positioning or compression for the film wasn’t good enough, and on the repeat views they generally determine there’s nothing worrisome. She taught me that maximum compression doesn’t mean the best picture – there’s actually an ideal level that you can tell by the firmness of the skin on the compressed breast.

She performed the most comfortable set of breast x-rays I have ever had. And nothing needed to be repeated. And I wasn’t even cold, because instead of having me remove the gown completely, she pulled off one sleeve at a time and tucked the gown into my waistband so that most of me was covered and warm. Did I mention that this person was amazing? 

None of this, by the way, was special treatment or “professional courtesy.” I never told her that I’m a doctor. We simply spoke to each other as we would want others to speak to us. I was honest. She was honest.

I have her card – and I’ll be sure to schedule next year’s appointment when she’s working. I also plan to relate my experience to the people who run the department. Everyone should have a mammography experience like the one I had today, every time. No need to freeze. No need to endure painful squeezing. But someone does still need to work on a lighter adhesive for the nipple markers…

I use my computer a lot, so I see a lot of advertisements. Many of them are for the latest two or three items I’ve priced online (which I find somewhat creepy but fairly easy to ignore). Many of them are generic, casting a wide net. These generic ads frequently talk about “one ridiculously easy trick” to halve your car insurance payments, lose 50 pounds, learn a foreign language, look younger, or drastically reduce your utility bills. Experts in the relevant fields apparently don’t want you to know about these ridiculously easy tricks, and the fact that “local moms” know about them makes the experts “furious.”

The websites promoting these ads either put malware on your computer or make their sites impossible to navigate away from (“are you sure you want to leave this page?” and if you click “yes,” they take you to another page selling the same thing) until you give them your credit card number to subscribe to deliveries in perpetuity of the magic product. They are scams. They are silly. Most people know this and ignore them, but some folks are sucked in.

Those that are sucked in are either looking for an easy way to do something that takes a lot of work or they’re annoyed and fed up with those the ads purport to infuriate. That’s the aspect I want to discuss – the annoyance and fed-up-ness. I can see that people might want to stick-it-to-the-man in situations where they feel like they have been treated less-than-fairly. I suppose there are people who hated their college’s foreign language requirement, resented the homework their professor assigned, and can’t wait to do what “makes language professors livid!” Of course, if you were to take a second to think about it, you’d realize that a language professor wouldn’t be angry if there were an easy way to learn a language – a professor wants her students to learn! But the ad tries to get people to act on an initial feeling of animosity. I find it sad that there is animosity toward teachers (some of my favorite people in the world are teachers).

And as a doctor, it bothers me that people are capitalizing on an impulse to do something that “infuriates doctors.” Again, if you were to think about it for a second, why would a doctor be angry if someone safely and effectively were to lose weight or quit smoking? But the fact that the impulse is there says that there exists among some a perception that doctors want to coerce patients into doing things that somehow benefit the doctors and not the patients. The perception is that the doctor wants his patient to take an expensive medication (which somehow financially benefits the doctor) rather than the mail-order magic berries or green coffee beans or whatever other magic potion the website offers for the bargain price of $69.95 per month – a 70% savings off the retail price!

Doctors need to do a better job in the PR department, specifically by working to partner with their patients to help them feel more engaged and empowered with their own healthcare. Physicians need to do a much better job in the general education department – educating their own patients and doing outreach to help educate the population-at-large on topics like how to evaluate a research study and what websites are trustworthy sources. For example, http://nccam.nih.gov/ is the site for the National Center for Complementary and Alternative Medicine, run by the NIH, which conducts and supports research on and provides information about complementary health practices, including use of supplements/herbs/etc.

What really infuriates the physician writing this blog is unscrupulous people looking to make a buck who try to drive a wedge between people and their doctors. I’ll post this blog later in Chinese, as soon as I finish the program that ticks off language professors, which I paid for with the money I saved on homeowner’s insurance using one ridiculously simple trick.

I had been working on an entirely different post, but I got sidetracked yesterday by a brief scare. I received a phone call in the late afternoon from someone very close to me. Please note that this someone is also a doctor. “Uh, I need you for a minute. I’m kind of freaking out. Can I talk to you?”

She had just gone to her local optometrist to get a new prescription for glasses. The optometrist looked in her eyes, told her that both of her optic nerves were swollen, that this was caused by a brain tumor or multiple sclerosis, and that she should proceed immediately to a hospital for an MRI. She has had no symptoms whatsoever that would have been indicative of either of these things. She realized this. I said that someone else needed to evaluate her and that there were much more likely (and benign) explanations. She of course knew this, but when a healthcare provider says something like that to you, it can be difficult to remain rational and objective.

She had already called the leading ophthalmology hospital in her region and had been told that the emergency room was overflowing and that it would be hours until she could be seen. A very wise woman, also a part of our conversation, suggested that she go to the ophthalmologist’s office where she had been seen in the past. One call to the office, and she was told to come in and that she would be seen right away.

The ophthalmologist looked into her eyes, still dilated from her earlier exam. She looked very closely. The nerves were not swollen. The ratios were not quite normal, but everything was crisp, as it should be. Her visual field testing was normal. Although the ophthalmologist who had seen her in that office years ago had since retired, the doctor now seeing her had access to past records and could see that this anatomic variant had been noted in her exam many years before, and needed nothing more than observation. No swollen nerves. No brain tumor. No MS.

The optometrist certainly did the right thing by refering her patient on when she noticed an abnormality. And the ophthalmologist said that swollen nerves were a reasonable interpretation for someone to make of her exam if she had not seen such a thing before or had not had access to past records. But a few things could have been done better. First, assuming the medical situation does not involve something that requires instantaneous action, taking a few minutes to look for a back-story, to find old records, and to think about what clinically makes sense in a particular situation, can be very useful. Even when a situation does warrant immediate action, this digging can be done simultaneously to the early action so that it can guide further actions. One of those benefits that will come when electronic medical records are all able to “talk to each other” someday is that this will be able to happen faster. Second, even though a patient is a doctor and could come up with a list herself of all the potentially horrible things that could cause something, and even though a patient with no medical training can also do a quick internet search and also come up with a terrifying list of possible causes, a healthcare provider should probably be careful, while of course communicating the need not to ignore something, not to scare the living daylights out of a patient.

For example, “Your belly pain and tenderness concerns me. This is not something we should ignore. There could be a number of different causes, but right now we need to make sure it’s not your appendix, so I’m sending you to the hospital. I’m calling now to let them know you’re coming,” rather than, “Appendicitis causes this pain. Get to the hospital right now.”  Or, “I see something on your EKG that doesn’t look quite right to me. You don’t have any cardiac symptoms, and your physical exam is fine, but I’d like a cardiologist to look at this. I’m calling Dr. Smith’s office now and will fax the EKG directly to her, unless you have a cardiologist who you already see that I could talk to,” rather than, “You’ve got an abnormal EKG. This could mean you’re having a heart attack. Go to a hospital and get a cardiac catheterization right now.” Or, “I’m seeing something that doesn’t make sense when I look at your optic nerves. I don’t want this to wait too long, so I’d like you to see an ophthalmologist today to be evaluated. Do you have an ophthalmologist I can call, or should I send you to one of the ones I know?” rather than what was said yesterday…

Of course it’s a balance for healthcare providers – you certainly need to convey a level of urgency and the importance of addressing certain situations in a timely manner, but a little bedside manner can go a long way. Yesterday’s situation could have gone a different way. Assuming the medical reality was the benign anatomic variant that it turned out to be, there could have been a big waste of resources: a trip to a random emergency room with a message from the patient that “my optometrist just told me my optic nerves are swollen in both eyes and that I need an MRI,” a quick look in the back of the eyes done in a light room with a poorly functioning ophthalmoscope by a doctor who is not specifically trained to distinguish subtle back-of-the-eye findings, and a very expensive, unnecessary imaging study. (Please note that I am by no means implying that a test with negative results is unnecessary – but in the above case an evaluation by a specialist and a thorough review of medical records made it unnecessary. Tests are frequently needed to rule out certain conditions, and ruling them out by no means implies that the tests were not important to do!)

If the eye findings had in fact been something dangerous, if there had been accompanying symptoms or visual field defects, then prompt imaging and diagnosis would have been imperative. I am glad that the optometrist was able to recognize that something was not “normal” and needed further evaluation. And here is where we find the doctor-patient interaction from years before lacking in effective communication. Even if a physical exam finding or idiosyncrasy is completely benign, a patient needs to know about it. It is the doctor’s responsibility to say to the patient, “You have an unusual finding – it doesn’t have any clinical significance, it is not at all harmful, and you don’t need to worry about it, but you should know about it in case another healthcare provider sees it and doesn’t know what it is. I’m writing down the name of it and a description, so future doctors can determine whether something they find on your exam is this particular thing or something else. Please have any of your other care providers call me with any questions about this in the future.”

And a fully empowered patient will ask, after any physical exam or test, what all of the findings are, even if the findings are benign. Ask for copies of any test results (disks of any images, copies of EKGs, etc.) and for copies of the test/imaging reports/interpretations. Ask for physical exam findings in writing. The more detail you ask for, the more healthcare providers will give you, and the more they’ll get in the habit of providing such written details to all their patients. Electronic medical records are making it easier for this to happen.

Any one of us has the potential to get scared, even when (and sometimes moreso when) we have a lot of medical knowledge. Call people who can help calm you down and think clearly. Gather your information. Seek expert opinion. Keep good records. And remember to breathe.