How to be Prepared as a Patient, More Medical-Legal Issues, & Menopausal Hormone Replacement

Topics discussed on the January 13, 2012 radio show included some hints to help prepare people to be better patients, some more issues illustrating how legal matters affect medical care, as well as some thoughts regarding hormone replacement for menopausal women.

First, one must always remember that YOU, the patient, are the best source of medical data, & as such, you should document that information for future use.  If you have access to a computer gadget you can find an "app" to help you organize & record that information.  I have an iPod & have found a very useful app called "My Medical," which is a free app which I use to organize my personal medical information.  It allows you to input personal information such as your name, address, & date of birth.  It then guides you to input your personal medical information such as blood type (if you know it), medical illnesses, past surgeries, allergies, medications/doses, & your physicians' names & numbers.  You can also enter the dates of your last mammogram, colonoscopy, immunizations, etc.  Once you input the data, you can print it out for doctor visits, & in case of an emergency, the data is available to appropriate medical personel.  Be sure to keep the data current... & to do so, consider reviewing it BEFORE appointments or surgeries, as well as afterwards!  Though there is a move toward a single computerized medical record, the system is not perfect & YOU are still the best source of information regarding your medical history... IF you apply yourself & keep it up to date!  And don't forget, a pen & paper work very well if you are not thrilled with computers!

Also, though a single computerized record (or national data base) of all your medical information sounds like a great advancement in medical care, we discussed issues related to problems that occur when the data recorded is wrong.  Often diagnoses are based on a doctor's best guess, so they are not always "proven."  Such is the case whereby a person presents to his physician with complaints of sadness, fatigue, & weight gain.  Many physicians would empirically (by educated guesswork) diagnose "depression."  However, if the patient failed to respond appropriately to treatment for depression, the doctor might then order lab tests to see if there is another cause for the depressive symptoms.  In this case he might find that the patient has hypothyroidism (a slow thyroid) which can make a person look & feel depressed.  Stopping the anti-depressant medication & starting appropriate therapy with Synthroid (or a similar thyroid supplement) will correct the patient's problem, but the computerized record might continue to indicate that the patient has/had "depression" when in fact that is an incorrect diagnosis!  Also, unlike a paper source which allows a doctor or nurse to correct inaccurate data with an obvious single scratch-through line, the computer record requires an ADDENDUM be placed at the end of the note indicating the change... and these are easily overlooked!  It is also much easier to make data entry errors when typing as opposed to handwritten data capture.  I recently saw an Emergency Room report which indicated that my 60 year old patient was not a drinker nor a smoker, but it said she was a drug-abuser, which she was not!  Obviously someone hit the "yes" button instead of the "no" button!  When I saw this in her record I asked her to go to that hospital to have the information corrected... & I think it took her 3 different attempts to have them complete that task... but again, they would only write it as an addendum, so unless the record is scrutinized, she is a drug-abuser!  We also made comments regarding misdiagnoses, such as a person who was in a car accident (not as the driver) after attending a party.  As the non-designated driver, he had had a few drinks, & his alcohol level was consistent with being drunk.  The ER doctor incorrectly "diagnosed" him as "alcoholic," though I learned that an alcoholic is someone who continues to drink in spite of negative consequences.  This person was in an accident, though it was not his fault, as he was not driving.  And though he was drunk, he was not breaking any law.  As to whether alcohol was negatively impacting his life, I doubt the ER doctor spent enough time with him to gather that knowledge.  So in short, I think this was a misdiagnosis, but unfortunately he will probably never get that off of his record!

On to other ramblings... it is NOT necessary to know your blood type, unless you are simply curious!  When or if you donate blood, they will be able to tell you your blood type.  Also, the Blood Bank does many compatibility tests, not just the ABO & Rh factors which most of us know.  In other words, even if you have the same blood type as someony else, you might not be able to donate blood directly to her, as there are many (not just 2) factors that must match.  If you are trying to donate for someone who is ill, the Blood Bank will gladly take your blood, though your friend or family member might not receive that blood.  Instead, they will give it to the person whom it matches best, & your friend or family member will receive "credit" for the donation.  Others who donate will hopefully match your friend or family member, so we encourage all healthy people to consider donating blood as this gives us more likelihood of finding a good match for everyone!  And remember, the Blood Bank is very strict in regards to who is allowed to donate.  This is what is necessary to provide SAFE blood for all of us.  So if you are healthy & take few medications, consider giving blood.  You never know who you might help with your generosity!  And don't forget to ask them how you can also be evaluated to be a bone marrow donor, as I understand it just takes a small sample of your blood (not a bone marrow sample!).

The topic of death certificates came up as an example of medical & legal intertwinings.  Did you know that your primary care doctor is charged by the law with completing your death certificate?  Only if the Medical Examiner feels your death warrants further investigation will you have an autopsy.  This means that your primary care physician can ASK for an autopsy, but the Medical Examiner can refuse, & in this instance your primary care doctor MUST complete the death certificate within 2 days of your death.  I had this happen years ago when a 60'ish year old patient (& friend) died suddenly.  The ME did not feel an autopsy was necessary as the patient was older than 50 years, & as she had cardiovascular risks.  I argued that there was no history of cardiac symptoms, & requested that an autopsy be performed as I was not able to determine her cause of death.  I was told by the ME that if I did not complete the death certificate, I would be in breech of the law.  I still refused, which got me a phone call from Tallahassee... the Dept. of Vital Statistics.  They informed me that "the Death Certificate is NOT a legal document" & as such cannot be used in a court of law.  Thus it is acceptable to guess as to the cause of death!  They further informed me that if the "family" wanted an autopsy, they could pay for a private one, but I still MUST fill out the Death Certificate as that is the law!  I later got a copy of the law from my malpractice attorney.  It indicated that the Medical Examiner shall conduct an autopsy "when the patient dies suddenly while in apparent good health."  I wrote to the group that oversees the Medical Examiners in the state of Florida, & I asked them whether that is determined by the primary care doctor who knows the patient or by the ME who does not.  Their reply in writing was:  "We don't have to answer that question."  I don't know about you, but that seems like a bureaucratic answer to a simple appropriate medical question!

In cases where the person has a life-insurance policy, the cause of death might affect the pay-out.  In these circumstances, if the family disagrees with the Medical Examiner or primary care doctor's assessment of the cause of death, they must pay to have a private autopy performed to truly determine the cause of death.  However, sometimes it is better not to know the truth, as was the case with one 40'ish year old patient who "drowned."  The Medical Examiner determined that it was an accidental death by drowning, but the wife believed he had suffered a heart attack.  She requested a private autopsy, but after reviewing his life insurance policy, she cancelled the request.  The policy would provide a benefit of $100,000 upon her husband's death, BUT it would provide $200,000 if the death was accidental.  Since the ME felt it was accidental, she & her family would easily recieve the higher benefits... as long as there was no evidence to the contrary!

Lastly, we briefly discussed menopausal hormone replacement, & why men might care in the long-run.  Menopause is in essence an absence of ovarian function... either they stop working or they are surgically removed.  Without the ovaries, women do not produce estrogen, progesterone, & testosterone.  This causes many changes in women, such as hot flashes, mood swings, & poor sleep.  Not all women suffer severely, but thin women generally have more symptoms, as heavier women have fat cells which produce some estrogen.  The choice as to whether a lady takes hormones after menopause is a personal decision which is based upon her medical history, family history, degree of symptomatology, & personal preferences.  In general, a woman with a history of blood clots (in the lungs or in the legs), or one who has had a stroke or heart attack is not a good candidate for hormone replacement, nor is a woman with a personal history or family history of breast cancer.  It is best to discuss these issues with your Primary Care doctor &/or your Ob-Gyn, & then make your choice.  There are pills, patches, & creams that will deliver these hormones, & that choice is also one of personal preference as pills are generally cheaper, but patches & creams are probably safer.  The idea of "bio-identical" hormones is envogue, but they will never be identical to what you had before menopause UNLESS you measure those levels in your youth, as everyone has different levels of estrogen, progesterone, & testosterone based upon genetics.  On the other hand, "bio-identical" hormones might also indicate that they replace what the body makes... in other words, estrogen, progesterone, AND testosterone, as until recently physicians only replaced estrogen & progesterone.  In the long run, though it is the woman's choice, it will affect her partner, as one of the other side-effects of menopause is "atrophic vaginitis."  This is a condition which is caused by a lack of estrogen which results in the vaginal tissues being dry.  Often the dryness & loss of elasticity leads to pain with intercourse, thus affecting our intimate relationships as well!

Again, here's to our health!


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