The Medical Insider

Allen, 56, has a decision to make. Should he start prostate cancer screening? He knows two prostate cancer survivors.

His father was diagnosed with prostate cancer, young – in his 50s. Opting out of treatment on his doctor’s advice, he died at age 84, of Alzheimer’s complications.  

His friend Kevin, 73, was diagnosed at 53. He underwent prostatectomy, radiation and followed up diligently. Though he felt fine, last year a workup showed bone metastasis to his ribs, shoulder and hip.

Prostate cancer is very common.

Alex, 18, is home from college. He’s studying to be a respiratory therapist. For his summer job, he bikes 16 miles from Avon to North Olmsted and back, leaving at 5:10 a.m. every morning. He’s affable, athletic and “not unique.” Most remarkable, he’s been a diabetic since age 4 – and managed to keep nearly perfect glucose control.

Alex’s body makes no insulin. For every meal and activity, he calculates his carb and insulin needs. He thinks nothing of it. But in the past few years, a problem has crept up on him, and eight million other insulin-dependent diabetics in the U.S.

From 2002 to 2013, the price of insulin tripled (a vial of insulin went from $231 to $736). Who knows why. A survey shows almost half of diabetics skip needed medical care because they can’t afford it.

I buy organic products, but inconsistently. I buy organic milk, but not organic yogurt or butter. I track the Dirty Dozen, but balk at the cost of organic strawberries, and how fast they rot. It’s fair to ask how do organic foods, a palmy 46-billion-dollar industry, actually benefit us?

Good Earth policy?

Pouring less chemicals into the soil and water is a good thing. But massive imports of organic produce from overseas creates pollution. It makes equally good sense to buy local produce, and reduce food waste.

Better nutrition?

The American Academy of Pediatrics (AAP) states organic food doesn’t provide “any meaningful nutritional benefits or deficits” over conventionally grown foods. An apple is an apple is an apple. With or without the organic wink, potato chips will – always and above all – be a junk food.

Anne’s migraines started in her 20s. During an evaluation as a fledgling flight attendant, she developed a blinding headache during final descent and threw up all over her supervisor. That was the memory of her first migraine.

One in five women (most common between ages 18 and 44) suffers migraines – twice the frequency of men.  

Doctors tackle migraines using two lines of attack: mitigate and prevent. To mitigate acute pain, many drugs (or combinations) work. Two stand out: fast-acting NSAIDS (ibuprofen, naproxen sodium) and triptans.  

Most migraineurs have their own cocktails. The problem I see often is taking drugs too late.

The Pill, oral contraceptive pill, is the most important innovation of the 20th century. (I’m a woman, sue me.)

Margaret Sanger, founder of Planned Parenthood, pushed relentlessly and heroically for its discovery and legalization. In 1910, Sanger, a nurse in New York City, witnessed the burden of unwanted pregnancies on women and families and the horror of self-induced abortions. (Her own mother had 18 pregnancies in 22 years and died young.) Birth control, she thought, would allow a woman to be “the absolute mistress of her own body," improving her well being and social equality.

Since the inception of the first pill, Enovid, in 1960, the Pill has come a long way.

Recently diagnosed with diabetes, Al, 65, a chopper pilot and chef, is taking two drugs, still short of ideal control.

Last month, he was relieved when the American College of Physicians (ACP) proposed a more relaxed goal for Type 2 diabetics (or adult-onset diabetes, 90 percent of all diabetics). But as soon as the guideline was released, it came under fire from multiple well-respected organizations including the American Diabetes Association (ADA).

“What do you think?” he asked.

Personally – and call me what you want – until the thinking caps calm down, I’m hiding. Staying dry, upstream, above the fray.

So, what’s the rationale behind the ACP’s change in attack plan?

Little yellow and blue flowers peeped out of melting snow, you snapped your fingers, trying to remember their name. Halfway to the gym, you turned around because you weren’t sure if you unplugged the iron. A trip to Aldi, you got three bags of groceries, everything except the one thing you actually needed: half-and-half.

How much forgetfulness is healthy? Given that I’ve just described my last week, let’s go there. 

Alzheimer’s disease (AD) accounts for the majority of dementia cases. Luckily, the age-specific cases are on the decline, have been for decades. In a 2017 JAMA article, Americans over the age of 65 diagnosed with dementia had decreased from 11.6 percent in 2000 to 8.8 percent in 2012. But with more people living longer, total cases are increasing. 

Rule 1. Your husband threatens to leave you – don’t blame the kids

Your husband, one-quarter of a decision tree, never had pets growing up; he likes a clean house. But you grew up with birds, dogs, turtles, anything you could rescue and adopt because your mom, like you, had no boundaries. He said he’d leave you when you brought home the dog, then when you got a rabbit, and again when you got the second rabbit.

So, when the kids got into animal foster care, frankly, he looked relieved. At least after two weeks the animals go back to the shelter.

At every annual checkup, in front of the vet’s office, my 70-pound shepherd mutt, Rosie, hams a scene for the Oscars. Collapsing dramatically on the concrete. I tug; she wails. I pull; she howls like she’d glimpsed an afterlife without liver bits, belly scratches, squirrels.

But I’m her. I hate going to doctors. Last year, I got my blood pressure almost down – there they went lowering the cutoff again.

Having the right primary care physician helps. How do you begin?

Within insurance network

Recommendations from your neighbors, yoga instructor or dentist are good starts. But don’t start with an out-of-network provider, not unless you absolutely need a second opinion from an expert – the only one of two in the U.S. who can explain why your family has odd-numbered toes.

Do you have an addict in your life?

Mine texted me yesterday; he needed groceries. A short list: frozen bagels, cream cheese, potatoes, white sauce, coffee for him, tea for her, canned soup. I ignored the nutritional value – now that most of their calories come from liquor, burned off by cocaine.

I want to help, yet these days I find myself asking the simplest questions: Am I helping? What happens to his unemployment and her disability checks? I can guess.

Tens of millions of Americans qualify for weight-reduction surgery, yet less than 1 percent pursue this option yearly. Shows like “My 600-lb Life” both promote and stigmatize bariatric surgery as a desperate measure for the desperately obese. I think differently. If you’ve dieted, exercised, divorced your carb crutch and still struggle with weight, diabetes, sleep apnea, back and knee pain – then surgery might help.

The criteria for bariatric surgery are simple: BMI of 40 and over, or 35 with at least one weight-related medical condition. If you’re 5’4” and weigh over 235 pounds, or over 205 lbs with diabetes, you’d qualify.

Currently your two best surgical options are gastric bypass and gastric sleeve. Adjustable gastric band, popular a few years ago, is disappearing because of unsatisfactory weight loss. Five-year data show both procedures have comparable weight loss, maintenance and complication rates. Gastric sleeve is easier surgically, but it’s irreversible and may worsen reflux, a major reason for reoperation.

When I offer flu shots, most people refuse.

“Never had the flu, I’ll take my chances.” I’m told. “I know someone who got the flu from the shot.” (You can’t.) And this year, “I heard flu shots don’t work.”

We need better flu protection. The measles vaccine, for example, struts a consistent, robust and reassuring 97 percent protection rate. The flu vaccine, with its "maybe we got it this year – or not" protection rate, makes science look like the fumbling guesswork of a colorblind chameleon.

Personally, I have two irrefutable reasons to get vaccinated.

Third in a three-part series on depression.

I consider depression a systemic disease affecting both mind and body. Adequate treatment can lead to better life choices, medication compliance, pain control and sleep; faster recovery from heart attacks, chemotherapy or a simple cold.

But lumping all depressions as a single disease is like calling everything you got on your birthday, a gift: the speeding ticket, the hangover headache, a gift certificate to a cooking class (your family can only hope). 

Upon diagnosing depression, I offer both drugs and counseling, but not all experts agree with this approach.

Second in a three-part series on depression.

Most depression I diagnose does not start with, “I’m depressed; I need help.”

Some people know they have depression, which begins, like most mental illnesses, in the late teen years and early 20s. People get good at living with it, working through it, smiling, clowning, hiding and toughing it out.

Their problem: they come to me late. What’s late? When minor things like going to the mailbox or answering a social call requires a major mental deliberation.

First in a three-part series on depression.

Jo’s father was quiet, distant, worked hard and drank harder. After he stopped working, he drank less; instead, he sat in the living room and stared at a blank TV screen all day. One day, he lurched from the sofa, vigorously “beating bugs” off his arm, collapsed and died.

So when her son told her that he was an alcoholic – at 21 – she didn’t believe him. He was sweet, outgoing and funny as hell. Their family, including his three older sisters, doted on him. Then calls started coming: from friends, EMS, police. Soon long sleeves, caps and sunglasses couldn’t cover the cuts and bruises from falling.

Today she realized both men had been severely depressed. Liquor simply worked better than Prozac.

My mom, age 84, and I don’t always have the easiest time. She doesn’t like me telling her what to do. I don’t like her dropping hints on how to raise kids. For sure, she missed the AARP memo on simplifying life after retirement.  

Months ago, in a freak accident mowing grass, Mom went airborne. I saw her in the ER, bruised and stitched. Two ribs and left elbow broken; left shoulder dislocated and broken.

Before I opened my mouth, she said, “Why the face? I’m not dead!”

Two month after her injury, she started painting her backyard fence. I asked how it went.

She said, “I hurt all over.”

“What pain med are you on?”

Her doctor prescribed piroxicam, a once-daily, nonsteroidal anti-inflammatory drug (NSAID), which she took – as needed.

“The drug works, Mom,” I said. “But you’re doing it wrong.”

I stay out of political talks, not because I have no opinion. The real problem: being a woman of a certain age, I know I’m always right.

The few privy to my sparkles of wisdom – by “few” I mean Mark, my husband – said this early in our marriage, “We’re like a pair of old shoes. You’re always right. I’m what’s left.” I chuckled, submitted “the joke” to Reader’s Digest and was promptly rejected.

Starting weeks ago, whenever I put on my reading glasses, Issue 2 popped out. Except during election years, I mused, who’s ever cared this much what Ohio thinks?

I asked around, “What’s ‘The Ohio Drug Price Relief Act’ – or Issue 2?” and got two answers: “I’m not sure,” or “it’s confusing.”

Then I found out the pharmaceutical industry is behind the aggressive negative campaign. Last year, it spent $109 million (out-funding proponents of the ballot 10 to one) and struck down an almost-identical measure in California. It was the most expensive ballot battle of 2016.

Months ago, Willie, 62, a diabetic, was laid off from her job assembling hydraulic pumps. Even before that, she hadn’t had health insurance or medications for over a year. She gets up four or five times a night to urinate, which she thinks is “normal” for women of her age.

Out of curiosity, I asked why she waited so long to come to the Lorain County Free Clinic, where I work.

She said she'd never heard of it, and she’s lived in Lorain for years. Last week driving down Oberlin Road, she happened to see a new sign for the clinic (it recently moved).

I know this story.

I’m a county-hospital-bred-and-trained workhorse. Yet I knew very little about the other clinic, until I started working there.

Part two in a two-part series on weight management.

Too often, you plunge into a new diet with the fervor of a first love: desperate, excited; the hope and promise of lifelong change; the all-consuming obsession with gluten, fat or sugar. And when the heart cheats – and the heart always cheats – inevitable self-loathing.

I think you should start a new diet like it’s the seventh year of your second marriage: calm, wise, wrinkled but not totally cynical, routine, legally binding – albeit with a prenup.

Because while you wholeheartedly will the relationship to work this time, deep down, you know things will go wrong. But it’s OK. No diet plan is perfect. There are ways to modify a plan until it fits your lifestyle.

Part one in a two-part series on weight management.

The blistering thing about dieting: Everything works, and nothing works – long term, that is.

Successful dieting is more than an act of willpower; it’s a marathon game of playing cat and mouse with your body and mind. Setting a realistic and generously forgiving goal in the beginning is essential. Here’re some basic facts.

1. What diet plan works best?

A 2014 JAMA study (1) looked at 11 brand-name diet plans. The average weight loss (for those who survived) is 10 to 14 pounds after one year. (Yes, you read that right, that’s an average of one pound per month). Low-carbohydrate (Atkins-like) and low-fat (Ornish) diets fare slightly better. The authors concluded that the differences between plans are unimportant. It’s much, much more important that you pick a plan that you can stick with for as long as possible.  

Forty years ago, my swim buddy Ashley (not her real name) was working too hard, worrying, smoking and drinking too much.

Concerned that the stress was “ripping” her health, she began a multivitamin/multi-mineral supplement “to bump me up.”

Years later, she drove off the road. Overnight, she stopped drinking, smoking, stressing and allowed her gray hair to show. But one thing she never stopped: her vitamins.

For our five-week trip to Quito, Ecuador, the kids, ages 18 and 15, and I competed for the lightest backpack. At 20 pounds and two ounces, mine weighed the most; the girl’s, at just under 16 pounds, the lightest. 

Quito, at 9,000 feet above sea level, sits in the foothills of an active volcano in the Andes. We had volunteered to work in a kindergarten for the indigent. Every morning, we took a bus and stopped in front of two huge dumpsters, spilling over with rotted vegetables, reeking of urine and fermented fruits. The street led into a huge municipal market. To the right of the entrance was the kindergarten, four big sunny rooms that were disinfectant clean.

My kids loved the one-year-olds. They didn’t mind changing diapers, spoon-feeding, and chasing babies who crawled, walked, got up and fell down like a scene from a zombie movie but with really cute zombies. After my last child, I’m very done with diapers. I stayed with the 3-year-olds.

Adolescence – the reason I don’t need to be young again.

I’ve gladly grown out of many obsessions and predicaments: Having to read books that “inspire me”; home perms; Jimmy W., only the third most popular boy at Spackenkill High School; wanting to be the president; finding the perfect husband; being the perfect wife.

But I, along with many adults, never did outgrow the one bully that taunted our adolescence: acne.

I have a friend, in his 60s, who loves and owns many “World’s Best Grandpa” sweatshirts. He belongs to a softball team and – much to his adoring fans' delight and his wife’s chagrin – slides into bases.

His knees are knotty like cauliflower. I’m guessing with some certainty that his X-ray will show osteoarthritis: loss of cartilage and joint space, bony changes. But he’s never complained of knee pain (at least not within earshot of his wife). 

Knee pain and knee osteoarthritis are like kiwi and emu; these flightless birds are related but not that closely related. Osteoarthritis doesn’t necessarily mean knee pain.

A patient of mine said this about marijuana and his Tourette Syndrome: “The only drug that’s worked!”

I believe him.

Medical marijuana is now legal in most states, including Ohio. A physician cannot “prescribe” marijuana – it’s a federal crime. Marijuana is a Schedule 1 drug, same as heroin or ecstasy, with “high potential for abuse” and “no currently accepted medical use.” But for a patient to buy marijuana legally, the state requires a “recommendation from a certified physician.”

I am the simple life.

I have but one winning formula: Set the bar low; pull the target close; paint the bull's eye big.

But I struggle to keep medicine simple. I believe, ultimately, a doctor’s decision should empower and enable you, not enslave, and sometimes it just might take a whole visit to get one simple thing straight – like cholesterol.

I followed with mild curiosity the “Revolution for Truth” crowd protesting outside the White House last week. One sign read: “OUR BABIES Were Well. THEY HAVE WELL-BABY MERCURY VACCINE. NOW 1 IN 6 KIDS NEUROLOGICALLY DAMAGED.”

The first thing that popped in my head: What’s with the small letters in an all-caps message?

Then I thought: What mercury?

Aside from some flu shots and one preparation of tetanus shot, mercury (thimerosal), a preservative, has been removed from all childhood vaccines for over a decade. And vaccines for measles, mumps, rubella, chicken pox, and polio do not contain mercury – NEVER DID. The vaccines-cause-autism theory is a dead horse that’s been running wild for 19 years, defying logic, science and common sense.

Who doesn’t know Miss Ruth?

At 86, she’s the reassuring voice that’s coaxed generations of Westlake toddlers to jump into the water. Recently, Ruth's sciatica acted up again. The pain starts at her buttock and radiates to her ankle. It’s been months. When she wakes up, the pain could make her cry. There’s no rhyme or reason to how the pain catches during the day.

And this pain has landed her in a crossfire between specialists.

Months ago, the rusty patched bumblebee became the first bee species to be placed on the endangered list by the U.S. Fish and Wildlife Service. Ohio is one of its last sanctuaries.

For years, to attract bees I’ve flooded my yard with flowering plants. By June, tree-size honeysuckles choke the eaves with white, pink and yellow blossoms. Last year, I saw one or two bees inconsistently. And it’s not just bees, I rarely see butterflies and dragonflies around our neighborhood anymore. It hasn’t always been this way.

Two streets over, a neighbor keeps a beehive in his backyard, an optimist who despite losing hives two years straight is still trying. He described the day his bees came home, staggering like drunk, and died en mass.

What does science say?

I was busily writing a beseeching piece on the health link between us and bumblebees when a news alert popped up. I dropped everything, and changed course to deliver you the newest on the oldest of health problems – back pain.

For decades, experts have pussyfooted around “pain” using language like “should, would, ought to consider” as they try to be sensible and sensitive, empowering, evidence-based and politically correct. The message was, as Tennessee Williams would have said, “all hawk, an’ no spit.”

The pain business remains murky water.

My blood pressure shot up when I turned 41. For a year, I ran and swam, squeezed stress balls and ate low-salt coleslaw. It helped, but not all the way. Finally, I showed up at the office of my good friend, Dr. Bob Bahler.

He listened to my history, including the “everybody in my family has hypertension, but I’m too young...” line. He chuckled when he heard I’d signed up for a marathon just to scare myself into exercising more regularly. 

“How’s that working out?” he asked.

“A little too well,” I said miserably, waiting for the floodgate of testing to begin.

“Nah,” he said, “you’re just getting old.”

No parent in their right mind will admit they have a favorite child.

But kids know. The boy says I favor his sister because the second something breaks, somebody cries or the dog barks, I always holler his name first. He gets punished more severely because he’s older, he’s bigger … he was there.

The girl says I favor her brother because – everybody knows Chinese favor their sons.

“You’re different,” I say. “I love you equally.”

But for what I do in primary care, I admit that I have my favorites, absolutely. Among the screening tests, an 80-year-old test for cervical cancer, developed by a Greek immigrant Dr. Georgios Papanikolaou, better known as the “Pap smear,” is it.

Medicine is a series of learning curves. Sometimes we land on our face.

We treated syphilis with mercury.

To reduce allergy, we said no to peanuts before the age of three; now we say yes to peanuts as early as you can.

We peddled estrogen to menopausal women as some fountain-of-youth elixir until 2006 when the Women’s Health Initiative showed hormone replacement could increase the very thing we’d tried to prevent – heart attacks.

We pitched a low-fat diet for those looking to lose weight, having high cholesterol or just good health metrics. It turns out the important thing about fat isn’t how much you consume but what type. Decades of high-carbohydrate diets fueled the nation’s obesity endemic. Yet we’ve done such a good job of hammering that message that when the new 2015-2020 Dietary Guidelines called to remove restriction on dietary fat; it had fewer “likes” than Michelle Obama’s mom dance with Jimmy Fallon.

But none compares to the current crisis of prescription painkillers.

What’s the best thing that’s happened to your relationship?

Don’t say kids.

While they’re the best thing to happen to us, they can glue and unglue a relationship. 

My husband, Mark, and I used to have deep and meaningful conversations about The X-Files, the best configuration for a Star Trek tricorder (bullet-shaped), and advanced alien form (fewer legs, more evolved). Now we agonize over who has the energy to start laundry.  

Thankfully, 10 years ago, our daughter, then five, did us a huge favor by failing – three times – Level One swimming, which, apparently, was a record of sorts.

If I had to pick the two most effective, all-purpose health interventions, I’d say: start walking and eat three artichokes each day.

Drugs, all drugs, are a game of rolling the dice against the devil. Each therapeutic benefit comes with a price – cost and side effects. Most of the time, we get away with either nothing or a rash, dizziness a mild headache. But all physicians have stories of patients whose guts turned into the Mar-a-Lago of drug-induced bugaboos after a short course of antibiotics. Or the current 78.5-billion-dollar nightmare of our “first-do-no-harm” profession: the epidemic of prescription drug and heroin abuse.  

The best way to reduce drug costs is to minimize the need for them. Let’s see if you can’t drop a drug or two with these two maneuvers.

Part two of a three-part series on ways to manage drug costs.

Writing this piece, on the problems and possibly a very effective solution to rising drug costs, has given me an epic, ethical headache.

The good news: Earlier this month, Bloomberg reported U.S. prosecutors are going after generic drug companies in “a sweeping criminal investigation into suspected price collusion.” They won’t name names, but I can easily guess three.

EpiPen, whose active ingredient epinephrine was isolated in 1901, went from $100 in 2007 to $609 in 2016. In 2013, a bottle of doxycycline, an antibiotic, went from $20 to $1,849 in seven months. About the same time, digoxin, a century-old heart medication derived from foxglove, went from 17 cents per pill to $1.18.

Part one of a three-part series on ways to manage drug costs.

Some facts just throw me. Here’s one: The U.S. makes up less than 5 percent of the world population, but buys more than 50 percent of its prescription drugs. Are we that sick? Wealthy? Pill-happy?

Yet, according to a 2015 Centers for Disease Control and Prevention report, almost 1 in 10 Americans don’t take their medications as prescribed because they can’t afford to. As a veteran internist, I consider myself well-schooled and informed on this issue.

Last Friday morning, I was juggling two rooms and running an hour behind, when I got a call. It was about an antibiotic I’d ordered earlier that morning. Because of the patient’s drug allergies, I’d opted for an old timer: nitrofurantoin. This little beauty has been around since the 1950s—the days of jukeboxes and poodle skirts. Just right for the job.

The Westlake | Bay Village Observer is excited to introduce a brand-new column, The Medical Insider. Diana Pi is a Westlake resident and board-certified general internist in practice for over 24 years. Her column will share important information on personal health from an insider's perspective – mixed with the lighter side of life.

Last month, on World Obesity Day, the World Health Organization (WHO) went ape over sugary drinks and proposed adding a 20 percent tax on soda, sports drinks and – here’s an eye popper – fruit juice.

But isn’t fruit juice healthy? Loaded with vitamin C and such?

At one time, the answer was a life-and-death yes. Back when the shape of Earth, round or flat, was still a scientific curiosity. Back when sunbeat seafarers, embarking on months-long journeys, subsisted on sea biscuits, salted meat and a mid-day ration of rum – and died in droves from scurvy, a severe form of vitamin C deficiency.