Being Smart about Spending Money for Health Care

The health care debate will rage through the summer and throughout the rest of the year. The final results will affect all of us but regardless of how it turns out there are things you can and should do right now that can lower your health care costs and the costs to the rest of us.

Understand the difference between “need” and “want”—you may want the latest birth control pill, anti-hypertensive, cholesterol-lowering agent but you don’t “need” it. Birth control pills have been around since 1960 and the remainder of these drug classes has been around for decades. There are plenty of generics available and they’re far cheaper. I don’t take name-brand drugs and you should think about doing the same.

Because you think you “need” to go to an emergency room for your sore throat or upset stomach or lower abdominal cramp doesn’t mean you should go there. Don’t take medical advice from friends—it’s often expensive, wrong and pointless. Numerous women go to emergency rooms every year because their mother told them that they may have an ovarian cyst—as if that were somehow dangerous or rare. Some ovarian cysts are dangerous—but very, very few. Call your provider’s office and find out what to do about your symptoms. He or she will be better equipped to advise you than your friend or mother in most instances.

Is there something cheaper available?–Don’t be afraid to ask your provider if he or she has something less expensive to offer you. A lot of women are afraid to talk about finances with their providers—don’t be. We understand that at the end of the day you still have a budget to balance. We can help you separate what you need from what you or someone else wants.

Question the need for lab work—if you have 2 doctors getting the same lab work there’s money being wasted somewhere. If you want to make things simple on yourself and your doctors keep a 3 ring binder with a copy of all of your lab work.

Don’t “insist” before you listen—a good doctor-patient relationship is invaluable. Frequently women get their health care advice from the internet, Oprah, Suzanne Sommers or another doctor who doesn’t know anything about gynecology. They may suggest a test or tests. Sometimes they’re right and all-too-often they’re not. Before you “insist” on getting blood tests to determine if you’re menopausal see if it’s necessary. If you haven’t had your period in 8 months you’re menopausal! You don’t need a blood test.

A woman was recently surprised to learn that the cervical cultures she “insisted” on having cost over 300 dollars. There was no reason for the cultures—the woman hadn’t been sexually active in a year. The laboratory fees came as quite a surprise because her other doctor neglected to talk to her to determine whether or not she really “needed” those tests in the first place. The woman was about to start a new relationship and wanted to make sure she was “clean.” For considerably less money I’d have been happy to send her to the Monroe County Health Department where she could have gotten her cervical cultures for free!

Doctors don’t like to say no—it’s usually our nature to be accommodating. But be sure that you really need 300 dollars worth of reassurance.

Pap Smears—exactly what are we trying to prevent anyway?

Your guide to abnormal pap smears, colposcopy, biopsies, the LEEP procedure and Gardasil HPV vaccine.

Every week we end up making a phone call to someone to report that their Pap smear is somehow abnormal. Usually these abnormalities are mild and, if left alone, would heal anyway. Nonetheless, for those women who receive this phone call they are often anxious and even tearful. After an hour or two on WebMD, other web-searches and the advice of “a friend of a friend” they’re convinced they’re never going to have children or die of cancer—or both.

The fact is that some 55 million pap smears are performed each year in the U.S. and about 3.5 million (6%) require some kind of follow up. Abnormal pap smears are common. The good news is that deaths from cervical cancer are rare—3,700 women die annually of the disease. This is about the same number of people that die each year by drowning and far less than die each year as a result of alcohol (80,000 per year) and firearms (29,000 per year).

So before you read much more remember this. More than one out of 20 Pap smears performed annually are abnormal and yet the number of women who die of cervix cancer is quite small. Keep in mind that each year 600,000 women die of strokes and heart disease.

The reason that deaths from cervix cancer are rare is because of the Pap smear itself. The Pap smear—invented by Georg Papanicolaou in 1943—has saved hundreds of thousands of lives in the past 60-70 years by offering early detection of cervical abnormalities.

So before we get into this subject take a deep breath and realize that if you’ve been coming for regular Pap smear and have an abnormal one you can be thankful that your “abnormality” was picked up at an early stage and will be monitored. Cancer is rare. It still happens, but it’s very, very rare. So don’t ignore the problem but remember that you’re much likely to be hurt by the stuff we live with everyday—texting-while-driving, rain-slicked roads, snowstorms, first and second-hand smoke and tanning beds.

What is the cervix and what’s so special about it?

From the diagram above you can see that the cervix is the opening to the uterus. The cervix plays many important roles in reproduction. Cervical mucous allows sperm to be transported into the uterus to promote reproduction. During the third trimester of pregnancy the cervix—which acts like a valve to prevent prematurity—begins to dilate and allows the baby to pass into the birth canal.

It is also where the cells that line the inside of the uterus (glandular cells) come together with cells that line the vagina (squamous cells). This area, where one cell type “transforms” to another cell type, is called the transformation zone (T-zone) and it is the only place that cancer of the cervix occurs.

Abnormal pap smears are classified according to a system called the Bethesda Classification System. The system was first used in 1988 and then revised in 1991 and 2001. The name is derived from a conference that occurred in Bethesda, Maryland. The system is complex and frankly I’ve struggled with a way to explain it and not put people to sleep. So read as much or as little of this as you wish. Remember that if you’re going to check out websites your best bet will be those sponsored by reputable sources–WebMD, the National Cancer Institute and the American Cancer Society. Avoid blogs, if at all possible, that are written by non-professionals. Keep in mind that people have agendas and unless you’re reading something from a reliable organization you may be getting poor information.

The Bethesda system classifies abnormal cell types as follows:

  • Atypical glandular cells (AGC)
  • Atypical Squamous Cells (ASC)
  • 1. ASC of “undetermined significance” (ASC-US)
  • 2. ASC “cannot exclude high-grade squamous intraepithelial lesions (HSIL)”
  • Low grade squamous intraepithelial lesions (LGSIL)
  • High grade squamous intraepithelial lesions (HGSIL)

Since most Pap smear abnormalities occur in squamous cells I will not address “Atypical glandular cells (AGC)” at this time.

What is a screening test and how is it different from a diagnostic test?

Now this is a source of quite a bit of confusion. In medicine we want a screening test to be non- invasive. So, although it’s a “pain” to have Pap smears every year—a test in which the cells of the cervix are brushed, placed into a liquid and analyzed by a lab—it is, by comparison a pretty non- invasive test (for instance, compared to a biopsy). Here’s the “catch” with Pap smears. If the Pap smear is negative then you can be very assured that you don’t have a problem. However, if the Pap smear shows some abnormality it isn’t good at telling how severe the abnormality is, where on the cervix it exists and how large the abnormal area is. These are answers that can only be found with further testing—colposcopy and biopsy.

What are squamous cells?

Squamous cells are cells that line the outside of the cervix—some people call it the “skin” of the cervix. The Pap smear in Figure 2 shows what these cells look like when they’re brushed from the cervix and placed in a liquid medium. When a cervix is biopsied these squamous cells look very much like they do in Figure 3 below. I won’t try to explain the technical “stuff” but note that the appearance of these cells change as you move from the lower left of the slide to the upper right. This is a normal progression of cell types from the deeper tissue to the more superficial tissue. This normal progression is called euplasia. Any disturbance from this normal progression is called dysplasia.

What are glandular cells?

Remember that squamous cells come from the outside of the cervix while glandular cells come from inside the cervical canal. Look at figure 5—a picture is worth a thousand words. These cells are clearly arranged differently. These cells arrange themselves in glands and are associated with the production of cervical mucous.

The region on the cervix where squamous cells begin to change and transform to glandular cells is called the transformation (or “T”) zone. In the photo below the T-zone has been stained so that it appears white. It’s very important to understand that the transformation zone is the only place that pre-cancerous and cancerous changes begin to occur!

What is an atypical squamous cell?

This is the category that drives doctors and women crazy! This means some cells that are slightly funny looking, but not abnormal enough to call dysplasia. (ASCUS stands for “atypical cells of undetermined significance.) This category could also be called “probably normal, but I want to keep a close eye on things.”

What about HPV? Does that influence what happens next?

These days the cytology lab automatically will test a Pap smear that is reported as ASCUS to determine if there is an HPV type that places the patient at risk for the development of cervical cancer—this is called an oncogenic (cancer causing) HPV type. If you don’t carry one of these worrisome HPV types you will probably be asked to simply repeat the Pap smear in a year. If, however, there is an oncogenic HPV type present you may be asked to undergo further testing including a colposcopy. A significant percent of women with ASCUS and an oncogenic HPV type have something called a dysplasia—which is a pre-cancerous change.

What is colposcopy?

Two things are done during a colposcopy. First, the cervix is magnified with some sort of magnification device/lens. Second, it is “stained” with a vinegar solution.

Vinegar tends to cause abnormal areas of the cervix to “stain” white. The photos below show how a cervix is transformed by simply washing the cervix with vinegar. These “aceto-white” (aceto for acetic acid and white for the obvious reasons) are often the site of a pre-cancerous change called dysplasia. Depending on the physician and the degree of suspected dysplasia a biopsy may or may not be taken.

In general, the “whiter” the area, the worse the degree of dysplasia. Another indicator the severity of the dysplasia is the appearance of abnormal blood vessels within the aceto-white area.

What is dysplasia?

This is a term a change in the orderly progression of cells that you see in Figure 3. Although colposcopy can provide an educated guess about the degree of dysplasia the final diagnosis is made through a biopsy.

Every year, between 250,000 and 1 million women in the United States are diagnosed with cervical dysplasia. While it can occur at any age, it is most likely to occur in women between the ages of 25 and 35. Most dysplasias can be cured with proper treatment and follow-up. Without treatment, 30% to 50% may progress to invasive cancer.

Dysplasia is subdivided into low grade squamous intraepithelial lesions (LGSIL) and high grade squamous intraepithelial lesion (HGSIL).

Here’s an important point to remember—dysplasia itself does not cause health problems—it is a pre-cancerous condition. Dysplasia, may, if left untreated progress to an early form of cancer known as cervical carcinoma in situ and eventually to invasive cervical cancer.

So before you panic understand that, in general, it takes about 10 years or longer for cervical dysplasia to progress into invasive cervical cancer. About 70% of women with LGSIL will return to normal Pap smears without any intervention. The more severe the lesion the less likely spontaneous healing is likely to occur, however.

Cervical dysplasia does not cause symptoms—that’s why regular Pap smear screening is so important. Detecting and treating dysplasias early is essential to prevent cancer. Once you’ve been treated you will need frequent Pap smears for a while to make sure that these abnormalities don’t come back.

What is a LEEP Procedure?

The LEEP (Large Loop Excision Procedure) technique allows both a diagnosis and a cure for cervical dysplasia.

You can think of it as a biopsy—but one that is large enough to remove all of the abnormal tissue. The tissue is sent to the lab for testing to insure that it the abnormal cells were completely removed while giving a very specific tissue diagnosis—the kind of preparation seen in Figures 3, 4 and 5. It’s worth repeating here. The Pap smear is only a screening tool. The actual diagnosis of a cervical dysplasia requires actual tissue removed from the cervix.

The LEEP procedure takes 10-20 minutes to perform and is done right in our office. During the procedure you will be given conscious sedation as well as a local anesthetic agent. You will feel no pain during the procedure. During the procedure a thin wire loop electrode is attached to a generator and a “loop electrode” is passed through the cervix allowing a fragment of tissue to be removed.

After the tissue is removed the “wound” is carefully cauterized to stop any bleeding. This is done in such a manner to preserve the delicate glands of the cervix. You will probably want to take off the day of the procedure but you should be able to return to normal activity the following day. Sexual intercourse, however, will need to wait 4-6 weeks so that full healing can occur.

It’s very important to know that most women with abnormal Pap smears will not require a LEEP Procedure and can be managed less aggressively.

What about Gardasil?

Gardasil is an HPV vaccine made by Merck. The vaccine first gained FDA approval in 2006. The Gardasil vaccine protects against 4 types of the human papillomavirus (HPV). Two of these HPV types (16 and 18) are responsible for about 70% of cervical cancers worldwide. The other 2 HPV types (6 and 11) are responsible for about 90% of genital warts.

But before you receive this fairly expensive vaccine or advocate its use for your child it’s worth your time to learn some cervical cancer and genital wart “basics” and put this disease in its proper perspective as a threat to you or your children’s health.

Hysterectomies, Robotic Surgery and The Health Care Debate

I am certainly no expert on how to meet the health care needs of 300 Million Americans and its 45 million uninsured. I know that health care has gotten out of hand—it’s far too expensive for those of us seeking it and those of us who provide it. There are many reasons but I don’t want to bore you with the kind of stuff you can read in the NY Times.

What I do know a lot about, however, is the technical innovations that have come about in gynecology starting in the mid-1980s and how physicians and consumers have been duped by a lot of unnecessary technology—that’s right, unnecessary technology. As an example let’s talk about what’s happened to hysterectomies in the last thirty-odd years.

When I started my residency in 1976 among the many procedures we learned was how to perform a hysterectomy. About half of them were done with a large abdominal incision while the rest were done vaginally (with no abdominal incisions). Vaginal hysterectomy was a beautiful blend of skill and science–patients generally stayed about 3 days in the hospital and were often completely recovered in 4-6 weeks. Of course, back then we actually kept people in the hospital to recover— I’ll say more about that below.

Then in 1989 a colleague and friend, Dr. Harry Reich invented what is today known as the laparoscopic hysterectomy. The purpose of the procedure was to eliminate abdominal hysterectomies and replace that large painful incision with 3-4 smaller ones. The recovery time for laparoscopic hysterectomy was as much as several weeks shorter than with abdominal hysterectomy but the advantages were clear—eliminating the large incision and saving a couple of weeks of recovery. The laparoscopic hysterectomy did not eliminate complications but rather substituted some complications for others. That said, laparoscopic hysterectomy is a great procedure–when indicated–and performed by a skilled gynecologic surgeon.

Now here’s an example of a new technology having unintended consequences. Instead of the laparoscopic hysterectomy replacing abdominal hysterectomy it actually replaced and eliminated the skill of vaginal hysterectomy. There are many reasons for this but it basically comes down to the fact that the skill required for vaginal hysterectomy was lost as new residents were more enamored with the “whiz bang” of laparoscopic surgery compounded by the fact that patients were “requesting it.”

The advantages of the old fashioned-vaginal hysterectomy compared to laparoscopic are many— they’re quicker, have a shorter period of recovery and far less expensive to perform. It turns out the traditional surgical instruments can be used more than once. On an average laparoscopic hysterectomy, however, over a thousand dollars of disposable equipment is used once and thrown away!

Now before you tell me that laparoscopic hysterectomies are performed as an outpatient procedure please remember that it’s not because their recovery is quicker than with vaginal hysterectomy—it isn’t. Thirty years ago we actually used to hospital as a place to tend to a woman’s need during her postoperative period. Today we simply kick them out and let them or their families manage on their own. Welcome to the future of health care.

And now it just gets sillier! In recent years hospitals have been spending millions to obtain new robots (the DaVinci) to aid in performing laparoscopic surgery. The robots are great for many reasons but were designed for especially difficult surgery deep in the pelvis—prostate cancer surgery for men and gynecologic cancer surgery for women. But hospitals, who are seeking to get the best “bang” for their “robotic” investment, are now advertising these robots as being the latest “technological” whiz-bang!

So here comes the next unintended consequence. Because robots make it easier—not safer—to perform laparoscopic surgery the skills of “old-fashioned” operative laparoscopy are also beginning to disappear. Surgeons are beginning to advertise themselves as “robotic surgeons” – I’m not making this up—as if that were a good thing. Patients are beginning to ask for “the robot” much the way they asked for “laser surgery” a few decades ago. Never mind the pile of money it takes to buy and maintain the DaVinci robot but many doctors rely so much on this technology that laparoscopic surgery may also become a lost art—along with vaginal hysterectomy. If you thought the costs of laparoscopic hysterectomy were high wait until you see the impact of robotic surgery on our health care system.

I don’t know how to “fix” our health care system—but along with clamping down on pharmaceutical companies, unnecessary procedures and tests we’ve got to take a look at our technology. The more we rely on technology the less we need the skills that have been time- honored in surgery. Look at what the calculator has done to the math skills of the past generation—do you get the picture?

You and Your Weight

I don’t need to tell you that we’re living in the midst of an obesity epidemic. As a physician it pains me to watch someone gain 15 pounds since their last annual exam. Often these are young women who are starting to pay for the kinds of dietary habits they could get away with years earlier but not anymore.

Your weight influences so many things but the long and short of it is that it will affect how long you live, the way you feel about yourself and the quality of your life while you’re still with us.

Calculate your BMI. Just go to http://www.nhlbisupport.com/bmi/bminojs.htm and learn where you are on the BMI chart. A BMI of 30 or more puts you in the obese category.

Obesity is associated with type 2 diabetes, heart disease, strokes, hypertension, kidney disease, sleep apnea, arthritis and certain cancers—breast, uterine, colon, kidney and esophageal cancers.

Here are common things I hear about weight loss:

1. There must be something wrong with my thyroid!

Thyroid disorders are fairly common in women but, in truth, they’re generally not responsible for the last 20 pounds you put on. We’re happy to check your thyroid function but be prepared for the fact that it will usually be normal.

2. I don’t understand why I gained weight. I haven’t changed the way I eat!

You don’t need to change the way you eat in order to gain weight. As we age our metabolism slows. Additionally, we often spend more time behind a desk in front of a computer or on a sofa. Most of us will need to take in fewer calories each year in order to maintain a stable weight.

3. I’ll exercise more and lose the weight that way.

No you won’t! For most people exercise alone won’t do it. The reason is simple. Many of us “reward” our self for a good work-out by eating that brownie or serving of ice-cream. If you burn 500 calories with a work out–and do this 4-6 times a week— you will lose weight if you don’t reward yourself.

4. I hardly eat anything!

This may be true for some women—but not for most. If you don’t believe me write down what you eat every day for a week. You’ll surprise yourself.

Common mistakes we make as we try to lose weight

1. Many people don’t sleep enough

When you’re chronically sleep deprived you crave the wrong foods and more of it! The first step towards effective weight loss is getting enough sleep under your belt.

2. Skipping breakfast

Unfortunately the hectic lives we lead cause many of us to skip breakfast entirely. Many women who have a breakfast think that cereal covered in sugar is nutritious. Read the label. You’ll be surprised how much fat and cholesterol you’ll find in that “wholesome granola” you’ve been gulping down. Eat a healthy breakfast. Make it a substantial meal. It’ll prevent you from starving by the time you get to your lunch break.

3. Believing that salads are good for you

Many salads are good for you! But salads that contain rich creamy dressings, bacon bits, croutons, eggs served on a tortilla shell aren’t salads—they’re an invitation to the coronary care unit! Get real for a minute. Just because a restaurant calls it a salad doesn’t mean it’s good for you. Think fruits, vegetable, lettuce and oil and vinegar instead of rich dressings.

4. Eating what he, she, or they eat

You’ve heard the saying that “birds of a feather flock together.” It’s true when it comes to obesity.

My wife recently visited a family we’ve known for years. The man of the house is about 5’9” and between 300 and 350 lbs. His wife is obese though far better off than her husband and 2 of their 3 children are obese. And when we sat down to dinner it was easy to see why. For the most part what they ate was healthy enough but their idea of what constitutes a reasonable portion was off the charts. We started out with salads that seemed healthy enough but then there was the barbequed chicken, slathered in barbeque sauce, macaroni and potato salads, along with potatoes au gratin. These were not anemic chicken breasts either but the kind that needed a plastic surgeon and reduction mammoplasty! And of course there was an assortment of deserts. I rarely ever seen such a spread of delectable “stuff” to stuff myself with but I’m sure I didn’t get away with less than 1500 calories that night.

What’s the lesson? Even though I consider myself a pretty disciplined person when it comes to overindulging, I had difficulty that night. If you eat with people who over- eat you’re much more likely to do so.

The way this works in families is that you might have to put everyone on a diet! If your partner’s thin and you aren’t asking yourself what you need to do, get going. Maybe your partner can get away with eating foods that you can’t–or maybe you’re just going back for too many “seconds.”

I recently had a patient come in and found that she’d gained 15 pounds in the last 3 months—she found a new boyfriend who “likes to cook.”

I invited them both in so I could tell her well-meaning boyfriend that he was slowly “killing her.”

5. Not being realistic—“if you do what you’ve always done you’ll get what you’ve always gotten.”

There are many ways to fool ourselves but this is the most common one. You go and promise yourself, your doctors, parents, your partner and children that you’ll lose weight. You’re all “fired up” when you leave the doctor’s office and join the gym and start walking during your lunch break—as if you could keep that up all year in Rochester! A week into your new exercise and diet routine you’re obsessed with eating something you’re deprived of or just too tired to go to the gym. You tell yourself that you get enough exercise at work or chasing the kids around the house. Whatever the reasons, there are always one or more for going back to your old habits—the ones that caused the problem in the first place!

So, if you’re 30 years old, stand 5’2” and weigh 260 lbs and have watched your weight increase every year by 10-15 lbs over the past 10 years you need to do something different. Maybe it’s time to think of bariatric surgery or going to an eating disorders clinic. Whatever you decide, don’t tell me “I’ll join a gym and get serious.” Chances are you that you are serious and have already tried gyms. It’s time to demonstrate how serious you are by changing something in a meaningful way.

6. Believing that exercise alone will help you achieve weight loss.

You cannot achieve longstanding weight loss with exercise alone. You must change the way you eat. I saw a woman earlier today and she doesn’t understand why she continues to gain weight despite the fact that she works out on the treadmill 5 times a week for 30 minutes at a time. The bottom line is that she’s gaining weight because the calories she’s eating exceed the calories she’s consuming. This woman finds it easier to make the sacrifice of exercise than the sacrifice of dietary change. Remember, that if you do what you’ve always done you’ll get what you’ve always gotten. Sooner or later she’ll have to deal with what’s most difficult for her—changing the way she eats.

7. Looking for a quick fix.

There are no quick fixes to weight loss! Fad diets and pills don’t work. You may get some short term gratification but you won’t be able to maintain it. Don’t lose weight by “revolution” but by “evolution.” Eliminate bad habits slowly but work on habits that will stick. Don’t try to lose weight with a diet that you know you won’t be able to sustain.

The Top Ten Ways to know if you have Estrogen Issues!

1. Everyone around you has an attitude problem.
2. You’re adding chocolate chips to your cheese omelet.
3. The dryer has shrunk every last pair of your jeans..
4. Your husband is suddenly agreeing to everything you say.
5. You’re using your cellular phone to dial every bumper sticker that says: ‘How’s my driving? Call 1- 800-‘.
6. Everyone’s head looks like an invitation to batting practice.
7. Everyone seems to have just landed here from ‘outer space.’
8. You’re sure that everyone is scheming to drive you crazy.
9. The ibuprofen bottle is empty and you bought it yesterday..
10. You consider cheating on your husband with Barry Manilow in front of 7,000 people.
http://www.youtube.com/watch?v=uy0VbiiUALg