Shootin’ for the Smiley

Reader question of the week: “My friend told me that you started her on bioidentical hormone replacement therapy without first checking any of her hormone levels. Is this a good idea?”

Answer: The American College of Obstetricians and Gynecologists (ACOG) just released an updated version of screening guidelines (dated 2/6/2013). They do NOT recommend checking hormone levels. Instead, they recommend asking the patient about her symptoms. While I don’t always agree with consensus statements, I wholeheartedly support the new ACOG guidelines. They have adopted a very unique position in medicine- Treat the Patient! Too many medical schools center their education on treating the lab results printed on paper. The problem in treating the paper is that we don’t have an appropriate baseline; we don’t know what the patient’s testosterone and estradiol levels were when she was younger and symptom free. The gold standard treatment is to start the patient on bioidentical hormone replacement and follow their symptoms. I will check thyroid levels and start my patients on natural thyroid replacement (Armour) if they haven’t had thyroid levels checked recently, but otherwise- no labs necessary. Keep up the great questions!

Any Ruidosoan who drives on Hull Road has seen the new interactive speed limit signs. The signs incorporate radar speed tracking and rate your compliance with an icon. We like to receive positive feedback, and these interactive signs capitalize on the studies that have verified their effectiveness. I use the signs as a personal challenge to make sure I get the smiley face from the moment the sign “sees” my vehicle. I’m sure Judge Rankin will appreciate seeing me in her courtroom less frequently as well! (Sorry, ma’am.)

As physicians, we tend to shoot for the smiley when we interact with our patients. We like to please, and the tendency is to order tests that may not be necessary or put patients on antibiotics for a viral illness (antibiotics do nothing to viruses) when the patient requests we do so. Constrained and packed schedules only make things worse. Instead of educating the patient on why their request is unnecessary and could actually cause harm, we tend to comply to ensure we get the smiley (don’t get me started on patient satisfaction surveys again).

As patients, we want to be validated and feel like the visit has been productive. If we walk out of a doctor’s office without a new Dx (diagnosis) that can be Tx (treated) with an Rx (prescription), we feel like the visit has been wasted. Our docs have taught us we don’t have to participate in our own wellness other than to take the medications prescribed.

I would like to again suggest a paradigm shift. As physicians, we need to return to patient based medicine. Treat the patient, not the paper. Only order labs or tests that will create a change in the treatment plan. As patients, we need to hold our physicans and healthcare providers accountable. If you are overweight and a physician doesn’t provide some counseling as to how to lose weight, ask them why they didn’t. If you smoke, expect to hear about smoking cessation. If your doc orders labs or tests, ask them what they are looking for and how the results will change the treatment. Be interactive with your healthcare!

Change is difficult and often resisted. Sometimes, small things like interactive signs can be the catalyst needed to help effect change. I pay better attention to my speed now that I have a goal. I’m shootin’ for the smiley!

Disclaimer: Dr Stephen Rath, MD, DABA is a board certified anesthesiologist, Air Force flight surgeon, paramedic, and pilot as well as the owner and medical director of Fusion Medical Spa located in Ruidoso, NM. His possible career in law enforcement has been (temporarily?) curtailed by his moving violations. Comments or questions? His email address is: