Archive for May, 2010

There is no Team in Medical Specialist

Tuesday, May 25th, 2010

Peter (not his real name) developed a red spot on the tip of his nose 2 years ago. He is now 16 years old. Last week the spots became more red and formed 2 blisters. His mother took him to a board certified plastic surgeon. The surgeon told the mother he didn’t know what the lesion was but that he could cut it out. He advised them Peter would be left with a permanent scar on his nose.
A 30 year old man told me every time he sees his dermatologist the doctor removes a mole from his body. A mother told me her dermatologist removed 6 moles at 6 different times from her 16 year old son. The moles were said to be “suspicious”. The moles were all benign!
A man came to me and said he had a lesion removed from his face. The doctor told him the biopsy showed “it was nothing”!!
A patient with arthritis was seeing a rheumatologist. He saw her monthly and did repeat blood tests each month which showed no change in her condition.
The chief of orthopedic surgery at one of our Chicago university hospitals billed a patient for a complete physical exam while she was in the hospital. He never saw her!
A patient went to a plastic surgeon asking for help with her neck. He did not comment on the anatomic abnormality which caused her neck appearance or on the obvious bone erosion of her chin due to a 35 year old chin implant. He offered to raise her eyebrows and do a facelift. (I raised my eyebrows too.)
An allergist did repeat series of allergic skin tests in a patient with eczema. The patient cleared in 2 weeks with a prescription for antihistamine.
The stories go on and the conclusions are the same. Many patients experience inaccurate diagnoses and needless care at the hands of medical specialists. The reasons are numerous and include the fact that payments are higher for performing a procedure instead of using diagnostic skills; reduced reimbursements lead to doctors spending less time with patients; failure of any effective oversight for medical care.
Yet the most overlooked cause may be the patient. Last week I did an informal survey of 10 consecutive patients. I asked each if they had seen a primary care doctor in the past 3 years. None had done so! In fact most did not even have a primary care doctor. Patients are self-referring to specialists, which raises the cost of medical care and deprives a patient of the managing expertise a primary care doctor brings. Most of us doctors spend little time in hospitals and because of that we rarely see each other. We certainly don’t talk to each other about our care for a mutual patient or whether our treatments conflict with one another. We don’t discuss what is best for the patient. This is the role of a primary care doctor. The patient who thinks the specialist is smarter than the primary care doctor is cheating himself. He exposes himself to abuse of possibly less ethical or less concerned specialists. He not only gets poor care, he deprives himself of the opportunity to get proper care. The team concept simply doesn’t work without a manager. Following my own advice I made an appointment to see my primary care doctor today. I suggest you do as well.

The Many Sizes and Shapes of Baldness in Women

Monday, May 17th, 2010

Baldness comes in various shapes and sizes, but when it appears on a woman’s head it is always bad. The problem is of such magnitude that doctors vacillate between dismissing female hair loss complaints and ordering a battery of tests they have little idea what to do with. An organized approach to the problem is necessary. In many cases hair loss can be slowed or stopped and in some cases it can be reversed.
Compounding the problem is that baldness now affects women from age 20 to death. Clearly, younger women are losing hair and losing it in greater quantities than in the past, and this has led to more cosmeceuticals and outright irrational remedies for a vexing problem. In addition dermatologists are making diagnoses of hair loss that do not hold up to rational examination.
Perhaps over simplistic, the most common examples of female pattern baldness can be understood in 3 categories, of which there are several subcategories. The most common cause of hair loss is called female pattern baldness or Ludwig’s female patterned hair loss. Most commonly women aged 50-80 present with these complaints however it is more and more commonly presenting in younger women. The hallmark of the process is the maintenance of the frontal hairline, although it may thin. In male pattern baldness the frontal hairline disappears or shrinks. Not so with women. Hair loss tends to be diffuse although most noticeable on the top of the head. Initial complaints range from “my part is getting wider” to “I can see my scalp” to “I am shedding hair everywhere”. Traditionally this is considered a form of genetic hair loss, a pre-programmed event in which cell death of the hair follicle precedes death of the individual. It is often called androgenetic alopecia even though blood tests for androgens, male hormones, are universally normal and the hair loss pattern is completely different from men. In questioning some of the leading authorities in the country I cannot get them to explain why they use this term.
The second most common form of female hair loss is called telogen effluvium. Hair growth goes through cycles: growing, regressing, and resting. The resting part of the cycle is called telogen and typically up to 20% of the scalp hair is resting at any one time. However, when a greater percentage of hair goes into a resting phase at the same time the hair begins to shed more than the normal 100-200 hairs per day and scalp hair appears less dense. Most often this occurs after pregnancy but other causes such as general anesthesia, trauma, infection, and medicines can cause this. The prognosis is excellent and hair growth normally resumes in 9 months as most of the hair will be restored.
The third category involves nutritional deficiency or hormonal abnormalities. Iron deficiency is known to cause hair loss and since many women have heavy menstrual periods with borderline or frank anemia and low iron levels it is one of the first tests ordered by dermatologists. Disease states characterized by hormone abnormalities are unusual but a known cause of female pattern baldness. Polycystic ovary disease (PCOS) and adrenogenital hyperplasia are diseases of the ovaries and adrenal glands respectively and are characterized by associations with masculine changes such as deeper voice, bearded face, and acne. Not uncommonly patients with over or underactive thyroid glands lose hair but often doctors know about their thyroid disease before the hair loss becomes a problem.
I have purposely left out diseases of the scalp since these patients complain of changes in their scalp as well as problems of hair loss. These patients also tend not to present with diffuse hair loss and maintenance of their frontal hairline.
While not an article on remedies, this blog is an attempt to make some sense of the frustration many women experience as they go from doctor to doctor in search of answers for their hair loss. As with all medical problems a history, physical examination, and sometimes a biopsy is necessary to make a diagnosis and from this rational treatments can be prescribed. A rational understanding as well as a realistic approach to hair loss are necessary if treatment is to be effective and if patients are to avoid the plethora of fake treatments available to grow hair.