All posts by Andy Smith, MD

Those Dreaded Side Effects

“So, it seems like the prednisone cleared up your allergic rash pretty well.  Did you have any side effects from it?”

My thirtyish female patient looked at me with a little smile and responded, “Does the term, ‘Psycho Chick’ mean anything to you? I stuck with it because it was clearing up my rash and itching so nicely.  But I was moody, couldn’t sleep, and was biting everybody’s head off.  My husband couldn’t wait for me to be done with it.”

On the other hand, in answer to the same question about side effects for the same medicine I’ve gotten the answer, “I love that stuff.  I had tons of energy, all my joints felt better and my mood was great.  My house is spotless.  I just wish I could stay on it.”

It never ceases to amaze me how differently people respond to the same medicine.  There are those who never seem to have a negative reaction to anything.  Then there are some who have reacted to 20 or 30 different med.  These are the patients where we are trying to find one antibiotic they still can tolerate, or the one blood pressure medicine that doesn’t make them feel badly.

And what about the endless list of dire reactions mentioned in television advertisements for certain medicines? The announcer rattles off possible side effects that seem to include everything from liver failure to growing a second head and usually ending with “death”.  You think to yourself, “Why in the world would anyone even think about taking that medicine if it can do all that?”

So how do we take a reasonable approach when sifting possible side effects and deciding whether or not to take a medicine or not?  First of all, realize that the rapidly-listed side effects on t.v., or the long list on the package insert serve more as legal statements than helpful medical information.  They want to mention every possible problem anyone could encounter with this medicine, whether it is at all likely or not.  Most of us are aware that if they ever did the same for something like aspirin and gave it some other name we didn’t recognize, few would take it.

The key is always to compare the likelihood and severity of the possible side effects with the likely benefit of the medicine.  For example, statin cholesterol medicines can bump the liver enzymes in about 1 out of every 100 patients taking them.  Varying quoted frequencies for muscle aches can range up to 10% or more.  However both of these side effects are easy to identify and generally clear quickly when the med is stopped.  On the other side of the coin, for a person at substantial risk for heart attack or stroke, studies show that statins can substantially lower the likelihood of these two devastating events and extend one’s lifespan considerably.

So, for the right person, the benefits far outweigh the possible side effects.  Yet occasionally someone who could clearly benefit from treatment states something to the effect of, “Statins?  Those things blow out your liver don’t they?”  And so a more informed discussion is needed.  Hopefully you can get a fair amount of feedback on these kinds of questions from your doctor as well.

Side effects of medicines can run the gamut from trivial to severe to even desirable (such as anti-depressants that help with sleep or certain diabetes medicines that usually result in weight loss).  It can be pretty complicated sorting through it all.  So, sit down with your doc when needed and weigh the pros and cons – it’s worth some thought before you either reject a very helpful medicine on the one hand, or take one where the cure might be worse than the disease.

Andrew Smith, MD is board-certified in Family Medicine and practices at 2217 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835



Keeping Your Medical Care Personal

aerial-aerial-view-application-935869In my last article, I alluded to how medical care is changing at near warp speed, as the volume of new knowledge keeps doubling every few years or less.  There’s a load of good treatment and care, as well as improved outcomes that comes from that.  At the same time, there are some downsides to the changes in medical care that I believe should be resisted when possible.  One downside is that the default drift of our medical care is to become steadily less personalized, less relational.

Consider the family doctor of past decades who would often help deliver the children, see them when they were sick, watch them as they grew up, do home visits when needed, and be present when death came.  They knew the families well and could administer care in very reassuring and intimate ways.  Of course, they often averaged only a few patients a day, had a low overhead, needed only minimal, if any, staff and had an exponentially smaller amount of medical facts to digest.  That is not in the least to diminish them; they were often brilliant, sacrificial, intensely devoted persons administering the most effective treatments of their time in a deeply personal manner.  But going back to that kind of practice with today’s medical realities and costs is probably not practical.

Continuing forward to my three decades of medical care, the depersonalization of medical care has continued apace.  I have watched the trend rather regretfully and most patients have been the poorer for it.  So, what are the driving forces for this depersonalization of care?  In my opinion there are several:  One is the smothering blanket of bureaucratic requirements that sucks more and more time away from the patient-doctor interaction.  Another force is the fragmentation of care.  Patients receive care from so many different doctors, walk-in clinics, specialists and non-physician providers that no one care-provider is likely to really know the patient in the way a physician of bygone decades would have.

Another driver toward depersonalization is the huge financial overhead that pushes a typical practice to see more patients, shrinking down a typical visit to a few pressured minutes.  Add to that the loss of physician/patient control of medical care brought about by the insurance-driven model of medical care.  With insurance typically collecting and then distributing the money in this system, they increasingly assume the power to decide what gets done, what the payment will be, who you can see (and that might change year to year) and what diagnostic and treatment options will be withheld.

In spite of all this, I love what I do.  But, at the same time, these forces, and probably many I haven’t mentioned, have threatened to sap away much of the blessing of providing personal, relational medical care.  My intent isn’t to be negative, but only to point out some of these forces with the hope of battling to preserve personal medical care.

Of course, no one is obligated to follow my suggestions.  But as a participant in medical care over three decades, my hope would be that many would:

  • Promote the right of patients and their physicians to direct medical care, not insurance companies and government agencies.
  • Consider joining one of the cost-sharing ministries to cover your major costs and then budgeting for your own basic primary care, perhaps through a direct primary care arrangement with your doctor, so that the financial power stays in your hands.
  • If possible, consistently see your own physician for your standard medical care so that you stay connected and a level of personal relationship develops that enhances your medical care.
  • Support policies that reduce bureaucratic burdens that suck away the time and attention of your physicians from actual personal care.

This is a topic that is close to my heart, but impossible to cover in the scope of a brief article.  Still, maybe this can stimulate a little of your own thoughts and ideas; maybe in some small ways we can, together, battle to keep the human touch, the focused personal connection of medical care.  Personally, I hope so.

Andrew Smith, MD is board-certified in Family Medicine.  He has recently relocated his practice to 2217 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835


Polymyalgia Rheumatica

Wow he’s really struggling coming up that hill.”  I was watching my eighty-something father-in-law labor up the hill to our house.  In context, you need to realize that, “Grandpa” is normally one of the most vigorous elderly guys you’ll ever see.  He generally comes blasting out of his room in the morning like a man on a mission.  After breakfast he may head down the hill to the barn and chop some wood, spray the poison ivy, or any number of other projects.  Even much younger folks are usually huffing and puffing after making their way back up the hill to our house.  But Grandpa was pretty used to it and usually took it in stride.

That’s why it seemed odd that he actually looked old as he slowly made his way up the hill, pausing a couple times along the way.  When he got in the house he quickly eased into a chair and looked spent.  On asking him if he was alright he responded, “I don’t know; I guess I’m just getting old.  Getting up that hill is really getting tough.  My thighs and shoulders are sore as can be.  I can barely get moving in the morning.”  I’d noticed he certainly wasn’t rocketing out of his room of late.

Given that he was eighty, there were concerns that maybe age had finally caught up with him.  Or maybe he had some hidden cancer, or late-onset rheumatologic disease, or any number of other problems.  With how he felt, it wasn’t hard to get him to come in for a check-up.  Most of the tests came back pretty unremarkable, but an old, simple blood test, the sedimentation rate, was very high.  It’s a non-specific test, but together with his other symptoms and the normalcy of most of the rest of his tests, it pointed to a diagnosis we see a couple times a year: polymyalgia rheumatica (PMR).  The clincher would be how he responded to a low dose course of oral steroids.  They tend to work like magic with PMR and that can help confirm the diagnosis.  Sure enough, a week or so after starting the steroids, we had the old “young” Grandpa back, motoring up the hill like it was nothing.

PMR is an uncommon, but occasional, illness involving the rapid onset of soreness in the large muscles of the thigh and shoulders with a sense of weakness and fatigue.  Sufferers are almost always over age 50 and more than twice as many women as men get it.  The cause is not known and is thought to possibly be autoimmune.  As noted, steroids work wonders for PMR and are slowly tapered over many months.  The entire course of PMR averages about three years.  It’s one of those diagnoses you don’t want to miss since it’s so debilitating to have, but so very treatable.

Interestingly, about 15% of people with PMR also have a condition called giant cell arteritis (GCA), which has also been called temporal arteritis.  GCA involves inflammation of arteries, most commonly the temporal artery up on the head.  GCA causes a substantial temporal headache, and if untreated (with higher dose steroids), can even cause sudden blindness.  Grandpa actually had some temporal pain that came and went.  In the end we had him get a temporal artery biopsy (which happily was normal) so as to not miss this potentially blinding malady.

Unlike almost 50% of individuals with PMR, Grandpa did not experience a relapse.  Several years later, he’s still going strong.  The only minor glitch – I hear him all too enthusiastically recommending prednisone to any of his older friends with aches and pains: “I’m telling you, get your doctor to put you on some prednisone – it fixed me right up in no time.”  But it’s a small price to pay to have him back as a young Grandpa.

Andrew Smith, MD is board-certified in Family Medicine and practices at 2217 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835



Medicine is Moving

           This has been a crazy, but mostly enjoyable week.  We moved our medical office about a half mile closer to the mountains on Rt. 321.  It’s exciting to see a band of workers busily laboring to turn a beautiful but empty shell of a building into a humming place ready to provide medical care.  When everything is first pulled out of a few dozen cabinets, drawers and cupboards, brought to the new place and strewn around, it looks like a bomb went off.  It seems impossible that that much stuff was stowed away in the old medical office.  It’s a bit overwhelming.  But slowly, with everyone doing their part, some semblance of order and organization is restored. Monday morning, we were (mostly) ready to roll.

It makes me think of how medicine as a whole is constantly moving, and the pace just seems to be constantly accelerating.  Some of the movement is exciting and helpful, while some of it is distracting, burdensome and counter-productive. The part that’s exciting is the explosion of medical knowledge: new treatments, better surgical approaches, more accurate understanding of the causes and prevention of disease.  Every time I start to get a migraine and reach for the medicine that stops it in its tracks and lets me keep working without the rather horrific pain I used to experience, I’m thankful for the advances of modern medicine, and that I didn’t live with migraines fifty or a hundred years ago.

At the same time, not every new discovery is better than what came before it.  New treatments sometimes come with new complications and almost always come at significant cost.  And realistically, trying to keep up with the steady doubling of medical knowledge is no easy task for any physician.  Happily, there are lots of online resources that can get you the information you need in a heartbeat.  Gone are the days of my bookshelves of medical texts that are already becoming outdated when they come to print, or the files of articles on recent studies that I used to keep.  Now a few clicks can get me where I need to go to find the latest studies and information on a given disease or treatment.

But as I make what I expect will be my final physical office move, I must confess to some major concerns about where medicine is moving.  Although much of this movement would apply to all branches of medicine, I’m mostly referring to primary care medicine – the front line, “blue collar” medicine done by family physicians, pediatricians, and general internists.  These are the first line of medical contact, often aided by physician assistants and nurse practitioners, who sort through someone’s symptoms and seek to arrive at a diagnosis and treatment plan.  It is estimated that 80% of the time a primary care doctor will completely handle whatever problem comes to them, and the other 20% or so, they will access an appropriate specialist.

So, what are the major threats to good, satisfying primary medical care?  Many answers could be given, but I see four major threats that end up producing the depersonalization of medical care.  By depersonalization in medical care, I mean that the idea of one human being trying to engage and help another achieve relief of symptoms and maximal health in the midst of a personal one-on-one human encounter, is being lost.  In its place is often a fast-paced, distracted, non-empathetic, and all-too-short visit.

While some efficiency is a good thing, medical care is best delivered when a personal human connection is made.  The iconic family doctor of Norman Rockwell paintings and stories of family physicians who personally knew their patients over decades seem quaint and unattainable in today’s medical and social climate.  That may be true, but if we recognize what is driving us toward an impersonal medical care we may be able to slow, or even reverse, the drift in that direction.  Next article I want to lay out the four factors that seem to be driving us toward an impersonal, unsatisfying medical care.  Maybe we can get medicine moving in a more positive direction, at least on a local level here in the Maryville area.

Andrew Smith, MD is board-certified in Family Medicine and practices at 2217 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835