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Ask Your Doctor

ASK YOUR DOCTOR ANYTHING

Below are the archives of Dr. Pat Guiteras'  "Ask Your Doctor Anything"

Question: I went to a dermatologist who diagnosed a basal cell cancer on the tip of my nose.  He said I needed to be treated by a Mohs surgeon.  I stifled the urge to say that I’d prefer Larry’s or Curly’s surgeon, certain that the dermatologist was too young to get the reference.  He gave me some literature on Mohs surgery and made an appointment for me.  I’d like to know if there is another way to treat this thing.  It looks like Mohs takes a lot of time and is expensive.  Can you give me some orientation?

Answer: There are many ways to treat your skin cancer but Mohs surgery is the best.  It gives the highest cure rate and best cosmetic result of all treatments.  It is expensive - there is high overhead and Mohs surgeons are one percenters, to be sure, maybe even one-tenth percenters.  Your insurance company will likely pay whatever it pays but a cautious person will determine if the surgeon accepts insurance as payment in full.  You might also want to check on your insurance company’s coverage.  Not long ago, one of the largest insurers in the State would not approve payment for  Mohs surgery for a basal cell cancer of the central face and insisted that the patient see a dermatologist who performed a procedure with a significantly lower cure rate and at a significantly lower cost to the insurance company.
How much better is Mohs than other treatments?  Reports of comparisons show varying results but the preponderance of evidence  is that the cure rate is 97-99%, less for other treatments.  You want the highest possible cure rate, especially on the nose, as these tumors are notoriously sneaky little devils and, if not eradicated, can invade adjacent tissue which leads to more and, possibly, disfiguring surgery.  On the rarest of rare occasions, basal cell cancers metastasize and threaten the patient’s existence.
How is it done?  Under local anesthesia, the tumor is cut out, then freeze-dried, cut into thin slices and examined under a microscope.  The specimen has been marked to orient it precisely onto the surgical site.  The surgeon looks for tumor cells crossing the margin of the excision and, if present, knows exactly where to go to complete the extirpation. The idea is to remove as little tissue as possible but to be sure the tumor is gone.  Sometimes the first excision is sufficient.  Sometimes two or three passes are needed.  The patient waits in the lobby, complementary latte and blueberry muffin in hand, while awaiting word. You might be there two hours or all day.  Then, after total removal is assured, the wound may be closed or left open, to heal gradually with daily cleansing and dressing changes at home.  Primary closure or gradual infill is a choice that depends on many factors, including patient preference.
Mohs surgery should be reserved for tumors of the central face, nose, eyelids and skin around the eyes, lips, ears and skin behind the ears as well as other areas depending on tumor size and subtype.  It is not needed for most basal cell cancers on the arms, legs, trunk and non-central face. 
The procedure has an interesting history.  Frederic Mohs, a general surgeon in Madison, Wisconsin, originated the procedure in the 1930's. He used a paste concocted of zinc chloride and bloodroot, applied directly to the skin over and around the tumor.  This fixed and stained the tumor which was then excised and examined microscopically.  The paste was painful and the procedure might extend over several days, depending on number of passes required.  Needless to say, it was not wildly popular though it was clearly effective.  When freeze-drying became available in the 1970’s and ‘80’s, then Dr. Mohs’ technique became widely accepted and is the gold standard today.
Hope this helps.  Good luck.
Patrick Guiteras

Question: This is more of an observation than a question.  I’d like your take on it. Several weeks ago I spent four days on the cardiac service at UNC Hospitals correcting a kerfluffle of my cardiac rhythm.  All went well and I’m back at Arthur Murray’s, charming the ladies with my nimble feet and quick wit, or is it the other way ‘round?  
I was impressed by the intelligence and courtesy of the medical staff but I must say that I couldn’t tell who was in charge and, if they hadn’t worn stethoscopes or taken liberties with my body that  are difficult to describe, couldn’t have discerned that they were doctors.  They introduced themselves as “Brice” or “Amy” and no one wore neckties or skirts; everyone in pants or surgical scrubs, though they were not surgeons.  And they all looked like high schoolers - even the head guy, after I figured out who he was.  

I haven’t been in the hospital since 1951 when my appendix was taken from me.  Can you help me adjust to the new world of the hospital?

Answer:  I can guess approximately how old you are from the date of your appendectomy, your cardiac problem and your take on what you saw this time.  It is a new day.  Times, and the doctors that go with the times, have changed.  Hospital house staff – the interns and residents who do the day-to-day work – are young, smart and more female than they used to be.  They are less concerned with hierarchy and appearance than their predecessors and they don’t dress like them, either. They all look young.  Get over it and be thankful for it.

They are smart, eager, ambitious and caring.  They work hard.  True, they don’t dress well or, at least, as we expect.  But they know what they are doing.  Sure, sometimes they make us wonder.  They say nauseous when they should say nauseated.  They say they diagnosed a patient when they should say they diagnosed an illness.  Most galling, they ask us to lay down, when people our age know what they should say.  But, is any of that important?  Maybe.
A resident from the hospital visited my office not long ago.  I caught him looking at the portraits on the wall of the closet that passes for my personal office.  I asked if he could identify the subjects.  He correctly named Abraham Lincoln and Martin Luther King, Jr.  He guessed on William Shakespeare.  He could not identify Teddy Roosevelt or his distant cousin, Franklin.  This, I could forgive.  What I could not forgive: he had no clue as to who was Roberto Clemente, Mickey Mantle or Willie Mays.  Is any of this important?  Maybe.

In regard to the dress code, let me tell a story: several years ago, visiting a patient in the cardiac care unit, I encountered an old friend, an attending cardiologist of my vintage.  We were catching up when around  the corner came two lissome doctors, stethoscopes slung around neck, scrub pants worn just low enough to show the slightest, teeniest rim of lower abdominal flesh beneath their tops.  They were my friend’s residents.  I expressed mock outrage, asking how he permitted such a thing.  His reply?   “They are excellent doctors and, what the heck, it makes the day pass more pleasantly.”
Was he condescending?  Sexist?  Was I?  I think not.  He was expressing reality.  The important point:  “They are excellent doctors.”  
So there you have it.  The new doctor is different from the old.  They see things differently.  They dress differently.  They don’t always use words properly or know our heroes.  They don’t wear neckties or skirts.

But – guess what? – they know what they are doing. That’s what is important.

Question:  I am miserable from hay fever.  First it’s tree pollen, now it’s grass.  Next come flowers then ragweed and goldenrod, followed by leaf mold in the fall.  Late fall and winter are fine, then the misery resumes.  I’ve tried all the usual stuff – Claritin, Zyrtec, Allegra – the nasal sprays and eye drops, but they don’t do much and I quit them.  Fifteen years ago I tried allergy shots and that didn’t help, either.  What am I to do, just suffer?  That’s what my wife suggests when I whine and whimper.  She says to be thankful I don’t have something that will kill me. 
She’s right, of course, but do you have any more practical suggestions?  And maybe a little sympathy, too?

Answer:  I am sympathetic and will give practical advice. Sympathy first:  hay fever is underrated as a human affliction.  It won’t kill you but it can make life miserable.  Embarrassingly runny nose, eyes watery and in need of constant clawing, throat so itchy you want to swallow a porcupine.  It can last days, weeks, even months interfering with work, play and sleep.  I’ve known it to cause a concussion.  A self-conscious 6th grade boy, confronted on the first day school with a pile of moldy text books just brought from storage, began to sneeze uncontrollably, striking forehead on desk so hard that he was rendered momentarily unconscious and fell into the aisle, landing next to a sweet, sympathetic 6th grade girl who gently cradled his head and asked, “Honey, are you alright?”  Bad as it was, it wasn’t all bad.
So much for sympathy; let’s get practical.  The most common reason allergy pills fail is that they are not taken properly.  For maximum effect, they should be taken daily during allergy season and started at least several days before the season begins.  If taken intermittently or for short periods, they will likely not do a great job.  The reason for this is that the allergic phenomenon involves millions of chemical receptor sites in the eyes, nose and throat.  If tree pollen gets there first, you’ve got an allergy attack.  If the antihistamine attaches to the receptor site first, then pollen is blocked and, Glory be!, no allergy attack.  Of course, the antihistamine doesn’t hold on forever and must be replenished regularly (i.e., daily) or else the allergen (pollen or whatever) will regain a toe hold and make life miserable. 
Same is true for nasal sprays, usually steroidal, and eye drops, though their mechanism of action is different.  By the way, a popular nasal steroid, Flonase (fluticasone) is now available over-the-counter.  Prescription anti-allergy eye drops are very effective but pricey.  I’ve found an OTC eye drop, ketotifen, that does a good job on eyes and is inexpensive.  Early and often applies to nasal sprays and eye drops as much as with pills.
Here are three home remedies that help: 1) shower and wash your hair if you are hit hard with an allergy attack. Pollen, especially, in large quantity resides in your hair, eyebrows and skin.  This repository serves as a constant supply of the offending agent and should be washed away.  2) Ice water compresses to the eyes. When you must stop everything to claw your itchy eyes then it is time for the ice water.  Relief will be yours in minutes.  3) Pineapple upside down cake.  Your mother will make this for you.  Take a bite and hold it against the agonizingly inflamed soft palate.  Lo, and behold!  The fire is extinguished.  I can’t say this treatment has been subjected to large scale, randomized, controlled trials but it always worked for at least one family of hay fever sufferers.  Give it a try; can’t hurt.
If all else fails, reconsider allergy shots.  Allergists have made improvements in allergy treatments in the past 15 years and I’ve known many a patient who has benefitted from them.
I hope this helps.
Question:  The local rumor mill reports you have taken up boxing.  Is this true and how can a doctor participate in such a brutal and unhealthy activity and, by participating, endorse it?

Answer:  Yes, it is true.  I took up boxing five years ago at the urging of a friend, a Shakespeare scholar at a local university, who’d been boxing for a number of years.
 I recommend it for us old folks.  It restores and enhances balance, agility and rhythm.  It teaches you how to relax under pressure and to breathe when you’d naturally want to hold your breath.  It is a maximal aerobic workout that sharpens the mind and spirit –parrying, blocking and slipping punches and throwing punches while constantly moving for three minutes is not easy.  Technique and strategy are essential elements – it is not merely flailing away at each other.  In fact, I’d say it is the most technically difficult athletic activity – possibly rivaled by golf – that I’ve ever participated in. You also learn humility as you stumble about trying to perform a simple move.
There is an emotional element to the training.  You learn more about fear and how to deal with it and you enjoy the exhilaration of performing an activity that is physically and emotionally demanding.

Let me emphasize that we do not hit hard.  That would be considered extremely bad manners in our class and would lead to a talking-to from our teacher.  Punches are pulled so that, when they do land, feel like slaps or taps, but you know you’ve scored or been scored upon.  And, of course, we wear protective headgear and mouthpieces to protect our beautiful faces. 

A woman is in our class.  Her technique, rhythm and balance are superior and her punches fly quickly and surely but land sweetly, like maternal caresses, as if saying, “Wake up, child!  Attend to your lessons!”

I do not endorse boxing as we see it practiced today.  The threat of permanent brain injury is too high for a conscientious physician or for any sensible member of the human race to support it.  Boxing has lost a great deal of public support over the years, unlike another brain-bashing sport, football, which has gained enthusiastic backing at the high school, college and professional levels even as revelations are made of brain damage among football players.  It is not a pretty sight to see a chronic brain trauma victim whether It be from football or boxing.

But come to one of our Saturday morning classes at Back2Basics Boxing, Harold Cook, master teacher, to feel the exhilaration of correctly throwing a left hook, of slipping and parrying jabs, of pushing yourself beyond what you thought possible and finally learning – after all these years! – how to breathe and how to move.  Now that makes for a better person.  No kidding.

Men and Ladders

This is not the usual Question and Answer format.  It is an essay, a warning about ladders.  Ladders are a hazard to the health of men (mostly men) who think they know how to use them but are simply deluding themselves.  Ladders are dangerous.
Between December 23, 2014 and January 5, 2015, I participated in the medical care of three men, ages 63 through 79, who had fallen from ladders or roofs (to which they had ascended via ladder).  Each was fit and experienced – or so they thought – with ladders.  They sustained injuries ranging from a tripartite pelvic fracture to a lengthy laceration of the knee to major bruises (he was lucky).  They were all lucky to survive.
I’ve seen all manner of mayhem visited upon men who climbed ladders in the expectation of doing something useful.  These men ended up paraplegic, impotent and incontinent.  One of the more fortunate had only a punctured lung, which healed. And that’s just the beginning – broken tibia, vertebral compression fracture, dislocated ankle are other injuries I’ve seen over the years.

According to the World Health Organization, the United States leads the world in ladder deaths.  Each year, approximately 164,000 of our citizens seek care in emergency rooms after falling from a ladder and 300 of those die.  Most falls resulting in injury or death were from a height of 10 feet or less.  Seventy seven percent of the victims are male.

Remember Max McGee?  The fun-loving,  witty wide receiver for the Green Bay Packers in the ‘50’s and ‘60’s?  Air force pilot in Korea?   Scored the first touchdown of the first Super Bowl on a brilliant one-handed catch of a pass from Bart Starr?  A guy like that should be able to handle himself on a ladder or roof, right?  Well, sad to say, Max plunged to his death in 2007 from the roof of his home while removing leaves with a leaf blower.  He was 75.
And so I beg you, fellows.  Stay off ladders.  Stay off roofs.  They are no place for amateurs.  There are plenty of professionals around who can do these jobs.  Go ahead – spend the money.  It may be far less expensive than if you do it yourself.

Question: I am a 65 year old who has just retired.  I have never exercised regularly – always found it so boring I couldn’t bear it.  But now I realize that I need to exercise if I’m going to make it through the next decade or two.  Please don’t suggest a gym; it’s not for me.  My idea is that I take up golf again, a game I played, pretty well, in my youth. By playing golf, I’d be exercised and entertained at the same time.  My brother, a fitness nut, calls it a game for “lounge lizards,” whatever those are and I’d be wasting my time and money.  What are your thoughts?

Answer:  You are spot on about needing exercise if you want to make it to 85 without your body imploding.  It’s not too late to start.  You may not regain the cut physique and musculature of your youth but at least you’ll maintain what you’ve got which, I assume, gets you from Barcalounger to refrigerator without too much grunting and huffing.  You owe as much to your family.  Lugging old Dad around is not what they, or you, want in your old age.

How you achieve this goal is up to you.  You’ve ruled out conventional work-outs – the treadmill, the stationary cycle, the elliptical, the free weights or whatever.  Can’t say I blame you; that stuff is really boring though, if done regularly, rewards you with increased energy and sense of well-being. 
About golf: it provides many rewards, too.  It gets you out of the house and into the outdoors.  Not the rugged outdoors, to be sure, but into a park-like setting which is usually pleasant and, at times, beautiful.  Then there is the social part.  You talk, joke, cuss a little if you want and, if your outlook is so disposed, you have a good time even if you play poorly.  Sounds like you won’t have a problem there.

Of course, you need to walk the course to achieve health benefits.  Riding in a cart is definitely for the lounge lizard, whatever that is.  There are measurable health benefits.  A study in Finland (yes, they play golf in Finland) showed improvement in aerobic performance, core strength, increased HDL (good ) cholesterol and reduction in waist circumference by almost an inch.  The study group consisted of men aged 48-64 years who played golf two or three times per week over a 20 week period.  Controls were an age-matched group that did not play golf.  The golf season in Finland is shorter than that in North Carolina so presumably the gains or losses would be greater here.
The results may surprise but keep in mind that a golfer walks 4 to 5 miles carrying or pulling a load of 20 or so pounds.  This corresponds to an energy expenditure of 1500-1900 kilocalories per 18 hole round.  Not a bad work-out but don’t spoil it with beer and chips in the clubhouse afterwards.

Golf can be as costly as you want to make it.  You can play Pebble Beach or Pinehurst No. 2 for around $400, plus caddy or you can play any of several public courses in the Triangle for much, much less.  New equipment is expensive but keep this cautionary tale in mind before blowing a bundle on clubs: I recently shot one of the best rounds of my life using borrowed clubs that could have been purchased at the PTA Thrift Shop for $25, less on Dollar Bag Day.   
Good luck in retirement. Hit ‘em straight and long and, most important, have fun.


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