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Talkin’ about your boobies (big and small, we love them all!)
91 Plays2 months ago
Dr. Sunshine takes us to class with a recap of interesting topics picked up from FMX including suicide + social media, “soft doctoring”, stigmas in medicine and national recommendations for Breast cancer screening. In honor of breast cancer awareness month, Dr. NoNo leads a super comprehensive talk about Breast Cancer. Get your screenings done!
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Transcript
Introduction and Catch-Up
00:00:17
Speaker
Welcome, guys, to another episode of Chocolate with a Side of Medicine. I am one of your hosts, Dr. Chris, and I am joined by my three lovely co-hosts. We got Amy Jo MD. What's up, y'all? We got Dr. Sunshine. Hello. And last but not least, we got Dr. No-No. Hey, guys. So how has everybody been? I feel like it's been a while since we've come together. We've been in these streets. Because we've been in these streets. We've been outside. Everybody's been outside. You guys also got together without me, too. So, you know. That's true. What'd you mean? A time was fair. We missed you.
Medical Conferences and Learning
00:00:58
Speaker
We did miss you. But a time was actually had. A time is always had. I was learning. I was learning in Phoenix at a conference. Oh, you're so smart. You got to keep the brain cogs moving. You got to keep the cogs moving, you know? Otherwise, they get a little dusty. They get a little squeaky. You know what I mean? You got to keep it moving.
00:01:15
Speaker
I mean, I went to learn too. I just cut class for like. Yeah, she did. Dr. Chris joined me. She just came. She flew in later. I'm like, what? I can't kill ah cut class for a whole day. I'm like, I can't do that today. Dr. Chris making her own schedule. I'm like, are you going to the conference? No. I was like, these days they don't work for me. I can't do it that day. I'm coming back home.
00:01:41
Speaker
When ADFM sent me my damn um a checklist on my progress, I should have had my ass there too. o Oh, crap. I got to check that. Listen, I get it. I probably just have 10.
Stress of Medical Certification
00:02:00
Speaker
You need $150 million. Let me tell y'all a story. If it wasn't for Amy Jo, y'all, I would have been lost in these streets with ABFM, OK? She was just like, did you get it? Shout out to AAFP conference, though, because this is where I learned the extent in which Dr. Chris was like,
00:02:21
Speaker
I'm just here so I don't get fined. It was really bad. She was like, oh, you didn't get these emails? I'm like, nah, I ain't got no emails. Like, you need to renew emails. I don't need to renew emails. And she's like, but you got to renew, too? I mean, we graduate the same time. I'm like, I know, but I didn't get no emails. But you know what pisses me off, though? Let me tell you what really pissed me off.
00:02:46
Speaker
I'm out here getting snapshots of my lack of progress on the regular, okay? Dr. Chris has no idea. She don't remember, continuing education, points matter and everything. So we get over to the ABFM booth and they're like, what's up docs? How y'all doing? It's a really cool booth. And and we're like, yo, help my friend out. Can you please help my friend? They're like, sure, let's do it. do Oh, you're good.
00:03:18
Speaker
o I put mine in, and they're like, well, if you can see it now, I'm like, what about me? What about me? They're like, if you get started now, you might make it by the dead lot. I'm so irritated. So how do this woman progress even when she doesn't know? That's why I say what you said, Dr. Sunshine. When we got on this trip, she's going to fall into a CEO position and be like, I don't even know how I got here.
00:03:40
Speaker
So for listeners, ABFM as the American Board of Family Medicine, we have to do continuing medical education credits in order to stay a doctor. So if you don't do those credits by the deadline, then they can take away your certification. Hence why it's a big deal.
00:03:57
Speaker
be and I almost lost my certification, y'all, but then I didn't, so. She was never in threat. I thought I was. I thought she was, but she was so good. I mean, we all, you know, did it, we were fine, but, you know, I couldn't believe how behind I was and how the person who didn't have any clue to what I was talking about was had no so far ahead and on schedule.
00:04:26
Speaker
That's how it always was. And I had no clue. Every time. But she was like, thanks for letting me know. Now I know. So we yeah. and So you know. Right around now is when you typically get, well, right before conference is when you typically get, I think you get like two emails, which I think just kind of helps people. I think they do it on purpose so they know folks who want to conference. So you get, for those of you all who do not know, every specialty, whether you're family medicine,
00:04:54
Speaker
internal medicine, OB, urology, ortho. We all have an annual conference. It talks about the goals of the year, you know who our executive staff is, you know what's coming up. So we get updates on like new bulletins. like This is how you should be treating this. This is what you should be doing. What's in the news? What's important? you know Here's the focus. like Something that we're missing. So you get all these great things. And we actually love it. um I don't know about it.
00:05:24
Speaker
Let me take it back. I love it. No, as do I, as do I. So if it feels like a learning environment without penalty. um So it's really cool to do.
00:05:37
Speaker
um But they probably do it because you could get points. So when you're trying to structure like what you want to see, what you want to listen to, it helps you kind of organize it. um I actually don't mind the ABFM um courses either. I actually like those quizzes, those big quizzes where you get the big points. The KSA? Oh, gosh, I love it. I learn so much stuff when I do those. Yeah, all of the learning material they have is really good. It's not very dry. And even like when you go to the conferences, like the the the presenters are really good. like
00:06:08
Speaker
Well, there's two types. There's the AF, AAFP conference and then there's the FMX. The FMX is the one that's the fun one. I like it. But it's more fast paced. But remember when we were, where did we go see? um We went to the one peripheral versus a central vertigo that was
Social Media and Mental Health Concerns
00:06:26
Speaker
like, Ooh, that was so good. Yeah. I didn't lecture on, I did a lecture on dizziness this time too. And it was very, very helpful. It's just like stuff, you know, but then it's just kind of just to, you know, it's, it's a thought exercise that you're having with other doctors and based on things that they've seen. And, and I felt like the, the slated things that they talked about, you meet doctors who do everything. You meet, you meet doctors who are in like,
00:06:50
Speaker
Half the doctors that gave the lectures that I went to, they're emergency room docs. They're family medicine, but they're in the emergency room. And some are like, oh, I'm a hospitalist. Or some are like, oh, I'm outpatient just like you guys. like So you meet all these people who are working in all these different areas. And you're in the sessions with docs who are in all these different areas. They had a lot of inpatient stuff, too, which I didn't go to. But I was just and was i found that to be interesting. They had a lot of inpatient topics, too. Inpatient, for the listeners, is hospital medicine. So yeah, it was good. It was dope. Learned a lot.
00:07:20
Speaker
Pretty cool. I do get the emails that Amy Jo gets. I pay attention to them and I try to stay up on it. If you don't, someone at your job is going to email you anyway until your shit is expired. and They're going to be like, doc. Right. And then you have to do the hustle last minute and then go renew your DEA or go renew your whatever it is that the hospital said that you're expired on. So you might as well just do it anyway.
00:07:42
Speaker
I definitely just got my hustle on for my DEA license. It's weird because in South Carolina, you have two. South Carolina, you have your South Carolina controlled substance license, and then you've got your DEA license. So my South Carolina one with- Why do they have two different ones? I don't know. No, some states have two. At one point, Chicago has two as well. Yeah, they still do. Yeah. Kelly, we only have one, but in Chicago, they have two.
00:08:08
Speaker
You know, thank God I live in South Carolina because I'm going to admit this to y'all. And I admit it when I call every year, every year, I wait till the last minute. And when I say last minute, like it's due tomorrow.
00:08:21
Speaker
And I have to call and I'd be like, my name is Amy JoMD and I am procrastinator. And the person that picks up the phone cracks up and they're like, doc, just send me your stuff. And I'm in the process. So God bless the office. this yeah Anyway, we're just changing.
00:08:38
Speaker
yeah But I did want to share one of the things that we talked about at the conference. And this can be because I'm trending topics anyway. So I learned a lot at this conference. And one of the lectures we went to, which is the same one he does every year, like 10 things I wish I knew last year. Great lecture. I love that lecture. Yeah. Dr. Frank Domino. It was amazing. Shout out to Dr. Domino. The conference this year was amazing. Yeah, but um one of the things that he really harped on, there's there's three little nuggets I'm going to bring in here. ah The first nugget that he harped on is, um so I've already talked about this in a trending topic, but this is just a hit home again.
00:09:17
Speaker
that we have a drastic increase in the number of suicide attempts, specifically in adolescents, and specifically even worse in adolescent women. um And the rates have like doubled, it's up like 188%. And they're noticing the anxiety and depression starting between the ages of like eight and 12.
00:09:37
Speaker
um A lot of this has to do with social media and if the kids have access to social media. But long story short, the emergency rooms and the hospitals are basically reporting that there's like been a doubling and tripling of women going to the emergency room because they're trying to commit suicide or at you know or did complete you know the suicide attempt.
00:09:57
Speaker
And it was kind of like a call to action to all primary care doctors to be like, hey, these adolescents are really going through a lot. A lot of them, it's linked to exposure to social media. And there's a study that was done that says for adolescents and adults, nowadays, the average adult is spending about two and a half hours on social media every day. it And as those numbers have gotten higher, the anxiety, depression and suicides have also increased. And it's causing our nation to have like a like a like
00:10:28
Speaker
it's we tryway mode We're mode. Yes, we are in crisis mode. That's exactly it. And then in the study, it shows that because you spend this two and a half hours on social media every day, that you're spending and like an exponential amount of time alone when in the past, this is time that you would normally spend with your friends or your family or whoever you're dating or whatever. But it's these people that are in spaces with each other but not interacting with each other. You're just on your phone alone.
00:10:57
Speaker
for two and a half hours. That's the average adult. um So it's kind of like brainstorming with other doctors how to like convey this to your patients, convey it to your teenagers, try to get them more active, interacting with other people because the more they interact with others, it decreases their risk of suicide and it increases their happiness, decreases depression, the whole thing. I think that's pretty intuitive, right? Like if you get people out and interacting, then they're, you know, they're more likely to create those bonds with real people in real life and then less likely to develop a lot of these things. So That was a big point that was hit on the entire conference all week long, so that's a big thing. The second thing that they hit on, which is interesting, is trying to change a lot of the but the verbiage a lot of the verbiage in the healthcare care system to make it more um
00:11:46
Speaker
ah Fluffy, a little more woo woo woo, a little more ah TLC.
Changing Medical Language
00:11:52
Speaker
They don't want us to use the word obesity anymore. They want us to retire it. No fat, can't say fat, can't say obese, can't say any of that. um Stop calling people diabetics. It's like, oh, a person who happens to suffer from diabetes. It's a lot of verbiage changes they want us to do to stop labeling patients.
00:12:10
Speaker
Because it's a promoting stigmas and it's making it harder for doctors to connect with their patients because if patients don't feel They don't feel welcomed, you know, it's like they have a warm environment I'll leave that there, but there was lots of lectures on that just kind of ah um If we're not with them obese then what are we calling them? I long phrase. I wish I had it in front of me. That's a great question. am me just It's like masters. No, no, no, no. No, it's like, ha no, it's like patient with elevated BMI above average. Like that's what they want. you're know that means or whatever like what It's a long phrase. And then when he said the phrase, like during the lecture, I'm like, first of all, that's too many syllables. I'm not saying all that.
00:13:00
Speaker
And I feel like even when you say goodbye. Is there an acronym? But they want us to stay away from all of these. Well, they don't want you to shame anyone for anything and then it also don't want to shame them But I just want people to know I agree with that, you know know Most people when they come and see you they're telling you I'm obese like they're bringing it up I don't a lot of times have to bring it up and tell them. Yeah, but you know, they know yeah, but I'm thinking about it's like so sometimes I'm having a conversation and I tell people all the time like when we're using this being a When we're using this BMI, just for the record, it is not a perfect system. yeah It is one tool of a lot of things that we're going to use to assess where we are from a lifestyle standpoint. So I might sometimes, I've sometimes said, well, you know, you're BMI 65 and they're like, okay. And I'm like, so, you know, a BMI of, you know, 30 to 39 class, one class, two obesity.
00:14:01
Speaker
BMI 40 and high morbid obesity and then I'm like oh oh I'm morbidly obese dang I didn't know so I think sometimes just giving them that you know this is kind of where we are here's here's our role right here's our role we've got to travel but we don't just use BMI and I'm like What are we supposed to do if we don't call it? There's a whole lecture on it. and like I'll find the PDF because like um i'll send i'll send it I'll send it to you guys. But it's a whole but it's a there were a lot of lectures about like, there's a lot of lectures on biased as well and how to not try your best to not be a biased doctor.
00:14:39
Speaker
I'm biased in all different types of ways, racially bias, diagnosis bias is a big thing, um especially not dismissing lots of patients because you see on their chart that they have like anxiety and you're like, oh, here they go. This, and this anxious patient is coming here to complain about something that's not a big deal. Like try to just a lot of like tempering bias. So that was a big thing too. A lot of verbiage stuff.
00:14:59
Speaker
so Just know that as your doctors, we're doing our best for staying up to date. We are here for you patients.
Addressing Misinformation with Patients
00:15:06
Speaker
So we take into account everything they let us know and we just try our best to do better. Whether that's pronouns, whether that's making you feel more welcome, no shaming, all of that. The most interesting lecture I think that they gave was one about um how to tackle difficult conversations dealing with misinformation. So misinformation about vaccines, misinformation about um
00:15:29
Speaker
basically everything because the patients are listening to political ads and they're also um listening to TikTok and they're listening to all these different things um and just trying to have conversations so that you can acknowledge their thoughts, your thoughts, listeners, but also they're on the TikTok and the TikTok is full of people who are doctors, who aren't doctors, who are things in between. So that's that.
00:15:53
Speaker
um Last little nugget I'll say, which will kind of lead us into Dr. Nono's talk, is that there was a really good lecture where they talked about if they're going to change the national recommendations for a lot of things. So one of the things they did talk about was breast cancer.
00:16:08
Speaker
and if it's coming down the pipeline for them to change the recommendations. Now, Dr. Nodal is probably going to touch on this, but I'll just say this. ah There are three organizations and these three organizations have different recommendations because there's the United States Preventative Service Task Force, there's ah the American College of Gynecology,
00:16:29
Speaker
And then there's the American Cancer Society. All three of these entities have different recommendations. We as family medicine docs and on our boards, we usually go by one set of guidelines. um So at the conference they talked about if we're going to change those set of guidelines, and the answer is no.
00:16:46
Speaker
I will let Dr. Nuno give her spiel on breast cancer, breast cancer awareness this October. Yay. And then I can chime in at the end, all about the boobs. So if she touches on it, then we'll cover it. And if not, then I'll let you know some of the things that the meeting of the minds were discussing, but we're not changing that particular one. The USPSTF isn't changing their recommendation and they put forth evidence as to why they're not changing it.
00:17:14
Speaker
so Listen, they stay they they'd be standing on business, okay? They do. Yes, they do. like Yeah, about that. Because they have the they have the strictest criteria for the type of studies that are required in order for them to change a national recommendation. so There's that. So yeah, those are my take home messages. So decrease the social media, know that your doctor is trying to be more inclusive and welcoming in terms of the language they use while providing you health care. And then also, there's lots of different recommendations for breast cancer screenings and things, um which Dr. Nona is going to talk about. And that's all I got. nice Thank you. I just want to say though that I did some soft doctoring.
00:17:56
Speaker
with a patient. For who? For who of the soft ones. Soft as a host or hard? Yeah, trying to use like, okay, you can do this, you got it. And he was so disappointed. When I told him he got out, he was like, what is this? I ain't come for this. I was like, what? He was like, I'm so disappointed. What? I thought you were going to go hard in the paint. Oh, what? Switch it up and then you have to go hard in the paint.
00:18:25
Speaker
What? Hard in the past? What? Were you trying something new with this guy? They were like, give him what they want. He was like, I want you to come in here and be like, you need to get it together. Like, you got a reputation, Amy Jordan. I do. You live up to it. I do. I mean, you should have seen his face. He was like, wait, we done? I'm disappointed. I'm like, what? He was like, I was just, I was expecting more.
00:18:46
Speaker
I'm like, sir, this is not a concert, okay? My name is not Beyonce. oh We are not about to have that. I said, and I gave you this speech like four times in a row, like you've already heard it. He was like, I know, but I just, you know, I thought you would go with it. again that is gonna be more forceful this time. Exactly. So I'm sure the stuff that that Dr. Sunshine is talking about is gonna vary on clinics, um ah who's in front of you, how long you've known them, are they new, you know, age, you know, generation. Like, just so y'all know that we're making these decisions about how to talk to you all and all of that stuff is coming to play. Some of us are better at it than others. But when I am talking to
00:19:32
Speaker
a patient, like I am, I am a, a strong advocate that you meet the people where they are. And so I am trying to speak your language and your genres in your sensibilities in all these things. and So that, you know, so it's hard to say, okay, officially we're not going to use this word. We're only going to use that word and we shouldn't be offensive. We should be inclusive. We want people to feel comfortable. We're also trying to have conversations and meet people so so that they understand like,
00:20:03
Speaker
what there's no There's no penalty here. Tell me what you want to tell me. let's Let's get through it and let's figure out how to make you better. i'm trying to find Oh, I'm sorry. My bad. I was trying to find the new phrase for obesity. When I find it, I'll message it to you guys. But it wants us to change the verbiage because it says, do not use the words obese, fat, or overweight any longer. When you talk to your patients, you have to focus on the phrase, we're doing we're in this together to achieve and maintain a healthier weight.
00:20:32
Speaker
Like, that's how you're always supposed to phrase it. Then why they keep harassing me about not putting obesity in this this note? Well, and when you still have to put it in your note. But when you talk to the patient, it's to focus on achieving and maintaining a healthier weight for you. That's what we're doing, though. it's Right. Well, you have to say it like that. But it says, it says never use obese, fat, overweight. I'm just reading. I'm telling you guys the yeah the national guidelines.
00:21:01
Speaker
Yeah, we're definitely not calling anybody fat. that That part, I get it. But it's funny because they're going to read their note. So the interesting is interesting thing is is that it's just recently, right? So you know we've been getting a lot of smoke about how you label obesity, right? So um so Dr. No, you won't know this, but now, so like now,
00:21:24
Speaker
If the BMI, it's for me now, it doesn't matter.
Challenges in Medical Documentation
00:21:28
Speaker
I mean, if you've got be a BMI greater than 40, then it probably doesn't apply, but I just uniformly do it. So now I can't just put under a problem, um obese. I have to have the BMI and I can't just have the BMI. So it has to be.
00:21:43
Speaker
Class 1, Class 2, Class 3, obesity, with the BMI of such-and-such, with or without serious comorbidity. And then in my, what I label it, has to be, I always put in there contributing to whatever I think is comorbidity. Because if you don't, you get a message back from the coder saying,
00:22:04
Speaker
You have incorrectly coded this. You have not said what the BMI was, what kind of obesity this is, and and it doesn't have a serious co-morbidity. No, we have to do that. We can't go without putting those co-motifiers on it. Yeah, but you didn't always have to do that. You just had to put in... No, before we used to just put in obesity, but now we have to actually put in those identifiers with it. Yeah, so you know I'm going to spend all this time you know soft-talking all the things, so but the insurance company... You would miss soft-talking.
00:22:33
Speaker
She's not about soft sauce, she's about hard talk, okay? you know you know money alone gotta to Keep it real. I like to call a spade a spade because I'm always surprised at how many people are like,
00:22:48
Speaker
Well, somebody mentioned it, but they didn't really make a big deal of it, so it wasn't for me. Like I'm always surprised about that. Like pre-diabetes, like you didn't know you're pre-diabetic? Well, no, I remember at one point somebody kind of mentioning like, um you know, ah I should be careful with my blood sugars, but they were just telling me to be careful. They weren't saying that I had pre-diabetes. And you know what what most patients say, if I had known I had insert whatever thing, I would have been you know kind of working on it. and so I'm always surprised when I'm looking at like five years of elevated BMIs, or five years of elevated A1Cs, or five years of elevated blood pressure, and I'm like, you didn't know that you were hypertensive? You didn't know at all?
00:23:35
Speaker
And they're like, I mean, no, they made it seem like ah it was just something that we were going to watch. I'm like, you may have been watching it, but you were for sure hypertensive. And now I am in this battle for our lives where they're like, how come you're the only one that's ever told me? And I've had people say that, like, why are you the only person that's ever said it? So now it looks like I am the outlier. And I'm like, let's turn this screen around here, friend, and let's run the numbers.
00:24:01
Speaker
you see all this red that i'm back i'm back back to 2018 do you see these numbers they're red this is the indication that your diagnosis is this and they're like wow your experience is my experience we have the same experience yeah I had to do that a couple times too. Someone was in denial that they were not a diabetic. And I'm like, sir, your sugars have been consistently above 250 for the past three years. But that phrase, that phrase, like, well, why are you the first doctor to tell me this? Like that phrase in particular, I hear that all the time. Gosh, it bothers me because then I'm like, I can't be like, well, all the other doctors you went to must have been trash. Like, no, you can't say that. you
00:24:44
Speaker
know you You really can't say that. Or no one. No one's as thorough as me. But that's not necessarily true. they Exactly. Because that's not. They documented it. But that's how they feel. Because after because after you turn the screen around and show them all this stuff, and they're like, well, what all these doctors been doing since 2018? How come nobody? I'm going to call this doctor's office. and I'm going to call this doctor. And I'm going to go off. I'm like, that's not. You have to tell them that's not the point. The point is.
00:25:08
Speaker
you know to acknowledge it and you know manage it, stuff like that. Right. Yeah. cause then they will Because then like, well, since I'm just not hearing about it, I think we should do lifestyle. And now we have to have a conversation about... We're past that point. We're past that, right? like You've been technically unbeknownst to yourself working on your lifestyle for five years. You've been uncontrolled for five years and we just don't have time. we don't while We still want you to work on your lifestyle, but while you're working on your lifestyle, the disease process is still doing its thing. So we need to protect you from your disease process and buy you some time to figure out your lifestyle.
00:25:50
Speaker
That's also why I like this whole rebranding obesity and diabetes into like some really long phrase. Like I feel that's going to confuse more people than actually help them. Like if I think of people here, I'm obese or I have diabetes.
00:26:09
Speaker
Like that is a for sure thing. It's not like, oh, your sugars are high, but you know, we're going to get through this together. We're going to help you out. No worries. All they hear is like sugars are high. Okay. I can get this down. They don't know that they actually have a diagnosis of diabetes or that, you know, they're way 350 pounds. They don't know that like they're more really obese. Like we don't, I feel like that's, that's kind of goingnna going to get lost like in the,
00:26:36
Speaker
lost in the class or whatever, lost in translation. Instead of rebranding it, just just tell it, you can deliver it in a way that's tactful and respectful, but like that's where bedside manner comes in. And some people, you can't teach that, but um in the most part, you just need to know, like hey, this is what you have, but we're going to work on it together. But for sure, you have diabetes, we're going to work on it.
00:27:01
Speaker
Because the thing is sometimes like you tell them you'll tell the patient, OK, you have prediabetes. They're like, OK, I'm going to do some things. like They'll be like, OK. And then when they have the diagnosis of diabetes, then they're like, oh, snap. This is real. like i know I got gotta to do something. And sometimes, once that happens, they make a whole like change. They do a 180. And it's great. you know like I have so many people come into the hospital that were told that they had prediabetes.
00:27:32
Speaker
but then that was just more of like, Oh, like, you know, we'll, we'll watch the sugars. We'll, you know, do the lifestyle changes, whatnot. Don't need to put you on medication just yet, but like, let's get the sugars down and everything to get it back where they're in, where they should be. And then they're coming in with sugars and like the 600s. And I have to go tell them like, yeah, you're in, you're in a DK. Um, you got diabetes and they're like, Oh, I was never told that. I'm like,
00:27:58
Speaker
But that's the thing, I completely agree with you guys because when I'm like reading all these, sitting in these elections and listening to all this, I'm like, it almost sounds like it's a study that was based on like, I don't know, like patient satisfaction scores or something like that. And I'm like, and I'm not saying that patient satisfaction is not important, but in my personal experience, and I don't like to paint everyone with a broad brush, because I don't like to put it right in a box, but I will say this,
00:28:24
Speaker
the majority of patients I have, especially patients of color, they like for you to be direct and a straight shooter.
Importance of Direct Patient Communication
00:28:32
Speaker
They're not really trying to have you like be around the bush and blah, blah, blah, because they already have a distrust of the system. They already are apprehensive about listening to you in the first place. So the last thing you need to do is try to feed them some BS like, oh, well, maybe who does that? No, like, hey, listen.
00:28:49
Speaker
We're in this together. I know you don't want diabetes. You are really close to getting diabetes, like real close. In fact, let me tell you how close, like they like for you to be direct because otherwise you end up in those conversations that Amy Jo was talking about where things have been going on for so long and you never want them to have that, well, nobody told me moment.
00:29:05
Speaker
because by the time Because when they feel that way, then they feel failed by the system. Like, oh, I've been going to the doctor. I've been in these i've been in these encounters. Why didn't someone tell me? So I'm like, OK, we can't do that. like We can't do that. And you're right. I do feel like some of this like fluffy woo woo woo woo woo woo stuff is kind of like going backwards. I'm like, listen, you're not here. like bedside manner is important. And I have a connection with my patients, but you're gonna get these facts. You're gonna get the facts you are. I would have been that lecture looking I'm like
00:29:40
Speaker
Like, what are what are we doing here? It's like we're trying to implement better bedside manner through health care policy and through, you know, standards of care. But to me, standards of care are standards of care. Now, it's your job as a physician, especially as a family medicine doctor. Like, I think that family medicine doctors are unique because you're supposed to do it in a way that nobody else does. You see everybody.
00:30:10
Speaker
in all phases and all stages. So you see them whether they are single or married, pregnant or not, sick or healthy. You see them at the beginning of life and you see them at the end of life. There is no point in your life that a family medicine doctor could not be present for. You are a pure generalist. You have got to know how to talk to everybody. That doesn't mean that we get it right. I definitely have people that I see and I'm thinking, this is not a match. Like, I'm not speaking their language. They're not speaking my language. Like, we're missing the mark. But I still think you can get out the encounter saying, I don't know that we're going to do this dance forever.
00:30:53
Speaker
But in this moment, I have provided some education. They are clear on what my concerns are about their health, where I think their focus needs to be. And we kind of made a right now, tomorrow, and and forever plan.
00:31:07
Speaker
oh And you you can't, policy doesn't make you do that, right? So i you know now i feel now I feel like I'm getting old in medicine because I'm complaining like the other doctors like everything, more and more everything seems to be, we're going to create this policy that then tells you how you have to talk to patients because we want to make sure everybody's being nice. And we're also being held hostage to all the documentation that makes sense for insurance.
00:31:37
Speaker
and reimbursements. And while both of those are important, those are in addition to the medicine you must do in front of the person that's sitting in front of you. Like those things don't necessarily include the medicine that has to be done. So now you're trying to do the medicine, you're trying to follow these guidelines, you're trying to document based on these guidelines. It just becomes a lot.
00:32:00
Speaker
Mm hmm. Completely agree. A lot of docs had a lot to say about it. And I'm like, I am. I wish I was there for that. I would have been more. What are we talking about here? do You know, afterwards they have the Q and&A portion, but it was it was cool. But go ahead. i will I will definitely be at the next one. All right. So the nitty gritty. So for Breast Cancer Awareness Month, a topic for today is breast cancer.
Breast Cancer Awareness and Screening
00:32:23
Speaker
Boobies. Yes, all the boobies. So this actually came, um I actually had a patient a couple of weeks ago, I saw an ER for something completely unrelated. um And we were doing like the full, you know, full body exam.
00:32:37
Speaker
And I was, you know, listening to her heart. And I felt like, like oh for legit hard, solid mass over her right breasts. So I'm like, you know, I asked her respectfully, can we, can we do like a full exam looked and it was textbook pew to orange appearance of her breasts. Like it was literally like, you took an orange and put it on her chest and just taped it there. That's what it looked like.
00:33:01
Speaker
wow And that is one of the classic, um that's like the classic presentation of someone that's coming up inflammatory breast cancer. um So unfortunately,
00:33:13
Speaker
Didn't expect to diagnose someone with breast cancer um during a night shift, but this is where we are. so um So for breast cancer, it is the number one most diagnosed cancer among women, just period. I mean, we get about 2 million cases a year. It is the leading cause of death in women worldwide. And usually with them people that do not have the screening protocol, it's usually sap-bounded people a lot earlier than than expected.
00:33:43
Speaker
So the incident rates have actually been going down and that is actually by like 1.8% per year, but that's purely due to the prevalence of the screening protocols that we have in place for it. The mortality rates have actually also have been going down since the 1970s and that's all with improved screening and also with the therapies that we have in place. So therapies being like ah surgery, you get a lumpectomy, mastectomy, um radiation, chemo, immunotherapy, all of those things have been, you know,
00:34:13
Speaker
have been advanced in the past couple of years. And that's where we're seeing the decrease in mortality rates. But the New York Times actually just released an article that we're seeing a lot more cases that are diagnosed under the age of 50. And there's actually been a spike in new cases among women between the ages of 20 and 30, which is very, very concerning. um Because like Dr. Sunshine had said earlier, the screening protocols between those three major, not people,
00:34:43
Speaker
Organizations. Organizations. All of those screening protocols differ, but I can guarantee you there's nothing in there in place for you know screening protocols for anyone under the age of like 30 right now, which is something that we probably need to revamp very, very soon.
00:35:00
Speaker
um so Like I said earlier, clinical features, you can have what I call the pew to orange. It's ah the kind of the dimpling of the skin and it feels really hard. It's ah like a rock hard mass that where your breast is located. and That's you know like what we learn in the textbooks. That is what we see or think about when we think about breast cancer. um but those can actually That can actually be the sign of a malignant lesion, which is a cancerous lesion.
00:35:30
Speaker
But actually the way that we can determine if it's cancerous or not is with the screening protocols that we have so mammogram ultrasound, and for people that are high risk or at higher risk for advanced disease they usually get the um MRI. So I will stop there and see if you guys at any.
00:35:46
Speaker
Obviously, you guys do screening protocols in your clinics. You probably referred people out, you know, if you saw something in clinics. I know self-breast exams are also have been in scrutiny, like should we do them? Should we not? um I personally say I think you should be doing them regardless, but um some of the screening protocols from the three ah entities that we have right now say, you know, it's kind of like a mixed bag with if you should do the self-breast exams or not.
00:36:14
Speaker
so
00:36:16
Speaker
I still ask. So every annual exam, I will ask every every patient have they been doing their self breast exams because even though they've fallen out of favor. so um One of the things Dr. Noah is getting at is that we don't, some of us still do them, but it's not a part of the screening protocol for us to do your breast exam in the office. And I know you're going, well, why? Well, simply because we're not all good at them.
00:36:47
Speaker
so they were there was not enough consistency in how the breast exams were being done that the numbers looked like we were really catching something right so it could not be you know safe as a screening tool so i don't i think what i wouldn't want somebody to do is walk in my office going well you know uh you doc you you you felt my breasts and you didn't find anything and i was already a little nervous about this mammogram because i hate how it smashes my boob in the glass So since you didn't feel anything, I think I'm okay. That's actually not true. And I remind people that if I can feel it, we're too late. Like we want to catch you super early and not we're too late. Like, oh, all hope is lost, but we just, it's not our preference on where to catch it. But I still do ask them, have they done them themselves?
00:37:35
Speaker
yeah so So the example that I gave, like the lady that came in with like the the big mass on her chest, that's that is not the norm. um And usually when you do the breath exams, either in the clinic or at home, you know you may not to be able to feel that. So usually that's why we have the screening protocols in place because they can look into your breast tissue and actually see masses that are deep within the tissue um that we cannot feel on a physical exam.
00:38:04
Speaker
so And then also, I think something that has been recently implemented implemented is that when they do a mammogram, they have to so tell you the density of your breast tissue. If you have super, super, super dense tissue, then that means that the mammogram has a higher chance of missing those little um masses, the speculated masses that would be picked up on the mammogram. And then usually when that happens, they will automatically refer you to get a breast and MRI.
00:38:31
Speaker
Yeah, I i do ask a lot of my patients if they do their own breast exam. and And I feel like it's good to know how it feels because then you can know if there's something that's different that pops up. And if it doesn't feel right, then you're able to tell me, hey, doc, I normally feel it and this doesn't feel right. right So now i when I go and I do my exam and I'm asking you, OK, where is it that you feel? And then I can see if I feel something too. right So I think that helps.
00:39:01
Speaker
helps the whole process. you know cause I think it's really hard to like know if there's something wrong if you didn't know how it felt before nothing was wrong. right right Very true. I think that, um, I know that my experience is different because I worked in a women's health clinic and I also worked for a government facility. So the way that we did things was drastically different from how everybody else does it. So, uh, I won't insert my experience here cause I feel like it's just gonna, it's just gonna.
00:39:32
Speaker
It's going to make the results skewed. No worries, no worries. But um I also, before we kind of get more into the talk, um because always I'm notorious for throwing out like doctor terms and no one knows what I'm talking about.
00:39:45
Speaker
So localized versus metastatic. Those are terms that your doctor may um talk to you to. So if they do see something on your mammogram or your MRI, ah they may tell you about localized disease versus metastatic disease. So local is just it's just that. They found like a mass somewhere in your breast, so local, so within the same area. Metastatic means that the breast cancer has spread to other parts of your body.
00:40:14
Speaker
And then usually people, sometimes people can come in with symptoms of where the breast cancer has spread. So things like if you have abdominal pain or if you look like you're turning yellow, um they do labs and your liver function tests are like through the roof, then that tells us that you may have some liver involvement. um If you have bone pain, leg pain, your alk phosphatase levels are also very high, then that tells us that they may have spread to the bone.
00:40:41
Speaker
Um, and then if you're having like a cough, you're you know constantly short of breath, go on a certain certain distance. Um, you know, they'll probably be doing imaging to see if this cancer has spread to your lungs. So, you know, breast cancer is a little nasty and that it spreads to a lot of different organs in your body.
00:40:57
Speaker
Um, so the big thing is that why we really hammer down on the screening protocols that we can catch it before it gets there. Cause when it becomes metastatic, it is very, very hard to treat. So that's why we want to, you know, get it when it's still in the boot. I co-sign. I will say to answer the original question, if my patients do self breast exams at home, I think that that's a good thing. I completely agree with Dr. k Chris, you know, you should know what normal feels like. So, you know, something changes. Um,
00:41:26
Speaker
The OBs, when they do a well woman exam, they actually like if you go to an OB for a well woman, when they do your PAP, they will usually also do a breast exam, but their criterias and their recommendations are different than primary care. So in primary care for the most part, and mind you, mind you.
00:41:45
Speaker
It's optional for OB as well, but nine times out of 10 for their well woman exams, they are going to do it in addition to the PAP and whatever else you need to be done. So that's something I think is also a little different as well. Now for primary care, for me personally, um, if a patient comes in and tells me that they have a breast concern, then I do do a breast exam if they have a concern, but at just to snip it into my life. The facility where I worked at, there's two different types of mammograms. There's a screening one, if nothing's wrong, and then there's diagnostic. We can't order a diagnostic one unless you specify in the comments where you found the concern. So you have to put in there like, hey,
00:42:27
Speaker
right breast, upper right quadrant, six centimeters from the nipple. I felt something, it's about two centimeters, it's mobile, but you have to put all the descriptors in there so that the radiologist knows exactly where to look to tell you if what you're specifically concerned with looks concerning. Other places I know, you can just order a diagnostic and you can just do, you can just order one and they just look, but I think that might change facility to facility though, I don't know.
00:42:54
Speaker
Yeah, that's the same at my facility. they um if Well, if you get the screening, they find something on the screening and then they'll automatically send for the diagnostic. It's it's like they'll they'll just do it on their own department.
00:43:05
Speaker
No, but if they come in for a complaint, you don't do the screening. like skips We skip screening. You go straight to diagnostic with the descriptor. But I don't know if, yeah, like I don't listen. Yeah, it's very similar in my my organization as well. Like if um you're you're at the age for screening, you want a screening, breast exam is due, you can make that appointment on your own. You don't need a doctor's order for a screening. Now, if you try to do that and you say you have a complaint or a breast pain,
00:43:34
Speaker
they will not order the, they will not let you schedule the appointment. They will tell you, you have to see your doctor first because then you would need a diagnostic one. Cause there's an issue. So we got to leave. Oh, even if they're there already. Yeah.
00:43:47
Speaker
They will not do it in mine either. yeah If you, if you ordered a screening and you needed a diagnostic, well, actually if they, if they do have some state in my, um, imaging center, they have some questions. And if, if they answered in any way that triggers it to need a diagnostic, they will cancel their appointment yeah and tell them to get in touch with their primary care doctor for a diagnostic screening. They just order the diagnostic screening.
00:44:15
Speaker
I don't know because they can do that, right? Because let's say a mammogram comes back abnormal and now they need ultrasound. I still get the order, but the order gets put in by them and sent to me. So they could always just say, you know, pour our screening protocols. Is the person qualified for a screening mammogram? No.
00:44:34
Speaker
If they catch me, like sometimes they'll call up and see if they can catch you and you can put it in. And when they can catch you, you do it, but you got to catch me like by the phone. So I don't know why they, I don't know why they do it like that. So I thought it was only my organization, but honestly, I don't like that they do that because it really kind of delays the care because like, if they can't, if I don't see the order in time or I don't do it, then they don't get this test done. And the thing with screening, like, you know, especially if you go for the screening and they're like, Oh, there could be something there.
00:45:04
Speaker
And now, you know, they tell the patient that right away. They tell the them the results and now they're scared. They're like, okay, but it could be something. Right. And so like, and they got to wait for the doctor to put in the order and all of that.
00:45:16
Speaker
And then they have all that building anxiety because they're like, Oh my God, doctor, they canceled my screening mammogram. They said I need another one because clearly there's something. And I'm like, what, what, what? And some people don't like the whole screening as often because every day like every time I go,
00:45:35
Speaker
there's always a problem something because you know they can't see it or my breasts are dense. So I always have to go and get extra screening. And a lot of times people don't want to do that. And I think and that's part of the reason why some of these organizations are like, well, let's not do it as often because of the potential harm it causes in the anxiety and I just need to change how the orders are put in, because that's just is silly.
00:46:05
Speaker
um just so oh I'm sorry, go ahead. I was just going to say, just to be really, really clear with the listeners, when we say a screening mammogram, a screening mammogram means that you feel great, you don't have any problems, you feel lovely, it's just due for your screen. That is a screening mammogram. A diagnostic mammogram is usually if you come into my office and you're like, doc,
00:46:27
Speaker
something is happening, I feel a lump on the left side or I have breast pain or this discharge from the nipple, something is wrong. And we want them to take a closer look at whatever spot is the issue so that they can look closer to see if this is something that is concerning. But what we're talking about is these are two different types of mammograms and sometimes they're read by two different people because one is just a screen of a healthy person and another one is ah you're looking for something.
00:46:54
Speaker
What Dr. Chris and Amy Jo are saying is that if you go in for your screening mammogram and everything's supposed to kind of like going in for your physical, you supposed to go in for your physical when you feel great, right? Lies. Cause y'all don't do that anyway, oh yeah now don't but supposed to go for your screening mammogram when you feel great. But when they give you that questionnaire and ask, do you have breast pain? Do you have any bloody discharge from the nipple? And they ask you all these questions. If you answer yes to a couple of those, they're going to say, Oh, you can't get a screening mammogram. You need a special one.
00:47:21
Speaker
And they wait for your doc. They have to tell your doctor and then your doctor has to put in a new order. And Dr. Nono is saying, why isn't the system just have it built in where if you need a different type of mammogram, they can just order it. That's what we're talking about. I'm assuming it's a billing issue. I think so too. It's always money. Isn't it always money? Well, because it costs more probably to do it.
00:47:45
Speaker
and The US has so many issues, but we're that's a whole other talk. um So pretty much the, so the breast itself, so Dr. Sunshine kind of touched on it. So bloody discharge from the nipple. So like your breast is not just a hunk of fat that's on your chest. There's actually a lot of stuff in there.
00:48:05
Speaker
um So the fat is actually containing lobulose that go into ducts that go into the nipple that are surrounded by the areola area. So any parts of that system within your breast can have ah and breast cancer or breast cancer can develop within those parts.
00:48:24
Speaker
And then not all breast cancer is breast cancer, if that makes sense. So there are other different types of cancers that can actually pop up within your breast, which we are not going to go into. But things like lymphoma, sarcomas, pageous disease, like those are other types of cancers that can pop up in your breast. But the majority of this talk is purely just about breast cancer. So kind of going along this line. So you get the mammogram, you see something on the imaging, no now what happens? So if you get the diagnostic mammogram and they they see like ah what we typically call a spiculated mass on the mammogram, then that needs to get biopsied. So biopsy usually can be done like same day. um That's usually done by either a breast surgeon or oncology or IR can sometimes do the
00:49:16
Speaker
interventional radiology can do the biopsy. So when you get the biopsy, that tells us what type of breast cancer that you have. And that is very important because that is how we guide treatment. So we can't, you know, and I get some people in Like in the hospital that, you know, they kind of, they, they have the mat they have the abnormal um imaging, you know, in the hospital for whatever reason, they come in for something else, something pops up on like a CT, and we're like, you need we need to get this taken care of.
00:49:49
Speaker
um So we don't know like what treatments we need for that until you get the biopsy and until we get pathology results. Because there are different types of receptors on the breast cancer cells that we use to target the type of treatment that would work best for you. So these receptors are hormonal based. So your estrogen receptor, progesterone receptor, and the human epidermal growth factor, which is HER2.
00:50:16
Speaker
So usually when you get a pathology result, it will tell you if your ER, PR positive or HER2 negative or the, I wouldn't say the the worst one, but the not the great one is the triple negative where all of those receptors are negative. So none of those cancer cells have any of those receptors on them. So again, that doesn't mean that there's not treatments for that. There are, but it's just that each treatment is tailored based on the pathology results that we get from the biopsy.
00:50:46
Speaker
Cool. We're good. Okay. So, unfortunately, so like I said, the triple negative type of breast cancer is actually more common in African American females. So a Carolina breast cancer study. So Amy Jo and Dr. Chris represent. but So they actually in this in this study, they actually compared um the types of pathology results between black women and white women. And they found that with actually alarming frequency that a lot of the African American women had ah triple negative breast cancers more so than their then the white women that were in the same study.
00:51:26
Speaker
so which is unfortunate because that is usually we talk about prognostic factors. And granted, like I said, you can still treat all of these breast cancers. It's just that there's a lot more nuances involved with treating triple negative breast cancer. And that usually triggers genetic testing because if you come in with triple negative breast cancer, then your doctor is going to say, you need to get genetic testing to make sure this is not like but you're within your genes.
00:51:55
Speaker
Um, they're actually 40% more likely to die than white women. Yes. That is very important. Yeah. So, um, with, uh, and then just kind of going into the genetics line. So if you have a strong family history, like we talked about, I don't know, a season ago, um, this is where we told you to be nosy and like talk to your folks. You really, really need to do that because if you have like, um,
00:52:20
Speaker
If you have first-degree cousins, you have your mom, aunties, if you have men in your family that are diagnosed with breast cancer, those are all things that are extremely important and that's where light bulbs start popping up in our heads. We're like, you need to get genetic testing and we need to do this yesterday. so that These are all things that we think no matter how mundane you think it is, that is all important information that we need to know to trigger that process.
00:52:48
Speaker
Um, and then I think my last part here is staging. So remember when we talked about localized versus metastatic disease? So this is where we kind of talk about the imaging that we do when you have that. So if you have very, we're not going to go into like all the staging of breast cancer because that's oncology talk. Um, but typically in a previous episode, we said, we don't want you to CT scan your whole body. This is that one exception where we're going to do that. So.
00:53:17
Speaker
ah We are CT and everything, chest, abdomen, pelvis. If you're coming in with a headache and you're just diagnosed with breast cancer, we are scanning your head. There is no question. um And this typically is done to kind of determine the extent of the disease. um So if you're, like I said, the symptoms, you know, if you're having bony pain, you're having belly pain, you're yellow.
00:53:38
Speaker
um You're having a cough or shortness of breath that will trigger different types of imaging studies that we need to get to see if you have any of these um masses or nodules anywhere else in your body. And that's that is definitely going to guide our treatment. So things like if you have localized disease and it's only confined to the breast, you may get away with just getting a lumpectomy and a mastectomy.
00:54:01
Speaker
um which is lumpectomy is you literally take out that chunk of where the breast cancer is located and you know you get good margins, make sure it's not there anymore, you're good. um But the mastectomy is typically where they take off your, and oh they they surgically remove your entire breast.
00:54:18
Speaker
um When we talk about genetics, if you guys remember BRCA 1 and 2, that is a discussion you're going to have with your genetics counselor and your doctor about if you want a prophylactic.
00:54:33
Speaker
ah prophylactic mastectomy, and that's where they take off both breasts. And that way, that's that's the end
Risk Assessment and Screening Protocols
00:54:40
Speaker
of it. um So if you have advanced disease, you know like I said, you're going to get the you're gonna get the whole incobutal, the whole CT scan of the bat body, and you make it what's called a whole body PET scan, which is just a more, it's a more fancy picture to kind of see if there's any places that the cancer is located that cannot be picked up on the CT scan.
00:55:04
Speaker
And I think that's it. So one of the things that, especially as we just finished talking about like USPSTF and screening and everything is that one of the conversations I have a whole lot is, you know, how often should I screen? When should I screen? And, you know, everybody now wants their MRI.
00:55:31
Speaker
Right. So they've been reading, they say, okay, the mammogram is not enough. I want the MRI. You know, can we order that? Now, of course, you know, I tell them we, we can order whatever you want us to. It may cost you, but if you wanted to not cost you your best bet is that in addition to the mammogram, there are some risk assessment tools that you can use to figure out how high risk you are or not. If you're just, if you're trying to, if you think, well, I don't know for sure. Cause my family keeps a lot of secrets.
00:56:01
Speaker
But I heard that my grandmother had breast cancer um when she was 65. You can put some of that information in. So you got the, I think it's the um It's like the Tyra Cusick model, and then also the the Gail model, our two that we use in our office, or that you can use to kind of document why you're escalating their screening from just a mammogram to a mammogram and MRI. So most of them are mammogram and, not mammogram or. So so if you do get to escalate, it's going to be mammogram and.
00:56:42
Speaker
Um, and I think it's nice that I've been putting those, um, been just using them to have a conversation about breast cancer because more and more is not enough just to be like, you should get your mammogram because it really makes sense. Like people kind of need to hear like where their risk score is, you know, are they at higher risk, lower risk? You know, what does that matter? We still, the the laymen still lumps cancer. Do you have cancer in your family? Oh yeah. We got all that cancer. Which kind? Oh, I don't know. Cancer.
00:57:12
Speaker
or if they find out it's like five different types, which is important. I empathize that you've got so many so much cancer run through your family. But for me, when I'm trying to make an assessment, I'm looking for a pattern. And there's no pattern if all five people have their own primary cancer. So you know just you know knowing that there are more ways to to measure ah how often you need screenings and different things. So we can make a case if we're going to venture past like what the USPSTF, you know, recommends or the American College of, I'm sorry. American Cancer Society. Yeah, I'm sorry, Sorry, I'll explain. There's a lot of different organizations and they're not always on the same page. So you got to also got to know which one
00:58:04
Speaker
you're going to do. and And then also when you get your mammograms done at the end, the radiologist puts their the recommendations based on whichever society that there are are there so many they're going by, right? And then they're like, well, it's every year.
00:58:22
Speaker
So Amy Jo brought up a really good point. So primary. um So I get that all the time when people I ask, you know, do you have your cancer in your family? And they just say, yeah, we have, you know, yeah i I think my grandma had liver cancer.
00:58:36
Speaker
whatever, um you know, but primary cancer refers to where the cancer started before it spreads to the rest of your body. And that is very different than cancers that have like spread to the liver or spread to, you know, the colon or the brain. You know, that really, it's it's a big difference to know like how we kind of guide our treatment. Because if we, like I said, breast cancer has those different receptors on those cells.
00:59:04
Speaker
Um, so if you say you, you know, if someone said you, you know, I had liver cancer, but if we do a biopsy on one of those liver cancer cells and it turns out to be breast cancer, that's how we know that the primary, so where the cancer came from is breast cancer.
00:59:20
Speaker
So, I know it's a, you know, it's a big ask, but whenever you talk to your doctor and they say like, um or if you talk to a family member that's been diagnosed with cancer, you know, ask them where the cancer started because that is going to be important. And that also tells us if you have some type of hereditary um predis predis business yeah predisposition.
00:59:44
Speaker
it late joea not you i'm got you Thank you. So different types of cancer. um So like Lynch syndrome um is one thing where, you know, you come in with all these polyps in your colon and that can tell that your risk for getting colon cancer just skyrockets, you know? So, you know, those things like that are very important for us to know. So when we say primary, ask your people, what was the primary? And that will be very helpful.
01:00:14
Speaker
Two quick notes that I'll add on. One quick note is that um you do have to go get your mammogram if you have breast implants. So for people who have breast implants, usually at my facility and probably every facility, they have a very different protocol and the way that they do the mammogram for people who do have breast implants. So be sure to tell tell your doc, your doc can write it on the order, but you also do need to have your mammogram too. You don't get to skip that. Just FYI. And that's important because I have several women in my office that do not get their mammograms because someone who did- They don't want to rupture they don't want to ruture their implants, right? Yeah, oh but no, but somebody told them they didn't have to, you know, that they couldn't get one.
01:00:59
Speaker
Of course they can get one. And I'm like, you can. And I have some that are are scared. They're like, no. um i you know I don't want to mess up my implants. Yep. I don't want to rupture my implants. I don't want to mess up my implants. So we have an implant protocol for our mammograms. Or if they really don't want a mammogram, they can they can opt for like alternative imaging. But they need to have some sort of imaging. They do. You just don't get to skip all imaging. That's not a thing. Because you can still get cancer, too. That's, yeah.
01:01:27
Speaker
um The second note, oh my gosh, I was gonna say, I had something something else to say. And it just can't really. It scampered right out of my brain. Oh, no, that wasn't it. That's a good thing to bring up. What I was going to bring up is if you happen to treat people um in the military population, breast cancer incidence is much higher in people who have a military background.
Breast Cancer Risks in Military Personnel
01:01:49
Speaker
um That's for men and women. Their cancer rates are higher in general if they've ever served because they're exposed to a lot of different things depending on where they were deployed and exposure to radiation.
01:01:58
Speaker
um So if you happen to have a military population or certain you know or you're seeing a veteran, you can ask them a little bit um about their deployments. And that's if they come to you for that, they might go to their VA a for that, but just know that they are at an increased risk if they've ever served. Just FYI.
01:02:14
Speaker
But but in transition, that is a whole nother discussion. She's talking about um if people are undergoing like gender affirming gender affirming hormone therapy, if they're transitioning like um trans men and women, um then yes, they actually do need to start get breast cancer screening. So example, trans women making a transition from male to female um sexual characteristics. Usually they're getting like hormone therapies and things like that. And they develop breast tissue. That breast tissue does need to be monitored.
01:02:43
Speaker
um because they're changing their hormones and things. um But that's like a whole different lecture. But yes, Dr. Nuno does have a point. Sure is. Because like also a double um mastectomy does not um ah eliminate your chances of having breast cancer. Correct. From a gender affirming standpoint or from like gender being gender fluid, like anybody is transitioning from female to male that has had The, you know, the breasts, you still have a risk of breast cancer. So it isn't, it is not something that you can forget about. There is still, um, probably a screening tool for you and you should be able to have a conversation about that, uh, in your office, which brings us full circle.
01:03:33
Speaker
that those are the things that we definitely have to get better about creating a safe space where people can come in and say, hey, you know, I don't know, my name is Samuel. And, um you know, I'm here for my physical exam, but hey, doc, actually, can we talk about mammograms? And we have got to get to a position where you say, yeah, sure, without a flinch versus
01:04:01
Speaker
wow Y'all can't see her face, but imagine it. you know And so you just gotta to be like, yeah, sure. And let them tell their story and be like, all right, well, here's what we need to do, right? We need to do XYZ, right? We need to get you screened and here are all of our options so that you know people can be safe and live their best life. Because your autonomy is um your quality of life. Your quality of functional life is our priority.
01:04:29
Speaker
So speaking of screenings, my um my friend actually sent me a a funny video. um So it was pretty much going over like things that would ah clue you into what you need to went to when you need to start screening um and things like if you had a rotary phone like growing up, if you use AOL Messenger.
01:04:47
Speaker
If you had a Blackberry, if you had Pager, walk you knew what a Walkman is. Do you know what this is? Yes, then you need to go get your memory.
01:05:00
Speaker
And I think we'll end it there. and
01:05:05
Speaker
I mean, it's not wrong. It isn't. Have you used a payphone to return a call from your major? If so, you should go get your call off. Listen, listen. I have to tell you what happens because I'm actually going to get it. I'm going to get an MRI screening. I'm going to do an MRI screening at the end of the year.
01:05:26
Speaker
so And then you can tell your story. I will. So my mother, you know, and will never be outdone and the Lord loves her. So she's had not one, but two primary breast cancers. So she's had a primary breast cancer and eat in one in each breast with about, you know, 25 years in between each. So for me, using the, um, the, uh, the risk assessment tool, the risk assessment tool, I qualify for a mammogram and MRI. So y'all know em MRIs make me fall asleep. So y'all just pray that my boobs and my body stay straight up so that they Oh, obviously that's the thing. I will be sleep. but okay you When sleeping, they tend to go wherever they want to go. Exactly. right You can't de direct them. They don't understand. They don't they don't understand. No, because y'all are well-endowed. Listen, these are big titty problems, OK?
01:06:31
Speaker
So I was like, man, you know, I'm gonna go to sleep. I don't know what I can't be held responsible for any movie. I don't know. I don't know. like of might andi They might go in different directions. I don't know what to do. You know, they'd be like, They can't. I think I did.
01:06:46
Speaker
I don't know. I don't know what woman tell i don't know what you want me tell them. They do what they want. Oh my gosh. The month is still young. So definitely go get your screen. Go get your screening. I think i think Amy Jo and I need to come out with the big titty Chronicles.
01:07:05
Speaker
Big booth Chronicles. I'm just a regular girl in a big titty What's going to be your theme song?
01:07:21
Speaker
Oh my gosh. This is what happens when we get a boy. I got to reel y'all in. I got to reel y'all in. I'm going to reel you in. Let me get to these questions. Great topic, Dr. No, by the way. So and of course,
01:07:36
Speaker
Our question actually ties in, so this is a good question, y'all. So, hey ladies, ah even though my last mammogram was normal, I want to repeat my mammogram next year. My doctor says I'm good for two years, but I disagree. How can I go around my PCP and get another mammogram next year? Can you just ask? No?
01:08:02
Speaker
Well, it also depends. Yeah, you can ask, but it also depends on your, on your age. Right. Cause like, it sounds like she asked and the doctor was like, nah, you good for two years, bro. I just realize it want to get it next year. And because like, you know, I never turned down the annual, I don't either. So, i don't either you know, ah we do the, we you know, and I know, I know the USPSTF says we do them. And we do them at high risk and we can make the argument. i I'm not sure.
01:08:31
Speaker
Um, how much melanin is in your skin, but for African-American women easily fall into the high risk category. So doing them every year is not an issue. Um, I've never pushed back. If anything, I've negotiated down to every other year for women who are like, Oh, I really don't want to do this. I'm like, okay. Every other year you can make it like good job. You did it. You get two more years before you have to do it again. And they're like, yay.
01:08:59
Speaker
But for women who are like, um but what about next year? I'm like, hey, no doubt. And in our system, you can it comes up every year, right? it Every year it comes up as due. So we do them every year in my office.
01:09:14
Speaker
Yeah. And you started at 40, right? Because, um, yeah, 40 every year. Cause the recommendation is depending. They said 40 and it's every other year. And then after 50 it's every year, but the USPFTF, I think it's still every two years, right? Yeah. yes But then of course you don't always have the little disclaimer, um, to be discussed, you know, with your, with patient also more and more now systems allow you to allow patients to independently schedule.
01:09:44
Speaker
their mammograms. So yeah someone doesn't need you may not need us to schedule your mammogram.
Patient Empowerment in Scheduling Screenings
01:09:50
Speaker
So to the listener, I would first see if you can schedule through like your MyChart or your um I don't remember what the one was for Cerner, but whatever that system is, sometimes you can just schedule your mammogram. Yes, I might not even need them. You might not need it. So enough reports come in, I know I'm not putting orders for all these mammograms. So people are just calling, they're they're calling or they're going through their MyChart and they're scheduling it and I'm okay with that. So you may be able to work it around. um If you can't and you are sincerely
01:10:23
Speaker
like at a standoff with your doctor and they're like standing on business like, no, I will not order this. That might be your cue.
01:10:36
Speaker
That's strange. Yeah. It would be very strange. Well, would it depend on what doctor you're seeing? Is it like your primary versus your gynecologist? Because I feel like the gynecologist and some gynecologist offices, they have their mammogram in like, it's in their facility. It's attached to the facility. So you go get everything done all the same day. Like you get all the way worked up. so Right. so i would think But I would think Onacology would say, yes yeah, sure, let's do it. um So i don't I don't know. So I'm hoping that the listener is just you know saying, what if they say no? But I agree with you, Dr. Sunshine. It almost sounds like they have gotten a no.
01:11:21
Speaker
Or sometimes people, so so I would, listener, I would ask to clarify the point because sometimes patients ask me a question and I'm answering what the standard of care is, right? And so they've asked a very generic question and I will just answer it to say what that he is. Like somebody will say, um how often should you have a pap smear? And I'll say, oh, every three to five years. And they'll say, dang.
01:11:50
Speaker
I needed one next year. They didn't clarify that they weren't sure that their passing was actually abnormal, so they needed to do it again. But if the only thing you asked me was how often should I get it done, I would have given you a very standard answer. But those answers can change based on who's in front of me.
01:12:06
Speaker
So if you said, yeah, but what about me? I'd have said, Oh yeah, sure. You can, you can have one. We can schedule that for your next appointment. Or let me put that order in. So I would, I would be very specific to say it is, I would like an, an annual mammogram.
01:12:25
Speaker
Can you please put that order in for me? I think you'll be surprised how many yeses you would get to say, yeah, sure, no problem. Exactly. The only people I've seen like stick to stuff like that, like hard, hard, hard, or maybe if they're a brand new doc that like just graduated, and that's like the only standard of care they know, and they just don't feel comfortable veering off the whatever they've learned.
01:12:52
Speaker
And every new doc isn't like that, but as doctors get older and as you learn more and you learn about different societies and different things, you feel more comfortable practicing the way you want to practice and doing what makes sense. Um, cause sometimes you get some of these guidelines and you're like, that's cute and all. Like we had a whole discussion about this, like this, this, uh, gentle, not gentle parenting. just doctor yeah that's right te apparently Yeah, exactly. We just had a whole discussion about these new guidelines for gentle doctoring and just being like, yeah, but We've also been practicing and we're like, yeah, that's like not the jam like what like but so As you practice longer you get more comfortable kind of like doing what makes sense But sometimes, you know when you're a fresh grad and a new attending I don't know if your doctor's young or old and you can kind of get the opposite would really really really old doctors and they kind of practice the same way they always been practicing they don't ever change anything ever so I'm just saying these all might be factors, but I I think also because breast cancer screening has been around for so long and it's been like everybody kind of pretty much knows about it.
Importance and Accessibility of Screenings
01:13:52
Speaker
It's paid by insurances. Yeah, it's covered in everything. There's other ways you can go and get screened like you can even go to your public health, the the health department to get like there's so many
01:14:04
Speaker
different ways and like, yeah they have mobile ways to screen, ah go into events and you can do screening. So like, um there's so you have options yeah so many options to try to improve. Well, get women screen because like, if you do have cancer, I mean, it's better to catch it earlier than later, right? Because just tend to, you know, you just have a better chance. I agree. Good luck listener.
01:14:30
Speaker
If you ask it and be direct about it, I'm sure you'll get a yes, if you haven't already. you and steel you be i receive yeah I would tell you yes. I would give you- I would tell you yes too. That's fine. We would all tell you yes. Because the because the downside of saying no is so great. like they's like If I say no, and it turns out you actually do have something, like why would I eat? What? like why Why take that?
01:14:54
Speaker
That's not like, fight that yeah, exactly. If I'm, if I'm balancing like the risk and the harms here, I'm like, let's just, sure, go ahead. Let's get you screened. Yeah. I'll risk talking to you about the anxiety for over screening then. Yeah. Then you being the patient on the other end of the spectrum, like I don't believe in screening. I'm like, okay, this is a different battle. Like but with so like I had, I had this patient, no lie. She did not want to get screened.
01:15:20
Speaker
for anything. She's like, I checked my breasts. I'm good. She was losing weight. I'm checking for everything. I did suspect that she might have breast cancer. You know what she did? She made a bet with a friend that she would get screened. And because she made that bet and she went to get screened, lo and behold, she had cancer. Wow. I was like,
01:15:44
Speaker
ah But that friend was smart. She knew her psyche. She's like, let me get her. And I've been, she'd been with me for so long and I've been trying to get her screened and I've documented multiple times. She does not want to get screened and she understands the reason. And when she got screened, you asked her what happened. She's like, Oh, I lost a bet with my friend. So I had to go get screened. And I was like, well, thank goodness you lost that bet. That is a great friend. I hope she Right. Shout out to the friend that made the bet that was like, I bet you won't wait to get that slid in there. That was smart. That was smart. i was smart
Conclusion and Listener Engagement
01:16:15
Speaker
Anyway, Dr. Nono, you want to tell the people where to find us? I sure can. All right, y'all. So find us on our website. We are at www.thechocolatemds.com where you can send us questions, advice, well wishes on our little drop down box. um Also check us out on our socials. Our handle for all of them is at thechocolatemds. We're on Facebook, Twitter. I'm sorry.
01:16:39
Speaker
X and Instagram. ah So feel free to check us out and we'll keep you posted. Don't nobody call it X. Bye y'all. Bye. Bye. Check your boobies. Check your boobies. Check your boobies.