Maintaining Your Health on Mackinac
Medical History, Good Communication Are Key in Healthy Lifestyle
By Yvan Silva, M.D.

Physical examinations are required for all of us - at birth, preschool, college, pre-employment, joining the armed forces, and at times when the assessment of health may be related to subsequent performance, as in purchasing life insurance, for example. But these are usually onetime events, and are not designed to provide comprehensive diagnosis and treatment. They are, more often than not, for healthy people.

With rapidly evolving technology, and the availability of powerful and reliable scientific tests, the importance of the routine, annual physical in healthy, young people is being brought into question. Cost effectiveness is often cited. Yet, experts agree it's important to have regular examinations for health maintenance, follow-up screening for heart disease and cancer risks, and post-treatment follow-up using indicated tests and technologies.

The familiar "clean bill of health" after a visit to the doctor has long been known to lack definition of continuing good health; we have all heard of unexpected and often catastrophic events, such as acute heart attacks, findings of advanced cancer, and other serious conditions being discovered soon after. The most important component of evaluation of an individual's health is the traditional history-taking, the dialogue between the physician and the patient. This opens the door to identification of problem areas that need attention. After taking a careful history, a physician

is best equipped to do a physical examination, and as an extension of this, to recommend investigations into specific suspected disease patterns, and to design plans for prevention, improvement, and maintenance of health and specific treatment options.

The yearly physical exam has been replaced with "periodic" checkups, the timing and the scope of which should be tailored to the individual, considering age, past medical history, risk factors, lifestyle, familial, and genetic factors, with the goal of early detection of potentially curable problems. In the past few years, physicians have been seriously counseling patients with an emphasis on prevention. The profession clearly understands that guiding and motivating patients to work for a healthful existence is important. For example, patients prone to heart disease are warned to control their weight and blood pressure, to follow guidelines for healthful eating, regular exercise, and to avoid smoking, alcohol abuse, and a host of other characteristic behaviors detrimental to health. Examples of failure to undertake responsibility for your own continuing health, and procrastinating checkups, can lead to serious consequences. Consider the case of a 65-year-old physician, who has been feeling tired for several months, but does not undergo testing to find the cause, and learns that he has stomach cancer. A 52-year-old man, who has not learned that he has heart disease, has a fatal heart attack while shoveling snow. A48-yearold woman with lower abdominal pain and weight loss over several months learns that she has ovarian cancer. Testing methods for these conditions are readily available. What then, are the guidelines for medical testing?

Your primary physician should take a thorough history and then complete the physical examination and plan further testing methods pertinent to your concerns and complaints; counsel you on healthful eating and use of dietary supplements, and discuss exercise and devise a specific plan if you are sedentary. There should be a discussion on the hazards of tobacco, alcohol abuse, and recreational drugs, with specific recommendations to enlist in programs designed to help you quit. Mental stress, signs of depression, and coping difficulties should be addressed. Eye care and dental care, risks of excessive exposure to the sun's rays, an accurate review of all medications and how and when to take them, and sexual practices and potential exposure to sexually transmitted diseases are also areas to be covered. Remember, it is a doctor-patient partnership in a real sense, and there should be no reason to avoid subjects that seem private and uncomfortable. Physicians are becoming more proactive in counseling and have been instrumental on getting people to quit smoking, helping some problem drinkers to cut down, and taking more responsibility with the use of safety devices. One focused study showed that two 15- minute counseling sessions led men to reduce alcohol intake by 14% and women to cut down 31% after one year when they kept records of their progress.

Screening tests for commonly occurring diseases are usually linked to comprehensive periodic physical examinations. Blood pressure should be measured at regular intervals depending on age; one in four older Americans has high blood pressure. More Americans are now monitoring their own blood pressure at home. The consensus on cholesterol is that screening should begin from age 35 for men and 45 for women. Younger adults with risk factors like smoking, hypertension, or a family history of heart disease may benefit from earlier screening. Maintaining normal cholesterol levels is important, and corrections must be made with diet, and when indicated, with medications. A panel of national experts recommends routine measurements in adults older than 20 at least once every five years.

Screening for pre-diabetes and diabetes is very important. Some 54 million Americans have pre-diabetes, and 20.8 million children and adults are diabetic. One out of every five people older than 60 has the disease. Diabetes itself is now considered the strongest risk factor for heart disease.

Screening consists of measurements of fasting blood glucose and other tests that identify the degree of the condition. Optimal treatment is directed to 24-hour control of blood glucose by diet, regular physical exercise, weight control, and medications. Monitoring of blood glucose by daily interval self-testing is an integral part of management.

Colorectal cancer takes the lives of 55,000 Americans every year, and it is estimated that the rate can be diminished by one-third if men and women older than 50 are screened by one or more methods, including stool examination for blood, sigmoidoscopy (visualization of the lower large intestine), colonoscopy (visualization of the entire large bowel), and xray examinations of the bowel. For high-risk individuals, with family history of bowel cancer, the presence of polyps, which can progress to cancer, requires removal of polyps and plans for screening at intervals appropriate to individual findings.

Immunizations advised for adults include a tetanus-diphteria injection once every 10 years beyond the childhood series. People older than 65 should get vaccinated against pneumoccus (usually once only), and flu shots should be taken by folks 65 and older and others who have chronic conditions associated with poor health. Flu-related deaths occur at about 20,000 per year, and in many cases are preventable.

Pap smears for women every one to three years after age 18 and at regularly spaced intervals are essential for early diagnosis of cancer of the cervix and vagina. A clinical breast examination is recommended to women older than 40, and once every three years between the ages of 20 and 40. There is general agreement that women older than 50 should have a mammogram every one to two years, since early cancer detection can result in cure. Selected women, with family histories of breast cancer or fibrocystic breast conditions, may require mammography earlier, with appropriate intervals of subsequent follow-up.

Experts in cancer prevention recommend that men older than 40 have an annual rectal examination to evaluate the prostate gland. In conjunction, measurements of PSA (Prostate- Specific Antigen) in the blood increase the yield in early detection of prostate cancer.

It is imperative to realize that there are several guidelines for health evaluation and screening. The consensus keeps changing as new scientific advances become applicable. The personal decisions for the maintenance of your health, the requirements for screening tests, and the necessity for "periodic" physical examinations are best made with close communication between your physician and you, the most efficient cornerstone of the doctor-patient relationship.

Dr. Silva is a professor of surgery at Wayne State University and a resident of Woodbluff on Mackinac Island.