San Antonio Express-News (Sunday)
Examining couples together not always best
Q: My husband and I have been going together to the same primary care physician for many years, every six months for routine checkups and sometimes in between when needed. In the past we always were examined in the same room, with each other present during the exams.
At our last visit our doctor told us he has to see us separately and gave us the excuse that he finds it more efficient to do it this way. I’m not confrontational, nor is my husband, but I’m not comfortable about this and said so, but he still kept us separated. We are both in our late 70s, and I think it’s important for us to be together during our exams for many reasons.
Can you help us with what we can say to our doc to change his mind? It may be in his best interests for this new policy, but I do not think it’s in our best interests.
A: There are several reasons to be cautious about seeing couples together, from a physician’s perspective. One is that sometimes, a disproportionate amount of time is spent on one person, and while that may be good for the person getting all the attention, the other person’s medical needs might suffer. Another is that a person might feel uncomfortable sharing certain medical information in front of their partner. This isn’t always the case, of course, but is a potential problem.
I have had cases where one partner admits infidelity (outside a visit) but tells me I may not discuss it with the partner. I have also had cases where there is partner abuse: This is so common that asking about it is recommended, but of course this cannot be done in front of the potentially abusive partner. Abuse can take many forms, including physical, psychological, financial and sexual. Both men and women can be abused, although it is much more common and more dangerous physically to women.
There are potential benefits to seeing a couple together as well. Often, the partner is able to provide critical information that helps the doctor make a diagnosis. This is particularly important if one person is a bit forgetful. Many couples just feel more comfortable together, as it sounds like you and your husband are.
There is often a way to compromise. The visit can start with the couple together, then each is examined separately — and any questions can be asked that seem uncomfortable — then brought back together to go over the plan. The first time I see a couple who want to be seen together, I do insist on separate examinations, if
only to screen for intimate partner violence and solicit any questions one person wants to ask separately from their partner. If there are no concerns after the visit, and both still want to be examined together, then it’s reasonable to do so in future visits. If one person needs extra time, they can always come for an individual visit.
For those who are able to settle on a way to have joint checkups, it’s important to note that as you are two patients, you will need to reserve two appointment times, and expect to see two individual sets of associated costs.
Q: I have been advised that I have a deadly disease called myocardial amyloidosis. If this is true, are there successful treatments?
A:
Amyloidosis is a condition where one of a number of amyloid proteins are deposited in tissues, outside of cells. The deposits can interfere with the
proper functioning of the tissues. Deposition of abnormal proteins in the brain is the major cause of many types of dementia. Amyloidosis can also affect the kidneys, lung, skin and other organs.
In the heart (“myocardial” means “heart muscle”), these abnormal proteins interfere with the ability of the heart to function, and eventually lead to heart failure, meaning that the heart can’t pump enough blood to take care of the body’s needs. Amyloid protein can also block the arteries of the heart, leading to heart attack, or may damage the electrical conduction system of the heart, leading to heart block or abnormal rhythms.
Years ago, the expected lifespan upon the diagnosis of cardiac amyloidosis in a person having symptoms was only six months. Newer treatments have extended the prognosis to an average of over five years. Partly, this depends on the type of protein deposited — the most common
are called light chain (“AL”) and transthyretin (“ATTR”).
Light chain amyloid is closely related to multiple myeloma and similar blood abnormalities.
ATTR amyloid is caused by a binding protein, which can be either normal (“ATTRwt”) or abnormal (“ATTRv”). As you might guess, the treatment also depends on the type of amyloid protein, with chemotherapy and stem cell transplantation used for AL amyloid. ATTR amyloid is often treated with tafamidis. Liver transplantation is considered for people with ATTRv.
As complicated as that all is, I’ve only scratched the surface of this complicated disease. You can read more and get suggestions on treatment centers at amyloidosis.org.
Q: My 96-year-old mother has stage 5 kidney disease (GFR is 12) along with congestive heart failure. She’s not your typical 96-year-old — she
is sharp as a tack, still attends church weekly and is involved with the assistance league! She is going to need to start some type of dialysis soon.
We had heard that home peritoneal was easier on the heart than traditional hemodialysis. When I asked her cardiologist about this, he said he’d never been asked that question before.
Is home peritoneal easier on the heart? Which method is better at “cleaning” her blood? In your opinion which method is a better choice for my mom?
A:
The kidney’s major job is to remove excess fluid, salts and metabolic waste products from the body by filtering the blood through very complex physiology. When the kidneys fail, dialysis is a process used to take on the role of the kidney.
Traditional hemodialysis uses a machine to take over the kidneys’ job, taking blood out of the body, filtering it and diluting out the toxins against large amounts of fluids that approximate blood plasma. This process is very safe on the heart and is effective at removing blood toxins. Only a small amount of blood is outside the body at any given time.
Peritoneal dialysis uses the peritoneum, the lining of the abdomen, which contains the organs, to mimic a kidney by using large amounts of fluid inside the peritoneum to absorb wastes without needing to remove the blood from the body. This is also safe on the heart and effective at removing toxins.
I’ve asked many physicians, including kidney specialists, which method they would use if they had to have dialysis, and 100 percent have said peritoneal dialysis. There are two major reasons why.
The first is that outcomes are better. People generally live longer and have a better quality of life with peritoneal dialysis compared with hemodialysis. The second is time. Hemodialysis takes roughly four hours, three times per week at a dialysis center. Peritoneal dialysis is done by the person, and can be done either at nighttime or continuously during the day, which means much less down time for the person.
There are downsides to peritoneal dialysis. The patient must be both motivated and capable of performing the dialysis on their own. This requires good eyesight and some manual dexterity. There are potential complications of peritoneal dialysis, including infection of the peritoneum.
Some patients never hear about the option of peritoneal dialysis, and I think that’s a mistake, because it is an excellent choice for many.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell .edu or send mail to 628 Virginia Dr., Orlando, FL 32803.