Immunization
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A final concept of preventive medicine concerns immunizations and other public health measures. These measures have far greater impact on health in developed nations than do the personal health services provided by physicians. Only a few years ago, smallpox, cholera, malaria, diphtheria, tetanus, and yellow fever killed entire populations. Now, these diseases are effectively controlled by immunization and other measures in this country.
There is a curious result of these health care measures; since no one in the country has smallpox, there is no one to catch it from, so smallpox vaccination is no longer routinely recommended. From the public health standpoint this is controversial; if the population does not remain vaccinated, a new epidemic could sweep the country. But in the absence of an epidemic there is little need to repeat immunization for this disease. Indeed, many immunizations do not need to be repeated nearly as frequently as was previously felt. Thus, for adults who have had their basic series of tetanus injections, tetanus boosters are not required more often than every 10 years. In many patients, smallpox and diphtheria immunizations last for life. With the increasing rarity of these diseases, the problems of side effects from the inoculations have become as great as the risk of illness in some instances.
Therefore, keep a careful record of your immunizations in the back of this book. Do not allow yourself to be re-inoculated just because you face a requirement for immunization and you have lost proof of previous immunization. If you haven’t had a tetanus shot in the past 10 years ask your
physician for a routine shot when you are in the office for some other purpose. You can save a trip and be protected for another 10 years. In general, don’t seek out the optional inoculations. Flu shots, for instance, are only partially effective and often cause a degree of illness themselves. They are recommended only for the elderly and for those with severe lung diseases.
Finally, here is a summary of what you need to remember about preventive medicine:
• You don’t need “checkups” except for a very few specific tests. Blood pressure, Pap smears, periodic self-examination of the breasts, tuberculosis screening measures, and testing for glaucoma continue to make sense. Most of these procedures can be obtained through public health departments at city or county expense. Take your doctor’s advice concerning the need for a urinalysis, urine culture. tests of the stool for blood, or sigmoidoscopy.
• Elaborate physical examinations and multi-phasic screening may worry you unnecessarily by discovery of trivial abnormalities.
• You should investigate methods of obtaining medical care before the need for care arises .
• You should be immunized according to recommended schedules, but you seldom need “boosters” in adult life.
If you follow these general procedures and if you control your living habits as discussed , then you are well on the way to taking care of yourself.
Early Treatment
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The best health maintenance strategy is to seek medical care promptly whenever a truly important complaint or finding occurs. If you find a lump in your breast, if you have unexplained weight loss, if you have begun to cough up blood, if you have been running fevers for more than a week; then you should seek medical attention without undue delay. These are not emergencies, but do indicate that attention should be sought within a very few days. Many times, nothing will be seriously wrong. On other occasions, however, an early cancer, tuberculosis, or other treatable disease may be located.
The guidelines of this book can help you select those instances in which you should seek medical care. In many cases, you can take care of yourself with home treatment. However, it is important to be ready when professional care is needed.
To insure timely treatment, think things through ahead of time. If you do need emergency care, where will you go? To an emergency hospital? To the emergency room of a general hospital? To the on-call physician of a local medical group? Rarely will you need emergency services. But the time that you do require them is not the time to begin wondering how to do it. If you have a routine problem which requires medical care, where are you going to go? Is there a near-by doctor who is available? Who has your necessary medical records on file? Define the methods you will use to obtain medical care before you need them.
Multiphasic Screening
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Multiphasic screening simply means that many laboratory tests are performed in an attempt to find an abnormality which is not readily apparent. Some multiphasic screening programs will perform fifty or more different tests, including blood studies, urinalysis, x-rays, electrocardiograms, and other procedures. With automation, these many tests can be performed surprisingly quickly and economically. You can sometimes have nearly a hundred tests performed for less cost than that of a physical examination.
As a rule, however, we do not recommend multiphasic screening. Experience with these screening systems over several years has shown that many laboratory abnormalities can be detected but that hardly any problems which need immediate treatment are found. Doctors have been required to follow up on the minor laboratory abnormalities, increasing cost and worry to the patient. Some medical administrators have remarked that the real purpose of multiphasic screening is to reassure the “worried well,” at the lowest possible cost. In other words, it is less expensive to send a patient a letter stating that the tests are all negative and that health is perfect than it is for a physician to examine a patient and say the same thing. Thus, multiphasic screening procedures have become a means of mass reassurance. It is now generally admitted that screening is justified only for those individual tests which potentially detect important and treatable illness. These are the same items mentioned earlier: Blood pressure evaluation, Pap smears, breast examination, and skin tests or x-rays for tuberculosis. Mammography of the breasts, eye testing for glaucoma, and testing the stool for blood are indicated for high-risk patients. In many settings, the blood pressure is the only truly important measurement.
The Annual Checkup
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The “routine checkup” is still urged by some schools, camps, employers, and the armed services. Curiously, doctors never go to each other for “routine checkups.” The “executive physical,” made popular a few years ago by large corporations that wished to insure the health of their most critical employees, is slowly being discontinued. Even these elaborate check-ups, which take several days, do not detect early and treatable diseases with any regularity. It is important to realize that the organization requesting a medical checkup has a different purpose than you do. They are interested in finding untreatable diseases which might affect your future performance; you are interested in finding conditions about which something can be done. If you heed the warnings of Chapter 1, if you apply the discipline necessary to regulate your habits, there are very few advantages to be gained from the “routine checkup.”
There are a few exceptions, and you should bear them in mind:
• Skin tests for tuberculosis [PPD or Tine Test) are an inexpensive and effective means of detecting exposure to this disease. Chest x-rays may be used for the same purpose but are more expensive, cumbersome, and involve exposure to radiation. [Although the amount of radiation in routine x-rays is small, your general policy should be to avoid x-rays whenever PoSsible). Frequently, these tests are available free of charge through city or county public health services. While it is customary to recommend these tests on a yearly basis, a less frequent schedule [every 3-5 years) is probably adequate unless you have definitely been exposed to tuberculosis or live in an area in which it is common. If your test was negative, and becomes positive, check with your doctor.
• If you are a woman over 25, you should have a “Pap smear” taken regularly to detect cancer of the Womb [cerVix). In early stages, this slowgrowing cancer is completely curable. See For Women Only for more information on Pap smears. If you are a woman over 25, you should also practice breast self-examination every month, and should check out any suspicious lumps with your physician. Mammography [a special breast x-ray) is not recommended as a screening procedure except for those who already have had a breast tumor or who have a family history of breast cancer. This procedure is expensive and not always reliable.
• A test for glaucoma [a treatable disease which can cause blindnf?ss) should be done after age forty if there is a family history of glaucoma.
• Urinalysis, urine cultures, tests for blood in the stool after age 30, sigmoidoscopy after age 50 are screening procedures which are ordered by many physicians. They have value in particular circumstances. Take your doctor’s adVice on these.
• During adult life, it is adVisable to have a blood pressure check made at least every year or so. This measurement can easily be done by a nurse, physician’s assistant, or nurse’s aide. A full examination is not required.
Congratulations: You just saved an executive examination costing $300.
The important elements of elaborate examinations are the blood pressure check, tuberculosis screening, breast examination and pap-smear tests for women, and glaucoma tests when a family history is present.
Health Myths
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Medicine has been criticized for being “crisis-oriented.” Often, the major emphasis of medical care has been on intensive treatment of the crisis rather than on measures for maintaining health and preventing the crisis. However, more and more interest is now focusing on preventive medicine and health maintenance. The idea of preventive medicine includes these four health care measures:
• The checkup or periodic health examination
• Multi-phasic screening
• Early treatment
• Immunizations and other public health measures