Dear Dr. Roach: In your response to “R.J.” in your column “In exams, doctors seem to have lost their touch,” you missed an opportunity to educate the writer on the role of the physical examination. There still is a role for the physical exam, but the evidence supporting a “complete” physical in asymptomatic people is lacking. Time that is spent looking in ears, feeling for swollen glands, etc., in people who have no symptoms or problems that warrant checking those areas can better be used to focus on examining parts that are relevant to the patient’s medical problems, or on discussing recommended screening tests or health behaviors (such as smoking cessation).
While it may be true that in some cases, the physical examination is a victim of time constraints, in others it is a matter of using the same amount of time more effectively. This is no different from how we should approach other types of “tests,” such as blood or imaging studies. Don’t do lots of things for the sake of doing lots of things and being “thorough”; do what you need to do to meet the needs of the patient, based on her or his individual risk factors, history and symptoms.
Dr. Roach responds: Thank you, Dr. Ejnes, for taking the time to write a thoughtful response. The physical exam is an important part of the doctor visit, and it has variable necessity, depending on the reason the patient is there. A reasonably complete physical exam probably makes sense on the first visit and then on an as-needed basis.
Dear Dr. Roach: My girlfriend, 58, smoked cigarettes for 30 years. She quit 10 years ago with the help of nicotine gum. The problem is that she still chews the gum — constantly. She is never without it, constantly changing for a new piece. I am concerned for her health. Isn’t this product full of carcinogens? I cannot believe this long-term use can be good for her. What is the truth about long-term use of nicotine gum?
Dear D.B.: Nicotine is a toxic substance, and can be fatal in doses as low as 30 mg. It acts on a nerve receptor in the muscle and brain. It is an effective insecticide but is considered too dangerous to use for this purpose.
Nicotine is not a major carcinogen. Tobacco smoke is certainly full of carcinogens, but the nicotine itself is not.
Ideally, your girlfriend (whom I congratulate on stopping smoking) would stop the nicotine replacement usually in eight to 12 weeks after quitting smoking.
However, there are some people who become psychologically dependent on the nicotine patch. In that case, you balance the health risks of the nicotine gum against the risks of going back to smoking. The risks of the nicotine gum are small, and the health hazards of smoking are enormous.
To me, if she feels the risk of her smoking again is high, then it is safer to keep using the gum. If she feels pretty confident about not smoking again, she can try gradually switching to regular (sugar-free) gum, since it may be the gum sensation more than the nicotine she needs. The Food and Drug Administration is considering an indication for long-term nicotine use.
Dear Dr. Roach: I live in the state of Maine. My parents warned me about needing iodine in our diet due to not having much iodine in our soil. They told me to buy iodized salt to prevent thyroid problems. I think you can get iodine from seafood, too, but I don’t know which kinds. If people throw out the saltshaker, what should they do to ensure they are getting enough iodine?
Dear L.C.: We almost never see iodine deficiency where I have practiced; however, you are quite right that many areas, especially the Northern United States and most of Canada, have low iodine levels in the soil. If you don’t use table salt (and good for you if you don’t), then you can get iodine from most dairy products, from saltwater fish and shellfish, from seaweed (think of nori, the wrapping of sushi) or from supplements.
Email questions to ToYourGoodHealth@med.cornell.edu.