The Importance of the Annual Physical

[+ tassojunior]

7 hours ago, Unicorn said:

Hopefully, our physicians are basing their decisions which are evidence-based, as determined by actual scientific study, and as summarized by professional guidelines. You have not provided enough details regarding your health to be provided with educated opinions, but there is a link to the professional guidelines several posts up, which you are free to peruse. One would hope that one's physicians are basing their decisions based on these professional guidelines, and not on "I'd think." You still haven't volunteered whether or not your clots were provoked or not, which is certainly your prerogative. As indicated in the guidelines, if your clot was unprovoked, serious consideration should be given to lifelong anticoagulation. Otherwise 3-6 months of anticoagulation is the recommendation of the consensus of the world's experts on the subject, and periodic testing in the absence of symptoms is NOT recommended. Anticoagulation definitely carries risks in addition to potential benefits. Obviously there are not so great doctors out there who might not be up to speed with professional guidelines. However, criticism of one's care should come from the basis of one's own study of guidelines, not on "I'd think." 

I'm not sure a layman always knows what is a symptom of things, skin bumps, moles or lesions or shortness of breath. The two whatevers that were removed as potential cancers were never noticed by me as any symptom. In fact they were too small to see.  My GP doctor didn't think my shortness of breath was at first and only as an after thought had me paged on the intercom while leaving to go to the lab for a d-dimer. I felt like a hypochondriac going in. At Kaiser Urgent Care the pulmonary specialist asked me if I had been on a "long airplane trip or long car trip recently". No one has ever told me if it was provoked or not but my assumption is it was not. The shortness of breath is recurrent on long walks and even on simple yard tasks on 100 degree days. But to get any sort of follow up testing on either I have to ask, it's never offered as routine. I'm told Kaiser has guidelines for patients in Advantage on Medicare that are different than other patients now and I suspect the cost of long-term Pradaxa is a factor, even though I certainly hope I don't need to be on it.  

After two years of zero follow up on either I am going tomorrow to the Kaiser Dermatologist on a 15-minute visit I "hacked" my way into 4 months ago to get several weird new moles checked and, sneakily, get a trained eye to look over my upper body for what could be any new potential skin cancers. He'll freeze off the ones he sees as harmless probably but the value to me is to get him to do a quick skin inspection I otherwise would not get without annual check-ups. 

[+ tassojunior]

15 hours ago, Rudynate said:

 Your treatment clearly sounds careless - I'm sorry that happened.  Was the d-dimer elevated?  There are other things that can cause an elevated d-dimer.  But an elevated d-dimer in the presence of symptoms is a whole other thing.

My only symptom then was a severe shortness of breath after going up and down a long flight of stairs to a second floor several times in a short period. I felt silly going to the GP and she assured me it was not alarming and my signs were normal. She ordered a d-dimer anyway as an afterthought. Then she called me on my way home and told me to get to Urgent Care immediately as they would be waiting for me and the CAT scan there showed a large clot at the top of each lung. 

My neighbor male couple in their mid 60's both recently died of clots after covid 6 months apart. Like myself they had previously been taking the baby aspirin every day routine most of us did for many years until it was stopped. It makes me wonder if the intersection of that routine ending and the onslaught of covid merging hasn't caused a lot more clots to appear, but I'm not a professional. I fully understand your concern with blood thinners as for the 3 months I was on them my dentist refused to even do any dental work. 

[Rudynate]

The guidance for that baby asprin regimen was very unclear.    They said that people who were already on the regimen should stay on it.   But nobody else should start it.    I suppose that means that the data hadn't shown there was any benefit from taking baby aspirin.  But also that there was no significant risk from taking a baby aspirin every day, so that if you wanted to keep taking your baby aspirin every day, it wasn't going to do anything for you, but it wasn't going to kill you either.  

I had a surgery not long ago and the surgeon wanted me off of the blood thinner for 6 days total.   I told him I was uncomortable with interrupting the blood thinner for that long,  so we compromised by agreeing that they would start aspirin immediately after the procedure.  Of course, that was kind of silly because an anti-platelet agent is not effective against venous clots. But, I lived through it. 

[Guest]

2 hours ago, tassojunior said:

... At Kaiser Urgent Care the pulmonary specialist asked me if I had been on a "long airplane trip or long car trip recently"....

Well, although there are other risk factors which can provoke a stroke, most of them would be pretty obvious (recent surgery, injury, cancer, pregnancy, smoking, obesity, etc.). I will also assume you don't smoke, as I can imagine that whoever took care of your blood clots would tell you that smoking is tantamount to suicide where blood clots are concerned. If you had an unprovoked clot, which it sounds as though may be the case, at a very minimum you should have had a workup for conditions which cause clotting, such as antiphospholipid syndrome, Protein C/S deficiencies, and so on. Some would say there's no reason to even do that--if the clot is truly unprovoked, lifelong anticoagulation is needed regardless. 

I can definitely understand why you might lose confidence in your PCP when he almost missed the diagnosis. Although your clot was unprovoked and out of the blue, the big hint that this could be a PE is that there is usually both rapid breathing and a rapid heartrate. In most cases, there is a pulse of over 100 and breath rate of over 20. Attention to the vital signs is, well, vital. 

As for choice of blood thinners, I, along with most physicians, prefer rivaroxaban over Pradaxa (dabigatran) in most cases, since if you need to stop it for whatever reason (such as dental procedures), it's really completely out of your system in 2 days, mostly gone in 1 day. It has a half-life of 10 hours. For that reason, rivaroxaban is the most commonly prescribed anticoagulant in the US. 

[+ tassojunior]

28 minutes ago, Unicorn said:

Well, although there are other risk factors which can provoke a stroke, most of them would be pretty obvious (recent surgery, injury, cancer, pregnancy, smoking, obesity, etc.). I will also assume you don't smoke, as I can imagine that whoever took care of your blood clots would tell you that smoking is tantamount to suicide where blood clots are concerned. If you had an unprovoked clot, which it sounds as though may be the case, at a very minimum you should have had a workup for conditions which cause clotting, such as antiphospholipid syndrome, Protein C/S deficiencies, and so on. Some would say there's no reason to even do that--if the clot is truly unprovoked, lifelong anticoagulation is needed regardless. 

I can definitely understand why you might lose confidence in your PCP when he almost missed the diagnosis. Although your clot was unprovoked and out of the blue, the big hint that this could be a PE is that there is usually both rapid breathing and a rapid heartrate. In most cases, there is a pulse of over 100 and breath rate of over 20. Attention to the vital signs is, well, vital. 

As for choice of blood thinners, I, along with most physicians, prefer rivaroxaban over Pradaxa (dabigatran) in most cases, since if you need to stop it for whatever reason (such as dental procedures), it's really completely out of your system in 2 days, mostly gone in 1 day. It has a half-life of 10 hours. For that reason, rivaroxaban is the most commonly prescribed anticoagulant in the US. 

Thanks. Although I often have a borderline high heartrate, my heartrate that day was fine and I doubt my breath rate was high. I was relieved when she told me things seemed fine and surprised when she later told me, in an abundance of caution, she'd get me a d-dimer. I probably didn't meet guidelines for it. 

Kaiser Mid-Atlantic has a deal with Pradaxa. They even have a Kaiser/Pradaxa office here. Not sure if they use any others. 

[+ tassojunior]

1 hour ago, Rudynate said:

The guidance for that baby asprin regimen was very unclear.    They said that people who were already on the regimen should stay on it.   But nobody else should start it.    I suppose that means that the data hadn't shown there was any benefit from taking baby aspirin.  But also that there was no significant risk from taking a baby aspirin every day, so that if you wanted to keep taking your baby aspirin every day, it wasn't going to do anything for you, but it wasn't going to kill you either.  

I had a surgery not long ago and the surgeon wanted me off of the blood thinner for 6 days total.   I told him I was uncomortable with interrupting the blood thinner for that long,  so we compromised by agreeing that they would start aspirin immediately after the procedure.  Of course, that was kind of silly because an anti-platelet agent is not effective against venous clots. But, I lived through it. 

I was told when on Pradaxa, to absolutely stop baby aspirin and when I came off Pradaxa told not to use aspirin regimen. IDK. I do know my surviving neighbor was in a big argument with his doctor over baby aspirin but I don't know if he was on thinners. He must not have been as he died of clots a few months after his partner and both had covid and recovered just before the first partner's death from clots. Both were professionals and I'm sure had excellent insurance and assumably excellent doctors. It all makes me a little "concerned" about clots.  

[Rudynate]

1 hour ago, tassojunior said:

I was told when on Pradaxa, to absolutely stop baby aspirin and when I came off Pradaxa told not to use aspirin regimen. IDK. I do know my surviving neighbor was in a big argument with his doctor over baby aspirin but I don't know if he was on thinners. He must not have been as he died of clots a few months after his partner and both had covid and recovered just before the first partner's death from clots. Both were professionals and I'm sure had excellent insurance and assumably excellent doctors. It all makes me a little "concerned" about clots.  

The usual instructions when on a blood thinner are to not take NSAIDs, such as aspirin.  I am on Eliquis and I definitely do not take NSAIDs.  I learned from personal experience that it's a very bad idea.  I have been on blood thinning medication for more than 20 years.  Before we had modern drugs like Pradaxa, Xarelto and Eliquis, the only alternative was warfarin, a very difficult drug to take.  When I was taking warfarin, I once took some ibuprofen, even though I knew better. I told myself "Oh, what can it hurt?"  The next morning, I woke  with a huge purple bruise on my side - and I was convinced.  The newer drugs are a piece of cake compared to warfarin.  When I finally got off warfarin onto Pradaxa, I felt like I had just got out of jail. 

 

[CuriousByNature]

Here in Canada our medical system is in a sorry state. While we don't face financial ruin if we become ill, it's nearly impossible to find a family doctor or GP, let alone get regular physical exams that are anything but superficial.

In my case I was very lucky. But first I had to broaden my horizons with respect to healthcare, which led to me visiting a clinic down the street from me.  The doctor is competent and friendly and even rubs my head playfully when I walk in.  And the big bonus is the new flea collar I'm given after each visit.

Edited August 21, 2023 by CuriousByNature

[Rudynate]

2 hours ago, CuriousByNature said:

Here in Canada our medical system is in a sorry state. While we don't face financial ruin if we become ill, it's nearly impossible to find a family doctor or GP, let alone get regular physical exams that are anything but superficial.

In my case I was very lucky. But first I had to broaden my horizons with respect to healthcare, which led to me visiting a clinic down the street from me.  The doctor is competent and friendly and even rubs my head playfully when I walk in.  And the big bonus is the new flea collar I'm given after each visit.

That's interesting.  So often Canadians say "There's nothing wrong with Canadian healthcare.  Americans just like to criticize it because healthcare in the US is so expensive."  It is true that the American system of healthcare financing is totally screwed, but healthcare itself is top-notch.  I belonged to a Facebook support group for people with autoimmune problems and the Canadians and Brits had a lot of scary stories about needing to wait for a year or more for an appointment with a rheumatologist.  The first time I saw a rheumatologist at Kaiser, I had an appointment in a couple of weeks.

[Rudynate]

6 hours ago, tassojunior said:

Thanks. Although I often have a borderline high heartrate, my heartrate that day was fine and I doubt my breath rate was high. I was relieved when she told me things seemed fine and surprised when she later told me, in an abundance of caution, she'd get me a d-dimer. I probably didn't meet guidelines for it. 

Kaiser Mid-Atlantic has a deal with Pradaxa. They even have a Kaiser/Pradaxa office here. Not sure if they use any others. 

I was getting my Eliquis through Kaiser, but even the co-pay was expensive - $300.00 for a 90-day supply.  I got it offshore for 300.00 for a one-year supply.   The full retail for Eliquis in the US is about $600 for a 30-day supply. 

[+ tassojunior]

2 hours ago, Rudynate said:

I was getting my Eliquis through Kaiser, but even the co-pay was expensive - $300.00 for a 90-day supply.  I got it offshore for 300.00 for a one-year supply.   The full retail for Eliquis in the US is about $600 for a 30-day supply. 

2 reasons I hope I don't have clots !

I think the Pradaxa I used for 90 days was about $100/month also through Kaiser. 

[CuriousByNature]

3 hours ago, Rudynate said:

That's interesting.  So often Canadians say "There's nothing wrong with Canadian healthcare.  Americans just like to criticize it because healthcare in the US is so expensive."  It is true that the American system of healthcare financing is totally screwed, but healthcare itself is top-notch.  I belonged to a Facebook support group for people with autoimmune problems and the Canadians and Brits had a lot of scary stories about needing to wait for a year or more for an appointment with a rheumatologist.  The first time I saw a rheumatologist at Kaiser, I had an appointment in a couple of weeks.

Yes, I have waited almost 18 months for a specialist appointment myself, and I know people who have waited almost 2 years for a consult regarding hip surgery.  In one case the poor guy was diagnosed with terminal and aggressive pancreatic cancer after waiting a year to see the hip surgeon, and he was taken off the wait list because he wouldn't live long enough to have the hip surgery itself.  Others have died after waiting 20+ hours to see a doctor in hospital ERs, and I know of at least one person who had a suspected stroke in a care facility and waited several hours at the ER before being seen.  This is why numerous people from Canada go to other countries for elective treatment in Asia, Eastern Europe, and Latin America.  Any attempts at providing alternatives for those with the means to pay privately here in Canada are almost always quashed, because there is nothing holier in Canada than universal health care, even if that means universal suffering with wait times and inefficiencies.  If you have decent health insurance and live in the USA, I think you are far better off than many Canadians - and particularly those with complex care needs.

[Rudynate]

52 minutes ago, CuriousByNature said:

Yes, I have waited almost 18 months for a specialist appointment myself, and I know people who have waited almost 2 years for a consult regarding hip surgery.  In one case the poor guy was diagnosed with terminal and aggressive pancreatic cancer after waiting a year to see the hip surgeon, and he was taken off the wait list because he wouldn't live long enough to have the hip surgery itself.  Others have died after waiting 20+ hours to see a doctor in hospital ERs, and I know of at least one person who had a suspected stroke in a care facility and waited several hours at the ER before being seen.  This is why numerous people from Canada go to other countries for elective treatment in Asia, Eastern Europe, and Latin America.  Any attempts at providing alternatives for those with the means to pay privately here in Canada are almost always quashed, because there is nothing holier in Canada than universal health care, even if that means universal suffering with wait times and inefficiencies.  If you have decent health insurance and live in the USA, I think you are far better off than many Canadians - and particularly those with complex care needs.

I have my share of complaints about Kaiser, but I'm definitely not going anywhere. I had a surgery a few weeks ago that cost me $400.00. I don't even want to say what the bill was.

[Guest]

3 hours ago, tassojunior said:

2 reasons I hope I don't have clots !

I think the Pradaxa I used for 90 days was about $100/month also through Kaiser. 

I just got out of the hospital again, back at home, after having my ureteral stone smashed. I need to amplify what I said in my last post. First of all, rivaroxaban is Eliquis, which another poster was prescribed. When I prescribed blood thinners, I would offer my advice thus: you can take blood thinners once a day or twice a day. Twice a day is much safer if you either have a bleeding problem pop up, or if you need to stop for a procedure (mostly out of your system in a day), but once a day is simply more convenient. More than 90% of patients took the hint and requested the Eliquis/rivaroxaban. My second point, which may not have been clear, is that you should get a 2nd opinion as to whether or not you need to be on long-term anticoagulation (not whether you need to have a D-dimer drawn or not). I obviously don't have all of the facts, but if your clot was unprovoked, one would need to give serious consideration to long-term anticoagulation (again, my preference is usually for rivaroxaban unless the patient really can't remember to take a medication twice a day). 

This is probably worth paying a few hundreds of $$ for if Kaiser balks at letting you see one of theirs for a 2nd opinion. By law, Kaiser must send your records to whomever you ask, on your request. After all, what do good escorts go for these days?

[Guest]

11 hours ago, tassojunior said:

...Kaiser Mid-Atlantic has a deal with Pradaxa. They even have a Kaiser/Pradaxa office here. Not sure if they use any others. 

Well, if you're stuck with Pradaxa/dabigatran, at least it has a kind of wishy-washy antidote. I wouldn't gamble on an ER doctor knowing how to use it, and it only helps to a certain extent:

Practical considerations on anticoagulation reversal: spotlight on the reversal of dabigatran - PMC

WWW.NCBI.NLM.NIH.GOV

---

Idarucizumab (Praxbind) is a humanized antibody fragment, that reversibly and with high affinityties up dabigatran (Pradaxa). Anticoagulation reversal is...

Idarucizumab is an antidote and has no reversal function, therefore, it inhibits the activity of dabigatran but does not stop the bleeding.

Idarucizumab is indicated in:

• bleeding in critical close-spaced sites

• persistent major bleeding despite local hemostatic measures
• acute ischemic stroke before fibrinolytic therapy (more evidence is needed in order to standardize the procedure)
• emergency surgery
• invasive and high-risk bleeding procedures

[+ FreshFluff]

Skin tags are typically benign. "Bumps" may or may not be.

I've had 3 non-melanoma skin cancers despite careful protection from sun exposure.  My advice: If you have a pearly pink "pimple" that won't heal or a mole that has changed, request a referral to derm.  If you have a family history of skin cancer, have had a lot of sun exposure, or have fair skin, a derm should do a skin exam annually. This is not only to check for melanoma, but for non-melanoma skin cancers like squamous and basal cell carcinomas. Basal cell carcinoma is very common and has a near-zero mortality rate, but surgery and reconstruction becomes more disfiguring as the malignancy grows. Take steps to catch it early. 

 

[Rudynate]

8 hours ago, Unicorn said:

Well, if you're stuck with Pradaxa/dabigatran, at least it has a kind of wishy-washy antidote. I wouldn't gamble on an ER doctor knowing how to use it, and it only helps to a certain extent:

Practical considerations on anticoagulation reversal: spotlight on the reversal of dabigatran - PMC

WWW.NCBI.NLM.NIH.GOV

---

Idarucizumab (Praxbind) is a humanized antibody fragment, that reversibly and with high affinityties up dabigatran (Pradaxa). Anticoagulation reversal is...

Idarucizumab is an antidote and has no reversal function, therefore, it inhibits the activity of dabigatran but does not stop the bleeding.

Idarucizumab is indicated in:

• bleeding in critical close-spaced sites

• persistent major bleeding despite local hemostatic measures
• acute ischemic stroke before fibrinolytic therapy (more evidence is needed in order to standardize the procedure)
• emergency surgery
• invasive and high-risk bleeding procedures

Rivaroxiban is Xarelto. Eliquis is apixaban.  There is a single antidote that works for both.  Why wouldn't an ER doc know how to use them?  I would think they of all people would know. 

[+ tassojunior]

16 minutes ago, Rudynate said:

Rivaroxiban is Xarelto. Eliquis is apixaban.  There is a single antidote that works for both.  Why wouldn't an ER doc know how to use them?  I would think they of all people would know. 

I can say I was mighty impressed with the Urgent Care docs and specialists at Kaiser when I went there for the clots. (They don't really know how to communicate with patients though like GPs.) More than worth the $50 co-pay over GP visits but I don't want to clog them up for lesser stuff like many people do emergency rooms. 

[Rudynate]

My husband went through a bad patch a few years ago - he was hospitalized several times for bad UTI's.  The care he got in the ER was amazing.  The first time, we walked in, they took a look at him, got him into a room and were hanging antibiotics within minutes, literally.  

[+ tassojunior]

7 hours ago, FreshFluff said:

Skin tags are typically benign. "Bumps" may or may not be.

I've had 3 non-melanoma skin cancers despite careful protection from sun exposure.  My advice: If you have a pearly pink "pimple" that won't heal or a mole that has changed, request a referral to derm.  If you have a family history of skin cancer, have had a lot of sun exposure, or have fair skin, a derm should do a skin exam annually. This is not only to check for melanoma, but for non-melanoma skin cancers like squamous and basal cell carcinomas. Basal cell carcinoma is very common and has a near-zero mortality rate, but surgery and reconstruction becomes more disfiguring as the malignancy grows. Take steps to catch it early. 

 

Nothing will get me to force my way into a personal specialist visit better than the phrase "skin cancer". Tele-medicine doesn't cut it even with high-res phone cams. I can't even see the bumps that concern them. I want a super-familiar trained human eye eyeballing my new bumps and spots of the year regularly. I will find some way to get that annual eyeballing of my torso and head skin one way or another. 

Edited August 22, 2023 by tassojunior

[Guest]

2 hours ago, Rudynate said:

Rivaroxiban is Xarelto. Eliquis is apixaban.  There is a single antidote that works for both.  Why wouldn't an ER doc know how to use them?  I would think they of all people would know. 

Thanks for the correction. And yes, you are correct in stating there's also an antidote for those two as well (different from that for Pradaxa/dabigatran, which works by a different mechanism). What I was trying to impart was that, if one has to take a long-acting oral anticoagulant, it's a good idea for the patient to be aware that an antidote exists. Having worked in primary care for decades, I can state from ample experience that the quality of ER physicians can be a crapshoot at best. Just over 2 weeks ago, I was in the ER as a patient with what turned out to be a stone at the base of my ureter which was surrounded by a mini-abscess, and was causing that ureter and kidney to blow up. I was in acute renal failure, with extremely high lactic acid levels, probably close to being in septic shock. I was in complete agony, shaking in pain, with sweat pouring down my body, blood pressure 195/120, hyperventilating, yet, despite my pleas, the ER physician refused to even talk with me until the radiologist read the CT scan (which he ordered, as I said, without even talking with me). My tearful fiance even spoke with the Charge Nurse to no effect.

I can only guess why the ER physician refused to evaluate me when I came in, although my screams were probably audible throughout the ER. If he thought I was some kind of a drug addict, he could have instantly checked the state CURES database, and/or he could have done a rapid urine drug screen, which would provide a result in minutes. I was in the ER for over 3 hours before he even popped in to take a look. When I commented on this doctor's incompetence to the RN who took care of me as an inpatient, he remarked "Yes, those ER doctors are something else. Sometimes I think they all get trained at the same 'Don't evaluate the patient' residency."! When I was re-admitted for the stone removal yesterday, the ER doctor was fine, and came by promptly to speak with me. 

I would suspect that in many cases, if the patient isn't himself aware of the availability of the antidote, the patient's best bet is that whoever is consulted knows about the antidote (such as a gastroenterologist if there's a GI bleed). 

 

[Rudynate]

5 minutes ago, Unicorn said:

Thanks for the correction. And yes, you are correct in stating there's also an antidote for those two as well (different from that for Pradaxa/dabigatran, which works by a different mechanism). What I was trying to impart was that, if one has to take a long-acting oral anticoagulant, it's a good idea for the patient to be aware that an antidote exists. Having worked in primary care for decades, I can state from ample experience that the quality of ER physicians can be a crapshoot at best. Just over 2 weeks ago, I was in the ER as a patient with what turned out to be a stone at the base of my ureter which was surrounded by a mini-abscess, and was causing that ureter and kidney to blow up. I was in acute renal failure, with extremely high lactic acid levels, probably close to being in septic shock. I was in complete agony, shaking in pain, with sweat pouring down my body, blood pressure 195/120, hyperventilating, yet, despite my pleas, the ER physician refused to even talk with me until the radiologist read the CT scan (which he ordered, as I said, without even talking with me). My tearful fiance even spoke with the Charge Nurse to no effect.

I can only guess why the ER physician refused to evaluate me when I came in, although my screams were probably audible throughout the ER. If he thought I was some kind of a drug addict, he could have instantly checked the state CURES database, and/or he could have done a rapid urine drug screen, which would provide a result in minutes. I was in the ER for over 3 hours before he even popped in to take a look. When I commented on this doctor's incompetence to the RN who took care of me as an inpatient, he remarked "Yes, those ER doctors are something else. Sometimes I think they all get trained at the same 'Don't evaluate the patient' residency."! When I was re-admitted for the stone removal yesterday, the ER doctor was fine, and came by promptly to speak with me. 

I would suspect that in many cases, if the patient isn't himself aware of the availability of the antidote, the patient's best bet is that whoever is consulted knows about the antidote (such as a gastroenterologist if there's a GI bleed). 

 

So you were venting your lingering frustration over a negative ER experience. That's unfortunate.   My experience with ER visits is that that is how they used to be but they have vastly improved.  Even 20 years ago, I went into the ER with a clot that turned out to extend from the back of my knee almost to my liver in my vena cava.  My right leg was twice its normal size and looked like a salami.  They jumped on it and wasted no time.  The ER doc glanced at it and ordered a venogram, which he said was the first one he had ever ordered.  OTOH, the inpatient care was pathetic. 

[Guest]

2 hours ago, tassojunior said:

Nothing will get me to force my way into a personal specialist visit better than the phrase "skin cancer". Tele-medicine doesn't cut it even with high-res phone cams. I can't even see the bumps that concern them. I want a super-familiar trained human eye eyeballing my new bumps and spots of the year regularly. I will find some way to get that annual eyeballing of my torso and head skin one way or another. 

Any primary care healthcare professional will be able to immediately identify a lesion which might be a potential concern for cancer. There is no need to use underhanded means to have the lesions evaluated by a dermatologist, "one way or another," as you put it. Of course, if Kaiser allows for self-referrals to dermatology, rather than having the patient be evaluated by a PCP first, they have only themselves to blame if patients clog up the referral process with "one way or another," resulting in 6-month waiting lists. 

[Guest]

16 minutes ago, Rudynate said:

So you were venting your lingering frustration over a negative ER experience...

I would like to ask you not to comment on my postings if you won't read them in their entirety. As I stated, my opinion of ER physicians comes from 33 years of practice, not from my personal negative experience earlier this month. My experience was only an example of many of incompetent care I witnessed while in practice. Does this mean all ER physicians are incompetent? Of course not. What I'm saying is that it can be dangerous to expect much of an ER physician (especially since one cannot learn anything about this physician before being assigned). 

I will also add that most MDs/FNP's I know share my opinion regarding ER physicians, as do many RN's, such as my RN in the hospital ward, who's also seen it all. 

Edited August 22, 2023 by Unicorn

[Rudynate]

Just now, Unicorn said:

I would like to ask you not to comment on my postings if you won't read them in their entirety. As I stated, my opinion of ER physicians comes from 33 years of practice, not from my personal negative experience earlier this month. My experience was only an example of many of incompetent care I witnessed while in practice. Does this mean all ER physicians are incompetent? Of course not. What I'm saying is that it can be dangerous to expect much of an ER physician (especially since one cannot learn anything about this physician before being assigned). 

I read the whole thing.  The bulk of your post was a melodramatic description of your recent ER experience with you screaming in agony and the docs ignoring you, which made it difficult to tease out your larger message.