Dear Dr. Roach: In your response to R.J. in your column, you missed an opportunity to educate a writer on the role of the physical examination. There still is a role for the physical exam, but the evidence supporting a 鈥渃omplete鈥� 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鈥檚 medical problems, or on discussing recommended screening tests or health behaviours (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 鈥渢ests,鈥� such as blood or imaging studies. Don鈥檛 do lots of things for the sake of doing lots of things and being 鈥渢horough鈥�; do what you need to do to meet the needs of the patient, based on her or his individual risk factors, history and symptoms.
Yul D. Ejnes, M.D., MACP, Chair Emeritus, Board of Regents, American College of Physicians
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 for which the patient is there. A reasonably complete physical exam probably makes sense on the first visit and then on an as-needed basis.
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Dear Dr. Roach: My 58-year-old girlfriend 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 鈥� constantly. She is never without it, constantly changing for a new piece. I am concerned for her health. Isn鈥檛 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?
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 have to balance the health risks of the nicotine gum against the health 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 that 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.
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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 [email protected].
