Not Your Granddad’s Disease: Here’s What to Know About Gout

Gout. Unless you’ve suffered it firsthand, you could dismiss it as something your grandfather might have had. Despite its fuddy-duddy name, gout – a type of arthritis that occurs when extra uric acid in the body forms crystals in the joints – affects more than 8 million people in the United States. Sufferers have likened the pain of a gout “flare” to glass chards or needles pressing in and out of the affected joint, often at the base of the big toe (though other joints can be involved). The immune system’s attack on the crystals in the joint causes redness, swelling and extreme pain, often while the victim sleeps, and can last several days.  

You may have heard gout referred to as the “disease of kings,” stemming from its long association with a diet heavy in red meats, shellfish and alcohol: all foods high in purines, which prompt the body to make uric acid to break the substance down. Purines, it should be noted, also occur naturally in our bodies. But gout cases are rising in current times, as the population ages, gains weight and consumes more of what is linked to the disease. Yet studies show us that several genes may also play a role in the development of gout, including those that regulate the body’s processing of uric acid. This might explain why some people can have hyperuricemia, or too much uric acid in their body, but never suffer the symptoms of gout.  

Given that gout is here to stay, despite its antiquated image, I talked with Virginia Mason rheumatologist Erin Bauer, MD, about how to reduce flares for those who have gout, and the red-flag signs that it may be causing more serious health problems.

According to Dr. Bauer, the first line of defense against dreaded flares includes:

  • Diet mindfulness. Though diet does not play as big of a role as once thought, there are some foods that increase the risk for flares due to high levels of purines – the compounds in animals and plants that our bodies convert to uric acid. These foods include potatoes, poultry, red meats, seafood and drinking alcohol (especially beer) or beverages containing high-fructose corn syrup.

  • Targeting helpful foods. There are some foods that may slightly lower uric acid levels in the body, including eggs, peanuts, non-fat milk, whole grain breads, cheese and non-citrus fruits.

  • Drinking more water. Keeping adequately hydrated is extremely important, as any decrease in your kidney function will prevent your body from getting rid of uric acid and could lead to the formation of crystals. Studies have shown that increasing water consumption is associated with significantly fewer gout flares.  

  • Dropping those extra pounds. Losing weight will prevent flares over time, though losing weight too quickly or on a diet that is too high in protein may actually cause more flares.

  • Medication consistency. If a uric acid reducing drug is prescribed, such as allopurinol or febuxostat, it’s very important to stay on it regularly. Stopping and starting these medications often causes flares. To prevent this for people starting the medication, another medication is often added for a short time to protect patients as much as possible.
Which gout symptoms say it’s time to see the doctor?
  • Count your flares. Dr. Bauer points to the most recent guidelines, which indicate that having two or more flares of gout in a year could be damaging your joints. Work with your doctor to determine what lifestyle changes or treatments might be appropriate for your repeat flares.

  • Lumps could mean trouble. Deposits of urate crystals (called tophi) can make visible lumps under your skin and tend to appear in the hands, feet, elbows, or the outer edges of the ear. Large ones are easy to spot, but smaller ones may only show up with imaging. Tophi can be painful if they are infected or pressing on a nerve. However, another threat of tophi is they can damage joints and lead to bone erosion.

  • Arthritis seen on X-ray. The longer you have gout, the higher the chances are for joint damage, or arthritis. X-ray evidence of arthritis in the joints affected by gout warrants further evaluation.

  • Beware of stones. The same urate crystals that cause painful gout symptoms can also invade the kidneys, interfering with kidney function and causing severe pain. Uric acid-lowering medications are often recommended for gout sufferers who also have kidney disease.

  • Check your medication. If you’re already on medication to reduce flares but are still having them, talk with your doctor about increasing your dose. Also, taking diuretics tends to increase uric acid levels. Lowering the dose of diuretics or switching to a different medication may be something to try.

Dr. Bauer says gout can be initially managed by a primary care provider, while more complex cases can benefit from evaluation by a rheumatologist. The good news is if diagnosed early, most people with gout can live normal, productive lives. Even if gout has advanced, lowering uric acid levels, with medications and lifestyle choices, can improve joint function and reduce the frequency and severity of flares.


Erin Bauer, MDErin Bauer, MD, is board-certified in internal medicine and rheumatology, specializing in general rheumatology, inflammatory myopathies, inflammatory arthritis and lupus. Dr. Bauer practices at Virginia Mason Seattle and Virginia Mason Federal Way locations. 

 

 

Bad Break, Good Outcome: Team Effort Restores Joint Function

“This is me leaving my apartment on my first day in Rome,” says Roberta Kelley, looking through her photo collection. “See how happy I was? And here I am having my first and only cup of espresso.”

Roberta’s dream vacation ended abruptly when after a long day of sightseeing, she stepped off a surprise curb and went down hard. Holding her tour map and phone, Roberta’s elbow took the brunt of the impact, crushing it. She remembers bystanders helping her into a cab and later, falling asleep in her rented apartment.

The next morning Roberta’s shock gave way to the realization her swollen arm was broken. A local hospital took an agonizing X-ray, and Roberta learned she’d need surgery to repair her ruined elbow. She could have the surgery done in Rome, the doctor told her.

“But I said no, I’m flying back to Seattle,” remembers Roberta. “I need to go to Virginia Mason where I get all my care and my doctors know me.” Roberta shares another connection with Virginia Mason, retiring in 2018 as a speech-language pathologist and orofacial myofunctional therapist (treating muscle disorders of the mouth and face).

Fitted with a temporary cast from her shoulder to her wrist, Roberta made the long trip home and then to Virginia Mason’s Emergency Department. She relaxed for the first time in days, with the team making her comfortable and gently guiding her through X-rays. That same morning Roberta met orthopedic surgeon Laura Stoll, MD.

Roberta in chair

Roberta Kelley

“Dr. Stoll showed me the images and explained her plan for surgery,” says Roberta. “She wanted me to know it was a bad break and there were no guarantees about what function I’d get back. I was so worried and nervous, but she said ‘I will take good care of you’ and gave me a hug. That made a world of difference.”

Roberta’s severe elbow fracture and dislocation required a prosthetic replacement of the radial head, the knob-like end of the radius bone that helps form the joint. The radial head sits in a pocket of the ulna bone, allowing the forearm to both flex and rotate. In addition to the prosthetic, Dr. Stoll rebuilt and repositioned Roberta’s elbow with a stabilizing system of plates and screws.

“Because elbows are mechanically complex, they are tricky to repair and surgical outcomes can be unpredictable,” says Dr. Stoll. “Roberta’s dedication to recovery and her positive attitude were so important. Achieving a good outcome really becomes a team effort.”

“Team Roberta” included Dr. Stoll working side-by-side with an occupational therapist in joint visits, going over X-rays and creating a rehabilitation plan. Roberta began a rigorous therapy regimen, which included daily home exercises. Roberta set her smart phone to remind her when to do them. At first she felt discouraged, not able to bend her arm enough to wash her face, put on make-up or even earrings. But her occupational therapist stayed positive and encouraging, even as she challenged Roberta with those very tasks each week to help condition her new elbow.

“My range of motion is excellent now, but it came with a lot of effort and exercise,” says Roberta. “I told Dr. Stoll she did fabulous surgery. She said ‘yes, but you did all the hard work.’”


A version of this story originally appeared in the Virginia Mason 2019 Annual Report.

Finding Light on the Ride: A Comeback Story

The tricky thing about hitting bottom is knowing when you’ve done it. Making his way to his usual bus stop, Jon Perry slipped on an icy sidewalk and grabbed for a garbage can to break his fall. That might have worked, except Jon weighed about 280 pounds and the force snapped his upper arm in five places. It hadn’t helped that he’d been drinking.

The day Jon was about to be wheeled into surgery on his arm he confessed to recent heavy drinking, and the surgery was cancelled. It had all the elements of hitting bottom: his arm would heal painfully and never be the same. But a year later, Jon was in the hospital again. Battling alcohol addiction and weighing 400 pounds, Jon was told if his kidneys didn’t start working in a few hours they could fail permanently. Here, finally, was bottom.

Jon Perry

Jon Perry, who once rode for Benaroya Research Institute’s bicycle team.

Jon’s kidneys did start working that night, but something had changed. “I had faced my mortality and here was another chance,” says Jon. “Something made me want to seize the opportunity.”

Maybe what kicked in that night was Jon’s muscle memory for facing challenges. He’d been a two-time Ironman triathlon finisher and competitive bike racer; one season riding to a state championship. That’s when the drinking slowly started. The more he drank the better he got at hiding it. But he couldn’t hide the toll it took on his spirit, swamping it in alcohol. Beyond exhausted, Jon fired his coach, kept drinking and his weight ballooned.

Jon’s choice to get better that night in the hospital might have flown away, but he had the benefit of community. Jon’s south Seattle loft is in a building designated for artists, who all applied and moved in at the same time. Jon gave his TV away and recommitted to his music, playing bass guitar and drums, and adding a passion he’d put aside: singing.

“It’s inspiring to be in this community, one I helped build,” says Jon. “It was a huge part of my recovery.”

Getting back to work and doing what he loved, Jon’s recovery leapt forward. Working long hours on his feet as a cook helped the pounds fall off, as did giving up alcohol – not so much as a drop, Jon says. Soon he could ride his bike to work; he kept feeling better and continued to lose weight.

Jim, Jon’s stepfather, witnessed Jon’s incredible transformation and was moved to help. It would be the last gift to his stepson: Jim had terminal lung cancer.

“We sat on the edge of his hospital bed and he said, ‘I want to do this for you, when you’re ready,’” remembers Jon. Jim was offering to pay for a big surgery – a body contouring procedure that would tighten the loose skin around Jon’s abdomen, the result of his significant weight loss. “He said it was to finish off what I had accomplished,” says Jon. “He believed in me.”

Several months after Jim passed away, Jon underwent a circumferential lower body lift at Virginia Mason – an extensive surgery to lift and reshape the front and back areas of the torso, removing excess tissue. Plastic and reconstructive surgeon James Schlenker, MD, says Jon’s strong motivation to be active again made him an ideal candidate for an operation with life-changing potential.

“Often people who lose a lot of weight don’t anticipate the impact of having loose skin, and there are many types of procedures available,” says Dr. Schlenker. “The lower body lift is a less common and more involved operation than abdominoplasty, but results can be dramatic for the right patient. The surgery had great benefits for Jon, helping him continue doing everything he enjoyed.”

Jon was buoyed by Dr. Schlenker’s enthusiasm for the surgery’s possibilities, and for his gentleness and knowledge. Recovery took all the weeks prescribed, but for Jon it’s been nothing short of transformative. These days you’ll still find him on a bicycle – at a leaner 175 pounds, reminiscent of his bicycle club days. And who knows? His next race may be just around the bend.

“It’s been a monumental time for me,” says Jon. “Life is rich. I have so many things and I’m incredibly grateful. I like to say there is light where we’re traveling.”

 

Total Ankle Replacement Restores Function

Roger Dunn battled chronic ankle pain for decades, an unwelcome side effect of playing college football and repeat injuries over the years. Finally tired of “dragging it along,” Roger got an appointment close to home with foot and ankle surgeon Matthew Williams, DPM, at the Virginia Mason Kirkland Medical Center. Dr. Williams discussed a treatment option Roger never knew existed: total ankle replacement.

RogerOrtho

Roger Dunn

“For years the gold standard for ankle arthritis was permanently fusing the joint, which relieves pain but decreases motion, leading to arthritis in nearby joints over time,” says Dr. Williams. “While earlier ankle replacement devices had high failure rates, recent advances in design and materials have significantly improved longevity and decreased complications.”

Roger needed no convincing to undergo the surgery, with his bone-on-bone ankle joint — the worst kind of daily grind. He scheduled the procedure, bracing for a long recovery and some next-level pain, but he was in for a big surprise.

“It just amazed the heck out of me that I never experienced any pain in the joint or in the surrounding tendons,” says Roger, who had the procedure in November 2018. “Once out of a cast I was religious about wearing my boot and not taking any chances. I went back to work on a knee scooter in two weeks, where I could also ride my desk chair around a bit.”

Soon Dr. Williams eased Roger off the scooter and into walking with a brace. Physical therapy helped keep Roger’s mobility on track, steadily improving his strength and balance. X-rays confirmed successful realignment of Roger’s foot, ankle and leg, something Roger never imagined possible with such an old, gnarled body, as he put it. What he didn’t know is everything that made his case unique informed a treatment plan designed for the best possible outcome.

“Before performing an ankle replacement, we use advanced computer programs to plan the surgical approach, building in correction for any existing deformity,” says Dr. Williams. “Sometimes it’s necessary to make corrections in stages to achieve the best function for patients. I also take great care when selecting patients who are likely to benefit from ankle replacement. Things like recreational activity level, age, occupation and body mass are all critical considerations for success.”

Roger wrapped up physical therapy a few months after surgery, feeling balanced and confident on his new ankle. A recent X-ray showing everything healed as expected told Roger he’s good to go. Now when it’s time to get a knee replacement on the other leg – another troubled joint destined for a fix – he’ll have the stability on the right to take whatever comes.

Would Roger recommend total ankle replacement to other people who wonder if it’s worth the time, bulky boot, scooter-cruising and physical therapy visits? Absolutely, he says.

“I was careful to follow all the rules of the road and was lucky I didn’t have any falls,” says Roger. “The no-pain part is what really worked for me. It wasn’t something Dr. Williams guaranteed going in, it’s something that happened because he’s an excellent surgeon.”


A version of this story also appears in the Virginia Mason Health System 2018 Annual Report.  

Weight Loss Surgery Creates New Life

Visiting family in another state, Sharalyn “Bunny” Staricka heard the plan to spend a day at the zoo. Her sister-in-law, niece and nephew clamored for Bunny to go, but she had to turn them down. At 375 pounds, Bunny knew she’d never make it around the exhibits – or even across the parking lot without severe pain.

“At my heaviest I couldn’t be on my feet more than 20 minutes at a time,” recalls Bunny. “I used to live a few blocks from Pike Place Market in downtown Seattle and couldn’t walk there without getting a ride home. Living at the bottom of a big hill, I felt trapped.”

Bunny started thinking about weight loss surgery back in college, but insufficient insurance and financial resources kept it out of reach. Life setbacks, including a divorce, moving far from home and the end of another long-term relationship, all contributed to putting on more pounds. Then the unexpected: Bunny met the love of her life, Mathias.

“A few months before our wedding I had concerns about my health and wondered if I’d ever be able to have children,” says Bunny. “It was time to find a doctor to do the surgery. In the past I’d had such good care in Virginia Mason’s emergency room, that’s where I wanted to look.”

Bunny watched a video of bariatric surgeon Lily Chang, MD, and was struck by her genuine desire to improve the lives of people battling extreme obesity. Bunny learned about the different options for weight loss surgery, ultimately deciding on the Roux-en-Y procedure. Roux-en-Y gastric bypass involves creating a small pouch from the stomach and connecting it directly to the small intestine, literally bypassing parts of the digestive tract that absorb calories.

post-surgery“The Roux-en-Y gastric bypass really is the gold standard for weight loss operations,” says Dr. Chang. “While there are potential complications, side effects and a risk of regaining weight, the procedure typically results in excellent weight loss and resolution of weight-related health problems. Surgery is one of the best tools we can offer patients to help them dramatically change their relationship with food.”

For Bunny, the months of dietitian visits leading up to her gastric bypass were a welcome combination of goal setting to reach a safe preoperative weight and preparing for success after surgery. “What I loved about the visits is they let me choose one or two small goals to work on at a time,” says Bunny. “I also learned new habits for a smoother transition to life after gastric bypass. I knew they wanted me to succeed.”

After Bunny fully recovered from surgery, a new way of eating began to take shape. Dinner-size plates gave way to small plates. Salads and veggies took center stage, while calorie-dense or fatty foods were reduced to a few bites. The sugary treats of Bunny’s lifelong cravings now tasted way too sweet. Far from feeling deprived, Bunny marvels at what disappeared after surgery: the incessant inner voice demanding high-calorie foods.

“When my system was out of whack I was obsessed with homemade flour tortillas, a favorite growing up in Texas,” says Bunny. “I got one after my procedure and it wasn’t anything like before … it was just gummy and unappealing. I found myself way more excited about the fresh salsa and guacamole.”

In just over a year since having gastric bypass, Bunny shed 170 pounds. Now she walks all over downtown Seattle and recently toured Japan, on a dream trip with her husband. Bunny also introduced him to rollerblading, an activity she loved as a kid. On a return visit with her brother’s family, they all got to enjoy the zoo. Bunny is living her best life now, she says, but acknowledges there will be at least some weight gain happening soon.

“One year after surgery Dr. Chang gave us the green light to start a family,” says Bunny. “We’re expecting our first child in October.”


A version of this story first appeared in the Virginia Mason Health System 2018 Annual Report.

Transgender Health Care at Virginia Mason: Providers are ‘Driven to Do This Work’

Longtime Virginia Mason patient Samantha Forney and the nurse caring for her sat down to talk. The nurse had made a mistake by referring to Samantha, who is a transgender woman, with male pronouns. Samantha saw an opportunity for teaching, with a receptive caregiver.

“To me it’s much more important to make something a positive learning experience,” said Samantha. “Getting my feelings hurt or being angry won’t make things better for the next person.”

Samantha.Forney

Samantha Forney

Samantha’s steadfast advocacy for transgender health care first caught the attention of her primary care doctor, who asked if she would join the guiding team working to develop transgender health care at Virginia Mason. Eager to be involved, Samantha applied to become a Patient-Family Partner (PFP), a unique volunteer program that invites patients and families to be active co-designers of patient care. In her new role, Samantha made an impression on the PFP clinical team: would she be willing to share her personal story while presenting to the medical center’s board of directors?

Samantha began work on her board presentation in the summer of 2017, a time when Virginia Mason’s development of Transgender Health Services was well underway. A bolstered strategy to support diversity and the individual needs of patients ignited in 2016, when the organization signed on to the American Hospital Association Equity of Care pledge: a national call for eliminating health care disparities among patient populations. A commitment to providing affirming care for lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) people spawned system-wide changes, from policies and staff training, to new care guidelines across medical specialties.

Virginia Mason’s health equity work was already changing the organization when Samantha presented to the board in September 2017, but sharing her own experience shed light on the human toll of lifelong struggle, loss and fighting for acceptance. It was the compassionate care that Virginia Mason had already given her, she said, that made her certain they could be leaders in providing the support and health services transgender people are often denied.

“Virginia Mason has these wonderful providers who really do care, they are driven to do this work.” — Samantha Forney 

“I told the board about both positive and negative experiences I’ve had,” said Samantha. “But Virginia Mason has these wonderful providers who really do care, they are driven to do this work. I see the team come together for my appointments. It’s a culture, a willingness to collaborate with each other and with other doctors that treat me. It’s so amazing to find that.”

It was Virginia Mason’s destiny, Samantha put forward to the board that day, to welcome a chronically mistreated community into the dignity and safety of comprehensive medical care. Now after more than a year of advising the organization as a PFP and working with the transgender service line (TSL) guiding team, Samantha admits being in awe of what people are doing, both on the clinical and administrative sides. It’s their energy, professionalism and humanity, she says, that motivates her to personally connect with more Virginia Mason providers.

“Every time I see a new provider I say ‘before I go, can I ask you to please consider joining the WPATH [World Professional Association for Transgender Health]?’” says Samantha. “And I also ask them to join the guiding team, because we need them.”

A face-to-face connection can open people to new ideas, a power that drives the TSL guiding team. Providers from across the patient care spectrum – from clinical staff to administrators to physicians and surgeons – join with patient partners to learn from each other as they plan improvements to the care experience.

“Guiding team meetings are a safe space for clinicians and staff members to ask questions beyond their own areas of expertise,” says Maria Rearick, director, Ambulatory Services at Virginia Mason. “It’s a unique forum, to have open discussions across care teams for sharing our progress and where we see opportunities.”

As transgender health care services at Virginia Mason grow across specialties – including primary care, speech-language pathology, gynecology, facial surgery, endocrinology, and urology – the voices of patients like Samantha ensure that awareness and sensitivity toward all LGBTQ patients keeps growing too. Working goals for the TSL guiding team include more staff education through facilitated discussions, creating a welcoming environment with everything from all-gender restrooms to affirming medical forms, and continued outreach to partner organizations and the LGBTQ community.

“This a new frontier in medicine,” says Samantha. “I’m very proud of the giant step Virginia Mason has taken in this direction. They are passionate about equity in health care and making things better for people. It’s an exciting time.”


Transgender Health Services at Virginia Mason offers a range of primary and specialty care services for transgender and non-binary patients. We provide gender-affirming, evidence-based care to meet individual needs and goals in a welcoming and supportive environment.    

 

A Horse Walks into a Hospital. No, Really.

mini horse 2

Brian Hohstadt with Baxter

A visitor to your hospital room wearing boots and a jaunty hat might not be instantly welcome – unless it happens to be a mini horse.

Baxter the therapy horse is just 26 inches tall at the shoulders, but he becomes larger than life for patients facing a difficult recovery in the hospital. Previously unresponsive patients will reach out to touch the horse. Others barely able to move after major surgery will sit up when they see Baxter. And hospital staff members report that patients tend to stay engaged, even after the visit.

Baxter is one of three mini horses that visit hospitals and other facilities with handler Brian Hohstadt, president of the Triple B Foundation for Pet Therapy. If it seems like beeping machines and slippery floors aren’t the ideal setting for even a scaled-down horse, exposure to novel sounds and situations are part of the horse’s training to become a certified therapy animal. Specially made rubber-soled boots help their small hooves track comfortably on polished floors. And bathroom breaks? They know to wait for a signal from their handler.

While published clinical data on the effectiveness of animal-assisted therapy are limited, the emotional reactions of patients, families and even hospital staff are a testament to the joy and comfort a mini horse can bring.

“When a horse trots into a patient’s room, it has a way of instantly making things better,” says Chelsea Sandlin, director, Volunteer and Ancillary Services. “We see smiles and often tears from patients and their families. Petting a horse and interacting with it really makes the patient’s day and gives them a break from whatever challenges they are facing.”

For some patients, seeing a mini horse helps them revisit fond memories. Others seem to forget, at least for a while, the limits of their immediate situation. The mission of the Triple B Foundation is “to enhance the well-being of those in need through the human-animal bond.” Maybe giving patients a break from the weight of illness – in the form of furry, four-legged love – is part of what the doctor should be ordering.

Pelvic Organ Prolapse: How a Restorative Treatment Helped Mother and Daughter

Kathy Silva describes the 12-acre farm where she grew up and where her mother, Rosemary Cockrill, still lives. Life in scenic Port Angeles, Wash. could be low key if you let it. But Rosemary, 86, kicks it up a notch, making time to go to concerts, see a play or a movie, or take a class at the senior center.

“She’s never going to get old,” says Kathy, who lives about 20 miles from her mom, in the town of Joyce, and works for the local school district.

Kathy.Rosemary

Kathy Silva (right) and her mother, Rosemary Cockrill

But Rosemary’s life wasn’t always so active. For years, she suffered the symptoms of pelvic organ prolapse, when weakened pelvic floor muscles and ligaments allow organs such as the bladder, uterus or rectum to drop, sometimes protruding out of the vagina. Pelvic organ prolapse develops over time, often long after childbirth has stretched connective tissues. When the bladder is the affected organ, a feeling of heaviness or pressure, compounded by the frequent need to urinate and the fear of accidents, can keep women from getting out and doing the things they enjoy.

“My mom asked me to please look at Virginia Mason’s website to find a urologist who could help,” says Kathy. “I chose Dr. Una Lee, who specializes in pelvic organ prolapse, and all the information we needed about her was right there.”

Dr. Lee confirmed Rosemary would benefit from surgical intervention. A minimally invasive approach using small abdominal incisions to repair the prolapse, and a supportive sling placed to support Rosemary’s bladder and urethra would relieve the constant pressure and incontinence. There was just one problem. “My mom doesn’t like anything to do with hospitals and she wasn’t excited about any of it,” remembers Kathy.

It was her mom’s evaluation at Virginia Mason that got Kathy thinking about her own discomfort. She wasn’t having any urinary problems, but she’d been feeling like she was sitting on something, and was constantly adjusting her position to get comfortable. A visit to Dr. Lee confirmed Kathy was also suffering from pelvic organ prolapse, which she learned can be hereditary. If her mom wasn’t ready yet, maybe Kathy could blaze the trail.

Dr. Lee completed Kathy’s prolapse repair in one operation through the vagina. The success of her daughter’s surgery eventually moved Rosemary toward a decision. She would have the surgery.

“Mom goes anywhere she wants now,” says Kathy. “My son got married in Vegas, and Mom insisted on going. She flew on the plane and enjoyed the whole trip without worrying about the bathroom. I know the surgery is what helped her make that trip.”

At the two-year mark after Kathy’s surgery, a check-in with Dr. Lee confirmed there was still a problem with prolapsed tissue near the rectum. Kathy’s previous repair to support her bladder remained in place, but she needed a second surgery in another area to fix what’s known as a rectocele, or posterior vaginal prolapse. Kathy credits both procedures for making her good as new, “and that’s not bad for 66,” she says. She has an enduring gratitude for Dr. Lee and the care teams who have encouraged and supported her over the years at Virginia Mason.

“No one tells you when you get older what’s not normal, and women may not be confident talking about it,” says Kathy. “Dr. Lee is easy to talk to, and she really wants to know her patients.”

Rosemary wholeheartedly agrees with her daughter, and then some. “Dr. Lee and this surgery have given me my life back,” she says.


This story also appears in the Virginia Mason Health System 2017 Annual Report.  

 

Empowered to Choose: What Women Should Know about Screening Mammography

These days women are getting conflicting recommendations about when to start screening mammograms and how often to have them. I talked with breast surgeon Janie Grumley, MD, who says that a better understanding of mammograms as a screening tool and knowing how early detection impacts cancer treatment provides the best context for decision making.


Grumley, Janie Weng 11

Janie Grumley, MD

You say some providers are telling their average-risk patients that annual screening for breast cancer may be unnecessary. Why are some women hearing that going two or even three years between mammograms is OK?

Dr. Grumley:  Recent studies have been in the media that give conflicting information about screening mammograms. What’s important to understand is that all the experts agree there is a benefit to breast cancer screening. Where conflict lies is around the ideal interval for screening. Many of the studies focus purely on the rate of survival, but survival alone is not the only benefit. When cancers are found early the treatments needed to achieve survival may be drastically different compared to cancers found later.

The reason why some practitioners are recommending longer intervals between mammograms is an attempt to lessen anxiety for women undergoing screening. But that may come at a cost, if the result is later detection of cancer and possibly the need for more treatment. Instead, I think it is more important to educate women about the limits of screening mammograms so they better understand the process and are not alarmed when called back for additional tests.

Mammograms are not perfect tests and a percentage of women will get called back for more views, and may even require a biopsy. What would you tell women whose anxiety may be keeping them from getting a mammogram?

Dr. Grumley:  Here’s something women should keep in mind: A mammogram doesn’t see cancer cells. It simply helps us see differences in how the breast looks. So we take that first look, and sometimes pick areas that need a closer look. Even biopsies are done when something looks different, not because we know it’s cancer. Providers could do a better job of helping women understand that after a mammogram, there is always the chance they will be called back. And that just means we’re not sure of the nature of the change we’re seeing. A very small portion of the women that come back will need a biopsy, and a much smaller percentage will actually have cancer.

Doing a mammogram every year, beginning at age 40, is the ideal way to track subtle changes in breast tissue and identify problems early. It’s the series of mammograms that will give us the best information. It’s like weighing yourself one day, but not tracking your weight over time. It’s a very limited piece of information. Getting mammograms every year creates a more complete picture and helps us see what we need to see.

That said, breast cancer screening is not one-size-fits-all. If a woman has very dense breast tissue, for instance, the type of imaging is important. Somebody with very dense breasts should have 3D mammography, and possibly a screening breast ultrasound. Those with fatty breasts can have a good test with a 2D mammogram. So it’s also about selecting the right tool for the right patient.

You mentioned the difference in treatment when breast cancer is found early versus at a more advanced stage. What do treatment options look like today for early breast cancer? For more advanced breast cancer?

iStock_000020255467XSmallDr. Grumley: I have a perfect example of a patient I treated. Her annual mammogram revealed a small tumor. Because the tumor was just a few millimeters, the patient could have a partial mastectomy, with breast reshaping using oncoplastic surgery techniques, plus one dose of radiation administered during surgery. She was done with her main treatment in one day. Had we waited another year, the tumor would likely be larger and require more extensive treatment, such as weeks of chemotherapy and radiation therapy. One day of treatment compared to months, with more toxicity and side effects.

We have to help women understand the screening process, how it’s important not just for survival, but also because if we get it early, we don’t have to do as much to treat you. Women often think breast cancer means mastectomy and chemotherapy, but early detection means we are doing far fewer of both. There have been great advances, including drug therapies that treat by cancer type, breast preserving lumpectomies and the possibility of intraoperative radiation therapy for localized tumors. Today there is good reason to be less fearful of what can be a very treatable cancer.

Educating women about the benefits of regular breast cancer screening could greatly affect decisions they make about their own health. How do you help more women get this information?  

Dr. Grumley:  I meet with primary care physicians and say it’s not about telling your patients what they should do, it’s about providing education. Explain what mammograms really tell us, what a callback means, what a biopsy means, and the patient can decide for themselves. Talk about how treatment plans change depending on when cancer is found. It only takes one good conversation. And if the provider wants more support for that conversation, they can have their patient follow up with a breast specialist. Because when it comes to screening decisions for breast cancer, receiving complete information is the best anti-anxiety medicine there is.

Integrated Behavioral Health: Taking Care of the Body and Mind

A Virginia Mason patient for 32 years, Tom Cyr visited his primary care physician with some familiar complaints. He had back pain, a side effect from a hard physical career, and his damaged knee – a decades-long condition requiring multiple surgeries – threatened to derail daily life. Tom’s doctor addressed those problems but was equally concerned about signs he wasn’t coping.

Annual Report - Primary Care“I was down,” remembers Tom. “Bad things had happened in my personal life. My doctor felt it even more than I knew it.”

Tom got an appointment that day with Megan Bott, LICSW, outpatient and Emergency Department social work supervisor, through a program integrating behavioral health care with primary care. Under the previous system, a patient might get in touch with social services by phone, and that’s where most interactions took place. Integrated services mean patients like Tom can see a social worker right away, for assessment and short-term counseling if needed.

Megan and Tom decided to meet regularly to start some basic cognitive behavioral therapy. Megan describes it as practical, skill-based therapy focused on identifying disabling thought patterns, reviewing what’s worked in the past and trying new approaches for problem-solving. Patients may have up to eight visits with the social worker, and be referred for continued mental health care when more support is needed. Megan and her two social work colleagues – covering Virginia Mason’s downtown Seattle and Kirkland locations – also provide crisis counseling, assistance to seniors, caregiver support, resources for people with special needs, and referrals for those dealing with abuse or addiction.

“For a primary care provider who realizes their patient is in distress, we offer a ready resource to support a variety of issues, often just in time,” says Megan. “After a diagnostic evaluation, we work closely with the physician, sharing observations and coordinating treatment to meet more of the patient’s needs.”

Forced into early retirement due to health problems, Tom was already struggling when the death of one family member and serious injury to another left him feeling hopeless and adrift. In sessions with Megan, Tom revealed an interest in volunteering, but didn’t know where to start. Megan told him about volunteer opportunities at Virginia Mason and offered to help with the paperwork. Soon Tom had a volunteer badge and a new-found expertise preparing large mailings for the medical center.

“The volunteer work was my savior through the holiday months last year,” remembers Tom. “Megan helped me with a lot of things I couldn’t cope with at the time. I probably would’ve been in my doctor’s office every other week and that wouldn’t have solved the problem.”

After Tom’s counseling sessions with Megan, a referral to psychiatry was planned but not needed. Tom says they both figured he’d graduated. Still a dedicated volunteer, Tom’s looking forward to his upcoming partial knee replacement that should have him walking pain-free. “But Megan made it clear her door’s still wide open,” says Tom.


A version of this story originally appeared in the 2016 Virginia Mason Health System Annual Report.