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Interviewer: It's time for Seven Questions. It's time, seven questions for a cardiologist. We've got Dr. John Ryan here and I'm going to ask you seven questions. Just want your answers just as they come to you, okay?

Dr. Ryan: Sure thing.

Interviewer: Don't think about it too much, as quick as you can. What's the best thing that I can do for my heart to make sure it stays healthy?

Dr. Ryan: Probably exercise 30 minutes every day, something that gets your heart rate up, and just get it into your routine as something that is part of your daily schedule.

Interviewer: All right. What's the worst thing I can do for my heart?

Dr. Ryan: Probably not exercise at all.

Interviewer: Really?

Dr. Ryan: Yes.

Interviewer: Even worse than like smoking or something like that?

Dr. Ryan: It is. Yes. Well, that's fair. I mean, you're going to assume that folks know that they shouldn't smoke, but even when you have people who have a normal weight and who don't exercise, they actually are at a higher risk of having heart disease and a higher rate of mortality than people who are overweight who do exercise. The sedentary lifestyle is really hurting us.

Interviewer: What do you know about the heart that everybody else should know?

Dr. Ryan: You really can make a positive change to your risk of having a heart attack. Really, it is not something that you need to give up on. And even if you've had a historical lifestyle of smoking, not exercising, eating fatty foods, your destiny is not to have a heart attack. You can actually change your destiny and really reduce your risk of having a heart attack by stopping smoking, actively exercising, losing weight, etc. So I think that's really just key to be aware of.

Interviewer: Can you scare somebody to the extent that they have a heart attack?

Dr. Ryan: There's definitely a stress component to having a heart attack. There are people who, at football games have heart attacks, at roller coasters have heart attacks, downhill skiers occasionally have heart attacks.

Interviewer: What about, like a victim of an April Fools joke?

Dr. Ryan: I think that would be really unfortunate and would kind of make you have to rethink the whole tradition of April Fools' Day in general if mortality from cardiovascular disease goes up on April Fools' Day, I think we need to rethink why we have this holiday.

Interviewer: What is your favorite song that has the word "heart" in it?

Dr. Ryan: The favorite, probably "Total Eclipse of the Heart."

Interviewer: Okay.

Dr. Ryan: It's an incredible song.

Interviewer: Why did you specialize in cardiology?

Dr. Ryan: I think you can really do a lot in cardiology because you can take care of the individual person across the way from you, but there's also a large public health component to it, in so far as trying to get your community to be more active. And that's just a fascinating part in America because we're so heavily dependent on our cars and we don't walk, we don't cycle around our neighborhoods anymore, stuff like that.

And then there is also the nutritional components. So, as well as having that one-on-one relationship, you also have this public health issue from cardiovascular disease, which I think is really important for cardiologists to be at the forefront of.

And then also the basic science in cardiology is just fascinating and has really made a significant impact in cardiovascular disease over the last 30, 40 years. And when you look at how we have cared for people and the advances we've made in terms of reducing the rate of heart attack, reducing the mortality from heart attack and stroke over the last 40 years, those impacts have been made because we have done significant basic science advancements and because we've also made community awareness about heart disease and how to lower your heart risk.

Interviewer: What advancement in your field has you the most excited?

Dr. Ryan: I think we're getting at a point where the technology is becoming really personalized. It is really exciting that people come to us with the data that they've generated, either from their phones, from their smart phones, from what people have collected from wearables, and that their health literally is in their hands, and they are coming to us with what they've found.

Whereas traditionally, we do tests and we would say, "Well this is what we've found." Now they're coming to us with what they've found, and that's a really exciting thing because that really shifts the responsibility of cardiovascular care and risk reduction to where it should be, which is to the individual.

updated: January 27, 2021
originally published: June 14, 2017

Interviewer: If you've ever had any questions about baby teeth, are they important? Is it okay if a child has a baby tooth knocked out? Is it a big deal or not? What about when you can start brushing? We're going to cover baby teeth next on The Scope.

Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. James Bekker is with University of Utah's School of Dentistry and he's going to give us some tips and information on baby teeth because you get a lot of questions about baby teeth. First of all, are baby teeth important or are they just that first set of teeth and I don't have to worry about them too much?

Dr. Bekker: Yes. Thanks for the question. That's a good one and we do get that a lot. Parents will often ask or say, "Gee. Why do I need to take care of these baby teeth? Why do I need to go through the expense or the experience of getting them taken care of?"

Interviewer: Or even the hassle of getting your kid to brush, right?

Dr. Bekker: Exactly. Baby teeth are very important because they are connected to where the permanent tooth is developing. So if you have a tooth that gets a cavity and gets infected, that infection can go from where it is in the baby tooth and into the jaw around where the permanent tooth is developing. Permanent teeth can be affected by baby teeth that are neglected.

Now if you lost a baby tooth, that brings up the other reason they're important is they hold space. If you lose a baby tooth early, it's like having bricks in an archway. If you pull out a brick in an arch, all the other bricks fall into that hole. Same thing happens with teeth. Everything else shifts and then your permanent teeth don't come in the right place.

So if you lose a tooth early it's important to hold the space and to maintain that space for the permanent tooth. It's also important to know that you're still losing baby molars when you're 12 years old. You've got some permanent teeth in your mouth when you have baby teeth in your mouth and that caries process or cavities process that happens with baby teeth really can affect the permanent teeth that you have.

Interviewer: So if you get a cavity in the baby tooth, is the effect on the permanent tooth underneath even more drastic than if I'd just got a cavity, like an adult got a cavity in a regular tooth? Does that make sense? Does it go beyond just the cavity in that situation?

Dr. Bekker: It depends on how far that cavity is allowed to go. If you just get a small cavity in a baby tooth and it gets fixed then there's probably no repercussions on the permanent tooth. But if that cavity is allowed to go on to get into the nerve, have the nerve become infected, and that infection travel down through the roots to where the permanent tooth is, it can have an effect on the permanent tooth development.

Interviewer: When should a child go to the dentist for the first time? You're talking about how important it is to take care of these baby teeth. When should you really start being concerned?

Dr. Bekker: We like to have children at the dentist at about a year of age.

Interviewer: Really?

Dr. Bekker: Yes.

Interviewer: That's much younger than I would . . . do most people find that to be younger than they expected?

Dr. Bekker: The American Academy of Pediatrics and the American Dental Association have collaborated on a number of studies and it is shown that if we get in early, you do some prevention of caries with the children. But the key point is you're educating the parents. I have so many children that come in at age three and they have a mouth full of cavities. If we were able to see that child at age one and do a little prevention, cleanings and fluoride treatments, that kind of thing, and educate the parents as to how to take care of those teeth, we could probably prevent a lot of those cavities that we see at three or at five.

Interviewer: Yeah. When should a child a start brushing his teeth? Or when should a parent start brushing a child's teeth? At one?

Dr. Bekker: Yes. As soon as...

Interviewer: When that first tooth comes in, start taking care of it.

Dr. Bekker: That's exactly it. Typically the first teeth are going to come in on the lower arch, the mandible, at around six months. Of course, the little kids aren't going to want to brush their teeth at that age. But we show parents how to hold them in a safe way that allows the parent to be able to brush the teeth while they're holding the child and how to effectively help that child get used to brushing, the taste of the toothpaste, and having the brush in their mouth. It's a process. Parents say, "How old should a child be when I let them brush their teeth on their own?" And I say, "About nine."

Interviewer: Up to that point it is the parent's responsibility.

Dr. Bekker: A lot of times, we say, "Have your child brush their own teeth and then mom or dad just check." And we say "check" with big quotation marks around them. You take that brush and you get in there and you go, "Oh, you did a great job on these. And, oh these over here you did a really good job." Mom and dad check the teeth and in checking they get in and get them really brushed done.

Interviewer: Getting a little brushing done. All the way to nine, huh?

Dr. Bekker: Well, thereabouts.

Announcer: That seems like a long time.

Dr. Bekker: Somewhere along in there, when the child can really understand how to effectively brush and floss.

Interviewer: Got you. Give us one great tip to end this interview. If somebody were going to do something for their child's teeth and do it well, if there was only one thing you could tell them and that's all the time you had, what would it be?

Dr. Bekker: Just take care of the ones you want to keep.

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Interviewer: Three things patients should ask and three things all doctors should be sure their patients understand. That's coming up next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Sometimes as a patient when you're in clinic with a physician, you leave and you're like, "I don't know what's wrong with me and I don't know what to do about it," and you're just confused. But if you ask these three questions, and if you're a provider you make sure patients understand the answers to these three questions you could solve all the problems. We're going to find out more about the Ask 3 Program. Darren Doman, he's the Patient Education Specialist here at University of Utah Health Care. What is the Ask 3 Program and it sounds magical?

Doman: It is pretty magical. It's an initiative put together by the National Patient Safety Foundation and it's meant to just help improve communication between health care providers and their patients in efforts to improve health outcomes. So basically they synthesize every visit into three main questions.

Interviewer: Okay.

Doman: First, "What is my main problem?"

Interviewer: Yeah okay.

Doman: That's a good question.

Interviewer: That's a great question. That's why you're there.

Doman: Exactly.

Interviewer: Yeah.

Doman: Put a label on it, give it a name. The second question is, "What do I need to do about it?" And then the third question is, "Why is it important for me to do that?"

Interviewer: I love that because I think it synthesizes in very, three very quick little questions. Like when you're a patient you leave and you don't understand what just happened and you're trying to figure out, "What could I have done to change it?" I think this is perfect.

Doman: Absolutely and there's some research out of Great Britain that shows that when it comes to an outpatient doctor patient interaction, 80% of people leave that visit without accurately recalling any information that the doctor told them.

Interviewer: So it would be hard for them to tell their husband, their wife, their kids, anybody.

Doman: Exactly, but when they probed the 20% that remembered something a little bit closer, only half of them actually got it right.

Interviewer: Really?

Doman: So it's really 9 out of 10 people leave the doctor's office not able to remember accurately what the doctor told them.

Interviewer: That's pretty incredible and that's based on research.

Doman: Based on research out of the UK.

Interviewer: All right so the Ask 3 Program, "What's my main problem?" "What do I need to do?" "Why is it important for me to do this?" Is there any research on showing if people ask these questions what retention rates are?

Doman: Well the most current research that I read was showing that patients aren't actually asking these three questions.

Interviewer: Okay.

Doman: So we need to take a step back, revamp the program, and maybe think about it a little bit differently. Which I think is a perfect opportunity for us to talk to providers and say, "You know, here's three great questions. If your patients aren't asking these questions, why don't you just help them out and give them this information?"

Interviewer: Yeah just make sure that they understand these three things.

Doman: Exactly and that speaks to the need for open communication between patients and doctors to really get the message home. Patients need to be asking the questions, doctors need to be telling the patients the right things, and they need to be checking to make sure that the message was received.

Interviewer: So it sounds like a good idea as a patient if I go in that maybe when it starts getting a little confusing I just need to fall back on those three, you know? Because sometimes the issues get a little muddled right?

Doman: Absolutely, and just bring it back to, "Okay what's the main problem?"

Interviewer: "What do I need to do?"

Doman: And, "Why is it important to do it?"

Interviewer: And as a provider it might be a good idea after you tell them these three things to ask them, "Okay do you understand what your problem is? Tell me what it is." When I was in my communication classes that's all part of listening, it's all part of checking to make sure the person understand what you just said to them is to ask them to tell you what you just said to them.

Doman: Absolutely and providers who are really keyed into this can do it very artfully. They can say, "I think your main problem is this," and then, "Later when you get home what are you going to tell your spouse that your main problem is?" Just to check and see.

Interviewer: Yeah, because a lot of times we assume that the person understood us and we don't want to insult their intelligence by insinuating on some level that they didn't, but a lot of times people don't. I mean there's a lot of a thing that can go wrong with communication, it's not either individuals fault.

Doman: It's true, and double checking message received is never a bad idea.

Interviewer: What's keeping patients from asking these three questions do you think?

Doman: When it comes to patients asking questions in doctors' visits I always think its fear based. They don't want to look stupid in front of their care provider. Maybe they kind of know the answer but they're a little bit afraid of actually hearing somebody else say it. So there are reasons why they might not pipe up and actually ask.

Interviewer: But at that point it's important beyond your ego, beyond anything else, to clearly understand what's going on, what you need to do, and how important it is.

Doman: Sure, yeah.

Interviewer: And how about physicians, is there a barrier to them adopting kind of just these three questions making sure patients identify it? Is it something they ever thought about before?

Doman: I think it takes that moment of just engaging your brain and checking in rather than getting into too much of a routine. Everybody kind of gets their routine going, they kind of do it the same way they've always done it, in and out, keep the flow going. But if we can actually engage with the patients say, "Here's my new routine, here are these three important things that I need every patient to understand," I think we're going to have a better go of patient interaction, better communication, and ultimately better health outcomes.

Interviewer: Any final thoughts on the Ask 3 Program? I think it's brilliant.

Doman: I think its brilliant too, and just getting the word out to patients and providers alike that it's a conversation. It shouldn't be one-sided doctor talking all the time. The patient should have some input as well and if the patient doesn't know quite what to ask here's three good questions. Anybody who asks these isn't going to look stupid in front of their doctor.

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Announcer: Examining the latest research and telling you about the latest breakthroughs, on the The Science and Research Show is on The Scope.

Interviewer: My guest pediatric oncologist, Dr. Joshua Schiffman, is on a mission to let physicians and patients know that in the case of childhood cancers there is a good chance that some are inherited. Knowing this information can make a big difference in patient care and even in preventing cancer in family members.
Dr. Schiffman, what prompted you to look at the inheritance of cancer?

Dr. Schiffman: When a new child is diagnosed in the middle of the night, the parents typically ask three questions. The first question that they want to know always is, will my child live or will my child die? Now fortunately in pediatric cancer we cure 80% or more. So we can reassure the patients, yes, yes, your child has a great chance of survival based on all the great stuff that we're doing as the Department of Pediatrics and Primary Children's Hospital and around the country.
Now the next question that often comes up is why did my child get cancer, and that's something that we're studying in our laboratory here at the University of Utah, trying to answer that question. For now what we tell the families is, well we don't quite know. It's probably a combination of environment and genetics, but we're working on it.
But the third question that always, always comes up is are my other children also at risk for cancer. This is an especially important question in Utah, where families have five, six, seven, sometimes as many as ten children.

Interviewer: Right.

Dr. Schiffman: And in the past the only answer that we had for this question, which is asked at every new diagnosis, was we don't think so. We think probably not, this was just random chance. But we don't know for sure.

Interviewer: You did a study looking at the families of children with cancer. What did you find?

Dr. Schiffman: This was a fascinating study. We were able to use the Utah Population Database to look back to 1966 to determine how many cases of childhood cancers there were in Utah, and of those cases where we were able to have a family history, which was approximately 4,482; how many of those children also had other family members with cancer.
We were able to show that yes indeed, if you are a child diagnosed with cancer, that you have a two to four-fold risk of having another first degree relative, often a sibling, with childhood cancer. Now there's a very important caveat here, which was that increased risk was only found in those families that already had an increased history of cancer.

Interviewer: And what could knowing that information mean for family members?

Dr. Schiffman: Based on this study, we can now say that in order to answer the question, are your other children at risk, what is your family history of cancer. And if they say, we have no family history of cancer, and then we can confidently say, based on our study, that we don't think your other children are at increased risk for cancer. It's the same as the population.
However, if they tell us, well actually yes there is a strong family history in our family of cancer, and then we could say, well, we know now that your other children are at a two to four-fold increased risk of cancer.

Interviewer: And what is the difference between an inherited cancer and an acquired cancer?

Dr. Schiffman: We often talk about the two-head hypothesis in cancer.

Interviewer: Right.

Dr. Schiffman: In the normal, health population like you or I, it often takes a lot of time and it's really a chance phenomenon that you would randomly get two mutations in the same gene that go on to develop that actual cancer.
In children in families with inherited cancer syndrome, they are already set up with their first hit. They are already far down the runway of cancer development. They just need their second hit, and once they get that second hit that's when they develop the cancer.

Interviewer: If you knew that one of the children you were seeing had an inherited cancer, how would that change how you treat the patient?

Dr. Schiffman: That's an excellent question. One of the things we know is that in terms of inherited cancer that in many of the children with these syndromes their cells do not repair DNA the way that normal cells do. That may translate into an increased risk of secondary cancers. So when choosing the therapy for a patient who has an inherited cancer syndrome, we take into consideration the risk that they could develop additional cancers if we don't choose the right therapy.

Interviewer: And so an inherited cancer would probably mean that you'll get it earlier in life?

Dr. Schiffman: That is correct.

Interviewer: And have you had cases where knowing whether a cancer is inherited within a family has made a difference for them?

Dr. Schiffman: Absolutely. We are now able to initiate at the University of Utah whole body MRI screening. We are able to screen patients at inherited risk for cancer who don't have any symptoms from head to toe in a single procedure in less than an hour and we have countless examples where we have found cancer before the patient even knew they were sick; before they had a single symptom.
Now imagine that; this completely shifts the paradigm of cancer. If we can identify who is at risk, then we can screen cancer, find it at an earlier stage and make a difference. We have found brain tumors. We have found lung tumors. We have found kidney tumors. We have found carotid body tumors. We have found pheochromocytoma in the adrenal glands. The list goes on and on. By knowing that a patient is at increased risk, we can improve survival and decrease morbidity.

Interviewer: Do oncologists normally take family histories of cancer patients?

Dr. Schiffman: Unfortunately the world of clinical oncology is a very busy place. There are many time constraints, there are many patients; there are insurance companies to talk to. There are pharmaceutical companies to talk to, there are clinical trials. There is so much going on that unfortunately family history often gets lost in the shuffle.
So we are working with other colleagues across the country to try to figure out a way to implement an easier and more fascicle way to collect family history and get that information to the clinician and also help the clinical oncologist to interpret that data to better understand if their patient should be referred for further genetic testing and evaluation by genetic counselors, and clinical oncologists with an interest in cancer genetics.

Interviewer: And what would your recommendation be for the cancer patients?

Dr. Schiffman: For cancer patients I would recommend that they sit down with their other family members and that they take a very careful family history; that they try to figure out what diseases run in their family, have there been other cancers that have occurred to figure out if they were, for instance, bone cancer. Was it truly a bone sarcoma, or was it another tumor, like a breast cancer, that had spread to the bone.
All of this information helps us in the world of cancer genetics along with the genetic counselors, who are by the way indispensable to this effort, to try to determine what the genetic risks are for disease in this patient. Once they've collected their family history, I would recommend that they talk with either their primary care oncologist, or to even their family medicine doctor, or general internist, or general pediatrician. Share that family history to see if there is a risk for inherited cancer syndrome in the family.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.