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DEAR DR. ROACH: How much power do you think administrative employees in a doctor's office should have over patient care? I like my doctor and his nursing staff, but I'm quite upset about a situation where a specialist from out of town faxed a request for a CT scan to my primary care physician's office. The assistant that received the request refused to schedule the CT scan because she said it would not be covered by my insurance (Medicare). I called Medicare, and they said a CT scan requested by a doctor will always be covered.

I wrote a letter to my doctor and the administrative employee over a week ago, and I've heard nothing back. I hoped to make my doctor aware that his admin could be making a decision that seriously impacts their patients. I am a lung-cancer survivor, and suspicious nodules were seen on a CT scan back in March. So, my pulmonologist wanted a repeat CT scan in June.

I am thinking that as much as I like my doctor, it may be time for me to seek out a different primary care physician. What do you think? -- D.B.

ANSWER: I think you already know the answer, which is that medical decisions should, of course, be made by medical practitioners, not by administrators. Still, there are a couple of important points.

The first question I have is: As a primary care physician myself, why didn't the out-of-town pulmonologist order the test themselves? It's usually possible to do so, even for an out-of-town physician. If not, then a phone call or an electronic message would have been more effective and polite. Direct communication between the generalist and specialist is critical to good patient care. This is particularly important when there is an abnormal finding like this, which needs to be evaluated right away.

Finally, I would think it prudent to speak with your primary care doctor directly so that they know what happened. Did your doctor even know about the misunderstanding? You can make a decision about staying with them based on their answer.

DEAR DR. ROACH: Is Zyrtec safe to take for 75 year olds? -- M.D.

ANSWER: Cetirizine (Zyrtec) is a "newer generation" antihistamine with fewer side effects than older antihistamines, like diphenhydramine (Benadryl). Even so, some people will experience drowsiness with this medicine. In large studies, 11% to 14% of people taking Zyrtec reported drowsiness, compared to 6% of people who had drowsiness on an inactive pill.

Older adults are even more likely to develop drowsiness, so it's recommended not to exceed 5 mg (half the dose for young adults) for people aged 77 or older. The reason for the lower dose is that older adults tend to have a slower metabolism, so the 5-mg dose is roughly equivalent to the 10-mg dose for younger people.

One problem that can happen when someone takes an antihistamine every day is that if they stop it, they can develop severe itching. To avoid this, don't take it every day unless you really need it, and even then, try to go without it periodically. If you are taking Zyrtec for chronic allergy symptoms of the nose, you might have better results with a nasal steroid, like fluticasone (Flonase).

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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 ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.

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