Primary Care for the 20 Something Generation

I was asked this week to comment on the status of primary care for those in their twenties.  I am using my answer for this weeks' post.  For more information and discussion on this topic click here.

Should 20-Somethings Have and See a Primary Care Doctor?
I am obviously biased in regards to this question, but yes, absolutely.  Do they need to go for frequent check ups if they are otherwise healthy?  No, they do not.  Early on in the twenties is a great time to establish a relationship with a doctor who can help guide them through their health for the decades to come.  For young women who are otherwise healthy, this may be their gynecologist.  An Internal Medicine physician is certainly appropriate.  That first visit is important to first establish a relationship.  That way, when illness or injury comes along, there is someone ready to help.  Secondly, it is a chance to evaluate one's health habits.  This decade is a critical time for establishing healthy habits which will endure a life time.  The human body goes through a big change in those years.  The ever active metabolism characteristic of adolescence simmers down to a slowly declining  state.  If anticipated and accounted for with dietary changes, the not so unusual 15-20 pound weight gain can be avoided.  It is much easier to maintain body weight than it is to spend the rest of your life trying to lose it.

Are Young People a Drain on the Health Care System?
Not at all.  In fact, young healthy people are viewed as one of the keys to controlling health care costs and being able to provide health care for our entire population.  If we did not have young, healthy people carry insurance, all of us will pay a larger price.  That said, if young people do not have a primary care physician established, they will present to emergency rooms with conditions which could easily be evaluated in a physician's office.  The cost of emergency care is exponentially higher than it is in the primary care setting.

What Tests Do Young People Need to Get?
In the absence of any concerning symptoms or physical findings the most important "test" to be done is that initial history and physical examination.  More than any battery of tests, that first visit will help guide the physician to tailor any testing to the needs of the individual.  If it has not been done previously, I recommend at least a total cholesterol level as a baseline.  A family history of diabetes may prompt testing for blood sugar.  Symptoms of fatigue in a woman with heavy menstrual cycles would prompt a test looking for anemia.  However, from a purely routine standpoint, that initial visit carries the most weight.

Do Doctors See a Difference in the Way in which 20-somethings Approach Health Compared to Older Generations?
I don't think a broad generalization is possible here.  I know many young adults who take exceptionally good care of themselves and are extremely health conscious.  I also just met a young woman who basically eats junk food for all three of her meals a day.  She starts with a pop tart.  Chips and soda often pass for lunch and she may finish at Taco Bell that night.  I do think that elderly patients think of their health a lot more but this is because they are now suffering from many more conditions than before.  Some ailments come as a natural result of aging but many could have been prevented had they cared for their health better when they were younger.

Staying Sharp

Mental health is something most of us take for granted until we start to lose it.  When I refer to mental in this instance, I am specifically referring to our ability to think, reason and remember.  Just as we need our muscles to move our bodies, we rely on the brain to direct all of our activities.  Our ability to do so profoundly affects our physical health.  I have a patient who is 106 years old.  She has experienced many years of good health but she is now blind and can hear very little.  She mostly mumbles to herself and her mind is no longer functioning well.  Though she has been healthy enough to reach such an advanced age most would agree that we would not want to be in such a condition.  I have another patient in her nineties who stays active and continues to teach a dance class.  Her mind is active and quick.  One would even say, "sharp as a tack."  If we are going to live a long life, we want to maximize our chances of staying "sharp."  Though there are no guaranties that we will not experience dementia or other problems, let me share some ideas on how we can maintain our mental acuity.

First, keep your mind free from mind altering substances.  Drugs such as alcohol and marijuana will dull our senses.  One of the biggest brain depressants are sedative sleeping pills.  One would think that getting a "good night sleep" will help you be more alert and less tired the next day.  However, studies have consistently shown that patients given sleeping pills function more poorly.  They perform less well while driving and doing tasks requiring concentration.  Antidepressants need to be used with caution as well.  Although depression itself can cause symptoms identical to dementia, the medications used to treat it can cause one to be less than sharp.  It is appropriate once an initial response is achieved to then decrease the dose if maintenance is required.

Stimulants trade short term mental activation for longer term lethargy.  Most who grab something with caffeine to "wake up" don't think of the longer term consequences.  Habitual caffeine use can result in more persistent, longer term fatigue and "brain fog."  Methamphetamine abuse is soaring.  Anyone who has known an addict will not confuse their mental sharpness with that of a sharp instrument.  I have the same concern for prescription stimulants used to treat ADD.  When they are absolutely necessary, the lowest possible dose should be used for the shortest period of time.  We really don't know the long term ramifications of regular use for more than just a few years.

One of the biggest determinants of brain health in later years is maintaining blood flow to the brain.  Just as decreased blood flow to the heart or the kidneys can cause disease, the same is true for the brain.  This goes right back to our physical health.  You want to be exercising, eating right and maintaining normal blood pressure and cholesterol values.  This has been discussed in more detail in my previous posts.

Just as regular exercise keeps our muscles strong and active, regular brain activity keeps the brain connections working as well.  It has been shown that those who do so have a seven fold decreased risk of developing Alzheimer's.  This beneficial effect is for greater than any medication or supplement.  Too many of us let others do our thinking for us.  We spend too much time in front of television screens and not enough time reading, writing, speaking a foreign language, playing a musical instrument or doing puzzles and games.

Someone with a sharp, active brain is more likely to take an active interest in their health.  They will study and learn about any conditions they have and may actually read this blog!  Let us all do what we can to hone our brain.  Let's keep our brains clear, let's stay active, let's stay sharp.

The Indomitable Human Spirit

One of the aspects that I love about my job is reading about scientific advancements.  The human body is a remarkable organism and the more we learn about it, the more amazed I am.  Each new scientific advancement is like peeling away the layers of an onion.  That said, there are times when I cannot explain by scientific means what I observe with my own eyes.  This often occurs at the end of life.  Time and time again I'll see a patient at the end of life in the hospital whose organs are failing and may not even be conscious any more.  I know as a physician that death could come at any time but what happens more often than not is that as soon as the last family arrives from far away, the patient will then slip away peacefully.  I am convinced that amid the millions of cells in the body resides the spirit of man that cannot be quantified or studied in the usual way.  Some how, some way, the patient senses the presence of his loved one.  The spirit then is free to leave this life and the body is left lifeless.

Though the details may vary, the belief in a higher power and of man's spiritual nature are pervasive through almost all cultures.  Assuming that we indeed have a spirit and that there is a higher power, how does that affect our health?  Researchers have even tried to study the effects of prayer on health.  The results have been controversial.  It is difficult to quantify the "dose" of prayer and faith and the effect it may have on an individual.  A more consistent finding has been that church attending individuals are generally healthier than their counterparts.  It is hard to know if this is due to increased spiritual power, to the beneficial effects of quiet meditation and prayer on stress, to healthier life styles or to a combination of all of the above.

I have my own beliefs, of course, and feel strongly that our spiritual lives most certainly affect our physical health.  It is not something I actively ask my patients to pursue but I do ask about it.  I certainly encourage patients to both reach out to others in their congregations when they are in need as well as avail themselves of such support themselves during times of illness.  I may not ask someone to pray but I will inform someone that I will pray for them.  I certainly pray myself that I may make good choices for my patients and do what is best for them.  I have felt a quiet power in my life as I deal with the stress of having someone's health depend upon my ability to both diagnose and manage thier conditions correctly.


If you have inclinations to seek for spiritual enlightenment, I encourage you to pursue them.  A strong spirit will lead to a strong body, as we strive to keep all things in balance.

Subduing the Stress Monster

I realize this is easier said than done. I also realize that not all stress is the same. That said, let me share a few thoughts on how we can tame the beast other than resorting to the instructions on the right.

First off, don't neglect your physical health. when life gets busy and tensions rise one of the first thing to fall by the wayside is healthy eating and regular exercise. If there is no time to cook, be smart. You can rush into a grocery store and grab a prepared salad or fruit cup just as quickly as stopping by one of the fast food joints to get a burger. Make sure to grab some fruit. They can be eaten on the go at any time, with no preparation. Keep a water bottle with you at all times.  Put one in your car or at work so that you are staying hydrated. At all costs stay away from the 'comfort foods.' It is not uncommon for the scale to go up commensurate with the stress level.

In regards to exercise, "make every step count" (see my previous post here).  Exercise stimulates your muscle enzymes to metabolize carbohydrates more efficiently. It also causes the release of specific hormones in the brain called endorphins. These neurotransmitters effects a feeling of well being and satisfaction. It is not unlike the emotions from eating chocolate, only it is achieved by much healthier means. This effect has been studied in a scientific trial of patients with anxiety. They were divided into two groups. The first group was given a commonly prescribed medicine called an SSRI. The group improved pretty much as expected. The unexpected result occurred with the second group. This group was given no medication but they patients were enrolled in an exercise program. They also improved and their improvement was to the same extent as the medication group. I remember watching an interview on the news some years ago. A couple was celebrating their 70th wedding anniversary. When asked what his secret of success was, the husband answered, "to be married this long, you need to be alive a long time. I attribute my longevity to advise I received when I was married. 'If you ever get angry at your wife, don't fight. Get up and go for a walk.' I am an example of the beneficial results of regular exercise!"

The next point to keep in mind is to prioritize. Much of life's stress comes from the feeling that there are not enough hours in the day. It is overwhelming to feel that we are not living up to expectations, whether they be set by someone else or by ourselves. What is the big picture?  Where do you want to be in 10 or 20 years?  How do you want to live?  Set intermediary goals that will help you achieve your
aspirations. Now, most importantly, make a list of all of the activities that make up your day. How do they help you achieve your goals?  Now prioritize them according to their usefulness. When we are actively working towards set goals we will have the feeling of accomplishment, which is very rewarding. The worries from our stress will change to the contentment of our progress.

Now going from the big picture to the little one. There are times that we "sweat the little stuff." sometimes the smallest thing can set us off. Telling someone to be patient and to relax doesn't really help. How can we defuse our temper when it threatens to flare?  One way is to anticipate stressful situations and plan in advance how we will react. We do much better when we are proactive rather than reactive.  A great way to physically calm down is to force ourselves to breath more slowly. Try it: breath in through your nose and out through your mouth. The act of slowing down our respirations increases the effect of the vagus nerve counteracting the adrenaline response. This will slow down our heart rate, improve the oxygen delivery to our whole body, resulting in calming down our physical body.  When that is under control, we can much more easily control our emotions as well.

This is by no means an exhaustive list but only a few of the weapons you can use to subdue the monster of stress that threatens to destroy your health.

Sabotaged by Stress

We all have stress in our lives.  The source of it may differ, but we all have it.  Even small babies show their stress when they are hungry, dirty or tired.  We may not cry out and scream like they do, but admit it, you've thought about it!  It isn't the stress that is the problem, it is how we deal with it.  If it weren't for stress we wouldn't get much accomplished.  Stress motivates us to work hard and be better.  The key is to manage it so that it works in our favor, not to our detriment.  When simple stress and worry turn to anxiety and panic, it will start to have adverse effects on our health.  It can and does effect nearly every organ system in the body.  Let me show you how.

Brain/Head: 

Stress commonly causes mental fatigue.  Our brain may feel overloaded and burdened.  As such it is harder to hold onto facts that were recently learned such as names, numbers, tasks, appointments, etc.  It also makes learning more difficult.  Headaches are an extremely common result of stress.  Migraines are common.  Tension headaches also occur. Stress can lower the effectiveness of our immune system resulting in frequent sinus infections.  Many people exhibit poor eating habits while under stress.  Quick foods including candy and sweets are over consumed.  This could result in poor dental hygiene and result in cavities and other mouth disease.  

Lungs/Heart:

Shortness of breath is very common in panic disorder.  To the extremes, hyperventilation can cause dizziness as well as numbness and tingling in the hands and feet.  Chest pain is commonly a result of stress.  It may be due to excessive adrenaline (a stress hormone) or just tightness in the muscles of the chest wall.  The pain itself becomes a source of worry, which tends to trigger a cycle or worsened pain and more anxiety.  Emergency Rooms are full of patients with chest pain due to this cause.  Palpitations or skipped beats are a natural result of these stress hormones racing through the body.  Blood pressure may be elevated transiently at times which can trigger actual heart problems.  There are even extreme cases where the coronary arteries (blood vessels of the heart) will spasm and close off as a result of a sudden, extreme stressful event.  

Digestive Tract:

The functional disorders of the gastrointestinal (GI) tract are all related to stress.  These include irritable bowel syndrome, functional dyspepsia and cyclical vomiting syndrome.  There are as many nerves in the GI tract as there are in the brain.  It takes a tremendous amount of coordination to take what we eat and move it through the whole system.  When our brains are under stress, those nerve connections often don't fire correctly.  This can result in problems with swallowing, bloating, gas, cramping, constipation, diarrhea and or pain.

Endocrine (hormone) System:

Most diabetics can attest that during stressful times, control of their blood sugar becomes more difficult.  This is due to the adverse effects of adrenaline, causing more cortisone to be released into the system,resulting in insulin resistance.  It is commonly understood that stress affects female hormones.  This can cause alterations in menstrual cycles and even increases problems of infertility.  

Skin:

Those who are predisposed to eczema or have psoriasis can attest that stress can make either condition worse.  I have seen patients with severe anxiety who constantly pick at themselves.  They can develop small sores all across their body.  

Muscles: 

Of course, one of the first responses to stress is to tighten our muscles.  In addition to the headaches and chest pains listed above, it can result in tightness in the jaw muscles (TMJ disorder) and especially tightness in the neck, back and shoulders.  This is especially true for those who spend too little time moving and too much time in front of key boards and monitors.  I guess that may apply to both you and me!

Have you experienced any of the conditions listed above?  In some form or another I suppose we all have.  In the next post I will discuss ways in which we can manage this stress which likes to sabotage our health.