Big Brother

On the eve of our national elections many are pondering the role of government in their lives.  We rely on our government for many of the basic necessities of life.  I am grateful to never have gone to bed at night worried that I could be bombed.  Likewise, the ability to turn on a tap and drink clean water is a privilege I take very seriously having lived for a year in Guatemala when younger.  The roads I travel, the electricity I use almost constantly, the schools my children attend are all a result of my citizenship in this great country of ours.  Additionally what makes our country great are the freedoms we are granted.  I am free to pursue whatever path of education and vocation I desire.  I am free to live wherever I want.  I can write such a blog as this and not worry about voicing my opinion.  That said, the delicate balance between taking care of its citizens and granting them freedom can at times be a tricky one to maintain.

Let me illustrate.  As a country the freedom of being able to drive wherever we want is tempered by speed limits, stop lights, qualifications of sobriety, seat belts and the mandate to have car insurance.  What may be viewed as protective laws by one could be construed as invasive antidemocratic abuses by another.  Such debates and concerns are also being raised in regards to the health of the population.

There are many social, moral and even economic reasons to improve the health of our citizenship.  A healthy society is a more productive society.  Disease and disability is a significant financial drain on the government. Achieving health reaches in to all areas of government.  More than delivering health care to the sick, health is fostered by reducing poverty, improving education and maintaining a safe water supply.  Do we as a society have a moral obligation to care for the sick?  What if it is illness that could have been prevented by healthier life styles?  Who bears the burden of such choices?  Those are not always easy questions to answer.

An obvious example is tobacco use.  By now, I would hope that we all know the dangers of smoking cigarettes.  I feel the government has done a good job of educating the public whether it be through packaging requirements, advertisements and to the youth in schools.  I, myself, spend a fair amount of time educating about its dangers as well as encouraging patients to quit and assisting them do so.  I have noticed, however, that the success of my efforts improves according to the price of a pack of cigarettes.  More heed my words when there is an economic reason to do so.  Is it right for our government to impose extra taxes on substances that degrade health?  Before all you nonsmokers cry out, "Yes!," think of proposals to tax sugared beverages.  How far can this be carried?

Is the health of our population the responsibility of society or the individual?  Certainly, as stated above, our society has a stake in our overall health.  Is it possible to legislate health?  How is that balanced with the freedom of choice?  Is it more important to safeguard the best interests of society or the freedoms we enjoy even if that means allowing the citizens to make choices may not be in the best interest of society?  There is a movement afoot that is shifting the personal responsibility of health from the individual to his or her physician.  In the past, we doctors, were viewed as personal healthy consultants.  Advice is given to patients for healthy living all the time but the consequences rested solely on the patient.  A diabetic patient who does not check blood sugars, does not follow a proper diet and takes the prescribed medication only sporadically, will suffer the consequences by developing the consequences of the disease.  Society, however, is coming to the understanding that the cost associated with a poorly controlled diabetic is born not only by the individual but also by the insurance agency and those who must pay the premiums.

These agencies are now shifting the cost of the disease to providers.  There is both a carrot and a stick approach.  We currently are rewarded when a high percentage of our patients achieve measures showing good diabetic control.  We lose that bonus when that number drops lower.  It is pretty clear that in the future, reimbursement from insurance agencies will be dependent upon these markers and that doctors will have to give money back to these agencies if the population of patients they care for are not doing well.

I have chosen the term insurance agency very carefully.  There are measures within "Obama Care," that encourage just what I have described.  However, before, we cast a disparaging vote in regards to the tyrannical oppression of our government, I think it is important to realize that these ideas are being espoused and acted upon with insurance companies as well. Regardless of the outcome of this week's election, such measures will be enacted.  I suspect that as a consequence, some patients will find it harder to find a doctor. Many physicians, tiring of the excessive regulations and now financial risk, are moving to non insurance models such as concierge medicine.  In such a model the patients are back to assuming the risk for their own health.  These are interesting times in which we live.  Your health is assuming a bigger audience than you ever imagined.  How we decide to cope with these issues as a society is likely to be debated for many years to come.

The Glycemic Index

This is a term used fairly frequently but is not often understood.  Simply put, it is a measure of how much sugar gets into the blood stream for a given food.  The scale is set by pure sugar, or glucose itself which is given the value of 100.  Other foods are rated in comparison to it.  Table sugar, which is sucrose, is composed of two glucose molecules bonded together.  Therefore, on a per molecule basis it would have a glycemic index of 200.  The glycemic index should also be viewed in the context of the glycemic load.  This is the actual amount of sugar that one ingests.

Let me illustrate an example.  A typical soda contains about 39 gm of sugar and has a glycemic index approaching that of pure glucose.  Fruit also has a high glycemic index but the sugar found in fruits and vegetables is from a molecule that has one glucose molecule bonded to a galactose molecule.  Only half of the amount of glucose is delivered to the blood stream as regular sugar.  In addition, fruit has vitamins, fiber and water to go along with the ingested carbohydrate, all of which is healthy.  A typical orange has 12 gm of sugar.  It is unlikely that someone will eat three oranges at a sitting, but that is what it would take to equal the glycemic load of one soda.  It is, therefore, important to interpret the glycemic index appropriately.  I give my patients free range on the amount of fruits and vegetables they eat.  Even my diabetics.  It is hard to ingest enough fruit to cause any significant damage.

Apart from fruits and vegetables, the glycemic index can be very helpful.  Most foods are fairly obvious.  Starches can be a big source of dietary glucose.  Potatoes, bread, rice and pasta need to be watched closely.  Many breakfast cereals are quite high on the glycemic index.  As a rule, the heartier grain, the coarser the starch, the better.  Brown rice is healthier than quick, white rice.  Seven grain breads are much better than processed white bread such as Wonder Bread.  It makes sense.  The harder it is for the body to digest the food, the less sugar gets delivered to the blood stream.

Now that you know the basics, head off to a web site and start looking up foods.  There may be a few surprises for you there.  Remember to keep it simple.

Harnessing Hay Fever

The itchy eyes, sneezing, nasal drip and tickle in the back of the throat are all well known to sufferers of hay fever or "Allergic Rhinitis."  What is not commonly understood is how fatiguing this condition can be as well.  People suffer from allergies because their immune system recognizes a foreign substance (antigen) that usually enters the body through the nose and mouth.  A primed immune system will bind that antigen by a histamine receptor to what is called a Mast Cell.  The interaction causes the Mast Cell to release histamine into the blood stream, resulting in an immediate release of inflammatory products which trigger swelling of the lining of the nose, throat and eyes.  This is what causes that runny nose and watery eyes.  The work required to create this inflammation is very fatiguing.  In fact, any medical condition that causes inflammation will cause fatigue.  Sufferers of Multiple Sclerosis, Rheumatoid Arthritis or Chron's Disease know this well. In fact, it is very common for a patient with pneumonia to still feel fatigued weeks after the cough has gotten better.

Most sufferers of allergies do just that; they suffer through it.  I'll admit that I am usually one of them.  Keeping them under control, though, can help you feel more energetic and less miserable.  Let me explain the different treatment options and the rationale for each so you can decide what is best for you.  The most commonly used medicines are the antihistamines.  This includes Claritin (loratadine), Allegra (fexofenadine), Zyrtec (cetirizine), and Benadryl (diphenhydramine) to name the most common ones.  They block that initial triggering event discussed above.  Logically, the sooner they are used, the better they will work.  If you wait till you are full of fluid, they will keep your allergies from getting worse but they will not help for what you have already been exposed to.  The horse is out of the barn in this case and it is too late to close the door.  During a bad season it may be best to take the medicine on a daily basis.  They can work quite well intermittently if given prior to an exposure.  I have used them effectively prior to wood working, mowing the lawn or going to a friend's house who has a cat.  The medicines are all available over the counter now and most have a generic form which makes them less expensive.  The main draw back is that they themselves can be fatiguing.  The least sedating is Claritin and Allegra, followed by Zyrtec.  Benadryl is the most sedating.  There are also antihistamine nasal sprays and eye drops.  Those are not sedating at all but have to be used more frequently.

Nasal steroids reduce the inflammatory response from the histamine release.  They can be used with or without the antihistamine.  Since they are absorbed right in the nasal passage, almost none of the medicine enters the bloodstream, making them quite safe.  The draw back to these medications is that many people do not like squirting medication in their nose and they are quite expensive.  Thankfully, one of the best ones, Flonase (fluticasone) is now available in generic form.  They do all require a prescription.  If used daily over many weeks or months, the lining in the nose can become too thin and result in nose bleeds.  Stopping the medication for 1-2 weeks will solve that problem.  They do not work quite as well as antihistamine medications on an as needed basis.  Many use them for a few weeks out of the year during a bad season.

Allergy shots are the most effective way of reducing long term symptoms.  They induce tolerance in the immune system by introducing a small dose of antigen on a regular basis.  Over time, the immune system becomes desensitized, similar to what happens with teenage boys when their mother speaks to them.  The trigger is still there but nothing registers.  There are some obvious drawbacks to injection immunotherapy (allergy shots).  First, they are given by injection.  Second, if the dose of antigen is too high, it can induce a more serious reaction in the whole body so they must be given at the doctor's office.  Third, they have to be administered weekly for the first few months and then monthly for many years.  The hassle factor can be a big impediment.  Lastly, if you move to a new area, you have to start all over.  The injections only work for the antigens in your current environment.

There are other possible ways to help your allergies as well.  The simplest, of course, is avoidance.  That may not always be the best course of action, however. There is some evidence that children born and raised in the city have more allergies than children born in the country.  There is likely a critical age in the developing immune system where exposure induces tolerance rather than activation.  The science behind this has not been completely worked out yet.  Some have suggested that ingesting unfiltered bee honey can help.  When bees return to the hive, they not only bring the nectar to form honey but also lots of pollen.  The rationale is similar to that of injections but instead of sensitizing to very specific antigens, this would in theory sensitize to a more broad range of them.  For this to work, it should be unfiltered honey from local bee keepers to make sure that the antigens are ones that exist in your own environment.  There are likely many antigens that would not be covered by the honey, such as animal dander or dust.

I hope you find this informative.  Thanks to Debbie for the requested topic.  If you have specific questions that I did not touch, on please let me know.

The Right of Vice?

The Bill of Rights

A patient comment recently had me thinking of the Bill of Rights.  It has been a little while since I took a government class so I decided to brush up on my history a bit.  As you may remember better than I, the Bill of Rights references the first ten amendments to the Constitution, specifically outlining the personal rights and freedoms that our government guarantees. It ranges from the right of free speech, to the right to bear arms, including  the right of a fair trial, to name a few.  

The comment that sent me on my historical inquiry was, "Everyone needs a vice, right Doc?"  It was in response to one of my encouragements to eat healthier.  It was said so authoritatively, I thought that it must be included in the bill of rights.  Now as I read through the list, the only one that might qualify is the eight amendment which reads, "Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishment." I suppose many may feel that taking away their chocolate, soda, ice cream, beer or cigarettes may constitute "cruel and unusual punishment," but I don't think that was what the Founding Father's had in mind.  

What is Your Vice?

According to one of my favorite sources of information (Wikipedia), vice is defined as follows:

"Vice is a practice or a behavior or habit considered immoral, depraved, or degrading in the associated society. In more minor usage, vice can refer to a fault, a negative character trait, a defect, an infirmity, or merely a bad habit."  

In this context, do we have the right to a vice?  My answer to the patient and to you is "No!"  What we do need are good habits.  We need to set up routines that edify our body and soul, not tear it down.  It has been shown that it takes on average twelve weeks to create a habit.  When embarking on a new diet or exercise regimen, the first three months are the most critical.  It is much easier to exercise when it is a foregone conclusion that has already been ingrained as opposed to a vigorous internal debate that has to be endured each and every morning.  

We all have habits. Look at the ones in your life. Fortify the ones that make you stronger and eliminate the ones that hold you down, the vices.  Rather than being constitutional guarantees; your vices guarantee declining health.  Get rid of them!

The Science and Art of Medicine

Terrified, on my mother's lap, gasping for each breath.  The doctor's office seemed a rather scary place to a seven or eight year old.  I can remember hearing frightening words such as "admit to the hospital" or "let's try this shot."  As poorly as I felt, I didn't even worry about getting the injection.  I just wanted to feel better.  I can't remember the pain of the shot but I can certainly remember my heart pounding nearly out of my chest.  I had been given an injection of epinephrine (adrenaline).  Even more terrified, I clung to my mother.  My breathing slowly improved and thankfully I was able to go home.  Though I am sure I had been in many before, this is the first time that I can remember being in a doctor's office.

A few years later I was in a different office.  It seemed similar, though less terrifying than the first.  I lay on the examining table on my back.  The doctor placed vials of serum on my chest and then held my ankles.  Somehow he could feel differences in my legs and would make notations in his chart.  From this he concocted serum that my father than injected into me once a week to treat my seasonal allergies (no, he is not a physician and yes, it was terrifying).  I was not a happy patient.  I had no trust in this homeopathic doctor's evaluation and resented each shot.  To this day, my mother is convinced that it helped us even in the face of the rude quacking noises coming from her sons' mouths.

These two experiences of mine illustrate a common occurrence in the practice of medicine.  As much as we have learned about the human body and how it functions, there is much we do not know.  Even in the face of accurate knowledge we often lack adequate treatments for some conditions.  That adrenaline injection I received is no longer considered to be an acceptable treatment for asthma.  Thankfully, the science has progressed, and the treatments have gotten better, less toxic and more efficacious.  The second treatment I received may still be offered in some corner of our society but has fallen out of favor.  Such treatments are not studied nor evaluated.  Therefore, there is no improvement.  They are discarded only to be replaced by some other theory.  I have little patience for proposed treatments that claim they offer something "your doctor doesn't want you to know about," claiming a conspiracy theory between scientific medicine and the pharmaceutical companies.  If someone comes up with a valid proposal, it will stand up to the rigors of scientific investigation.  Refusing to study such treatments is tantamount to snake oil in my eyes.

I am not suggesting that only FDA approved medications should be used in the treatment of health conditions.  If you have read my previous posts, you know that I am all for avoiding medications through healthy habits.  Regular cardiovascular exercise has been studied extensively and has found to be beneficial over and over again.  It is getting people to actually make such a habit that is difficult.  Being able to show patients the studies that support my claims helps me to make my point.  One of the favorite parts of my job is eliminating a medication due to a patient having changed his or her behavior.  Seeing people lose weight, stop smoking and drop their cholesterol or blood sugar values is very fulfilling.  Writing prescriptions to treat chronic conditions that could be otherwise controlled, if a patient would just change their life style, is frustrating.

I am grateful to be in a profession that forces me to keep learning.  We still have many inadequacies as a profession, offering "adrenaline" type treatments with the hope that better alternatives are on the way.  As much as we learn and as advanced as our treatments become, though, it is important not to lose sight of the basic tenets of good health.  Nothing will ever substitute for eating a healthy diet, getting plenty of regular exercise and keeping our stresses in check with balanced living.  Remember, keep it simple.

My Balancing Stick

I have hit a lag in my posting.  I appreciate all of you who have noticed.  Sometimes it is hard to know if it is being read.  Part of the reason for my lag is that I am running out of ideas.  I would love some feedback.  What would you like me to discuss?  I have had one request for migraines, so I will be thinking about that topic. Another reason for my lag is due to a consuming project that has been taking up almost all of my free time for the last six weeks.  In fact, it is the topic of this post.

The premise for "Simply Healthy" is just that, to keep health simple.  My four pillars are watching what goes in, to keep moving, maintaining balance and to ask your doctor about the rest.  I haven't touched too much on maintaining balance and will do so today.  As I talk to my patients and ask about their lives I have come to appreciate that we all have stress.  It comes in different forms.  It may be family related, work related, money related and often healthy related.  We all have times when it is worse than others.  How we manage it makes all of the difference.  Taking our mind off of the cause of our stress is essential.  Exercise is one of the best ways of doing that.  Another great way is to have a hobby or special interest.  Mine turns out to be wood carving.

As a young boy scout I was introduced to "whittling."  I loved using my pocket knife to make spears and arrows.  Making a chain out of a stick was more difficult but quite rewarding.  I never thought about doing more until about eight years ago when I decided to try and carve the nativity scene on a walking stick.  It was my first attempt to carve a human form.  I got hooked after that.  I started to find myself looking at arms and legs in a new way, paying extra attention to where the muscles came together and fit in with the body.  I would look at all the noses that came my way to try and decide which one I would use on my wise man.  At first, I used a simple exacto knife. I finally found a friend who also carved and he introduced my to "real" tools.  I started to collect not just knives but gouges, and bits to fit on my rotary tool and an electric chisel.  When I am working on a project my whole focus is centered on that piece of wood.  It is a great way to take my mind off of the stress of work.  I love the feel of the grain and get great satisfaction when a piece turns out well.

My recent project is for my wonderful parents.  They recently completed fifty years of marriage.  We have four children in our family.  Each of us are married and we all have four children. My oldest child married this April so that makes a total of 27 people in our family.  About a year ago I decided to carve something for my parents but couldn't come up with an idea.  One night I literally woke up with the idea for my project.  A verse in the fifteenth chapter of John came to mind where Jesus declares, "I am the vine and ye are the branches."  I envisioned creating a walking stick with vines wrapping up the stick, each leaf representing a member of our family.  I love working with cedar which has a red inner core.  I thought the stick would look great if I carved down to that red core and making the branches and leaves out of the outer white wood.  This symbolizes our family, tied together, centered on Jesus Christ.  With that in mind, I went out in the woods on my in-laws property and found a cedar tree that had been knocked over but was still alive.  I cut it down, sawed off the many branches and stripped the bark.  I let it sit in the basement for about six months prior to working on it.  I decided that I wanted each leaf to be centered on one of the knots in the wood, which would tie it to the red core.  I traced out my leaves and vines, counting over and over to make sure I had all twenty seven of them on the stick.  I would like to say the project then started in earnest but I didn't do much on it for many months after that.  I tend to work better when I have a deadline.  As the summer approached and the anniversary date started getting near I got more serious about the project.  At times in the beginning I nearly gave up on it, feeling it wasn't turning out as I had envisioned it but I kept at it, modifying the details as I went along.

I took it to every outside event that I went to, using the time at camp-outs, soccer games, and cross country meets to work on the project.  Several weekends ago, in its nearly completed stage, I took it to a scout retreat.  I was mostly sanding at this point.  Being around hundreds of scouts and leaders, many of whom had made walking sticks in the past, made me feel like a rock star.  I was pleased to see the response of those that wanted to see it and ask about how it was made.  The final task was the most rewarding of all.  After finally completing the many hours of sanding it down to a smooth sheen, I applied teak oil to the wood.  As I had hoped, it made the red core jump out of the wood, bringing out the grain and the knots.  I love how it turned out.

I know that this is not too "medical," but thought that many of you would enjoy seeing and hearing about my project.  It truly is a stress reliever.  We all need to have a stress relieving outlet besides the television set.  If you are feeling overwhelmed by life, pull out that old guitar, paint brushes, knitting sticks or whatever else it is that you love to do but may have put aside for awhile.  It is not just good for the mind, it is good for our health.

Safe in the Summer

We work all year long, saving our pennies to go on that family trip.  This is the time of year when we break with routine, let loose and just have fun.  We may not be thinking of our health when we are packing our suit cases and on our way but we all have likely experienced a vacation gone bad due to illness.  This week I offer three simple suggestions to ensure a healthy happy vacation.

First is likely the most obvious.  Beware of the sun.  Many of us spend a great deal of time inside all year long.  We work in offices, not fields.  Our body is not used to the sun.  I have seen my son turn into a swollen red lobster before my eyes.  He is old enough to give him the tube of sun screen and allow him to take care of himself.  Too often, the excitement of the beach, mountains or other activities overwhelms him and he doesn't take the time to prepare.  No, we don't need to use a truck full of sunscreen but it really does work.  Preparing before hand is helpful as well.  Plan to be outside on the weekends at least.  Some sun exposure is good and needed.  I do not recommend tanning beds.

It is not just the sun's rays that can affect us.  It's heat can cause us to dehydrate through sweat and evaporation.  Out of our routine, we usually do not drink as much precisely at the time when we need to drink more.  I find it interesting that the time of year with the highest rate of kidney stones is September and October.  The reason is that it takes on average three months for a stone to form and those who don't drink enough water in the summer time pay the price in the fall.  If you travel by plane, bring an empty water bottle with you. Fill it up when you get past security.  If you will not be near a drinking source, make sure you plan to bring plenty of water with you.  Staying well hydrated will keep your energy level up, prevent headaches and muscle soreness.

One of the most common reasons I see patients in my office after they have been on vacation is for foot pain.    Many spend a lot of time on the feet when on vacation.  Make sure that you are preparing before you leave. It is just one more good reason to stay active and to exercise.  Make sure you bring footwear that will help, not hurt.  If you are staying at a place that has a freezer, take one of those water bottles mentioned above and freeze it.  When you get back at the end of the day, roll your feet over the bottle on the floor.  It will help cool off inflammation and stretch out the tissues in the feet.

Have a great summer time.  Hopefully by taking a few minutes to prepare for the sun, by staying well hydrating and by taking care of your feet you will be able to both enjoy your vacation without having to pay unnecessary consequences later.

What's Your Number?

I participated in a sprint triathlon today at Innsbrook, here in MO.  It was a beautiful day, sunny and warm and not too hot. What a blessing!  I had some time to think during the race and came up with a few questions.  All of the participants in the race are marked with two numbers.  One is the race number we are registered under.  The other is our age, on the back of the left calf.

The first number doesn't say much to a general observer, other than how committed we were to the race.  The numbers are ordered by when we signed up.  I was number 595.  There were only about 610 participants, so that tells everyone that I committed to this race quite late in the process.  The other number seems to garner more attention.  It is our age.  The race is started in several heats or waves according to age and gender and which course is being competed in (there was a long and a short course).  The start is in the lake swimming.  No one is really paying any attention to the numbers of others in the water.  Most of us are trying to just not drown.  However, on the bike and on the run portion of the race most of us will glance at the person's age that we are passing or who is passing us.

I notice that if I am passed by a man with a 55 on his leg, I tend to push a little harder and try to stay up with him. I don't pretend that I am going to win the race, but I would like not to be passed by someone older than myself (though that did happen twice today!).  Here's my question: If we all walked around with our blood pressure and cholesterol numbers on our forehead, would it change our behavior?  I think it is worth a thought or two.

Many of us are rather competitive at heart, but not all.  Some tend to be more fatalistic and feel that it is all out of their control.  It doesn't really matter what someone else's numbers are, does it?  I guess if that other person were a loved one we might be more inclined to try and assist and support them if we saw that they weren't so good.  Would seeing other's numbers spur us to better habits?  It might.  The most obvious benefit to me is that it would ingrain in all of us what the normal ranges are.  I know what they are but I do this for a living.  I deal with these numbers every day.  These are numbers we should all know.  It is most important to know our own numbers but it doesn't do much good to know just one number without having a value attached to them.

Here are the ranges:

                          Optimal         Borderline               Bad
B/P:                   <130/80     130-140/80-90        >140/90

Cholsterol:
Total                  <200 (depends on the breakdown though)
HDL (good)      >45                35-45                     <35
LDL (bad)         <130              130-160                >160
LDL (for those with diabetes or heart disease:
                         <70                70-100                  >100
Triglycerides      <150              150-200                 >200

So look at these numbers closely.  What are your numbers?  If you are not in the optimal range, talk to your doctor about how to improve them.  In the race of life we win by being healthy.  We can all be winners.  It is easy to get discouraged.  One of the greatest things about participating in a triathlon is that there are many spectators who cheer loudly for all of the participants.  It really gives a boost.  Let's all cheer for each other. Don't give up if you are discouraged.  Keep running and keep trying.  Your health is worth it.

Super Size This!

We live in a day of convenience and ease.  Have you ever seen the process our pioneer fore bearers went through to just make soap?  It took about a week of stirring pot ash over a fire, separating impurities and repeating the process over and over.  Think about the work to eat a piece of bread.  The wheat was often grown by the family itself.  Fields had to be seeded, crops had to be cut.  The grain was taken into town to be milled into flour.  The rest of the ingredients had to be procured.  The dough needed to be kneaded and allowed to rise.  The oven had to be heated by a fire until the correct temperature was achieved.  We don't even think twice about such things now.  We walk down an isle, plop items in our cart, wave a piece of plastic and go on our merry way.

Not long ago, most professions in our country required physical labor.  This is not the case any more.  Even farmers are not as active as they once were.  Vast tracts of land can be plowed from an air conditioned cab on large equipment.  A farmer patient of mine recently told me that in ten years he suspects that most farms will be worked by unmanned equipment.  Many of us spend a large part of the day sitting in front of a computer screen.  Our cars take us right to the doorstep of almost any destination.  If we have to walk more than 100 feet after parking, we get cranky.  I know because I hear it from my patients all the time.

My point is this, most of us cannot live our lives and expect to be active enough to stay healthy.  Obesity is a huge problem world wide and especially in our country.  My patients ask for pills and hope beyond hope that the latest dietary supplement will truly help them lose weight.  I talk to them about diet and exercise and most people recognize that what I am saying is correct.  It is one thing to know it; it is another to do it.  Let me share with you, two ways to view your day to maximize your health.

First of all, you must move.  The reason why we eat is to provide fuel for our muscles.  If we don't use our muscles, there is no reason to eat.  Here's my offer: you only have to exercise on the days that you eat.  Now of course we all eat every day, but every time you open your mouth for a bite you should think about how much activity you have done for the day.  I have a daughter that was a swimmer up to and all four years of college.  While in training, I have seen her and her friends eat more calories than I can imagine eating myself. That is OK, they needed those calories.  Conversely, I have seen her bypass a dessert, saying "I didn't swim today, I can't eat that."  She has figured out that we must earn every bite that we take.

The last point I want to make is this:  eat all the fruits and vegetables you want.  Even if there was no exercise  in your day, you can sit down to an all-you-can-eat buffet with fruits and vegetables for all three of your meals.  No one ever died from super-sizing their fruits and veggies.  It is recommended that we get 4-5 servings a day.  Not a week, a day!  More is even better.  Use it for a snack.  A banana or other piece of fruit in the morning is a great way to start your day.  A salad will often be 2-3 servings of vegetables.  If you get the munchies before bed, eat a few grapes.  Sure it takes more effort to buy the fruit.  I know that it is more expensive, but it is worth it.  Go ahead, super size it!

The Hippocratic Oath for You

It is customary for medical school graduates to take an oath as they graduate from school and enter the profession of medicine. This practice stems from Hippocrates, widely consider the father of western medicine.  There are many facets of the oath ranging from answering to deity, providing free medical education, practicing confidentiality, not working beyond our expertise, proscribing abortion and avoiding personal relationships with patients.  The most widely known tenant is in regarding doing no harm.  The original version states:

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice (www.pbs.org).


I recently saw a patient who told me she was trying to apply the Hippocratic oath to her own body, meaning she was trying to first, do no harm to her body.  As I thought about that concept, it sat rather well with me.  I spend much of my day as a physician preaching the admonition to first do no harm and second do your body right.  Harm comes in many forms.  The human body is an incredible organism capable of self repair and growth.  For most of us, if we give it the chance to work right, we will have the means to live a long, healthy life.  If the body is forced to deal with self inflicted damage, it's defenses will wear down and it won't have as much energy to spend on normal processes to keep the body going strong.  


The easiest form of harm to conceptualize comes from that which we ingest.  This ranges from that which we eat as food, the medicine that we take and the supplements that we consume.  I have discussed all of these previously in earlier posts (see categories: watch what goes in).  Illicit drug use, cigarette smoking and alcohol consumption are the most important toxins to get a handle on.  Each is truly a poison and will only lead to harm.  Other chemicals such as caffeine and artificial sweeteners are less dangerous and not as well understood but should be avoided or limited at least.  The more food we eat off of bushes, picked from trees or dug out of the ground, the better off we will be (God's food).  The less processed food (that which comes out of cans, boxes and wrappers) we consume, the less toxins we have to process (Man's food).  Keep it simple and keep it healthy.  


Harm also comes in the form of exposure to infectious diseases.  Those we do not follow safe sexual practices may harm themselves for the rest of their lives.  Good hand washing skills are important to limit exposure. Simple measures such as coughing into the crook of one's elbow instead of the hand may not keep us from being ill but it may for our close contacts.  Using helmets on bikes and motorcycles and seat belts in cars can be life saving.  Being smart about sun exposure and using sunscreen is another simple measure to avoid harm.  We can do harm to our bodies by getting too little sleep.  Stress, likewise, can adversely affect our health.  


Lastly, there is sometimes a need to experience short term harm for beneficial long term effects.  Avoiding a prescribed medication due to possible side effects, while ignoring a serious health condition can cause serious harm in the future.  Exercise also falls into this category.  Muscles and bones get stronger, only after first being broken down, thus the adage, "no pain, no gain."  Again, our physical body is a marvelous structure.  You are the steward of this great gift.  Will you take the oath?  Will you accept the challenge?  First, do no harm.

Using "E-Cigarettes" to quit smoking

As part of my duties as a volunteer teacher at Washington University, I periodically have medical residents (doctors in training) spend a month with me at the office.  I have been fortunate to have Dr. Seema Mahale with me this month.  She will be entering the practice of medicine in a few weeks and has been wonderful to work with.  I invited her to write a post for my blog.  She graciously accepted.  I hope you enjoy!

Dr. Mahale's post:

As I was walking by a kiosk at the mall, I was approached by a salesperson selling E-cigarettes.  While I didn’t buy into the man’s pitch that I will look very sophisticated and cool with an e-cigarette, I couldn’t help but wonder if and how this new device could be used to help people stop smoking. 

First I needed to find out how e-cigarettes work. It turns out there are several different styles available, but the main idea is there is a network of metal filament heated by a rechargeable power source that heats a liquid reservoir. A vapor then is created that the user can inhale. The liquid is made up of water, flavorings and nicotine.

Unfortunately, there have not been many studies done to see the potential beneficial use of E-cigarettes and there are differing opinions. The FDA looked at many different brands of E-cigarettes and studied the content. They found there were traces of tobacco specific impurities that are associated with adverse health effects. Their report also notes there is no way to predict the amount of nicotine actually delivered when inhaled. The FDA also feels E-Cigarettes may even promote younger generations to start smoking since it is a new device. Based on this, the FDA does not feel E-cigarettes can be used for smoking cessation.

However, a small study done by Boston University School of Public Health found that E-cigarettes are much safer than real cigarettes. While E-cigarettes do contain carcinogenic components, the amount is 1000 time less than real cigarettes. The study goes further to suggest that E-cigarettes can be used as an aid to stop smoking as it mimics motions that one does while smoking.

There is no doubt that smoking is bad for you. It increases the risks of several disease such as cancer most notably lung cancer, heart disease, emphysema and poor circulation. However, it is very difficult to stop smoking, as it is one of the most addictive substances available.  Therefore, I feel it is important for one to realize all the different modalities available to help kick the habit. Some combination of counseling, support from family and friends, medications (such as Chantix and Wellbutrin), and nicotine replacement (patches, gums, etc.) are needed for one to be successful to be become smoke free.

I feel E-cigarettes can help people stop smoking and most importantly by using E-cigarettes people are not exposed to such harsh chemicals. The bottom line is a person should pick the method that works for them the best. While it may take multiple attempts, quitting smoking is the most important things you can do for your health. 

In Memory..

As hard as I work, as hard as I study and learn, as much as I want to do what is best for my patients I know that every last one of them will die.  Does that make my efforts futile?  Of course not. Promoting good health enhances life now, each and every day.  It helps us function well in our older years.  It is not my goal as a physician to make some live as long as absolutely possible but it is for them to live as well as possible.  There comes a time when added minutes and days do not add to added quality of life.  Even when we understand that a love one is suffering and lingering, it is still hard to say goodbye.  It is in these heart gripping moments when we achingly say goodbye to the ones we love that we grieve the most.  These goodbyes are especially hard when life is cut short unexpectedly.  Grief may turn to despair and even depression.  While we must go on with our own lives, I am grateful to have a day set aside to reflect on those who have passed before us, a time to celebrate the memory of their lives and the impact they have had on our souls.


As a physician in training, I always figured that as I became more experienced, handling the death of my patients would get easier.  Having now been in practice nearly fifteen years, I can testify that the opposite is true, it is exceedingly more difficult.  To sit at the bedside of a patient that is now a dear friend, look them in the eye and say good bye for the last time is heart wrenching.  To be someone's physician is an honor and a privilege.  I always hope to say goodbye with no regrets, having done the very best that I could.  


As difficult as it is to say goodbye as a physician, I recognize that it is immeasurably more so as a family member.  Even when the loved one is clearly suffering, their departure leaves a void in our lives.  My own personal belief in a God and of the resurrection takes the sting out of death to some degree.  I am not sure how I would feel without such beliefs and am grateful for them.  Dr. Russel M. Nelson, a notable cardiothoracic surgeon, now a leader in my church recently said the following, "If the body’s capacity for normal function, defense, repair, regulation, and regeneration were to prevail without limit, life here would continue in perpetuity. Yes, we would be stranded here on earth! Mercifully for us, our Creator provided for aging and other processes that would ultimately result in our physical death. Death, like birth, is part of life" (April 2012).  Granted, it would be easier if God would just take us up in a twinkling of an eye, but that is not the way of life.  There are lessons to be learned at the end of life, both for those who leave as well as those left behind.


I would, therefore, like to pay tribute to my dear friend, patients, who I have grown to love and are no longer with us.  Each in his or her own way has taught me life lessons.  I am grateful to have been their physician and hope that the happy memories of their lives will sustain their loved ones who still miss them dearly.  Happy Memorial Day!


Editor's Note: I would like to acknowledge Daniel Pearlmutter, a patient friend and professional illustrator who graciously offered to provide the art for this post.  I am thrilled that he has taken an interest in my blog and know that you will enjoy his work.

Family Heroes

As a teenager, it was common for me to come home to having a grandparent in the house.  Both my father's father and my mother's mother spent time with us toward the end of their lives.  When I was nineteen years old, I lived for a year as a missionary for my church in Guatemala. A severe knee injury cut short my time with the wonderful people I grew to love there.  I returned home to have my anterior cruciate ligament repaired.  My mother talked Grandma into coming to stay with us by saying that I needed her there to nurse me back to health.  On my first day out of the hospital she told me of being a young woman and working as a nurse's aide at the local hospital.  Sponge in hand, she scrubbed me, telling me how she had been taught to "wash down as far as possible, then wash up as far as possible, and then washing possible."  I grabbed her hand and said, "Grandma, I'll take care of possible."  As Alzheimer's Dementia would later rob her mind of memories, I cherished the times we spent together.  Later, coming home from college, she loving looked at me and declared, "I used to know you!"  Her overall concern was that she did not want to be a burden to her family.  She spent time with all four of her children.  The bond and memories with Grandma was more than worth any burden caused by her care.

My grandfather also spent time with us.  Towards the end of his life, heart failure sapped his strength.  Ultimately he was done in by a fall which resulted in a subdural hematoma-bleeding around the brain.  He became too much to handle for my parents alone and ultimately spent his final days in a nursing home.  It was a difficult decision to make. The care received at the end of life is a decision that affects generations.  I have an elderly couple in their mid 90's.  The wife has Alzheimer's and the husband has been weakened by aspiration pneumonia and a blood clot to his leg.  They became too frail to live on their own.  An attempt to live with a daughter in a far away western state resulted in agitation and delirium.  The decision was made to bring them back to their home and their granddaughter now oversees their care.  She works full time during the day and spends every night with them.  The family has hired care givers during the day.  This loving granddaughter is spelled by her husband on the weekend.  I am amazed by her dedication.  I have no doubt that they have received better care than they would in any institution.

Family heroes come in many shapes and sizes.  Another patient of mine is a widow with no children of her own.  Her mind has slowly slipped, though she is loathe to admit to any problem.  She saw her husband decline from Alzheimer's and is terrified of having the same happen to her.  Her nephew has taken it upon himself to direct and guide her care.  He persists patiently despite my patient's unwillingness to admit to needing any help.

I feel strongly that our society is blessed by generations living together and spending time together.  Benefits are seen not only to the elderly in need of assistance and care but also to the youth who are able to get to know their grandparents better.  Nursing homes will always be needed to provide care that can not otherwise be given.  I want to salute those who stand up and take on the challenge of caring for loved ones.  They are healthcare heroes  Who are your family heroes?  Share with me your stories.

Fact or Fiction: High Cholesterol-Part 2

"I was in for my annual physical two weeks ago and the letter you sent me said that my cholesterol reading had increased from 210 to 216 over the last year.  You said you wanted me to come back in 6 months to get retested.  My questions are:

1.       I take one 900 mg fish oil tablet a day - would it be beneficial to double that?

2.       Some of the "natural" remedy information indicates that cinnamon tablets are helpful - any thoughts on that?

3.       My wife wants me to take "Cholest-Off" which is advertised as an all-natural means of reducing LDL numbers - would that be worth trying?

4.       Any thoughts on the Juice Plus program and if that might help?

5.       I eat a fair amount of peanut butter at lunch and drink 2% milk most nights for dinner - is that a problem?

I am eliminating or reducing my favorite vices - brats and ice cream sandwiches - probably  a good thing no matter what my cholesterol number is."  Name Withheld


The last post described what cholesterol is and how it can be damaging.  I want to go back to this email and discuss some of the issues that were brought up.

Let's start with fish oil.  It has been observed that a diet high in fish consumption is protective for heart disease. Now to be clear, seafood itself is not healthy, it is fish.  Crab, lobster, clams and other shell fish are actually bad for us.  It is the fish that swim that are healthy.  For many of us it is tough to eat fish 3-5 times a week.  For that reason it was thought that purifying the oils contained in fish could be used as a supplement.  Sure enough, fish oil has been shown to lower cholesterol, specifically the triglyceride fraction.  Within the last few months a study has come out that looked at whether or not this would lead to a decrease in the rate of heart attacks.  Those in the study had the expected improvement in their triglyceride levels but unfortunately there was no benefit in the heart attack rate.  It is only one study but it is the best information we have so far.  My feeling is that if you sit down to a big steak dinner and pop a fish oil tablet, you are not going to do yourself any good.  One of the good things about eating fish is not just the oil but it is also the fact you will not be eating something else that is not healthy.

What about cinnamon tablets?  Quite simply, I have seen no data in regards to cholesterol lowering effects of cinnamon.  I have seen modest data in regards to lowering blood sugar.  The effect is quite small.  Avoiding sweets will have a much greater effect on lowering blood sugar than ingesting a little bit of cinnamon.

  

Moving on, let's discuss "Cholest-Off."  This is a plant based sterol put in margarine that has been shown to lower cholesterol levels.  It has actually been around for several decades.  The effect is not huge but it has been demonstrated.  If an oil spread is going to be used, it is best to pick one that works for you, not against you.  It has also been put into capsules aswell.  I have no problems with "Cholest-Off."

The next item is "Juice Plus."  The idea behind this product is to get the benefits of multiple servings of fruits and vegetables in a few capsules.  I know of no data showing that it helps cholesterol levels.  It is high in vitamins.  My biggest concern is that people will take these capsules and fail to eat fruits and vegetables.  If so, the food they do eat is more likely to be of a lesser quality.  Eating fruit and vegetables is more than getting vitamins.  It is filling up with good fiber and an excellent source of water.  The more whole food and fruit that we eat, the better off we will be.  I do not endorse this product though it is safe.  Let's make sure and get our 4-5 servings of fruits and veggies in a day.

What about peanut butter and milk?  Peanuts are a decent source of protein but peanut butter is usually about 70% fat by calories.  It is not the worse thing that can be eaten but if one has high cholesterol, there are better alternatives.  In regards to milk, it is all about the fat.  Two percent is better than whole milk but not as good as skim milk.  I drink nothing but skim.  I think it tastes great.  Your taste buds will adjust, you don't need the extra fat.

The last paragraph on this email is my favorite.  Nothing we have discussed so far will make a difference at all if the brats and ice cream sandwhiches are still being eaten.  I can think of nothing worse for cholesterol than brats.  It is like a wrapper for fat.  Ice cream has the distinction of being the deadly double.  It has both fat and sugar in it.  No amount of cinnamon, fish oil, Cholest-Off, red yeast or even Lipitor will negate eating poorly.  It is not rocket science, it is quite straight forward.  If we use our common sense over our taste buds we will be "simply healthy."

Fact or Fiction: high cholesterol

I recently received an interesting email:

"I was in for my annual physical two weeks ago and the letter you sent me said that my cholesterol reading had increased from 210 to 216 over the last year.  You said you wanted me to come back in 6 months to get retested.  My questions are:

1.       I take one 900 mg fish oil tablet a day - would it be beneficial to double that?

2.       Some of the "natural" remedy information indicates that cinnamon tablets are helpful - any thoughts on that?

3.       My wife wants me to take "Cholest-Off" which is advertised as an all-natural means of reducing LDL numbers - would that be worth trying?

4.       Any thoughts on the Juice Plus program and if that might help?

5.       I eat a fair amount of peanut butter at lunch and drink 2% milk most nights for dinner - is that a problem?

I am eliminating or reducing my favorite vices - brats and ice cream sandwiches - probably  a good thing no matter what my cholesterol number is."  Name Withheld

I thought this would serve as a good launching point to discuss cholesterol.  Let me first explain what cholesterol is, what it's function is and how it can cause problems.  

Cholesterol is basically blood fat.  It is made mostly in the liver and is used in the body to create the membranes that keep our cells intact.  There are many different components to it.  The most important to understand are the LDL (low density lipoprotein), the HDL (high density lipoproetein) and the TGs (triglycerides).  The LDL particles are the most atherogenic (meaning they cause blockages in the arteries).  When in excess, they will be deposited in the membrane of blood vessels and start an inflammatory process resulting eventually in build up or "plaques."  They are referred to as the "bad cholesterol."  HDL particles are like tiny little fat vacuums. They circulate and will take up the extra LDL and other fat particles keeping them from forming plaques.  The higher the HDL, the better off you are.  The triglycerides are particles that are less toxic than LDL particles but still harmful.  Together with fatty acids, they will also strain the body's metabolism and increase insulin resistance, which can lead to diabetes.  

The total cholesterol is the sum of the LDL and the HDL and 1/5 of the TG's.  We typically say that the total cholesterol should be less than 200 mg/dl.  However, that depends on the makeup of the other particles.  For example, I just saw a patient whose total cholesterol was 240 mg/dl.  That seems rather high but her HDL was outstanding at 135 mg/dl.  Her LDL and TGs were well within the normal range so her cholesterol  profile was perfectly normal.  I could only wish mine be so good.  We would like to see everyone above 40 mg/dl for the HDL.  As of yet there have been no good medications developed to increase the HDL.  Regular cardiovascular exercise remains the best way to increase it.  That and having good genes.  

The LDL is partly genetic but greatly influenced by the foods that we eat.  The culprits tend to be animal fats (red meat, bacon are the worse).  Butter and other oils which are solid at room temperature are also dangerous.  The LDL in low risk individuals should be under 130 mg/dl.  In higher risk patients it should be less than 100 mg/dl and even some studies show that driving it down to 70 mg/dl gives additional benefit.  Those at high risk are anyone who has had a heart blockage, those who have blood vessel disease elsewhere such as in the neck, brain or legs, and anyone who has diabetes.  I'll talk more about specific dietary recommendations in a future post.  

The triglycerides are the easiest to lower without medication.  They are increased by ingesting too much greasy food, alcohol and simple carbohydrates.  Sugared beverages are some of the worst culprits.  Even the simple carbs in bread and pasta can cause elevated triglycerides.  The TGs should be less than 150 mg/dl.  A level over 200 mg/dl greatly increases one's chance of developing diabetes.  At very high levels, such as 800-1000 mg/dl, pancreatitis can even be triggered.  

With a basic understanding of the cholesterol components, I can now start answering the questions I received above.  Stay tuned next week for some answers!

Occupational Challenges

Last week I wrote about what I enjoy most as a physician.  This week, I'll share some of the challenges that I face.  Let me just say upfront that the good outweigh the bad.  I hope it will forever be the case.  My daughter once asked me what the hardest part of my job was.  She had an occupational survey to do for a school assignment.  My mind went immediately to the part of the physical exam which is most distasteful to both me and my male patients.  Upon further reflection, though, I decided that delivering bad news was probably the hardest.  As I said last week, the end process can be very satisfying, but that initial conversation when I need to tell someone that they have cancer, or another serious illness, is very difficult.  It is gut wrenching.  About the only thing that comes close is when I was in a movie theater many years ago watching the "Lion King" with my daughter.  Simba's father falls to his death in the canyon stampede.  With tears in her eyes, she looks into my face and asks, "Is he going to be all right, Daddy?"  You want to respond that all is going to be fine.  It is important to give hope when there is hope and to be positive so that the patient remains positive.  However, it is also important to be truthful so that they understand what to expect and how to plan.  Some are not ready to hear the bad news and it may have to be explained several times.  Patience is the key.

Sometimes I wish I could be perfect.  There are many stresses that come with our job as physicians.  We have the stress of trying to stay on time, of writing complete notes, of being too busy, of not being busy enough.  We have phone calls and tasks and emails, faxes and letters all pulling us in a hundred different directions.  Now we have the stress of the electronic health record.  We have to make sure we have clicked every box and entered every requirement or we are told that medicare will void out the entire visit.  It is stressful to respond to a patient who is requesting a medication that we feel would do them more harm than good.  By nature we want to please.  Some patients can become very upset if they are not given an antibiotic for their cold or pain pills for their headaches.  Above all else, my greatest stress, though, is the stress of missing a diagnosis or of making the wrong treatment decision.  There have been times when I have made a subtle diagnosis that has likely saved a patient's life.  One in particular was that of picking up prostate cancer in a 38 year old man.  I did an exam and it felt abnormal so I sent him for a biopsy.  He now lives 2000 miles a way but just last year, while visiting St. Louis, he came to say hello and thank me once again.  He is doing fine.  Instead of feeling good about this, it frightens me.  When I saw him, I thought he was over forty.  I did the exam by mistake.  It was pure luck that allowed for his early diagnosis.  Another example is that of an older woman with a fatty mass in her thigh.  I have felt many of these, "lipomas" in patients and sent them on their way, telling them it was nothing to worry about. In her case, it felt just a bit different than the others.  It was a little more firm and more fixed to the leg.  I can still recall the back and forth of my thoughts considering course of action to take.  I was so close to letting it go that her words of gratitude terrify me.  I know how close it was.  She had an aggressive tumor that is usually fatal.  Another month or two may have made the difference between life and death.  It terrifies me that there will be someone else who I may decide to go the other way.  I know I cannot always be right, but I want to be.  I want to do the best for my patients.  That is my greatest stress.

This may be more truth than what you want to hear from a physician but I felt like it would be good to share.    Let me know what your concerns are as you come to the doctor's office.  What worries you the most?  What are your expectations?

What a Great Job!

Let me start by saying that I love my job.  I feel very fortunate to work in area that is stimulating, rewarding financially and most of all where I can make a difference in the lives with whom I work.  I thought it might be interesting to others to know why I do what I do and what I enjoy the most.

Being a doctor is a wonderful profession.  Being a primary care doctor is even better.  It is a great feeling to be able to have someone come in to the office, diagnose their problems, and work together on solutions.  Just being able to tell someone what their problem is often all they need.  I can see the worry in their eyes when I come in to the room.  They have been on the internet.  They are quite sure they have MS (multiple sclerosis) or perhaps a stroke.  Maybe it is celiac disease or possibly autoimmune relapsing polychondritis?  (No, not even spell check knows what that one is!)  It is easy to get frightened by the possibilities.  More often than not it is something more common, less dangerous.  It is a good feeling to be able to reassure and educate them.

As good as it is to fix problems, I get much more enjoyment in preventing them.  Health is so much more than the absence of disease.  Health is determined by all the choices we make in a day.  It is a feeling of well being when all parts of our life are in harmony.  Last week I saw a young woman for a routine physical examination who truly had no medical problems.  Yes, she could exercise more.  Junk food is pretty rare.  Though not perfect, she does a good job with nutrition.  She doesn't smoke, she does not drink alcohol.  It seemed that all was well.  After a busy morning of seeing people with lots of problems, I thought to myself, "this is great, to see someone so healthy."  Literally on the way out of the door, she asked "is there anything good you can give me for anxiety?"  It turns out her husband is an alcoholic.  I need not outline any details but her mental health has taken a beating for awhile.  I could not solve her problems in those few minutes together, but being able to discuss them with her is a step in the right direction for her well being, for being truly healthy.

One of the hardest parts of my job, but one that I take a lot of satisfaction in, is helping others understand and deal with bad news.  I understand that we are all mortal.  All of my patients will eventually succumb to some sort of illness.  It is my job to tell them and their families what process is occurring, what their options are and what they might be able to expect in the future.  Sometimes it is better to stop treating all of their problems and focus on a patient's level of comfort.  It may no longer be important how long someone lives but that they be surrounded by the ones they love at the end.  End of life discussions are gut wrenching, emotional but are so very important.  My warmest hugs, my most heart felt compliments and expressions of gratitude have not been received from those who finally started to exercise and eat right, it has come from the family members of my dear friends who have passed on from this life.

Do you know what is the most fun?  I love the look in someone's eye when I walk in the room and they have lost seven or eight pounds from their last visit.  They have been trying so hard to eat right.  It has been a struggle to get up and exercise, but they have been determined and are really doing their best.  Their blood pressure is down, their blood sugar numbers are down and they are excited.  They are quietly waiting for me to notice on my own.  I love saying, "good job, keep it up."  This is especially true with smokers.  Sometimes I need to be stern and "lay it on the line."  Sometimes I am more of a cheer leader.  Sometimes I just need to listen.  That is the art of medicine.  I know I don't always get it right.  There is nothing better than having someone come in who has finally quit smoking.  It may take years and years of trying but when they do, I know that I have helped them achieve health in a more significant way than any surgeon or specialist ever could with their expensive surgeries or their fancy procedures.  My greatest reward is to see my patients be simply healthy.

The Individual Mandate

This has been a hot topic of late in regards to healthcare with the Supreme Court deliberating as to if this portion of the law is constitutional or not.  I thought I would share my thoughts on the matter.  As a disclaimer, I do not consider myself neither a Republican or Democrat, more aptly a Republocrat.  My expressed opinions are just that, opinion.  I may even change them next week as I consider new possibilities and ideas.

I find it interesting that we can have a law requiring anyone who drives a car to carry automobile insurance and have very little complain about it.  In fact, in an accident, he "who doesn't have insurance" is looked upon in quite a derogatory manner, someone who is a drag on society.  Those same people who support the driver's insurance mandate look at the health insurance mandate as being one of the craziest ideas ever put forth.  I understand the reluctance.  Who wants to be told by the government that we "have to" do something?  As Americans we are fiercely independent.  Freedom has been ingrained in our very being from the start.  In my mind, the bigger question is not whether there should be an individual mandate but it is whether our society has an obligation to provide basic health care to its citizens.

There are two rather charged words that delineate this conundrum, "socialized" and "rationed."  Many of my patients fear that if the government gets too involved in healthcare we will end up like Canada or England having a healthcare system where there may be long wait lists for not only elective surgeries but even just imaging tests.  We want the best and we want it now.  We don't want to see our care "rationed." The truth of the matter is that we already exist in a system that rations healthcare.  Do I treat patients differently when I volunteer at an indigent spanish speaking clinic once a month?  Sure I do.  I see patients in my office without insurance from time to time.  Do I treat them differently?  Absolutely.  We don't even consider sending one of them for joint replacements no matter how bad their arthritis may be.  Sending one of them for a screening colonoscopy is out of the question.  I recently saw a patient in my office who is becoming demented.  As part of his evaluation I sent him for an MRI of the brain.  This looks for evidence of stroke or other conditions that can be contributing to his memory loss.  It is a recommended part of the evaluation but frankly has a very low chance of affecting how he is treated.  I was able to see the patient and have the test done all in the same day.  If he had no insurance, I likely wouldn't have even offered the test to the patient or the family.  Taking care of diabetics who have no insurance is like playing darts in a dark room.  They cannot afford the strips to check their blood sugar levels.  If they are on insulin, I try and choose a dose that won't harm them, knowing that tight control is not going to be possible.

The American Health Care system is widely regarded as the best in the world.  The health of our society, however, is not the best.  Other countries do far better than we do in many areas.  I firmly believe the reason is because we don't think of the dark side of our system, those without insurance who are on the outside looking in.  We have two systems, a very good one and a lousy one.  The flip side to freedom is equality.  If we decide that equal access to basic health care is not important in our society, then so be it.  We will continue to exist in this two headed monstrous state of medical feudalism.  Are we that far away from "The Hunger Games"?

I feel that if we are going to provide basic services to all of our citizens, we must have an individual mandate.  Guess what happens to the uninsured patients I described above who have a truly life threatening emergency?  They get taken to an emergency and are taken care of.  If they need heart surgery, they get it.  If they are in a serious care accident, they get fixed up.  The hospital rights off the charges but it doesn't end there.  The hospital cannot afford to sustain such losses so those costs get consumed by the revenue that comes in from all the other patients who have insurance.  The cost gets shifted to you and to me.  This is one of the many reasons why our cost of healthcare is so high.  I would much rather see us ask all citizens and non citizens to pay for insurance than to see my own costs go up and up and up.  Thanks for reading my thoughts.  I would love to hear yours and respond to them.  Let me know what you think.

Laughter is the Best Medicine :)

The following is a post from my colleague, Dr. Benjamin Voss.  Great information-enjoy!

Is Laughter really the Best Medicine?                                                                

 

This talk was originally presented on July 29, 2010 at Washington University School of Medicine Grand Rounds. This is backed by real research. Smile, it’s true.

 

I have always been told the laughter is the best medicine and when I finished residency, I was determined to investigate if this is indeed true. The story of the The Roseto Effect peaked my interest. In the 1950s, a visiting professor named Dr. Stewart Wolf noted that he rarely found anyone from Roseto, Pennsylvania under the age of 65 with heart disease. Their diet was high in fat consisting of lard, pizza, and biscotti, they smoked heavily, and the majority of them were overweight. After years of research, he concluded that their unique Community where they recreated their Italian heritage was health protective. They had three-generation family meals, talked to each other in the street, respected elders, enjoyed the calming effect of church, and had many civic organizations. The protective social structure insulated them from the pressures of the modern world.

 

Depression is obviously bad. However, its severity is traditionally underappreciated. Depression is an independent risk factor for developing heart disease and dying regardless of one’s other medial problems. Answering yes to “During the last month have you felt so sad, discouraged, hopeless, or had so many problems that you wondered if anything was worthwhile?" more than doubled one’s risk of developing heart disease. People with a Type A personality have a 2-fold increase risk of having a heart attack. Depression after a heart attack predicts the likelihood of death as much as developing heart failure after the heart attack. There are many physiological theories and explanations for this, but the key is that one’s body has “chronic sympathetic activation,” or a stressed body and mind all the time.

 

Positive affect, defined as “the experience of pleasurable emotions such as joy, happiness, excitement, enthusiasm, and contentment,” has the opposite effect on people. Comedian Bill Cosby once said “Immortality is a long shot, I admit. But somebody has to be first.” While humor is his occupation, the research actually supports his idea. Studies have shown people with a positive affect have better immune function and a greater resistance to upper respiratory infections. People who have hope and curiosity have lower blood pressure. Agreeing with one of the following four statements:“I felt that I was just as good as other people,” “I felt hopeful about the future,” “I was happy,” and “I enjoyed life,” showed a lower risk of stroke. While depression increases the risk of death in diabetics, positive affect lowers that risk. Hospitalized patients who answered yes to “I still enjoy things I used to enjoy” lived longer than patients who disagreed. Positive affect lowers the risk of death after a heart attack and in patients with AIDS. The physiological explanation here is enhanced parasympathetic activation, meaning lower heart rate, lower blood pressure, and increased glucose tolerance.

 

“Behavioral activation interventions” have been studied and these include increasing the frequency of enjoyable hobbies and activities. Exercise has been shown to reduce depression. Nutritional counseling in order to avoid overeating when stressed is important. Stress management options include yoga, vacations, and music. Social support is critical and walking groups are a great way to exercise and build community. So while it is critically important to take your medication and listen to your doctor, try adding a laugh or two to your daily routine.

 

Thank you Dr. Fuller for this opportunity to be a guest blogger. I do my best to get him to laugh everyday.