An opportunity to serve.

I have a new adventure in my life personal life.  As most of you know, I am a member of The Church of Jesus Christ of Latter-day Saints.  I was recently asked to serve as a counselor to our new Stake President, the ecclesiastical leader of our church in the St. Louis region covering 8 different congregations.  I am excited for the challenge.  For those who may be interested, I felt impressed to share my feelingss about the process on my personal blog page, My Fuller Feelings.

This will not replace my occupation as your physician.  I will continue to work full time and plan to do so for many more years to come.  I am grateful for the team I have in place now to help do that job even better than before.  Please let me know if you have any questions.

The Foundation of Exercise

This is the second installment from Maria regarding foundational principles for health.  The first was on nutrition and now I would like to share some thoughts about nutrition and its connection with exercise. 

Our bodies are designed to feel stress (hunger, sleep, desire…) and then we are designed to expend energy to overcome or satisfy whatever is creating the stress we are experiencing.  In the past if we were hungry we would have to catch something to eat, or walk into the woods to gather food, raise crops, walk to the places where food was sold, etc.  We would have to run away from danger or stand and fight.   All of these activities took energy and this was not only a way to get food or survive danger, but these activities played a role in burning off some of the calories we took in. 

Today that process is short circuited.  We can get into our cars and drive to get food, which burns very little calories.  Also the calorie density of foods today is much higher than when we ate foods that were directly from nature.  There were no machines to process our food, but rather we had to process them ourselves.  If we wanted a tortilla, we would have to pick the corn, mash it up into flour and then make and cook the bread.  This would be a several hour process and burned many calories.  Now all we have to do is open the package and put on our favorite toppings (also processed for us). 

Processing really robs us of a very natural way to burn energy and get nutrition.  A simple example is when we drink a glass of apple juice vs. eating an apple.  If we eat the apple the sugar we get from the apple is more slowly introduced into the body as the stomach works to separate the sugar from the fiber of the apple.  The glass of juice is already broken down so our body has less to do and the sugar hits the blood stream faster and all at once.  This theme is repeated over and over again with so much of the processed food consumed in the US and around the world. 

Moreover, our brains are designed to want high calorie density, because when food was scarce the higher calorie content made it more likely we would survive famine to live and have babies;continuing the species.  Thus, it is very hard for us to refuse foods that are the highest in calories because we are fighting our evolutionary brain design.  It is important to understand this so that as we are working on keeping our weight under control we can understand what drives us and how we are designed to become and stay fit. 

Finally, much of our stress is more emotional than physical as it may have been in days past.  In the past if we ran from a tiger or physically fought to defend our lives (assuming we survived) we would not only burn calories, but grow stronger and increase our stamina.  Today we run and fight emotionally and that is not the way our bodies are designed to relieve stress.  Thankfully, our bodies cannot tell the difference between running from a tiger who may want to eat us, or running on a treadmill, or walking around the block, or riding a bicycle, or dancing.  In these ways we can use our bodies to eliminate some of the chemicals we produce as a response to stress.  We can help resolve stress through physical activity because this is what we are designed to do.  If we don’t do this our stress response can turn against us and lead to health deterioration.

Maria Motta FNP

Well said, Maria.  I agree with everything she has said here.  Understanding the biologic underpinnings of our body helps explain why it is so hard to lose weight.  It is impossible to do it without a combined effort in regards to healthy eating and vigorous, regular exercise.  

Dr. Fuller

Health Foundations

For this month’s blog post I wanted to first give an update on how things are going with my new practice arrangement.  As introduced in last month’s post, I now have Maria Motta FNP working with me.  Her assistant, Rachel along with Michelle who you all know well and Kym form a true team to help take care of you, my esteemed patients better.  I couldn't be happier with how things are working out.  Maria is a wonderful addition.  She is allowing me to offer additional services to my patients.  She begins seeing patients at 7:30 AM every day.  I suspect that many of you who work will appreciate those hours, allowing you to not miss work for a routine appointment.  I am available to her to answer questions by phone but this allows me to continue to see my patients who are in the hospital.  As you may know, there are not many physicians who still see their patients who are admitted.  I feel strongly that I want to continue to offer this service.  No one knows my patients better than I do.  I feel confident that I am the best one to deliver care that is needed at the most critical times of someone’s life. 

Maria will also be starting a monthly educational class for those who are having the hardest time controlling their diabetes.  We are working together on the curriculum and be making invitations soon.  You do not need to have poorly controlled diabetes to attend.  If any of you are interested in attending, please let me know. 

Other benefits of my team approach is freeing up time for me to visit my most vulnerable patients in their homes.  I have been able to six different patients so far with plans to do others.  I have long since desired to find a way to do this.  I am glad that it is finally happening.

For those of you who have met Maria, you know what a great person she is.  I encourage the rest of you to welcome here with open arms.  I have asked Maria to share some ideas she has about healthy living with you.  Similar to the simple facets of good health I have outlined previously, she has labeled these her “Health Foundations”. 

In sports there are foundational elements that apply to players across all levels of development weather a beginner or a major league star.  They are basics that, if done right, create a solid athlete who is able to instinctively make decisions that result in the best plays.  Health foundations are very similar.  So, once you have a routine to follow the basics, then health and happiness have a greater chance to follow.  I believe there are five foundations for a healthy life and I want to make sure all my patients are aware of these elements.  In this way, as a team, we can try to head off health problems or work on following a path that leads back to health when you are ill.  The elements are: Nutrition, Exercise, Rest, Peace of Mind, and Prevention.  You may be thinking “nothing new here”… but I want to argue that doctors and nurses spend most of their time treating health problems that develop as a result of a dysfunction in one or more of these areas.  Medications and treatments have a valuable role to play in care of patients, but I want you to know that YOU ultimately have a lot of control over your health.  Over several blogs I want to begin to address each of the elements in more detail and, because we are all on the same team, I would like to hear from you about the positive ways that you approach your health.

First up: Nutrition (part one)

Many patients have very little knowledge about what to eat so they follow traditions instilled by their families and those that are propagated by the media (including fast food commercials and those selling diet books).  Over time what to eat has been debated vigorously and the argument goes on even today.  I want to send a clear message that the earth has been providing products since the beginning of time that provide adequate nutrition for life.  In the present age we have drifted away from eating the whole foods the earth provides in favor of highly processed and altered substances.  I’m not interested in imposing restrictions, but rather want to encourage you to find whole foods that you like and then providing information about health benefits these foods can provide.  Most importantly, I want you to develop your own healthy way to get the nutrition you need.  I want to share my recipes with you and am interested to see what you can find to share with us.  I would like for you to review the new simplified recommendations from www.myplate.gov to build a plate of health and to think about building a “rainbow of food” for nutrition.  These show pictures of what should be on the plate (both types of foods and amounts) and remind you to seek out multiple colors of foods to get all the micronutrients you need for your best health.  These are easy steps to remember and can be a fun way to approach healthy eating.   

Mickey and the Measles

We are currently experiencing a measles epidemic in the United States.  I have received many questions regarding immunity and vaccination.  Let me answer those questions for you here in my blog space.

Earlier this year measles was introduced into our country by way of visitors to a certain theme park based on a famous rodent.  Mind you there are several diseases that can be spread through such animals but we are pretty certain that the incident case was a person visiting from another country where the disease is more prevalent.  According to the CDC, from California the outbreak has spread to 17 states and there are over 120 people as of February 6th.  It is important to realize that almost everyone that has come down with the infection was not previously vaccinated.

Vaccination occurs through the combined MMR vaccine which includes not just measles but also mumps and rubella.  One dose of the vaccine confers immunity to 93% to the individual.  A second dose more than 28 days later increases that percentage to 97%.  Here are answers to frequent questions that I have been asked:

Should I be revaccinated?  

High risk individuals (health care workers, international travelers, those with a low immune system and those that live in close quarters such as dorm rooms) should receive two doses of the vaccine.  If you were born before 1948 a booster vaccine is not required.

How do I know if I am immune?

Look for your old vaccination record.  If there is documentation of two doses, no further vaccination is required.  If not the choice is to proceed with vaccination again or to see your physician to draw lab work to check for immunity.  It does not hurt to receive a third dose of vaccine.

Where can I get the vaccine?

For adults, many offices do not carry the vaccine, such as ours.  The county health department is a good resource for vaccines.  I recommend looking there first.  

What are the signs of measles?

Almost all patients have fever, a significant cough, lots of drainage from the eyes and nose and a diffuse rash.  If you think you may have measles, please call your doctor.  Make sure you alert the staff so that you can wear a mask if you need to come to the office, thus protecting others that you may come in contact with.

A Whole New World

 After a long sabbatical, I am writing my blog again.  My goal is to post monthly.  Welcome back to myself and all of you.  Recently as I have thought about how best to deliver patient care I have come to the realization that I cannot continue to function as I have.  The demands of primary care have increased greatly in the last five years.  More and more of our time is taken to process referral requests, obtain authorizations for medications, call insurance companies to obtain hospitalization approval, etc.  In addition, insurance companies including Medicare are beginning to change the whole structure of physician compensation.  In the past we would receive payments from insurance companies according to what transpired as part of a patient visit.  While that is still mostly the case, in the future, it seems clear that we will get paid to take care of a panel of patients, regardless of whether they come to the office or not.  We will receive compensation according to the severity of the health conditions that they have and how well they are cared for. 

As such, it is now necessary to create a system that can track high risk patients, watch over the most vulnerable ones, and improve communication between doctors as well as patients and their families.  It is quite apparent to me that I cannot do this on my own. It is all that I can do to take care of the patients that come through the door each day, let alone all those who are not present.  I view my choices as either entering “Boutique Medicine” which would limit my panel and require yearly supplemental payments of upwards of $2000 per patient, or of creating a team of health care workers to join together in maximizing the overall health of my patient panel.  I have personal and ethical problems with the first option.  I have decided to pursue the team approach. 

I have put a lot of thought and effort into this endeavor and I am quite excited about it.  It has rejuvenated my career and look forward to putting it into practice.  Let me introduce my team.

It begins with me.  You will not lose me as your physician.  You all know me.  I will keep a very hands on management style to your care.  Michelle has been my assistant for eight years and is invaluable  in helping me take care of you.  She has worked extremely hard.  She deserves more help and I am pleased to introduce the newer members.

Kym Jackson has been a very valued employee here at Associated Internists as a medical secretary for the last 16 years.  She will now be my team’s dedicated secretary. She will be verifying appointments, fixing my schedule, processing referrals, scanning documents as well as other duties.  We are very excited that she is now dedicated to my panel of patients.

I have also hired a nurse practitioner, Maria Motta, to assist me in seeing patients.  I asked her to write a paragraph, introducing  herself:

“I am a family nurse practitioner, a graduate from Maryville University.  I am so pleased to have an opportunity to get to know you all and have a chance to join with Dr. Fuller to provide excellent and compassionate medical care.     

I have been a nurse in the St. Louis community for the last twelve years and I have many years of experience in the field of sleep medicine.  Also, I have experience in the urgent care setting as well as family medicine.   Importantly, I have a special interest in the use of diet and physical activity to build physical and emotional health and will seek to promote these in our practice.”

Maria will be able to help see you for physical examinations as well as routine and sick visits.  She will be starting earlier than me, at 7:30 AM which will likely be a more convenient for many of you.  She, like me, has a passion for health and prevention.  I cannot be more pleased that she is joining with me.  She too will have an assistant to help in the office.  Her name is Rachel.  Please extend a warm welcome to them when you are in the office.  I would love to hear your feedback.  Let me know what questions you have.  

La Casa de Salud

"Hormiga," said the young Guatemalan girl as she grabbed my finger and pointed to an ant on the ground.  "Yerba," she said, pointing to the grass. Having recently arrived in the country, I was wet behind the ears and scared to death.  Only 19 years old, I decided to serve a mission for my church for two years.  It was my first Sunday in the country and though I studied Spanish in school for 5 years and intensively for eight weeks prior to my arrival, being in Guatemala seemed to be a whole new game.  Everything came much quicker, words seemed to be all joined together and I was having a hard time understanding what was being said.  While my companion, Elder Castellanos (a guatemalan himself) was speaking to the leader of the congregation, the bishop's eight year old daughter tenderly took me by the hand and taught me words in Spanish.  Her acceptance of me, a foreigner in her land, warmed my heart.  I immediately grew to love the people of Guatemala.  I later had the opportunity of working with Mexicans, Dominicans, Puerto Ricans and others.  It was during these two years as a missionary that I knew that I wanted to pursue a career as a physician.

Having done well in school and loving the challenge of solving problems, I Initially studied to be an engineer in college.  During my mission years I came to desire to be in a field where I could interact with and bless the lives of others as well.  There were many times when we would visit people in hospitals who were sick and I enjoyed my efforts to be of help.  I began to think of being a doctor and on returning home, I changed my course of study and pursued medicine as my career.  After completing my residency training at Barnes Hospital here in St. Louis, a friend of mine introduced me to a fledgling Spanish speaking medical clinic called, "La Clinica."  It was held in the bottom of a Methodist church.  Though primitive, it grew into a respectable organization.  Unfortunately when the economy took a nose dive in 2007 the funding dried up and the "La Clinica" was no longer viable.  In its place came "Casa de Salud" (translated Home of Health).  St. Louis University has been a generous sponsor and I have continued to be a volunteer physician as before.

I view these efforts as essential to my overall development as a person, as an essential part of my health, really.  I don't really give that much.  I am only there, a few hours, once a month, and I share the knowledge that I have been blessed to acquire.  In return, I am showered with appreciation, compassion and care.  I can see in the patient's eyes gratitude for my efforts.  I feel wanted and that perhaps I am making a small difference in another's life.  Doing so without being payed monetarily changes the interaction dramatically.  I find that as I give of myself, I leave with more than I had before.  Sure there are days when I am already exhausted and I don't relish the thought of driving down and extending my day  but once there, my spirits rise and I leave refreshed.  At some point in my life when my children have all left the house, I will probably increase the time I spend at the clinic but for now I keep it simple, I try to stay balanced.

The image of that sweet Guatemalan girl is never far from my mind.  Last week, I put my daughter on a plane as she begins a journey to Brazil.  She too has decided to be a missionary.  We are so proud of her and I know that by dedicating her life in serving others, she will come to know the beautiful person that she is even better than she does now.  She will find her own little girls that will reach out to her, taking her by the hand and bless her life.  A life of giving brings out the best in all of us.

Touching Lives

"A mensch, do you know what a mensch is?"  I had to admit that I had no clue but it didn't sound good.  With the ever present twinkle in his eye, Aaron declared that my education was insufficient and that he would take it upon himself to teach me the important words to know in Yiddish.  It was the least that this good old Jewish boy could do for his "mormon" doctor.  Through the next few years we grew closer together as he overcame lung cancer, struggled to control gout and progressively deteriorated as his emphysema progressively sapped his body of strength.  Knowing he could not live forever, we discussed his goals for the end of his life.  He did not want to linger on machines but he was certainly not wanting to give up on life either.  At the end it was a massive heart attack that took his life.  He was rushed to the hospital, the cardiologists tried to open up the blockage but his frail body could not take the damage and he did not make it back up to the intensive care unit.  Not knowing these details at the time, I was on my way to see him and happened to meet his family in the lobby of the hospital and learned that they had been called urgently to come up to the ICU.  I ran up the stairs before them, only to learn of his demise.  It broke my heart to turn and notify his loving family of his passing.  Tears were shed together.  As I told his daughter how much I cared for him, she responded, "he loved you, you were such a mensch."  To what seemed to be harsh sounding consonants those years before, now rang with sweet praise.  What an honor!

A few short days prior to saying goodbye to Aaron, I had to also say goodby to Thomas.  I dare say that was not his given name, having been born in China, being a soldier in the Japanese War many years ago.  He and his wife have lived in St. Louis for a very long time.  Though they hold on to their beloved Chinese traditions, they have readily embraced America and love being here.  He worked as a Chinese cook.  We made it through a severe staph pneumonia together, managed his diabetes but watched him slowly decline in strength the last six months or more of his life.  We tried physical therapy, adjusted his medication but at the end it was a simple fall that sealed his fate.  It resulted in a fractured hip and then a devastating stroke that left him partially paralyzed and unable to safely swallow.  He had previously made his wife promise him that she would not let him "rot in a nursing home" but now she was being told that he must have a feeding tube placed and that he would have to be cared for in a facility.  Together we had heart felt discussion about end of life care.  We agreed that his care should be tailored to making his last days as comfortable as possible, not making those days last as long as possible.  Hospice services were arranged and he was able to pass relatively peacefully at home.  On my shelf in my office sits a jade colored plaque inscribed with Chinese characters.  It sits as a reminder of the sweet spirit of that noble man.  He gave it to me about a year prior to his passing.  When I asked him what it means he said, "Good Doctor."  I call it my doctor trophy.

The last farewell that I will share started with Shirley and ended with Millard.  Having dealt with repeated lung issues, Shirley was declining and was adamant that she did not want to go back to the hospital ever again.  Her family called me in a panic on a weekend, as her breathing had become worse and she was struggling to breath.  They wanted desperately to do something for her but did not want to go against her wishes.  I told them that I would meet them at her house and arrange for nurses to come by.  I then called the hospice team and arranged for them to meet me there.  My wife was out of town, so I brought my boys with me to the visit.  I calmed the family's fears and promised that their wife and mother would not be allowed to suffer.  The hospice nurses did a wonderful job and she was allowed to stay at home until the end.  That night as we turned to leave their home, her husband, Millard, turned to my boys and told them how grateful he was to me, their "angel" father.  His kind words to my sons deeply touched my soul.  Over the next 5-6 years, Millard himself slowly declined.  Once an avid cyclist, he was discouraged by his inability to get around as he would have liked.  He had to give up his beloved home.  He made the best of his situation, taking up his oil paint brushes which had long laid dormant.  In the last few years of his life he completed portraits of his dear wife, his two children and of himself.  I saw him regularly, keeping an eye on his kidney function but in the end his old body just started to give out.  He developed Parkinson's which made it difficult to move around.  I received a call from his daughter who told me he had become too weak to even go downstairs to eat.  I told her I would stop by.  He knew it was the end.  We arranged for the hospice nurses to come again.  He did not last long, passing quietly at home.

It is hard to say goodbye to these friends I have made, patients of mine.  My whole goal as a physician is to keep people healthy but at the right time, my job is to relieve suffering, to minimize pain as well.  Success is often measured in the quantity of life but one's quality is equally as important.  I view my interaction with my patients as a wholly satisfying experience.  Each one touches my life for good.  I certainly feel that I receive more than I could ever give.  I wanted to pay tribute to all of my patients, those who have left us and those still living.  To touch a life is a sacred experience, a solemn honor that I take seriously.