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.