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SALT WATER OR MODERN MIRACLE?

2012-05-25T12:38:28Z

May 25, 2012

Now I’ve seen everything. I’m outraged and disgusted by the unscrupulous marketers that prey on my elderly and the unsuspecting patients who seek health in a bottle and instead pay good money for snake oil.

I’m equally frustrated by the fact that these same patients either shun conventional medicine or can’t afford the pills that have been proven to improve or even save lives. Recently, I’ve written about the harm done by Pharma’s TV advertisement of their merchandise. You’ve all seen the commercials proclaiming that product “X” can save your sex life, helping you be ready at a moment’s notice while warning of the dangers of a four hour erection, loss of vision, back pain, or worse.

The purveyors of snake oil have no such restrictions and make no mention of any negative associated with their products. Today, my patient brought in the “dietary supplement” her father purchased at the cost of $70 FOR 64 OUNCES (my children tell me typing in all caps means I’m yelling). Product “Y” claims to be full of trillions of “redox signaling molecules” essential to life. Product “Y” claims to be natural. It comes with very specific instructions and is to be taken 2 ounces once or twice a day ($2 - $4 a day).

This miraculous substance, cheap at about a dollar an ounce, is salt water. Yes, the label lists the ingredients as distilled water and Sodium Chloride (salt). The label also proclaims that the product may have a chlorine odor as the product has trace amounts of natural chlorine. Yes, the miraculous product appears to be chlorinated, distilled and then salted water.

Salt water for a little over $1 an ounce. What will they think of next? By the way, this product is sold to all comers. If the FDA had assessed this product, the product warnings would have alerted patients with heart disease and hypertension to the perils of taking salt water. Yes, salt is essential to life; but too much salt can kill you if you have congestive heart failure.

A little (or a lot of) skepticism goes a long way! Remember, the life you save my be your own.

Could, A Word I Would Do Without

2012-05-24T12:30:38Z

May 24, 2012

“Could” is a word I would do without if I had my way! Unfortunately, my patients love it!

“Doc, could my headache be from stress?”

“Doc, could my husband be suffering from depression?”

“Doc, could my son have ADD?”

“Doc, could …?” is a question I hear multiple times a day. The funny thing is the answer is always the same. Realistically, anything “could” be true. So every time a patient asks the question, “could,” the answer is yes.

“Yes, your headache could be from stress.”

“Yes, your husband could be suffering from depression.”

“Yes, your son could have ADD.”

Unfortunately, the “could” question often misleads my patients. While the answer to a problem could be stress, depression, or ADD, often those are unlikely sources of the problem at hand. Explaining why they could, but are unlikely, is time consuming and stressful for the patient and the doctor. I particularly hate when a parents ask the “could” question in front of their child. It is not uncommon to see fear immediately consume the patient’s face.

The question my patients should be asking is, “Doc, what is the probability that stress, depression, or ADD is the problem?” Differential diagnoses are based on probabilities. A differential diagnosis is a list of the probable causes for an illness ranked from most likely to least likely or most dangerous to least dangerous.

Knowing what my patients’ concerns are is critical. Cyberchondria is real and the internet stirs up trouble on a regular basis. Learning to avoid the word “could,” and using “probable” instead, helps allay a lot of fears!

Could this article help you find the answer to what’s bothering you? I hope so!

GAMBLING WITH YOUR LIFE

2012-05-23T12:27:16Z

May 23, 2012

This article was originally published in December of 2010. Unfortunately, I continue to meet gamblers and continue to see the high rollers lose (their lives or their health). Don’t gamble with your health!

Today was a stressful day. When “high rollers” come into the office to be seen, my day is more stressful than usual. Today, I saw an unusually large number of “high rollers”.

“High rollers are those patients who bet their lives on the premise that they “know their bodies” or they are “healthy”. Their bet is a real one; and, when they lose, they either lose their lives or suffer major losses to health and dignity. No matter what I say or do, “high rollers” insist they understand the risks involved and will live with the consequences of their decisions if they are wrong. The problem is that they really can’t imagine what the consequences of having a stroke or heart attack are until it is too late. They really can’t understand what the consequences of an untimely death are and never will. They will not be here to witness the aftermath.

To make my point, let’s examine two typical, but fictitious, all too real patients. Patient number one is a male in his mid fifties. He comes into the office complaining of chest discomfort. He has had some “discomfort” in his chest off and on for a few months. “Doc, it’s not bad. Doc, I think it’s my meds or something I ate.” He has significant risk factors for heart problems and I explained that he may well have angina pectoris, a condition stemming from a serious vascular problem with his heart. I advise him to see a cardiologist in the very near future and start him on medication. He states he that is too busy and won’t seek further help or diagnostic tests until after New Years. I warn him that he is gambling with his health and may not see the New Year. “Doc, I know my body! It’s just my medication. It’s not bad! It’s no big deal.” I hope he is right but I fear he is wrong. I tell him about Tuesday’s article and the cartoon my mother sent me. Would you rather spend two hours of your busy life assuring your heart is ok or 24 hours a day being dead?

Patient number two is a sixty year old female who feels perfectly healthy. She just wants her refill and to go home. Because she feels well, she does not have her annual health exam, pap and mammogram. After all, she is healthy! The problem lies in the fact that most people are healthy until they are not. Preventative healthcare’s goals are to find problems and fix them before they find you! Every year I diagnose the earliest stages of cervical, colon, breast, and prostate cancer and eradicate the cancer prior to its devastating course. I find subtle signs of heart disease and stop it in its tracts. Those patients blessed with the knowledge that they have a curable disease, treat that disease and live long lives. During the same year, I have to diagnose cancers in their late stages and then witness the devastation caused by metastatic disease. I meet patients in the cardiac intensive care unit after a major heart attack and talk about rehabilitation and limitations. The healthy “high rollers” bet that they will always be healthy. Some win, many lose. The loss is often catastrophic. Many are afraid of what I will find if they come in for an annual physical. To those patients I say, “Be more afraid of what finds you than of what I find”.

May you be so blessed as to never know what disease you prevented! Have a happy and healthy New Year.

Oh, My Aching Back

2012-05-22T12:53:54Z

May 22, 2012

Oh, my aching back! Yes, for those of you who don’t know me, my youthful indiscretions have left me with a lousy back. Fifteen years after my first back surgery, I had my second. That was fourteen years ago! Now my back is flaring again.

I wake up every morning feeling stiff and old. A hot shower and some stretching make me young again. I can conquer the world, at least until 4 pm. After 4 pm, I start to age again. It’s 6:30 and I’m 75 years old. I am not complaining! It’s a fact of life. Most days, no one notices how I feel.

When my staff starts telling my wife, “He’s Grumpy,” I know my back pain is showing. I haven’t heard the “grumpy” word in a while so I guess I’m doing pretty well. I’m sharing my personal story in hopes of helping others who live with pain. I have choices and want to review them in this article.

I can take medication to either treat or hide the pain. I hate medication! Yes, I’m a doc and I hate taking pills. Anti-inflammatory medicine alleviates my pain by removing the inflammation caused by my spinal arthritis. I bloat on anti-inflammatories putting on 3-4 pounds of fluid during the first few days. By the 10^th day, my stomach is upset and I have to take anti-ulcer medication. I’d rather tolerate the pain than plump up and get indigestion.

I could take pain medications to hide from the pain. I can’t take codeine and work so that’s out! I can’t imagine not going to the office and seeing my patients. Besides, codeine constipates me. There is nothing worse than being constipated, sitting on the porcelain throne and straining when your back hurts.

I could take muscle relaxants. Their effect is akin to what I imagine the 70s would have been like if I hadn’t been so perfect. You certainly would not want to see a doc on Flexeril. Do you understand why I don’t like pills?

My favorite treatment is a shot in the rump of Toradol, a potent anti-inflammatory that works really fast. Unfortunately, Toradol only lasts 6-12 hours and, if used repeatedly, has all the side-effects of oral medication. Besides, I hate seeing my staff draw straws to see who sticks the old man, especially if I’ve been “grumpy.”

My second favorite treatment is something called an epidural injection. Dr. Schneider is a real master at injecting me in the spine with potent steroids and helping me stay healthy. Going directly to the root (pun) of the matter makes the most sense. Unfortunately, I’ve had a lot of epidurals and have to save them for the times the pain is unbearable.

Of course, there is always more surgery. The problem with back surgery is that, while healing, you form scar tissue, and the scar tissue can create the need for future surgery. Besides, if I ever need to return to the surgical suite, the third one won’t be the charm. Following two successful surgeries and the passage of close to 30 years, the third surgery will be a “tear down and completely remodel” job. I’m really not looking forward to that.

I am actively working at getting thinner and healthier. Stretching and exercise seems to be my best approach. Massage therapy helps! Have you seen how expensive massage therapy can be? Unfortunately, insurers don’t believe it works so they don’t pay for it. Physical therapy helps but what working doc has the time?

That leaves me with saying a prayer every night and grinning and bearing it! The good thing about pain is it reminds me I’m alive. The hours when the pain is gone also reminds of how good it feels to be healthy. I am healthy and wellthy and wise. I know there is a good chance that this current flare up will subside. I know my physical, emotional, nutritional, and spiritual accounts are growing by the day despite my backache.

I hope that this article helps others who are living with their back pain. What’s right for me is not necessarily right for you. See your doc, review your options, and find your health. Most of all, don’t let pain sour your outlook on life.

Fifty Shades of Grey

2012-05-21T12:55:44Z

May 21, 2012

Fifty Shades of Grey is the name of the book all of my female patients are reading. It is also an appropriate description of the practice of medicine. In my world, there is very little that is black and white. Even death is no longer permanent!

Over the last few years, I have published articles dealing with the words “Necessary” and “Unnecessary.” Patients, insurers, Medicare, and doctors can’t quite reach an accord on what is truly necessary. Why? The answer is simple. There are very few things in the medical world that are truly definitive, black and white.

I hospitalize a patient for chest pain and fever. The radiologist reads his chest x-ray as a probable pneumonia. The pulmonologist (lung specialist) does not believe that my patient has pneumonia. He thinks my patient needs a cardiologist. The cardiologist (heart specialist) is pretty sure my patient’s heart is not the problem and that he has pneumonia or some other lung disease. My patient thinks everyone is wrong, insisting he has a severe case of indigestion. A PPI (medicine for the treatment of ulcers) makes the patient feel better. What does my patient have?

As it turns out, my patient has metastatic carcinoma of the lung. The CT of the chest revealed that the abnormality in the chest x-ray was a cancer. It also becomes apparent that he has coronary artery disease and fairly severe GERD (reflux of acid into his esophagus). In the end, everyone is partially right!

Gray is the color of medicine! Often, practicing medicine is like assembling a 1000 piece puzzle. You know the pieces you are looking for are somewhere on the table, you just can’t find them. To make matters worse, all the pieces are shades of gray that can be fit together in a myriad of ways and sometimes 2-3 puzzles get mixed together haphazardly. Doctors have to be master puzzle solvers. They have to keep an open mind even when they are convinced that they know what the final picture is supposed to look like. They often need the help of their peers in order to complete the picture.

The real trick is in transforming the completed puzzle into a picture of health. They say patience is a virtue. Be virtuous while your doctor is hard at work caring for you and understand that there are some puzzles that can’t be solved. Like my patient discussed above, add your thoughts on the puzzle often but remember, keep an open mind!

DOCTOR-PATIENT RELATIONSHIP

2012-05-20T12:13:07Z

May 20, 2012

Yesterday, KevinMD published an article entitled, Necessary is a word best defined when looking back in time, I wrote the article early in the month in response to a comment made on KevinMD by an angry reader. The comment had to do with doctors ordering unnecessary tests. In response to my article, a reader posted, “Another post suggesting that a doctor must care about you to give good treatment. What do you do with those patients you don't like, give them lousy medical treatment?”

The answer is NO! However, often I have to work six times as hard to give them excellent care. Yes, just as patients have the right to dislike their doctors; doctors have the right to dislike their patients. When a patient is unhappy with, or dislikes his doc, he simply transfers his care to another doc in the community until he finds a medical home he can be comfortable in.

When a doctor is uncomfortable with or dislikes his patient, the situation is much more complicated. The doctor-patient relationship is governed by both medical ethics and law. Doctors are supposed to be clinically detached from their patients, making medical decisions based on scientific fact and evidence-based medicine. I have never understood how to care, yet be detached. I believe that caring for the patient comes before science and evidence. So what do I do when I find it hard to care?

First, I analyze the situation, diagnosing why the patient makes me uncomfortable. Why is it so hard to care? Sometimes, the patient’s illness makes it hard to care for an individual. Imagine a patient who has a personality disorder. He hates people, is rude to the staff, verbally abusive at times, and on occasion, is physically threatening. It’s hard to care for the above mentioned patient, yet his illness requires care and understanding.

Caring for a person who does not care for himself is hard. Patients often abuse themselves, drinking too much, eating too much, and smoking. Caring for a patient who asks for help and then refuses to help you help him is difficult. Non-compliant patients fall into this category. Many non-compliant patients have passive-aggressive tendencies.

“Another post suggesting that a doctor must care about you to give good treatment. What do you do with those patients you don't like, give them lousy medical treatment?” I work hard to find what the patient needs to succeed. I work to find the best in my patients. When I can’t, I tell them that I am not the right doctor for them. I try to help them find a doctor more suited to their personalities or who can reach them when I cannot. Just as patients have the right to change doctors; doctors have to have the right to change patients. In my opinion, if you can’t care for a patient, you should not treat him.

Yes, the doctor-patient relationship is a sacred one. It should encompass mutual care and respect, be grounded in good communication, and mutual goals. When that relationship is flawed and beyond repair, it should be severed for the sake of both parties.

AGENT X

2012-05-19T15:24:22Z

May 19, 2012

After watching T.V. tonight, I’m amazed my patients are willing to take the medications I prescribe. I’ve watched four commercials extolling the benefits of four different prescription medications. At the end of each commercial, the commentator listed a litany of horrible sounding possible side effects and warnings. It appears that the same medication that can save you from the problems associated with asthma can also kill you. What’s a patient to do?

The problem with T.V. commercials and package inserts warning about possible side effects and risks of taking prescription medications is that they do not come with any comparators. Without establishing a frame of reference, a life saving medication sounds horrible and people who would benefit from its use often are too afraid to use it!

Now imagine that a medication, we’ll call Agent X, was developed that prevented you from getting cancer. Research showed that the twice daily ingestion of one pill would prevent you from ever having a cancer. What a great T.V. commercial that would be! Oops, I forgot the legal mumbo jumbo at the end of the commercial. The commentator, speaking in a rapid cadence says, “It is estimated that of 20 million people taking Agent X, 5 million people may experience a significant injury of which 2 million people will be left with some form of disability. There will be 35, 000 deaths a year as a result of taking Agent X.” Would you take Agent X?

Now, let’s look at those statistics from a different point of view. According to the National Safety Council (NSA), “there are more than 12 million motor vehicle accidents annually including more than 20 million vehicles. This results in over 5 million nonfatal accidents annually of which approximately 2 million are disabling injuries including approximately 1 million work-related auto disabling injuries.” In 2011, there were 35,000 deaths from motor vehicle accidents. Do you drive a car?

Of course you do! The benefits of driving a car far outweigh the risk! It’s funny how statistics can look different depending on your frame of reference. The next time you hear a T.V. commercial lauding a medication, listen to the warnings but recognize that, if the benefits did not outweigh the risks, the medication would never had made it to the market. In the case of Agent X, the FDA would have looked at the side effect profile and refused to approve it for use in the U.S.

Also, recognize that following the rules of the road help decrease your chance of being injured in a car accident. When your doc prescribes a medication and the pharmacist fills the prescription, they give you “rules of the road.” Follow those rules, follow up when you are supposed to and make sure you have laboratory tests done in a timely manner when prescribed by your doc. The life you save may be your own.

HAPPY MONTHIVERSARY, RENEE!

GOALS AND THE LIST

2012-05-18T12:52:23Z

May 18, 2012

The following was handed to me by one of my patients today. I love it! Setting realistic goals and then working to accomplish those goals is the formula this patient used to achieve success! I hope you appreciate this list as much as I do. I also hope you will make your own list and work to be a better you.

2012 Goals / Concerns

To continue to improve my physical, mental, & spiritual conditions.

What needs to be done?

I need discipline, discipline, & discipline to follow my doctor’s directions and for me to do what I know needs to be done.

What I am striving to achieve

Want to have four (4), five (5) pound weight reduction sessions
Continue to reduce my medication to control my diabetes
Continue to work on eating healthy
Increase my exercise program by minimizing any excuses not to.
By eating healthy, proper exercise & following my doctor’s advice, I hope to reduce and/or eliminate other medicine I currently take.
Improve my balance, strength, & dexterity
Improve my golf game, have my desire to play again back
Strengthen friendships & develop new
Want to continue to get compliments how I look better and healthier in order to inflate my ego.

Some accomplishments this past year

I like myself better
I have lost 10% of my March 2011 body weight
Continue my fight against tobacco usage
Much better person not consuming alcohol
Have reduced & eliminated some prescription drugs
My legs have gotten stronger
Balance has improved
My overall outlook & attitude has improved.

Concerns for 2012

I have a soreness, itch (no pain) in my left hip & butt
Can’t stand to long, lower back starts to hurt
Urinating more frequently, every 2-3 hours
Could I not be digesting a pill, either Metformin or Gabapentin ?

Concerns of 2011 that I had & that I am continuing to work on

I can be very judgmental, always want to know why?
I’m always trying to analyze everything even when it does not concern me.
Hate waste and incompetence even when it does concern me.
Things that that don’t concern me, or effect me, bother me.

Favorite Quotes

My daddy told me 60 years ago, “the harder you work, the luckier you get”.

If I do what I have done, I will get what I got.

I got to remember, Failure is not an option.

You can’t fix stupid

Fall three times, get up four

Dear god, I have a problem, it’s me

Do the math, count your blessings

If there’s no wind, ROW

There are no bad soldiers under good generals

Options is power

You never saw a fish on the wall with its mouth shut

HOW TO STAY YOUNG

1. Throw out nonessential numbers.

2. Keep only cheerful friends.

3. Keep learning.

4. Enjoy the simple things.

5. Laugh.

6. Tears happen.

7. Don’t take guilt trips

8. Surround yourself with what you love best.

9. Cherish your health.

10. Tell the people you love that you love them, at every opportunity.

11. When all else fails, read the instructions. THE BIBLE

BY THE WAY

2012-05-17T13:43:26Z

May 17, 2012

Oh, by the way . . .

are four simple words that cause most docs to shudder. Yes, shudder! Your patient signed in for a sore throat, congestion, and cough. The nurse did her job. She’s recorded the patient’s chief complaints. She’s taken the patient’s vital signs and readied the patient to see me, the doc.

I take a history, asking questions about the problems that brought the patient to the office. I ask pertinent questions about the patient’s health history, medications he takes, allergies he has. I order appropriate tests, make a diagnosis, and discuss treatment options. I write prescriptions and give the patient a print out summarizing the finds and plan as well as follow up instructions. I ask the patient if he has any questions. I say good bye and end with “be happy, be healthy,” my wish for all of my patients.

As I am reaching for the door, I hear “Oh, by the way . . .” and I shudder. I was on my way to see the next person, the one that has been patiently waiting in the next room. I did my job and did it well. Now I have to start again. I have to re-open the chart, start at the beginning, and do it all over again. If I ignore the “Oh, by the way . . .” moment, I may miss something critical. If I ask the patient to make another appointment to discuss the new complaint, I may injure the patient. If I start the appointment process over again, I will delay the next patient’s care. I shudder!

Recently, I saw a child for a sport’s physical. On the way out of the room, her parent said, “Oh, by the way, I just don’t feel right and I’ve been having shortness of breath off and on lately.” The office is busy and wait time is around 30 minutes. It’s late in the day and I am tired. I shudder but not because I have to start all over. I shudder from an adrenalin surge. “I don’t feel right and I’ve been having shortness of breath” is potentially serious as in heart attack territory.

I start all over again. My nurses notify my other patients that I am tied up and will be a while. While vague, the history is troublesome. The patient is too young to have serious disease, but he does. The “Oh, by the way . . .” literally saves his life.

Prior to visiting your doc, make a list of everything you want to discuss with him. Take the time to prioritize the list and put any “Oh, by the ways” on the list. Share the list with your doc’s nurse. Share it with your doc. The nurse and your doc will then be able to set their own priorities and negotiate them with you. In this case, I would have moved “not feeling right and short of breath” from last place to first place. The child’s physical could have waited.

Had the father forgotten to discuss the “Oh, by the way” with me, he may well have died. If I had ignored the complaint or postponed dealing with it, he may have died. Partner with your doc. Give him a list of your priorities and work with your doc. What you think is trivial may not be. Always remember, the life you save may be your own.

ANTS

2012-05-16T13:02:28Z

May 16, 2012

The following article was originally posted February 18, 2011. In the last 2 weeks, I have treated too many patients with "ANTS." Must be the bad economy.

Artsy, the octogenarian I wrote about recently, just introduced me to the world of “Automatic Negative Thoughts”, otherwise called “ANTS”. Over the years, my elders have taught me many important lessons. Artsy has managed to give me two significant presents in the same week.

Ants are the pesky little insects that overrun your picnic or show up in your house if you leave food around. They are industrious little beasts, incessant in their tasks whatever it are. Most humans hate ants and will do just about anything to get rid of them. Go to any hardware store and you will find shelves full of ant killer sprays and traps.

“ANTS” (automatic negative thoughts) are just as incessant and industrious as their namesake; however, they are much more destructive. If you thought having ants in your pants was bad, “ANTS” in your head are intolerable. Everyone has “ANTS” from time to time. Sometimes, “ANTS” take on a life of their own. One leads to another; and, before you know it, you have a huge ant hill of negative thoughts spewing forth and overwhelming you. “I’m a loser” leads to “I’m no good” which turns into “Everyone is judging me” and “I’ve let everyone down” and, finally, “I hate myself!”

Just as the hardware store has shelves full of ant killers, the internet has many pages full of “ANT” killers I’ll call “ANT EATERS”. I pride myself on staying open to new information and staying current. I was happy to find so many “ANT EATERS”. My best “ANT EATER” is “Blessings List” published on November 17^th, 2010. Another is to have an “Attitude of Gratitude”. A third approach, for anxious people, can be found at: http://www.anxietynetwork.com/hstop.html

“ANTS” are ever present and it is incumbent on each of us to develop our own unique “ANT EATERS”. So listen, read and learn from others. Talk about your “ANTS” with family and trusted friends. If you are overwhelmed by “ANTS” or are plagued by those darn red stinging “ANTS”, find a professional “ANT” exterminator (family physician, psychologist or psychiatrist). Most of all, pledge never to give in to those pesky, lousy “ANTS”.

SELFISH, GOOD OR BAD?

2012-05-15T11:35:23Z

May 15, 2012

This article was first published in 2011. It is just as true today as it was then. Some things seem to never change.

My family, my friends and my patients think being selfish is bad! I bet you do, too. I used to think so, as well. Twenty seven years in practice has taught that being selfish is good. Actually, selfishness is essential to an individual’s health.

Today, I saw a selfless young woman who was ill. She had an assortment of complaints. She had not felt well in months. If she was the CEO of a Fortune 500 company, she would have been diagnosed with executive burn out and given two months at Canyon Ranch, an executive retreat. Unfortunately, she is the CEO of a typical American family. She is married, has five children, a dog and works full time. She has living parents who are aging and require help. She is a hard worker, dedicated to caring for her nuclear and extended family, as well as excelling at work. She has no time for self. She is one of hundreds of such mothers in my practice. She is stressed to the max but does not have the luxury of going to Canyon Ranch.

I often tell the story of the hand. The thumb is you. When you are young, you are self centered, egocentric. The world revolves around you and only you. One day you realize that you have parents (your index finger), and you are responsible to them, as well as yourself. As you age, you meet the love of your life (the middle finger) and are responsible to your mate. In time, children come along (ring finger) and they need lots of your time. You become very responsible for them. Then you have you job (little finger). As you grow in your job, responsibility grows as well. You are a good person and want to excel at everything. Your parents are aging and require more attention. Your children are aging and require more attention. Your job is growing more complex. Your mate, who is often responsible like you, is in the same position.

So what do you do? Things are out of control! You have to take care of your parents, your mate, your children and your job. The only thing you control is you, so you sacrifice yourself. Try using your hand without using your thumb. What you find out is, without the thumb, your hand is useless. No matter how hard you work to make your four fingers function, without the thumb, the hand falters.

If you are not healthy, you cannot help those who need and depend on you. If you are not selfish enough to save time to care for and nourish yourself, you will get sick. Those around you will have to function on their own. Why wait until you are exhausted, burnt out or sick? The answer is simple. Your parents taught you not to be selfish. They taught you to be a responsible individual. It is time you teach your loved ones to be responsible to themselves, to set healthy limits, to take time off, to laugh and be happy. Set a good example; get healthy. At first, those who are used to getting all of you will rebel. They may call you selfish. Teach them that a part of a healthy you is better than part of an unhealthy you. In the end, by being selfish, everyone will be better off.

WHOSE FAULT IS IT?

2012-05-14T13:19:11Z

May 14, 2012

James C. Salwitz, MD asks an interesting question in his article which was recently published on KevinMD. “Are smokers to blame for the damage they do to their bodies?” is well worth reading!

Whose fault is it? Those who read this column know that I tend to agree with Janeben’s comment posted in response to Dr. Salwitz’s laying blame on the pusher and not the user. Accepting fault for one’s own mistakes appears to be downright un-American.

However, I agree with Dr. Salwitz that the pushers in society should be held responsible for the damage they do in providing the cigarettes to the smoking addict! While I take particular offense at healthcare providers (pharmacies) that sell cigarettes and prescribe and sell medications, I think the larger responsibility should be borne by our government.

Yes, our government sanctions the sale of cigarettes while posting warnings on every pack. They reap the taxes from tobacco sales on the front side and pay for the treatment of COPD and lung cancer on the back side. Does that make sense to you?

It only makes sense if you are a politician dependent on contributions from the tobacco lobby! These are the same Congressional leaders who passed Obamacare. They are the same leaders who demand that healthcare cost be reined in. They are the leaders who will ration healthcare in years to come.

In a monumental “Catch 22,” the smokers damaged by years of legalized tobacco use are the patients who will be most affected by rationing of healthcare in the future!

If you smoke, quit now. If you can’t quit, ask your doc for help! The life you save may be your own!

WEIGHT LOSS

2012-05-13T14:09:27Z

May 13, 2012

Doc – “Good morning, Mrs. Smith, how can I help you today?”

Mrs. Smith – “I want to lose 20 pounds. My daughter is getting married in 4 months and I want to look good. I was hoping you would prescribe some Phentermine (a diet pill). My neighbor’s doc gave her Phentermine and she did great!”

Unfortunately, the above interaction is a common occurrence. My patients want to lose weight for a host of reasons. Many have lost and gained hundreds of pounds over their adult lifetimes. Many have been on fad diets, used pills, seen hypnotists, and nutritionists. They have vilified carbohydrates, banning them from the dinner table. On other occasions, they have vilified fats or proteins. They have juiced, taken nutrients in pill form, powder form, and used other unnatural forms of nourishment all for the sake of weight loss.

It’s downright pitiful! There is one good reason for weight loss and that is to improve your health. Unfortunately, like Mrs. Smith, most patients seek weight loss for vanity sake. Their successes are usually temporary and followed by weight gain in excess of their prior weight loss.

Doc – “Mrs. Smith, I see from your chart that you have been dieting for years. Since I first examined you in 2001, you have lost 40 pounds and gained 55. Don’t you think it’s time to set some realistic, long term goals?”

Mrs. Smith – “I know I’ve been bad, but I have to look good for the wedding. I promise that I’ll keep my weight off this time. Can you prescribe Phentermine? Diets just don’t work for me!”

Yes, diets don’t work. Diets don’t work for Mrs. Smith and they don’t work for the majority of my patients. Don’t get me wrong. If your goal is short-term weight loss, diets work. If your goal is to establish a healthy lifestyle and long- term weight loss, then you have to define and refine your own diet. You have to improve your physical, emotional, nutritional, and spiritual selves.

In short, you have to establish a permanent, new you! You can’t stop being “you;” but you can work at being a better “you,” improving slowly over a long amount of time. Establishing a long term image of who you want to be is the first key to success.

The second key to success is establishing accountability. Once you establish your long term goal, you need to be accountable to yourself, your family, and those who can help you achieve success. My most successful patients are those who involve a coach, like Betsy Weisbach or me, in their quest for better health. Regular weigh-ins and counseling sessions help insure accountability.

The third key to success is reliability. You have to rely on yourself, your consultants, friends, and family as you work to refine and polish your new lifestyle. Assembling a healthcare team will help you during those temporary lapses that all humans experience. Yes, we are all fallible. Some of us succumb to overconfidence while others succumb to the dread plateau.

If your only goal is weight loss and your only gage of success is the pound scale, you are doomed. Your weight will plateau! You will get frustrated. Remember, there are multiple ways to measure success. There is even a happiness scale.

Your goal should be to be healthy and happy.

Doc – “Mrs. Smith, you have 16 weeks to lose 20 pounds. I don’t recommend Phentermine. Let’s do it right this time! All you have to do is work daily at being a better you, slowly improving your own diet. Not only will you lose your weight, but this time you will keep it off. Better food choices combined with some exercise is just what the doctor ordered.”

Mrs. Smith – “But my neighbor did so well on Phentermine!”

Doc – “And has she kept her weight off?”

Mrs. Smith – “Well . . . No, she hasn’t.”

Doc – “Exactly! Why don’t you read Diets and Other Unnatural Acts or any of the myriad of books that teach lifestyle modification and weigh in next week. I’ll work closely with you. I see you have an I Phone. Please download the Lose It app and track your intake for me. Why don’t you buy a pedometer, as well? I’ll teach you to compete with yourself.”

It’s been 6 months and Mrs. Smith is doing great. She looked good and felt great at the wedding. Yes, she has had a few lapses but, thanks to the support group she has established, the lapses have been short lived. Most importantly, her transition to a healthy lifestyle has been easy.

Have a great Mother’s Day, Mrs. Smith!

WHAT HAPPENED TO CUTTING EDGE RESEARCH?

2012-05-12T13:18:47Z

May 12, 2012

Over the last few weeks, I have scanned the medical literature for new material for this column. I have looked for new research regarding common diseases, new drug approvals, new diagnostic tools, and helpful preventative tips.

Unfortunately, there is nothing new to report. It’s as if I have been journeying through a veritable desert. What’s really scary is that new medical breakthroughs seem to be drying up. I haven’t had a new antibiotic in years; no new treatments for diabetes, hypertension, dyslipidemias, or arthritis, either.

I have been in practice for over 30 years. I have been spoiled for over 30 years. I have grown accustomed to learning about and utilizing “breakthrough, cutting edge” technology and treatment protocols. I’m starting to believe those days are over.

From where I sit, it looks like Dr. Rich is correct. Covert rationing of medical care has been a tremendous success. Turning big pharma into a money grubbing villain has taken its toll. The bad economy has taken its toll. Stricter governmental control has taken its toll. The destruction of the doctor-patient relationship has definitely taken a toll.

So, what does the future look like? From where I sit, not very good! The destruction of my profession is just beginning. Obamacare or Whatevercare is coming with a fury. Whether the government or the insurers are in control, the drive to rein in the cost of medical care will accelerate. As we move from the care of the individual’s needs to the care of society’s needs, covert rationing will increase.

Our government will not call it rationing. Insurers will not call it rationing. “Necessary” care will be redefined; science will be used as a cost cutting tool. Algorithms and protocols will dictate what a patient will receive and what he will not receive.

Do I sound depressed? I am! I’m also worried. Bacterial resistance is on a rise! What will I do when my patients develop untreatable infections? Progress has been made in the treatment of diabetes, heart disease, and stroke; yet people still die from these diseases. Do we accept that what we have now is the best we will have? I think so!

So, what can we do? As the care shifts from the individual’s needs to those of society, it will be more important than ever to do everything you can do to be healthy. Start small and “Chicken Step” your way to a healthy, "wellthy" lifestyle. Diet and exercise makes a difference. Being happy with what you have makes a difference. Preventing what you can and treating early can make a big difference.

I don’t care how you do it, just do everything you can to be healthy and hope that your doc will have the tools and the authority to do what you need him to do for you. Read “Diets and Other Unnatural Acts” or any other books on health you choose to. Learn how to be healthy now!

I hope I am wrong about the future. I hope new treatments and cures are just around the corner. Sometimes it feels good to be wrong. I will pray I am wrong but expect I will be right. I will keep teaching a healthy lifestyle on this blog and hope you will share it with others.

BACTERIAL VS. VIRAL

2012-05-11T12:21:25Z

May 11, 2012

Often, the most difficult part of my job is deciding whether my patient has a viral or a bacterial infection. The second most difficult job is explaining to a patient who has a viral infection why an antibiotic will not work. Patients suffering from respiratory tract infections (URI) want me to cure them. They want antibiotics, the supposed cure-all! In my early years in practice, it was impossible to differentiate between a virus and bacteria. Antibiotics were considered relatively harmless and everyone who suffered from a URI received one. Since my patients got well (because of or despite taking an antibiotic), they grew to believe that, without an antibiotic, they would not get well. Over the last decade, antibiotic resistant bacterial infections have dramatically increased due to the overuse of antibiotics. In the decades to come, appropriate use of antibiotics will be imperative.

In the real estate business, it’s “location, location, location”. I often hear, “Doc, I’ve got a sinus infection and need an antibiotic.” “Doc, I’m coughing up green sputum and need an antibiotic.” Sinusitis, bronchitis, tonsillitis, pharyngitis, gastritis, and cystitis are all infections in certain locations within your body. The easy step in diagnosing an illness is determining where the infection is. The hard step is determining what “bug” (virus vs. bacteria) is causing the infection at the given location.

“Bugs” can all cause the same symptoms. A sinus infection, complete with facial pressure, green discharge, fever, and chills can be viral or bacterial. A viral sinus infection is treated with symptomatic measures and eventually goes away by itself. Once your body recognizes the virus, specialized killer cells (lymphocytes) are produced and then hunt and kill the virus. Antibiotics assist your body in getting rid of bacterial infections. Once your body identifies an invading bacteria, it makes specialized killer cells (neutrophils) that eradicate bacteria.

In the early stages of any URI, mucoid secretions are clear. As the infection worsens, they often turn yellow, grey then green. Green is actually good. Green is the color of white cells (lymphocytes or neutrophils) engaging the enemy. Green means your body has found the invader and is attempting to heal you. Mucous, in itself, is a problem. It nurtures and shelters the invading “bug”. Symptomatic treatment is aimed at helping you clear mucous. Mucinex is my favorite agent. My instructions also call for saline nasal sprays and the ingestion of copious amounts of fluids. Please avoid orange juice. While it contains vitamin C, it also contains citric acid. The acid content further irritates the throat and increases mucous production.

So, how do I determine if you have a bacterial or viral? As stated above, it’s not easy. Bacterial infections tend to cause higher fevers and tend to be associated with more severe physical findings. Viral infections tend to cause severe symptoms with milder physical findings. In the early stages of a communal illness, diagnosis tends to rely on highly educated guess work. That may sound shocking, but it’s true. Once I have seen ten or more cases, it becomes easier. The disease takes on its own personality and becomes predictable. Recently, Lake Zurich was hit by an outbreak of viral laryngealpharyngitis. The symptoms and course was predictable and many of us were still coughing 3 weeks later.

I rely heavily on the ability to do blood counts in the office as an aid in diagnosing viral vs. bacterial infections. Low white counts are usual for viruses and high white counts are seen in bacterial infections. Normal white counts may indicate an infection with a mycoplasm infection (modified bacterium/bug).

In person, it is difficult to accurately diagnose a URI or any other medical problem. Diagnosing over the phone is often impossible. Sometimes, it takes several visits to solve the mystery of what is infecting you. One reason I keep an open, extended hour, schedule is so that you can easily be seen. Please come in when you are sick. The life you save may be your own!

A GREAT DAY

2012-05-10T13:39:12Z

May 10, 2012

Today was a great day. I cared for 15 caring individuals. Yes, caring is a two way street. Despite ailing from a host of illnesses, today’s patients were, for the most part, happy and caring. Each patient seemed genuinely interested in how I was doing. Many complimented me on how much weight I had lost. My patients who were suffering from viral illnesses even thanked me for not prescribing antibiotics.

Yes, today was a great day. Not all days are as good. Jordan Grumet, M.D. wasn’t as lucky. “Being A Physician Is Like Trying To Parent Two Thousand Teenagers,” published on KevinMD today, tells a different story. Despite spending 15 minutes teaching his patient why an antibiotic is contraindicated in viral illnesses, his patient walked out angry.

The family of a 100 year old comatose patient on tube feedings was furious when Dr. Grumet informed them that their loved one’s kidneys were failing and that she would not tolerate dialysis. They accused him of trying to kill her.

To make matters worse, he had to spend significant time explaining why narcotics were inappropriate in the treatment of chronic musculoskeletal pain. The patient threatened to report Dr Grumet to the authorities for refusing to fill her hydrocodone. Of interest, the Illinois Controlled Substance site revealed that she had filled 250 hydrocodone from various other docs.

Yes, I had a great day; Dr. Grumet did not. Unfortunately, there will be those patients suffering from a viral infection who will be angry with me if I don’t give them an antibiotic no matter how much time I spend teaching them about the treatment of viruses and antibiotics.

There will also be families who will not accept the impending death of their loved ones. They will refuse Hospice and palliative care and demand that every possible treatment available be given their 100 year old grandmother. End of life issues are often the hardest to deal with!

Even worse, there will be drug seekers who will take up precious time weaving a story designed to get their narcotic fixes. They will be convincing, having a list of allergies including Tylenol, Advil, Aleve, and aspirin. They will have failed on everything other than Norco (hydrocodone). Luckily, the state of Illinois has an electronic registry of all narcotic prescriptions.

Doc - “Mr. Y, I see you have received 250 Norco in the last week from five docs and two emergency rooms. Here is a referral to the local drug and alcohol rehab program.”

Mr. Y – “Someone must have stolen my identity. I never filled any of those prescriptions.”

Doc – “Sounds like I better call the police and report your identity theft and the illegal use of narcotics.”

Mr. Y – “Doc, I’ll get help, I promise. I just need a few days to tide me over.”

Yes, today was a really great day. I wish everyday could be just as good! By the way, to those patients I saw today, thanks for caring about me. When care is a two way street, things go much better.

IMMUNIZATIONS

2012-05-09T12:30:05Z

May 9, 2012

This year, in accordance with the Illinois Department of Health rules, “students entering the sixth and ninth grades will be required to provide documentation of receipt of at least one dose of Tdap for the 2012-2013 year.”

“Tdap is a vaccine licensed and recommended to protect pre-teens, adolescents, and adults against tetanus, diptheria, and pertussis (whooping cough). Tdap is licensed for routine use on or after the 10^th birthday.”

Most of my patients are too young to remember the effects of full blown whooping cough, diptheria, and tetanus. As a matter of fact, I’m too young to have seen tetanus. In the 30 years I have been in practice, I have treated diptheria and whooping cough and can truthfully say I never want to see another case.

Vaccines work! Despite all of the fears parents have over the perceived risk of vaccinations, I have been fortunate enough to have never witnessed a bad reaction or side effect. In my early days in practice, I admitted children with whooping cough, measles, chickenpox, mumps, and meningitis to the hospital all too frequently. Since the advent of vaccines for each of these diseases, treating kids has been much more rewarding and the pediatric ward at the hospital has become a ghost town.

Please review your children’s vaccine status and make sure they are up to date. Don’t wait until the last minute. Young adults going to college for the first time often need Menactra and Gardisil immunizations.

While you are at it, when were your last Tdap, Pneumovax, and Shingles immunizations given? Yes, parents need to practice what they preach!

COMPETITION

2012-05-08T12:06:00Z

May 8, 2012

Are you competitive? Do you hate to lose? What if you could enter a competition in which you were guaranteed to win? One of my patients has found the perfect competition. Mr. X is competing with himself, and, as long as he keeps it up, he is guaranteed to win!

Actually, Mr. X is winning while he is losing. Confused? You shouldn’t be! By competing with himself he is losing weight while gaining strength, endurance, and health! Mr. X is using his MotoActv device to monitor his daily activity. By striving to be more active on a daily basis, Mr. X is running a race in which he is his own opponent.

Mr. X loves technology. Mr. X’s Droid is capable of tracking his eating habits. By tracking his daily ingestion, Mr. X can define what his dietary intake really is and then refine his diet, chicken stepping his way to nutritional health. Mr. X is happy with his progress.

Taking pride in his weight loss and new physical prowess adds to Mr. X’s emotional account. Sharing his success on Facebook and with his friends, Mr. X is setting a great example. Mr. X has found his true “Wellth!”

I want to congratulate Mr. X on an amazing transformation from his former being into a state of health and “Wellth.” “Diets and Other Unnatural Acts” teaches the concept of obtaining “Wellth” by first defining who you are and then working on refining who you are. Learning to be the best “you” that you can be pays off big. By letting technology help him, Mr. X has become a consummate competitor.

Become a competitor and get healthy. Win every day by competing with yourself. Can you take 10 more steps today than you did yesterday? If so, you are a winner! Can you eat 10 calories less today than yesterday? You win!

On you mark, get set, ready, go!

A MATTER OF ETHICS

2012-05-07T12:37:41Z

May 7, 2012

Ever stop to think about the ethics of selling illness in a place of health? Think about it. You go into either of the large national pharmacies with a bad cough/bronchitis. You walk to the back of the store to see the nurse practitioner who prescribes the medication on her company’s formulary list (the one her bosses want her to prescribe/? most profitable?). Next you go to the pharmacist to fill your prescription.

On the way out of the store, standing like a gauntlet, is the cigarette counter where you buy your smokes. Yes, you smoke; and, because you smoke, you have chronic bronchitis. Now think about the ethics of the same establishment selling the disease they treat! It’s the American way, “One Stop” shopping at its best.

Everyone knows that our healthcare system is a disaster. We complain about the cost of healthcare, the availability healthcare, the doctors, the insurers and just about everything else. I think it’s time we complain about healthcare providers that sell illness.

These peddlers of medications and cigarettes are on every street corner. Selling the complete package, healthcare and illness, in one building appears to be good business. They are incredibly savvy marketers. Most of my patients use them because they have drive up services available. As they continue to grow, their product line has expanded into alcohol and candy (two more unhealthy treats).

While other national pharmacies are located in retail stores, customers can exit many of their stores, medication in hand, without being assaulted by their nemesis, the almighty cigarette.

I know, you are thinking Doc Segal is making too much out of this issue. After all, Doc Segal is a militant when it comes to smoking. Trust me, if you knew how much of the funds you pay into Medicare and Social Security went to support smokers’ habits and healthcare, you would be a militant, too!

The next time you need to fill a prescription, ask yourself, “Do I really want to support the unethical policy of the tobacco selling pharmacy?” If the answer is “NO,” then find a more ethical pharmacy. Yes, you will have to park and walk in. The walk will probably do you some good.

By the way, go straight to the pharmacy and not the candy aisle. Remember, the life you save may be your own.

STIGMA

2012-05-06T17:35:21Z

May 6, 2012

I confess. I wear pink shirts. My daughter doesn’t think men should wear pink. Apparently, wearing pink is unmanly and is stigmatized.

According to Wikipedia, stigma is defined as:

A badge of shame, a physical mark of infamy or disgrace
Social stigma, a severe social disapproval of personal characteristics or beliefs that are against cultural norms

But I don’t think there is anything wrong with wearing pink clothes. As a matter of fact, I think it takes a true man to stand up to social norms and hazard the criticism of others.

Dealing with a clothing stigma is one thing. Dealing with a stigma associated with disease is quite something else. Unfortunately, depression and anxiety are two illnesses that still carry significant stigmas. Depressed patients often avoid coming to the doc’s office or discussing their problems with anyone due to old prejudices.

Depression is not a character flaw. Most of the time, it is not something you can just “buck up” and fix on your own. Depression is not a choice. Depression is not something to be ashamed of. Like wearing a pink shirt, it takes a true man to face depression and ask for help!

Sometimes, I feel like we are still living in the dark ages. It really is time to step away from old prejudices and open our minds to the reality of depression and its causes and effects. Once a hopeless diagnosis, depression is now readily treatable with counseling and medications.

Talking about prejudices, you should see the looks I get when I refer my patients to those two-headed monsters who “shrink” people. Psychologists are teachers who help people learn about themselves and how to deal with their individual quirks and illnesses.

Patient - “Doc, I’m not going to talk to a stranger about how I feel.”

Doc – “I’m a stranger and you are talking to me.”

Patient – “But you’re a doctor.”

Doc – “Yep, so is the psychologist. She’s a doc who specializes in what’s bothering you emotionally.”

Often, my patient is really worried that a “psychologist” will probe his mind, opening doors he wants kept shut. A good psychologist won’t open the doors of a patient’s mind without permission. Psychologists don’t use crowbars!

Shed the stigma and face up to whatever is bothering you. If you are feeling depressed, talk to your doc, family, and friends. Get help and get well. The life you save may be your own and you may find you like and understand yourself better than you ever thought you could.