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Our greatest glory is not in never falling, but in getting up every time we do. 

Confucius
Chinese philosopher & reformer (551 BC – 479 BC)

A very wise man, named Gary, posted this quote on his facebook page; and I fell in love with it.  There are multiple ways to fall.  My patients fall literally, bruising, breaking, and lacerating their bodies. Then there is falling in a figurative sense.  My patients fall from grace by cheating, lying, or worse.  They fall out of love.  They fall off the wagon, off their diet.  They fall for the wrong person.  Falling is a human trait.  Falling leads to suffering and misery.  Getting up from a fall leads to recovery.

Confucius was right. What separates humans is not the act of falling, but the act of getting up, dusting yourself off and repairing the damage that leads to glory.  Over the last 30 years, I have seen many of my patients fall and injure themselves.  I have witnessed every type of a fall and some truly miraculous recoveries.  After reading Gary’s post, I realized the people I admire the most are people who keep getting up no matter how they fall or how often they fall.

Gary’s post was very timely.  As many of my readers know, I have started taking my own advice, eating properly, exercising and generally appreciating life. I want to warn you:  The older you are the harder it is to get up after falling.

I fell off my diet and exercise routine over the last few months.  Between the surgery, the Parkinson’s, and the depression accompanying the loss of my profession, I was attacked by the “too die for” foods of my past and I succumbed.  I was having trouble returning to my healthy lifestyle until I read Gary’s post.  “Our greatest glory is not in never falling, but in getting up every time we do.”  I’m up on my feet and back on the right path.

The next time you fall, get up as fast as you can.  If you can’t get up on your own, call for help from a friend or family member.  If you hurt yourself, get help.  When you can’t admit you fell due to personal pride or shame, recognize we all fall at one time or another and the true glory is in getting up!  

Confucius should have added an addendum.  Once you are back on your feet, learn from your fall.  Knowledge will protect you from the pitfalls of life.  If you can’t stop falling, you may need a cane, walker, psychologist, or priest.  Whatever the cause, get help!

Be happy, be healthy!

SUDDEN DEATH

Here today, gone tomorrow.  The older I get, the more often I get the call: “This is the ER at Any Hospital, can you hold for Dr. X?”  Dr. X then comes on the line and tells me my patient had a catastrophic event, that the paramedics and ER crew did everything possible but that the patient expired.

My patient had no reason to die.  He was relatively young and healthy. Life had been good to him and he had been good to his body.  He didn’t die in an auto accident or on a ski slope.  He died at home and apparently, from nothing.  I can’t describe the feelings of loss, frustration, curiosity, and wonderment that accompany such an unexpected call.

Yes, people die from nothing.  In my world, it’s not uncommon to lose perfectly healthy patients.  Usually they die in an accident; but, occasionally, they just die.  Sudden death is a mean foe.  Sudden death gives you no time to react and is almost always permanent.  Sudden death also denies family and friends a chance to prepare for the loss.

As a doctor, the tsunami of emotions accompanying “the call” begin with loss.  He was one of those patients who always made me smile.  Even when he was miserably sick with a cold, he always had something nice to say.  When his life’s stresses mounted, he always found the positive side.  Yes, his death is a tremendous loss to my practice and the community.

When patients get it right, cares for themselves, follow the rules and still die from nothing, it’s frustrating.  I believe in preventative medicine.  There are healthy habits and there are those habits that are unhealthy.  Eliminating unhealthy habits, eating right, stressing less, enjoying life, and exercising should be rewarded with long life.  When a patient who does it right just dies, it makes me want to drown myself in hot dogs and chocolate cake!  I think I’ll go to Portillo’s and throw my own wake.

Curiosity strikes next.  Why?  Everyone wants to know why?  The pathologist is the doc who answers that question.  The pathologist is the doc who knows everything.  Unfortunately, the pathologist knows everything; it’s just too late.  Autopsies help answer the question why.  Hopefully, by answering the “why,” families can mourn in peace and docs can accumulate wisdom that can help them become better docs.  Unfortunately, there are times when even the best pathologist cannot answer the “why” and everyone has to accept that, in death as in life, there are questions that will never be answered.

Did “wonderment” seem like an inappropriate emotion when I listed it above?  It’s not.  I am always awed by how precarious life really is and how much people take it for granted!  If today is your last day, are you going to enjoy it or are you going to waste it worrying about tomorrow?  Do you have an “attitude of gratitude” or are you so involved with life’s stresses that you forget to give thanks for what you have?

If today is your last day, did you contribute to your demise by neglecting your health?  Did you waste your time on earth or did you accomplish what you set out to do?  Are you proud of what you’ve accomplished?  Did you make others smile and bring happiness to those you met?

SUDDEN DEATHI believe in preventative medicine; yet sudden death seems to make a mockery of it.  My patient died much too young.  Would he have died sooner if he had not played by the rules?  I have to believe he would have.  I have to believe that taking care of your body adds years to your life.  I know that “an attitude of gratitude” adds quality to your life.

IT’S VALENTINE DAY, GIVE THE GIFT OF LIFE

It has been a very long day so this will be a very short article.  In the past, I have written about the miraculous ability the body to respond to its environment in order to survive.  In response to environmental stresses, your body can make new bone, muscle and blood vessels.  It can thicken your skin (calluses) to create a protective exoskeleton.  It can also learn to make new blood more efficiently.

The donation of blood and blood elements may well be the gift of life for another individual. Giving blood costs you some time and nothing more.  What you get in return is more than helping another soul survive.  You help yourself survive.  Giving blood is a stressor like running on a treadmill.  Your body has to replace what it has lost.  If you give blood on a regular basis, your body will learn to make blood more efficiently and faster.  If you are in an accident or bleed from an ulcer, your body will be better able to repair itself.

Donating blood proves that, by giving to others, you improve your own lot in life.  Sign up at your local blood bank.  Give and give often!

SOUTHERN FOOD

You can take a southerner out of the south, but you can’t take the south out of the southerner!  I just spent four days in Charlotte visiting with my children and all of my bad southern habits blossomed.

I’m not sure if I would still be alive had I stayed in the south.  Day One started with a seafood Po Boy.  For those of you who haven’t had the pleasure of eating a Po Boy, it’s fried oysters, fried crawfish, fried shrimp and fried sausage, all on a bun slathered in Cajun mayo.  In other words, it’s a heart attack on a bun.  Did I mention that it’s served with fried hush puppies and collards?  

That was one of the healthiest of meals. Dinner on Night One was Southern Fried Chicken doused in peppered honey and more collards followed by chocolate cream pie.

I won’t bore you with the rest of the details.  Suffice it to say that I slid downhill from there into a vat of grease and collards (cooked in bacon fat).  In a previous article, I asked, “Why does bad food have to taste so good?”   I’m still looking for the answer.  After an unbelievably great trip, I have a new question.  Why didn’t I become a cardiologist and practice in Charlotte?  I bet business is good and I would be rich!

Renee, where’s my Crestor and when are we going back?

PREDIABETES

Ever hear someone describe herself as pre-pregnant? Of course not! You are either pregnant or you are not! When I trained forty years ago, I was taught that the physiologic changes of diabetes started ten years prior to the clinical diagnosis of diabetes. Despite all the advances in our understanding of diabetes in the last forty years, very little has changed.

According to Medpage Today, the incidence of diabetes continues to rise. “An estimated 25.8 million Americans, or 8.3% of the population, have diabetes and almost a third don’t know it, the CDC said.” That is a staggering figure. “Another 79 million people have pre-diabetes, with high fasting glucose or hemoglobin A1c levels but not quite at the frank diabetes level.”

In the midst of an epidemic of diabetes, the medical world continues to be politically correct and it tells patients that they have a precondition entity and they have time to do something. It is my belief that understating the magnitude of the problems associated with diabetes is one of the driving forces behind the rise in the incidence of diabetes.

From my point of view, pre-diabetes is as absurd a diagnosis as is pre-pregnant. So why do physicians soft sell the diagnosis of diabetes? In my opinion, there are several answers:

  1. There are insurance implications involved in making any diagnosis. Pre-diabetes does not carry additional risk of being rated by the insurance industry.
  2. There is a stigma associated with the diagnosis of diabetes.
  3. Diagnosing diabetes means having to teach about diabetes, blood sugar monitoring, medications, diet and lifestyle modification. Education takes time and is rarely paid for by insurance companies.
  4. Patients do not want to hear that they have diabetes.

So, what’s the big deal? Knowledge is power! If you know you have diabetes and you know what you need to do to treat diabetes, then you have the power to reverse or control the disease. When you have a “sort of diagnosis” that requires you to change your lifestyle to prevent a disease you don’t really have and may never get, you “sort of” address it and will get around to it in time. Meanwhile, the physiologic changes of diabetes continue to erode your health.

On a daily basis, Docs see and diagnosis some of the 79 million patients who have pre-diabetes, hyperglycemia, elevated blood sugar, abnormal glucose metabolism and other names ascribed over time to this condition. Someone once said, “The devil comes in many disguises.” Undiagnosed diabetes is the devil; and the sooner you recognize the devil, the easier it is to get him out of your life.

The next time your doctor tells you your blood sugar or hemoglobin A1c is slightly elevated, think early diabetes. Regardless of what your doctor calls it, take it seriously. A diabetic diet and diabetic lifestyle are a healthy diet and lifestyle. If we all adopted the diabetic lifestyle, the numbers of patients diagnosed would fall precipitously. It is not as simple as “cutting out sugar”. Sugar is not bad. Nature does not produce “bad” foods; there are just foods that are abused and misused.

HELP

In 2013, I wrote, “The problem is that I can’t quit!  Not caring for my patients would be like not breathing!  I’m a doc and I’m old school.  I believe my profession is a calling, not a business to be run by corporate America or the government.  I can’t imagine not taking care of Nolan, or JJ, or Hadley, or 1,000 other souls I am entrusted with.”

Six years later and I’m retired, not by choice, but out of necessity. Nine months into retirement and I still can’t breathe. I wake up every morning wanting to dress and go to the office.  Instead, I go to my computer and write.

This blog is my way of communicating with my patients old and new (readers). It’s also helping me breathe.  In reviewing my old articles, I have a rare opportunity.  I get the benefit of listening to a younger me lecturing the old me on how to live with Parkinsons and recover and maintain as much “Wellth” as possible.

Unfortunately, my blog is poorly organized, making it next to impossible for a new reader to see what’s available.  There are 121 articles published so far.  While they contain 40 years of accumulated knowledge, you have to scroll through a lot of material to find what you are looking for.  If any of you know WordPress and want to pitch in, let me know.  In the meantime, please make sure you are sending links to your friends and family.

I know there are people out there whose lives can be improved by reading my articles and sharing in my legacy. My hope is that, long after I’m gone, people will find answers and solace in my articles.

A DOCTOR DIES TWICE

Baird Brightman, PhD’s article published December 23, 2019 really hits home.  I’ve been trying to deal with the loss of my practice and the systematic destruction of medicine as a whole.  Dr. Brightman’s insightful article has helped me understand what I am dealing with.  By clicking on the title of this article, you will be transported to Dr Brightman’s article.

In the past, I wrote about “AI” and its new place in the medical world.  For those of you that missed the article, “AI” is Artificial Intelligence. For years, doctors have warned the public, government and insurers about an impending shortage of primary care physicians.  That shortage has arrived!  On a daily basis, I hear from patients who can’t find a new doc.

I now believe that the shortage plaguing my patients was no accident.  Many of my colleagues and I spent the last 15 years fighting the insurers, PBMs and government on behalf of our patients.  We did not enjoy the fight.  We did not profit from fighting.  We had a sacred responsibility to care for our patients and put their needs above all else.  That relationship has killed the practice of medicine.

We, as a once powerful group, cost the insurers, PBMs and government a lot of money as we jumped through hoops getting approval for testing, medications and necessary procedures for our patients.  Slowly but surely, our power diminished.  We were demoted from physician to providers.  We were forced to accept treatment guidelines as law.  We were accused by the media and government of “fraud and abuse” which supposedly runs into the hundreds of millions of dollars.  The latest assault on physicians, as a whole, has to do with the “opioid crisis.”  Is it any wonder that people no longer want to go into primary care?

In a recent article on the net, a physician pointed out that, in the future, nurse practitioners (NP) will be referred to as “advanced practice providers.”  Physicians will still be referred to as “providers.”  Doesn’t it sound like an “advanced practice provider” has more training and experience than a lowly “provider”?  

I have trained nurse practitioners and physician assistants for years. I have been impressed with their capabilities and dedication, but they are not physicians.  Their training falls far short of your physician’s training. In the beginning, their licensure required that they be supervised by an M.D.  Those requirements are vanishing.

A recent article noted that 60 physicians employed by a local hospital conglomerate were fired and replaced by NPs.  Why?  The answer is simple.  NPs cost less than MDs!  Are you wondering what my point is? 

“AI” is cheaper than physicians, NPs, and PAs.  “AI” will not form a sacred relationship with patients.  “AI,” at least for a while, will obey the rules. It will not argue over a denial of services.  Google will become your provider and the younger generations will be happy to accept Googles advice[rS1] .

I’m actually scared!  Our upcoming move to North Carolina means that Renee and I need to find new docs.  That’s not going to be easy.  We are on Medicare which pays poorly.  I am sick, requiring multiple referrals which will mean extra hassles and expense for any doc who takes care of me.  I’m on multiple meds further complicating matters.  I also want a physician who will be caring, attentive (listen to me), and available when I need him/her.  My patients are telling me that such a person no longer exists.

If I’m scared despite all my knowledge and experience, I can’t imagine what you are going through!  Again, I’m sorry I had to leave you when I did.


 [rS1]

YOUR DOC, THE CSI TECH

In a previous article, “Your Doctor, The Master Chef, I compared the treatment process to the making of a gourmet recipe. I teach by using analogies and “The Chef” is one of my favorites. CSI is another of my favorites.  A large part of being a Doc is teaching.  Over the years, I’ve found that the use of analogies as a teaching technique helps my patients understand what they need to learn by presenting the information in a format that conforms to their life experience.  Thus, a foodie will relate to a master chef, a car buff will relate to an analogy of a mechanic and a fan of night police stories to a CSI.

There are three basic parts to your visit to the doc. Part one is the “listening,” where facts are gathered and pertinent history is recorded.  Step two is the “touch” stage, where you are examined. The exam may include physical, chemical, electrical and radiological probing of your physical being. Step three is the “cooking” stage, where your recipe for health is concocted and begun.

As a CSI (Crime Scene Investigator), most docs will combine steps one and two, collecting evidence from the minute they walk into the room. Not long ago, patient “X” saw me for “anxiety.” She was worried that something was wrong; she just couldn’t explain what she felt was wrong. We talked for 15 minutes, followed by a brief review of her vital signs and a very cursory exam. As I started into part three, formulating a treatment plan, Mrs. “X” quipped, “Aren’t you going to examine me.  You haven’t even listened to my lungs and heart!”

Mrs. “X” is not the first patient to complain about not having a stethoscope placed on their chests. Most patients are oblivious to the techniques of an expert CSI tech. I explained to Mrs. “X” that I had actually begun my exam before she had even gotten into the exam room. To illustrate my point, let me digress.

I was walking out of my office as the nurse was weighing Mrs. “X” on the hall scale. Mrs. “X”, a woman in her 30s, stepped easily on the scale and looked away as the nurse weighed her. While she is relatively thin, she was uncomfortable with her weight. I greeted her and she returned the greeting less than enthusiastically. Mrs. “X” is usually gregarious and warm. Again, she appeared uncomfortable.

On entering the exam room, Mrs. “X” appeared nervous, agitated and somewhat aloof, all very unusual for Mrs. “X”.  I asked how her family was, she said “fine”.  She avoided eye contact. Her complaints were vague, and she seemed to be worried about a problem in her genitourinary track. She had seen her gynecologist twice in the past two weeks and reported that both exams were “thorough and normal.” She complained of being anxious but appeared nervous and somewhat defensive. When I checked her pulse, her skin was moist. She was sweating. Her pulse was minimally elevated. I checked her neck for an enlarged thyroid, finding a normal gland.

As I started to tell her what I wanted to do, she erupted in anger that I had not adequately examined her. I had made the mistake of not putting my stethoscope on her chest. I was going to order some labs, order a mild anti-anxiety medication, and set her up for a follow-up visit. I didn’t need to do a more thorough exam today; my preliminary exam had revealed many clues and I was pretty sure I knew what was going on. I’ve been a CSI tech for 30 years — I’ve seen this before.

Mrs. “X” pressed for an answer, again atypical behavior for this patient. I asked her my favorite question, “What do you think is wrong? Is there anything else I should know?” Mrs. “X” came back at me with the usual, “I’m not a doc, what’s wrong with me? I’m not crazy! Tell me what’s wrong!”

When pressed for an answer, I always go over the differential diagnosis in my head and then share it with my patient. 

  1. Anxiety Disorder — possible 
  2. Thyroid Malfunction — unlikely 
  3. Occult Infection — unlikely 
  4. Guilt — very likely 
  5. Other

Gently, I say “Mrs. ‘X’, I agree you are not crazy. I don’t think this is anxiety or thyroid disease. If I had to make a guess today, I’d guess you were having an affair. Am I right?” The last clue I needed to know I had correctly read the signs were the tears. Mrs. “X” won’t feel better for a while. Step three, the recipe for health is on the cooker. Not bad for never having put a stethoscope on her chest!

Your doc, like the CSI techs on TV, starts collecting clues (examining you) the minute they greet you. There are all kinds of exams, all kinds of tests. What’s important is discovering which villain is attacking you so a treatment plan can be made, and balance restored. 

The next time you think, “But he didn’t even examine me,” think again!

All patients are fictitious. They represent many patient interactions over the last 34 years.

Virus

We all know those dreaded four letter words that, as children, we dared not say on penalty of having our mouths washed out with soap. Today, I diagnosed a friend with a viral upper respiratory tract infection. Upon hearing the word “viral,” my wife remarked, “viral has one letter more than a four-letter word yet it’s just as nasty.”

My family always hated it when I pronounced that the cause of their illness was viral. It was not uncommon to hear my wife say, “I don’t care if it’s viral, I want an antibiotic!” My family is no different than the rest of the world. When they are sick, they want pills.

I hate viral infections. It takes me three minutes to prescribe an antibiotic; and, in the eyes of my patient, I am a hero. It takes me ten minutes to explain why I’m not giving my patients an antibiotic, and they walk out angry! Antibiotics do not kill viruses.

“Dr. Segal didn’t even listen to me. He spent 30 seconds in the room, told me I had a virus, and sent me home to die from this horrible sore throat!” The patient did not hear anything I said after “antibiotics won’t help.” I wish I had a prescription placebo!

I have written multiple articles explaining how docs make diagnoses and treat illness. Unfortunately, most people are too busy making a living to take the time to read about healthcare.

When you are infected (sick), you need to know two things:

  1. Where is the infection? 
  •  What organism is causing the infection?

In the real estate business, it’s location, location, location! It’s the same in illness. When your doc uses words like pharyngitis (infection in throat), bronchitis (bronchi), gastritis (stomach), and pneumonia (lungs), he is defining the location where the illness resides. Think of infection as a crime. Location tells you how potentially serious the crime may be. (Generally, infections in the throat are less threatening than infections in the lungs.)

My brother has been in law enforcement for many years. His job often entailed identifying which criminal(s) perpetrated the crime. He had thousands of potential suspects. I have it relatively easy. My criminals fall into three classes: viral, bacterial, and fungal. Fungal infections are relatively rare so my job boils down to differentiating between bacterial and viral perpetrators. Bacteria respond to antibiotics; viruses do not! Your body has to kill viruses. (Your body can kill bacteria, as well; but antibiotics can help.)

After 30 years as a doc, I can tell you that deciding between viral and bacterial causes of infection is often difficult. I would like nothing more than to prescribe a harmless antibiotic to every patient who comes to see me with an infection. The problem is that I don’t have a harmless antibiotic.

Antibiotics come with risks. Antibiotics can cause allergic reactions, nausea, diarrhea (sometimes potentially life threatening), yeast infections, and something docs worry about called bacterial resistance. Treating patients always involve a risk-benefit ratio. Treating a virus with an antibiotic has no benefit, leaving only risks. 

So, to my patients and family I’d like to say, “I’m sorry you have a virus! The good news is you should be better in a week or two. The bad news is that antibiotics can’t help you.” Eat well, rest when you can, and drink plenty of fluids. See your doc if you get worse as he/she could be wrong about the diagnosis or you might develop a secondary infection.

Yes, “virus” is worse than a four-letter word. Unfortunately, it’s a word we can’t avoid!

ALLERGIES

Do you love your perfume/cologne/after shave?  It smells great, doesn’t it?  While your favorite perfume/cologne/aftershave smells fantastic to you, it may not smell good to someone else.  Your pleasure may be someone else’s poison!

Yes, I have patients who are allergic to your indulgence.  They see me on a regular basis to refill their antihistamine, nasal steroids and leucotriene blocking agents.  Without their medications, they are in trouble.

I have other patients who suffer from migraine headaches.  Sometimes aromatics, such as perfumes, colognes and aftershave lotions trigger their migraines.  They come in to see me on a regular basis to get their pain pills and controllers.

Are you coughing?  Is your nose running?  The other day I saw a patient who was complaining of a horrible cough, runny nose and irritated eye.  I started coughing as soon as I approached her.  Her perfume irritated my airway.  If you are sick, putting on perfume, cologne or other aromatic products may be adding to your misery and you may not know it!

Your docs’ office should be a safe zone for patients who are allergic to or have other reasons to avoid inhaled irritants. Please take that into consideration before you come to see me or your doc and abstain from wearing anything that others can smell.My patients and I thank you for your consideration