Month: December 2019

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

Once, 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.

Uh Huh!  Two potentially dangerous words!  When my children were young, we visited with my wife’s parents in Virginia.  I was sitting at the kitchen table reading the newspaper.  My mother-in-law placed a plate loaded with eggs and bacon in front of me which led to my asking, “What’s this?”  Her reply was “You said you wanted it!”  My 10-year-old daughter, with the wisdom of youth, then proclaimed, “GRANDMA, when my father says, “Uh Huh” it means he’s not listening to you!”  The eggs were great (her food always was), but I really didn’t need the bacon.

In my mother-in-law’s kitchen, “Uh Huh” caused no great harm.  In my office, Uh Huh could be lethal.  Let me explain.  Medication errors are a fact of life in the world of medicine.  We work hard to prevent them, yet nationally, the numbers are embarrassing!  So, how does this happen?  On every visit to my office, the nurse reviews your medication with you.  Then I come in and review your medicine with you. 

Nurse: “Mr. Patient, are you still taking 30 mg of medication A?”  

Mr. Patient  “Uh Huh”.  

Nurse: “120 mg of medication B?”  

Patient: “Uh Huh”.  

This process then repeats itself over and over until the bottom of the list.  The result is errors in medication doses and names.  When I come in to see Mr. Patient and ask about his medications, he often sounds put out.  After all, the nurse just went over them.  Again, I get “Uh Huh”.  Mr. Patient thinks all this is ridiculous. His doctor should know what he is taking.  He says, “Don’t you keep records?

Previous articles have focused on the doctor patient partnership and education.  In a true partnership, both sides take responsibility for the outcome.  In an educated partnership, the conversation goes like this.  

Nurse: “Mr. Patient, are your still taking 30 mg of medication A?” 

Patient: “Let me check my list.  Yes I am.”  

Nurse: “120 mg of medication B?’   

Patient: “No, I’m on 240 mg.  My cardiologist increased it the last time I saw him?”  

Nurse: “Are you taking medication C twice a day?”  

Patient: “No, the gastroenterologist stopped that one.”

Now, I know the gastroenterologist and cardiologist are supposed to send me consult notes.  Those consult notes have to be read and filed.  All of that takes time.  It’s a complex dance fraught with possible omissions and errors, especially if the patient is also saying “Uh Huh” in the specialist is office.

Making matters worse is the phone call to the office requesting “Please have the doctor refill my medications”.  Often patients make blanket statements, giving no name, no dose, no directions, just please refill all of them.

Most practices have instituted electronic prescribing so that, ideally, requests come directly from the pharmacy and prescriptions go directly back to the pharmacy.  All of patients are encouraged to carry an up-to-date list of all of their medications with them at all times.  Patients should go on the patient portal and review their medications for accuracy.  Rather than calling the office for refills and having the front desk staff transcribe the request and send it to the nurses, we encourage you to request your refill directly thorough the portal or through your pharmacy.  It is of paramount importance that we, patient and doctor, listen carefully to ensure the best of care. 

I hear it all the time!  “I didn’t come in sooner because I thought I would be better in the morning.”  Instead, I’m interviewing the patient in the Intensive Care Unit of my local hospital.  Ever hear of a man dying from indigestion?  Neither have I.  What I too often see is the patient (usually a male) who says “Doc, I thought it was just indigestion.”  It wasn’t!  It was a massive heart attack and precious time was lost as heart muscle died and, ultimately, so did the patient.

Not long ago I saw the patient who was having bad headaches and walking into walls.  His symptoms persisted for over a month before he saw me.  Again, my patient rationalized his problems.  “I’m just stressed.”  Stress does lots of things but it doesn’t cause you to walk into walls.

The earlier the diagnosis, the more chance I, and my team of specialist, have to intervene on your behalf.  The emergency room has special procedures called “stroke alerts” and “cardiac alerts” designed to quickly and expertly bring together a team of highly trained individuals and advanced medical techniques proven to limit the damage from a heart attack or stroke.  There is a golden window of opportunity.  In the case of a stroke, the “alert team” has to intervene within the first six hours of symptom onset.

So please don’t linger at home in pain, presuming it is indigestion or stress.  If you are not sure what to do, call your doctor.  Please, do not drive yourself to my office or the hospital.  If you lose control of your car you may well kill yourself and innocent bystanders.  Use the paramedics!  Their ambulance is a mobile intensive care unit.  Their skills are phenomenal.  They can have the appropriate “alert” team waiting for you at the door of the hospital.

One last thing, please listen to your spouse.  In the case of the husband, I know it breaks the unwritten rule that men cannot listen to or admit that their wife is right, but she is!  And remember, when your spouse threatens never to talk to you again if you call the paramedics, if he dies, he certainly won’t ever talk to you again!  Go ahead and call the paramedics and spend the next 30 years with a silent, but living, spouse.

Sometimes, you just can’t win!  In medicine, sometimes is way too often!  “Doc, do I need that test?” published in February 2011, reviewed the issues surrounding screening colonoscopy exams.  The dilemma is always the same.  Do I order a test or don’t I?

If I order a test, there are consequences.  Some are obvious; some are not.  Tests cost money and money is in short supply.  One consequence of ordering a test is that my patient may be held responsible for a big bill.  Having to pay for the test may well stress my patient and his/her family.

A second consequence is that the test may not prove anything or help make a diagnosis.  In this case, not only have I wasted hard earned money, but I have frustrated my patient.  Ordering too many tests that turn out normal shakes your patient’s confidence in your abilities as a doctor.  It may also lead to the accusation of profiteering or practicing defensive medicine.  In reality, a negative test helps remove items from the “Differential Diagnosis” list and helps make an accurate diagnosis.

A third consequence is that a positive result may lead to more testing, more expensive and more risky procedures.  PSA testing is used to screen for and diagnose prostate cancer.  A positive PSA test is suggestive of a problem but certainly is not definitive.  If your PSA is elevated and your digital rectal exam is normal, your doctor may simply repeat the test in a few months to monitor the situation.  If there is any question of malignancy, your doctor will probably refer you to a urologist for further testing.  Further testing often entails multiple biopsies of your prostate, painful and expensive procedures.

As a physician, you are really damned when the positive blood test leads to a biopsy and the biopsy is negative!  Rather than being happy that he does not have prostate cancer, your patient is pissed that he had to have a biopsy and even more pissed that he has to pay for everything.

You are also damned if you don’t order a test!  Fail to order a test that might have revealed a disease at an earlier date and your patient will be even more pissed!  

“Cyberchondria,” a relatively new phenomena, is a disease in which patients read about illnesses on the internet and then convince themselves that they have those illnesses.  They often come in requesting an assortment of tests, some expensive and some invasive in nature.  While making your patient happy is preferable, ordering a barrage of tests without clinical reason is both wasteful and inappropriate.  The patient who thinks they have “XYZ” disease wants an MRI of his/her brain.  “XYZ” is extremely rare and present only in people of Asian origin and your patient’s family is from Hoboken, New Jersey, having come over on the Mayflower.  Do you order the MRI? No!  You explain that you see neither signs nor symptoms of “XYZ” and look for another cause for the patient’s ailment.  The patient eventually finds   a “real” doc who orders an MRI and is pleased to find that they don’t have “XYZ.”  They tell everyone you are a “quack”, don’t listen to your patients, and don’t care.

You are really, really damned when the MRI verifies that your ex-patient is the first non-Asian in medical history to have “XYZ.”  

So, as a physician, what do you do?  How do you win?  You partner with your patients.  You make your patients responsible members of the medical team.  You help educate your patients to the benefits, risks, limitations, and costs of testing and treatments.  You listen to your patients and offer your best advice.  You write a nightly column.  Then you say a little prayer!  May you be so blessed as to never know the disease you prevented.

If you watch TV or use the internet, you’ve probably have seen commercials for ED (erectile dysfunction).  I’ve seen three different commercials for ED.  The message is a simple one; men, you have to be ready at a moment’s notice, so take a pill.  ED is common.  Fifty two percent of men between the ages of 40 – 70 have ED.

Recently, I was at a lecture on ED and impressed by a quote from Tiefer and Melman, “Erection is truly at least a sensory-motor-neuro-hormonal-vascular-psycho-social-cultural-interpersonal event.”  Yes, the male erection is much more complex than just taking a pill.  Being ready at a moment’s notice relies on many things coming together all at once.  Is it any wonder 52% of men between 40 – 70 years old have ED?

So, is the pill the answer?  Not really.  There are multiple risk factors for ED including high blood pressure, high cholesterol, diabetes, smoking, low T (testosterone), alcohol abuse, drug abuse, anemia, coronary artery disease, Peyronie’s disease, vascular surgery, depression, and obesity.  With such an impressive list of possible causes, a medical work-up should be performed and associated causes should be appropriately treated.

“Erection is truly at least a sensory-motor-neuro-hormonal-vascular-psycho-social-cultural-interpersonal event.”  Note that psycho, social, and interpersonal relationships can be significant factors in ED.  Trying to over-ride psycho, social, and interpersonal issues with a pill can be perilous.  Facing psycho, social, and interpersonal issues can be difficult but rewarding in the end.

The most interesting material addressed during the lecture was the effects of lifestyle changes on ED.  Exercise had the ability to improve ED in the studies quoted.  As exercise also improves high blood pressure, high cholesterol, diabetes, coronary artery disease, and obesity, as well as improves ED, EXERCISE!

Over the last few years, I have written many articles extolling the benefits of exercise.  Convincing patients to exercise is difficult at best.  Now I have one more reason why men should exercise!

So, men, if you want to optimize your erection, exercise!  Women, if your husband’s ED is a problem, get him a membership at the local gym and workout with him.

If all else fails, chill and take a pill.  First, make sure your doc agrees that it is safe to take a pill and you have reviewed its risk with your pharmacist.

Published on February 17, 2015, this concept is still relevant and understanding it may save your life.

While I would like to believe that I am better at predicting storms than the weather- man, unfortunately, I am not.  If you are wondering if I’ve lost it, I haven’t.  Yesterday, my first patient of the morning left the office by ambulance.  After taking a careful history and performing a thorough exam, my assessment was that he was in imminent danger, much the way the weatherman declares a tornado/storm alert.

Yes, a major storm was in the making, one we docs call sepsis.  Calling in the paramedics is the equivalent of calling up the National Guard.  As always, they responded quickly and efficient, securing my patient against what could have proven to be a major tempest.  Today, my patient is much better.  The storm has blown over and, thanks to G-d, was nowhere near as devastating as I had predicted.

Unfortunately, there are times when medical storms strike fast and appear from nowhere.  No matter how good my patient and I are at practicing preventative care, there are many occasions when medical twisters touchdown in our lives wreaking havoc.

So, what can we do?  In the case of a severe weather alert, most of us get busy securing our homes, checking on our flashlights, making sure we have gas for our generators and snow blowers and fill our pantry.  We check on our loved ones and neighbors and then hunker down for the night.

In the case of a medical alert called by your doc, respond promptly, heeding his advice.  If the doc says, “Call 911,” call 911.  Take proper precautions.  If your doc warns of an approaching storm in the form of a future heart attack/stroke/diabetes, take action by improving your lifestyle, complying with medication and seeing the specialist when recommended.

Yes, my predictions are often wrong.  When I warn of impending doom and it fails to develop either due to your precautions or not, I’m one happy camper.  Now, if I can only figure out how to predict those sudden acts of terror that occur when illness is lurking in the wings but invisible to the modern medical eye.

Often, I use the analogy of peeling an onion to help my patients visualize their illnesses and health.  An onion has many layers, each unique yet looking similar to the ones next to it.  Each layer of an onion affects all the other layers.  

When you buy an onion at your local supermarket, the outside layer is often thickened and discolored.  In order to assess the quality of an onion, you often have to peel away the outside layers until you reach the healthy core. 

When dealing with humans, physicians often have to get past the thickened, discolored outside layers of a person’s life in order to reach the healthy, vital core of their patient’s existence. 

“Doc, I don’t feel good.  Do you think it’s stress related?”

“Doc, I’m having problems maintaining an erection.  Do you think I have low T?”

“Doc, I have . . .  Do you think it’s  .  . .?”

Solving my patient’s problems often means peeling back the layers of his life, carefully, one at a time.  Rarely is there a simple cause for human suffering.  Most of the time, the bad layers adversely affect the good layers; and, sometimes, it is impossible to discern which layer is the culprit.

When something is bothering you or making you sick, carefully peel back the onion and explore what is under the surface.  Share your findings with your doc; it will help him help you.

This article was published in March of 2014.  It is even more relevant now:

Happy Anniversary, Renee. Forty one years of marital bliss! It seems like just yesterday that we said, “I do.” It’s been a great 41 years. Of course there’s been both good and bad times but we’ve weathered them together.

I think the secret to a good marriage is “WORK.” Yesterday’s article addressed divorce. Marriage is like a house a couple buys and settles into. Imagine living in a house which has never been kept up, repaired or cleaned. After 37 years of neglect, it would be uninhabitable.

Unfortunately, many of my patients take their marriage for granted, never bothering to tidy up little messes or simply sweeping them under the carpet. I’ve often imagined that each of us has a large steamer trunk in which we shove little tidbits of unaddressed problems into. After years of accumulating junk, the contents of the chest begin to rot; and, when we open it to shove in the latest junk, the trunk threatens to explode its rank contents onto us and those we love. So, we try to seal the trunk and move on or we try to empty the trunk ourselves.

Think about it for a minute. Many of you own just such a trunk and those tiny tidbits of garbage have grown into monsters over the years they have sat, rotting in that trunk. Do you really want to open it on your own? I think not.

Marriage counselors are trained professional whose job is to carefully open your marital steamer trunk of neglected problems and, one by one, disarm them. Let me give you an example. The following is a true story.

I once had a couple whose marriage was disintegrating rapidly. While talking with them in the office, I challenged the wife by noting that her anger appeared to be markedly out of proportion to anything her spouse had done. Surprisingly, she responded, that 27 years ago, her husband had insulted her mother’s cooking by criticizing her meatloaf and that she would never forget the hurt look on her mother’s face. The husband’s dumbfounded look on his face was accompanied by the emphatic statement, “But I loved your mother’s meatloaf and everything she cooked!” He had no recollection of ever insulting his mother-in-law’s cooking. The other fact you need to know is this gentlemen was a 300 pounder and obviously enjoyed eating!

A minor misunderstanding 27 years ago had been left to rot at the bottom of a trunk in this woman’s mental closet and had ended in the threat of divorce. Why hadn’t she said something 27 years ago? Probably it was just easier to sweep it under the rug and go to bed.

The moral of the story is simple! If your marriage has been neglected, is stale or worn and dirty, don’t throw it out. Get some help. Talk to your doc and find a good counselor and get to work restoring it to its original luster.

From a strictly personal point of view, watching my patients go through the misery of separation and divorce drains my energy and you don’t want to do that, do you? So get to work and fix it now. Spring cleaning can be more than just fixing up the house and working in the yard!

(Renee’s addendum: Happy Anniversary, Stewart! When both of us have to ask each other how many years we have been married and then actually mathematically calculate the number of years, I’d call that a good sign.  It takes communication, even when it’s hard. As you said, marriage is work and is always a work in progress as we change with age and the stages of our life. We’ve always tried to remember that, in the end, it was going to be the two of us left after we had raised our children and cared for our parents. We are finally there. Here’s to us and our future! Thank you for a great 41 years!)

I have a new job!  Yep, my new full-time job is seeing my assortment of docs and following up on their orders.  I just saw my urologist who prescribed a new medication and a lab test to be done in 2 weeks to monitor the new medication.  I’ve already made an appointment to have blood drawn and will follow up as directed.  Don’t worry, I’m ok.  I’m just an old man who stops at every bathroom he walks by.

Below is an article I wrote about this subject:

Please, don’t get mad at me! When I last examined you, I gave you instructions on when to follow up with me. I gave you prescriptions for enough pills to last you until our next visit. I told you to see me before you ran out. Now you are running out and being seen in the office doesn’t fit with your schedule.

Medications are prescribed for very specific reasons. Each medication comes with its own benefits and its own risks. Monitoring your medications for both effectiveness and harmful side effects is my responsibility. You are supposed to be my partner in this endeavor. I need your help!

Making me the bad guy is not in anyone’s best interest. I don’t like holding your refills as hostage to your next visit; but, over the last many years, I have come to the conclusion that putting off your doctor’s visit is a universal human trait. Everything is more important than following up with your doctor!

After all, you feel fine. I’m happy you feel fine. My job is to keep you feeling fine. If the medicine I prescribed for you is injuring your liver, there are two ways of finding the problem. My preferred method is to monitor you for liver injury on an appropriate schedule. The second way is to wait for you to turn yellow. Appropriate follow up and monitoring of potential side effects makes more sense than treating rare but serious side effects, doesn’t it?

Unfortunately, the electronic medical record and the “portal” make it too easy to dodge your follow up visit. Sending me an electronic request for a refill or having the pharmacy contact my office for a refill means never having to talk to my staff or your doc. In the end, you get mad at me. Your expectation is I will refill your medication without question and you will eventually see me.

While I’d like to be your friend and play the role of the good guy, I have to be your doc. I have to make sure any treatment I give you is as safe and effective as I can make it and that means seeing you for appropriate follow up.

My recommendation is that you take an empty bottle of your medication and put 2 weeks worth of pills in the bottle and put it in your medicine cabinet. When you are down to your last 2 weeks of pills, it’s time to come in. Pretty simple, huh? Help me help you. The life we save may be your own!

With the holidays coming up soon, Sara Debbie Gutfreund’s article on Aish.com entitled the “Top 10 Gifts Every Wife Wants,” is excellent and very thought provoking. The ten items she listed are:

• Appreciation
• Compliments
• Empathy
• Kindness
• Friendship
• Affection
• Respect
• Acceptance
• Authenticity
• Laughter

At first glance, I thought this was an excellent article and should be shared with my patients. As my readers know, I have written about the surge in divorce I was seeing in my practice. Gutfreund’s article might be an antidote to the sickness afflicting my patients’ marriages.

Then it dawned on me. Should this not be a two-way street? Gutfreund’s article should have been entitled “Top 10 Gifts Every Spouse Wants.” Then I realized that the husband’s list needs to have an eleventh item listed: sex. Now where do you think that goes on the above list?

While we are on the topic, I’m sure you’ve heard the saying, “If momma’s not happy, ain’t nobody happy.” Why haven’t you heard, “If daddy’s not happy, ain’t nobody happy?” I suspect that the answer is that momma controls the eleventh item on the list.