WHY?

Why?  Why won’t you tell me why?  I need to know!  If I know, I can help!  I’ve been practicing medicine more than half of my life.  You would think I would know why, but I don’t.

I’m frustrated.  I’ve learned so much, studied so hard and worked all my life to provide the best care I can.  No matter!  Unless I can find this last piece of the puzzle, it may all be for naught.  Why?  Tell me why!

Why won’t you take care of yourself?  Is a little exercise too much to ask for?  Is cutting back on bacon and salt so hard that it’s worth cutting your life short?  Life is so precious!

Why must you harm yourself?  Sure, smoking is an addiction.  Shouldn’t living “well” be an addiction?  Isn’t the risk of cancer enough of a threat?  Tell me why you won’t listen to your body.  You cough every morning.  You’ve been coughing for months.  You want a cough medicine.  You’ll take a cough medicine, but you won’t stop smoking.  Why?

I’m frustrated.  I don’t get it!  You’ll take medicine for your diabetes, blood pressure or emphysema but you won’t take care of yourself.  You’ll suffer through surgery and chemotherapy for your cancer, but you won’t take care of yourself.

Proper diet and exercise is the one prescription you won’t follow.  Why?  Why suffer at your own hand?  Why make your family suffer?  Why?  Please tell me why.

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DON’T LIST

Surfing the net for knowledge is one of my pastimes and last night I struck gold.

A not-to-do list for those with chronic pain or illness” by Toni Bernhard, JD instantly caught my eye!  Coming off a miserable week of back pain, I could use some advise even if it’s from an attorney!  Here goes(taken from her article):

  • DO NOT say “yes” to an activity if your body is saying “no.” 
  • DO NOT call yourself names or otherwise speak unkindly to yourself.
  • DO NOT try a treatment just because someone said it cured him or her.
  • DO NOT wait until the last minute to get ready for something.
  • DO NOT strive for a spotless living environment.
  • DO NOT “shop ‘til you drop.” 
  • DO NOT wear uncomfortable clothes.
  • DO NOT think about pleasures from your pre-illness life, freeze them in time, and assume they’d be as much fun today.

I want to thank Mrs. Bernhard for her sagely advice and add a few of my own:

  • DO NOT tell someone to take the day off, go home and take it easy when they appear to be in better shape than you are.
  • DO NOT sit too long in any one position and expect to be able to stand up gracefully.
  • DO NOT try to fool your patients.
  • DO NOT fail to thank those who show their concern for your wellbeing.
  • DO NOT get short with your coworkers and spouse.

Chronic pain or illness is no fun but how you choose to live with it can make a world of difference.  Oh yes, there are two more big “DO NOTs” for your list:

  • DO NOT forget to follow you doctor’s instructions.

Last but not least, DO NOT give up hope!  An answer may be right around the corner.

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REGRETS

Regret is a harmful emotion. Regrets are best avoided. It’s one thing to regret buying a stock that plummets; it’s another to regret that you ever smoked because your chest x-ray shows a large tumor. 

People often don’t appreciate what they have until they’ve lost it. When you’ve lost your health, you will regret its loss for the rest of your (shortened) life. Not long ago, I wrote about non-compliance. Imagine that you were supposed to take your medication every day. Your doc prescribed the medicine because, without it, you would be at risk of having a heart attack. Imagine you decide that medications are expensive, bad for you, and that you are going to use all “natural” over the counter pills to treat yourself. 

Now, imagine you wake up in the coronary intensive care unit. Your doctor tells you that you suffered a cardiac arrest (died). You try to ask him a question but gibberish comes out. The doc explains that you are stable; but you were without oxygen for too long and you have suffered hypoxic brain damage. You’ve had a stroke. You realize you can’t move your right hand and leg. You’re alive, and, for the first time in your life, you understand what being healthy was all about. 

You understand that you may never walk, work, drive, or even make love again. You understand that you will have to take medications, go to rehab, have full time help, and learn to live a new life. You understand that you should have never stopped your medication. You will regret that decision for a very long time. 

Every day, I plead with patients to take their medications, get their colonoscopies/stress tests/ x-ray, done. I plead with them to stop smoking and drinking. I ask them to give up cholesterol, sugar, and other goodies so that they can be healthier. I write articles (over 625) aimed at helping them understand how important their health is. 

Every day, my patients tell me they are going to try to care for themselves. I hate the word “Try”. To me, try implies failure. I ask them to work at being healthy. I explain that the stakes are high, often to no avail. You don’t know what you have until you lose it. A healthy person cannot imagine what it is like to lose his health. A healthy person cannot imagine how much “regrets” hurt! 

Life is full of regrets. Do everything within your power to be healthy. Live a “wellthy” life by investing in your physical, nutritional, emotional and financial wellbeing with the same fervor as you invest in your financial health. Work with your doctor. Learn all you can learn. Follow your doc’s instructions. Don’t fall for the hype of the “all natural” neutraceutical world. If you don’t believe you need a treatment or a test, discuss it with your doctor. 

Staying out of trouble is much better than getting out of trouble. Remember my favorite blessing, “May you be so blessed as to never know what disease you prevented.” Be “Wellthy” and live a long life without regrets. 

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EXPECTATIONS

I just read an article about expectations in medicine.  Expectations can make or break a relationship.  They can be the source of great excitement and joy or of great disappointment and sadness.  Expectations, in medicine need to be clearly defined and, when possible, successfully met.

Several years ago, I did a full physical on a new patient.  Patient “X” had been referred to me by a mutual friend and I did my usual, thorough job.  I was dismayed when my friend called me to report how disappointed patient “X” had been!

I called patient “X” to discuss the results of his exam and why he felt I did a “crappy” job.  Mr. “X” started with, “Doc, I like you, but you did not do/order a stress test, Carotid Doppler, lung function test, PSA or colonoscopy.  I went to Dr. “Y” and he ordered them for me!”  To Mr. “X’s” surprise, I asked him why he thought he needed those tests.  Mr. “X” responded, “My partners’ docs ordered those tests.”

In retrospect, the problem was obvious.  Mr. “X” had expectations I did not meet.  I had expectations, as well.  My expectation was that Mr. “X” wanted a thorough, customized physical.  “Mr. “X”, I’m sorry you were unhappy.  Let me venture a guess:  your partners are all in their mid-sixties.”  His answer was “yes”.  “Mr. “X”, had you been in your sixties, I would have ordered those tests and perhaps more.  You are 41 years old and, with your personal and family history, as well as excellent physical condition, I did not feel you warranted any of those tests.”

Mr. “X” cancelled all of his tests and sees me yearly for his exam.  I learned a valuable lesson.  My patients’ expectations may not match mine.  Setting realistic expectations are an important part of any doctor-patient relationship.  Patients must recognize that doctors have expectations and doctors must realize that patients have their own, distinct expectations.

Expectations can range from fantasy to reality.  In the medical arena, it is crucial that expectations be founded in reality.  As your doc, I expect you to follow my instructions.  I expect that, if you are going to vary from my instructions, you will let me know.  These are realistic expectations.  

An example of false or unrealistic expectations would be if you were 75 pounds overweight, drank a bottle of wine and six cocktails, and smoked two packs a day; and I expected you to lose your excess weight while giving up smoking and alcohol simultaneously within 6 months.  (I would give the above patient at least 6 1/2 months). 

Sometimes I set unrealistic expectations for myself and my patients.  When the stakes are high enough, you do what you have to do in order to survive.  Unrealistic expectations can be met when truly necessary!

Patients often set unrealistic expectations.  The most common example of an unrealistic expectation is when the patient, mentioned above, expects his doc to cure his cough, repair his damaged liver, and save him from the heart attack he is about to have.  Doctors don’t heal patients; they help patients heal themselves.  Expecting your doc to save you from a sinking ship while you are punching holes in the hull is another example of false expectations.

So, what can you do?  Discuss your expectations with your doc.  Let him/her know exactly what you want; what you are thinking.  Be sure of what your doc expects of you.  Expect that your doc will work your expectations.  If he/she falls short, discuss it with him.  Work at meeting your doc’s expectation.  Expect that your doc will confront your shortcomings, as well.  Most of all, be honest with yourself and your doctor.

P.S. – I believe in miracles.  I have been blessed to see many miracles in the last 40 years of practice.  It is ok to have false or “fantasy” expectations, as long as you know that the only way they will come true is to receive a miracle.  It is not OK to sell yourself on false hope as the vast majority of time it will end in disaster.  

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WHAT’S A GUY TO DO?

Medically speaking, what’s a guy to do when there is no right answer?  My patient’s solution is often to ask me what I would do given his particular circumstance.  He isn’t happy when I respond with, “I truthfully don’t know!”

In reality, I always know what I would do.  I’d gather knowledge, see consultants, and explore every possible option to its fullest.  Then, most probably, I would still not be sure what I would do unless I was in the situation myself.  “What’s a man to do” is a very personal question with many, nonscientific factors to be taken into account.

Case in point.  I’ve counseled many patients with prostate cancer.  I know all the treatments available and the pluses and minuses of each approach.  The common options include “watchful waiting”, some form of radiation, surgery, or a combination of the latter two.   

What’s a guy to do if he has prostate cancer?  This is one disease where the answer is difficult and the stakes high.  Several years ago, I had an elevated PSA (screening test for prostate cancer) and an abnormal prostate exam.  While waiting for my biopsy results, I got a chance to look at all the options from a patient’s point of view.  I now know what I would do if my biopsy was positive, but my decision-making process was unique to my life and what I feel is important.

I counseled a patient with a precancerous lesion of his colon.  A routine screening colonoscopy revealed a polyp (tubular adenoma) that could not be fully removed by the gastroenterologist and has the potential to become a cancer.  Again, his options were watchful waiting with careful follow-up versus a surgical resection of part of his colon.

What’s a man to do?  Watchful waiting means yearly colonoscopies and biopsies.  In my early days as a doc, I saw a young lady with a slightly abnormal mole on her back.  I started to advise a watchful waiting approach when I realized that I was watching to see if she might develop a malignancy.  After I explained my reasoning, I removed the lesion.  The pathology report came back as an early stage of melanoma, a particularly nasty cancer.  Since then, I have not been a fan of watchful waiting.  Luckily for my patients, I surrounded myself with conservative surgeons who provide a nice balance to my aggressive surgical leanings.

Colon resection is no picnic, either.  To have a colon resection for a lesion that may never turn cancerous carries its own risks and expense.  What’s a guy to do?

In the business world, it’s called “due diligence”.  According to BussinessDictionary.com, due diligence is a “measure of prudenceresponsibility, and diligence that is expected from, and ordinarily exercised by, a reasonable and prudent person under the circumstances.”  A reasonable and prudent patient, when presented with a disease that does not have a clear cut treatment option, needs to collect all the information he can to define his options, the risks and benefits of those options, and the costs; then he has to make a decision and live with its consequences.

Life’s a bitch sometimes.  Making decisions is hard work and you know you’ll win some and some you’ll lose.  What’s important is being able to live with the results of the ones you lose.  If you did your best to answer all the questions, to weigh all the choices, you’ll be able to live with your losses.  If your decisions were ill-informed and hasty, not only will you have to live with your losses, you will have to live with regret, as well.

Until they invent a “retrospectoscope”, a man has to work hard to understand his situation, to know in his heart that what he chooses to do is right at the time, and to accept his account, whatever it is.

I’ve always said that, if you can make something good come from something bad, the bad wasn’t so bad after all.  Somebody once said, “man plans and G-d laughs”.  At least I’ve given G-d some good laughs over the years. 

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GETTING OLD

In the morning, I often feel like the pilot of a 747, getting ready to start up his engines and going through his pre-flight list.  Renee, my co-pilot, has her own list and, often, we check each other’s list.  It goes something like this:

“Gas, check, more than needed this am! 

“Fluids, check.  Better drain the system before it develops a leak.” 

“Waste dump, check.  Overdue by 3 days.  If not performed soon system will go critical.  Consider procedure 13, suppository.

“Landing gear, check.  Creaky but adequate.  Improve after first 10 steps.  Renee, where’s the Aleve?”

“Back, check.  Working good this am.”

“Neck, check.  Not working so good.  Where is the Aleve?”

“Heart, check.  BP, check.  Windshield, check and foggy.  Where are my glasses?”

Pilot to co-pilot, “All systems go.  Check your list.  Central computer, check. No headache.  Chassis, check.  No back pain.  Ventilation system, check.  No cough.  To hell with work, how about I take you out for a spin?”

“OK!, I’ll get serious. Time to wash this baby off and take off for the rest of today.”

  Sometimes, getting old can be complicated!

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WHAT’S NECESSARY

The flowing article has been published several times over the past few years.  It is even more appropriate today than it has been in the past.

Originally published on March 5, 2011, this article ranks in my all-time top five viewed publications.  As insurance and Medicare become more restrictive, medical luxuries become more important.  With the recent move to brand many tests and interventions as unnecessary, what was once cutting edge and “necessary” now falls into the realm of luxury.  The statisticians look at what is “enough lives saved” in their quest to define necessary.  PSA screening is no longer “necessary” as not enough lives were saved for the cost of the test.  If your life is saved by a test of intervention, doesn’t that qualify as “enough?”  “Medical Luxuries” addresses the word “need.” 

The word “need” means different things to different people.  In an earlier article, I referred to “need” as the new four letter word.  People overuse and abuse the word “need”.  In my practice of medicine, I defined three levels of need. 

A level one need is critical and worth fighting over.  I saw level one needs two to three times a week.  Level one needs are exemplified by the 60-year-old hypertensive male who has chest pain.  He needs to be in the hospital now!  He needs to go by ambulance now!  His life depends on it.  When he refuses to follow my advice, I dial 911.  When he is at home and refuses to heed my advice, I call 911 and his wife.  Level one needs are absolute! 

Level two is where I spent the majority of my time.  My job was to inform you why you needed whatever it was you needed, what the benefits and risks were, what the expense was and how soon I think you should get it done.  I then left it up to you to decide if and when you were going to do it.  I might disagree with your decision but respected it.  A routine colonoscopy is the standard of care at the age of 50.  It is a level two need.  (If you have a family history of colon cancer, it is a level one need.) 

Level three needs are luxuries and the topic of tonight’s article.  Luxuries are needs you can do without but can do better with!  In medicine, a luxury is anything that is either unproven (but promising), not standard of care, or not covered by insurance.  We live in a peculiar world.  I have patients who won’t get a chest x-ray ($200) because their insurance won’t cover it.  They drive to the office in a BMW but won’t spend $200 on their own health.  I have patients who eat at expensive restaurants every weekend ($50 per person) yet want an inferior generic because the branded cost is $100 per month.  The insurance world has convinced us that if, they won’t pay for it, either you don’t need it or it is too expensive to afford.  

Luxuries can save you money and your life.  Several years ago, I was called in to the hospital to see a very sick patient at 5 a.m.  I dressed quickly, jumped into my car, backed out of the garage and slammed into my daughter’s car.  I had not spent the extra money to buy back up sensors when I purchased my car.  My decision had consequences.   I had to tell my daughter I smashed her car.  I had to pay for her repairs, as well as mine.  What seemed like a luxury item at the time turned out to be more of a necessity than I had anticipated and a costly error in judgment as well.  Luckily, the patient did fine. 

So what are luxury medical items?  Cardiac Scoring is a good example.  It measures the calcium load in your coronary arteries and predicts coronary artery disease.  A healthy 50-year-old male with no family history of heart disease is buying a luxury when he gets one.  Insurance won’t pay for it and technically he doesn’t need it.  So why get it?  Most of us are healthy until we are not.  If his results are normal, he gets peace of mind.  If his test is strongly positive (it happens to the healthiest of us), he may well have saved his life. 

Every year there are unexpected deaths in our community.  Could the purchase of a healthcare luxury, an annual physical, an EKG, blood test or x-ray, have saved their lives?   I would like to think so.  The next time your doc asks you to get a test or buy a medication that is not a covered benefit, think twice before you dismiss the idea.  Times are tough and money is tight; but, if your roof was leaking, you would find a way to get it repaired.  I often use analogies to make a point and my favorite has to do with your house.  Your house is very important; and, when it needs repairs, we find the means to do so.  Your house shelters your body; your body houses your soul.  Do everything you can to protect your body and keep it fit for many years to come. 

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Lose Lose Situation

Everyone has heard of the win-win scenario but what about the lose-lose scenario.  Imagine I just got off the phone with an unhappy patient.  He has had a very sore throat and a temperature of 99 degrees Fahrenheit for 24 hours.   He “knows” he needs an antibiotic and can’t come in to be seen.

“Doc, I know my body.  When I get a sore throat, I always need an antibiotic!”

“Mr. A, the vast majority of sore throats at your age are caused by viruses.  Antibiotics don’t kill viruses.  In reality, the risks of antibiotics far outweigh any potential benefit at this time.  Give it a few days.  Gargle with warm saltwater, drink plenty of fluids and take acetaminophen if your temp goes above 102.”

“Doc, I can’t afford to be sick.  It will ruin my weekend.  I know I need an antibiotic!” 

My patient does not sound happy.  He is sick and convinced that nothing short of an antibiotic will help.  What’s a doc to do?  The easiest thing is to give in and call his local pharmacy.  After all, what’s the worst that can happen?  He could have an allergic reaction or an antibiotic-induced diarrhea, that’s what!

What else could happen?  Frankly, he could get worse!  If anything, antibiotics mayl assist the virus in attacking its host by wiping out the patient’s normal flora.  What else could happen?  

By prescribing an antibiotic inappropriately, I will reinforce the idea that my patient needs an antibiotic every time he gets a sore throat.  The odds are strong that he’s going to get well; and, if I’ve given in, he will attribute his newfound health to the antibiotic.

In a future world where doc’s pay is dependent on patient satisfaction surveys, Docs will constantly be faced with this lose-lose scenario.  Is my job to satisfy my patient or to provide evidence-based, appropriate medical care?

Making matters worse, some urgent care doc, whose job is dependent on patient satisfaction surveys, will likely see my patient this weekend.  He/she will likely give in quickly and prescribe the antibiotic that I refused to prescribe.  He/she will enjoy the win-win of pleasing the patient in a 4-minute visit and will not have to deal with the aftermath.  So goes the life of a family doc.

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LETTER FROM AN ANGRY PHYSICIAN

Below is a letter I wrote shortly before going on medical leave.

I’m angry.  I don’t like being angry.  Being angry is unhealthy and counterproductive.  Physicians are not supposed to get angry at their patients.  I can’t help it!  This week I’ve seen multiple patients for self-induced illnesses.  Health is a precious commodity and watching patients piss away their health makes me angry.

I’m supposed to repair the damage my patients are creating.  I’m supposed to perform that miracle without running all sorts of tests and without prescribing all kinds of expensive medications.  After all, Docs are accused of running unnecessary tests and prescribing expensive medications.  Aren’t they?

I’m also expected to deal with angry family members who, by law, aren’t privy to the facts of their loved one’s case.  All they know is their family member’s health is failing and it must be the doc’s fault or the medication’s fault.  They also complain about the cost of all the tests and treatments and specialists.

“Doc, you’re bankrupting my parents.  We can’t afford to pay their bills.  How did things get this bad?  You’ve taken care of my dad for 20 years.”

Exactly!  For 20 years, I’ve instructed my patient in the intricacies of diabetic care.  I’ve sent him to diabetic educators.  I’ve sent him to see a nutritionist.  I’ve provided literature.  I’ve explained that diabetics need to develop a Master’s level of education in the disease and manage themselves.  I’ve met with his wife and gone over things with her.  She’s tried to help but failed.  For 20 years, my patient has refused to do anything for himself!  The end result is not pretty.  It makes me angry.

It’s not just diabetes.  There’s the overweight hypertensive, basking in salt and lard whose family can’t understand why his kidneys are failing and why he’s had his third heart attack.  There’s the alcoholic who can’t understand why he’s so broke and can’t keep a job.  He refuses counseling:

“Doc, I can’t afford to see a counselor and I don’t have a drinking problem.  I’m just down on my luck!”

Of course, he can’t afford to see a counselor.  A fifth of booze a night plus a pack and a half of cigarettes eats up a lot of cash!

Wow, I feel better now that I’ve got that off my chest!  I can only do so much.  The person who has to care the most about my patient is my patient!  I can’t do it alone.  I can’t save a person from years of self-abuse.  

So, please help me help you!

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THE ANSWER

Yesterday, I promised to give you a gift today that would help you improve your medical care and wrest control from the insurance companies.  You can skip to the end of this article for your present or read on.  I suggest that you read the entire article first. 

Recently, one of my readers wrote the following:

“We were just discussing this at work.  The first consideration in medical is the expense and the hospital liability, rather than the patient. Also frustrating is that we all have teams of doctors that seem to never come together to talk about a patient and how best to treat the patient.  They all just do their specific part.”

Let me address this reader’s concerns line by line. 

“We were just discussing this at work.  The first consideration in medical is the expense and . . .. Expense is often the first concern of patients as well as doctors.”  

While patients pay a fortune to the insurance company to cover their care, they pay a pittance to the family doc or internist responsible for their care.  Patients, after reviewing their EOB (explanation of benefits), would often comment that I got ripped off (indeed I did).  Some would offer to pay the balance that my office was forced to write off.  By contract, we could not accept it.

“The first consideration in medical is the hospital liability, rather than the patient.”

Liability is a huge concern both for the patient and the doctor.  Malpractice insurance costs your doc tens of thousands of dollars.  We live in a litiginous society. Just look at the TV commercials where the lawyers tout the fact that their clients pay only if they collect. Bringing a frivolous lawsuit costs you nothing and, since defending against a frivolous suit can cost $50,000 or more, many docs will cut their losses and settle even though they did nothing wrong.  The cost of medical liability drives the cost of medical care in the U.S.  Even worse, the cost of practicing “defensive medicine” adds even more expense.

“We all have teams of doctors that seem to never come together to talk about a patient and how best to treat the patient.  They all just do their specific part.”

The Bears have a head coach who’s responsible for coordinating all elements of his team’s game.  He is a highly paid, respected (some years) individual.  Your family doc or internist is the head coach of your team.  He/she is not highly paid.  In fact, he/she receives nothing for the coordination of care that is so sorely missing in today’s medical world.

After a ten-hour day seeing patients, I would spend 2-3 hours on the phone with patients and specialists coordinating care and another hour or two reviewing letters from specialists:  yes, fourteen to sixteen-hour days were the usual.  The electronic medical record actually made the situation worse.  No longer to I receive succinct written correspondence.  Instead, I would have to review a 5-6-page document and glean out the pertinent facts.

Here’s your present.  FIND A CONCIERGE DOC!  In other words, hire a head coach who is responsible for your care and who is paid to manage your team. While you pay huge sums of money to your insurance company, they do not have your best interest in mind.  They do not pay your doc to manage your care.  Most pay for a 6-minute visit.

I loved my concierge practice and patients.  Most were not rich.  All believed that personally investing in their care was worth it.  I had Concierge hours set aside so that I would not be rushed.  My assistant coach, Ewa, carried the concierge phone and was available, like me, 24 hours a day. (Our Concierge patients loved her.) I never heard a complaint!  Practicing medicine with a group of patients who were truly dedicated to “Living Wellthy” was not only emotionally rewarding, but fun!

Currently, a new way of providing care is growing.  “Retainer” medicine and “Direct Primary Care” practices cost less than Concierge Medicine and offer savings on lab work and prescriptions as well as easy access to your doc/head coach.  Dr. Dan Di Iorio has established a hybrid practice in Barrington.  For more information on DPC click on his name and review his web site.

Have you ever heard, “You get what you pay for!”  It’s a lie.  With insurance, you don’t get what you pay for.  Often, you get f..ked.  With Concierge Medicine, you get what you pay for and it’s worth it.

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