Month: February 2020

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.

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!

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

My patients often question whether stress is the cause of whatever is ailing them.  Stress has been linked to many diseases and certainly is a factor underlying most of what ails us.  The only problem with stress is that it is unstoppable.  Of all the successful men and women I see over my lifetime, not a single one has successfully avoided stress.

Since stress is unavoidable, then proper stress management is the key to a happier and healthier lifestyle.  There are thousands of books written on stress management.  There are college level courses, seminars and stress management coaches available to help you.  Drs Wright and Lapporte are psychologistS who worked out of my office. They can teach you how to better manage your stress.  It would be great if stress management was taught in elementary and high school but, for some strange reason, it isn’t.

In keeping with my theme of investing in your health the same way you invest in your financial wealth, I want you to think about your emotional health as if it, too, existed in a retirement fund.  My patients have long term emotional goals (dreams).    “One day” we’ll get a cabin in Wisconsin; travel to Europe; get a boat; sky dive, but today we need to work to save money.  We need to save money so “one day” we can be happy, stress free.

The problem with the one-day scenario is that we really don’t know how many days we, or our significant others, have.  I have lots of patients who have only regrets as their “one day” came one day too late.  I advise my patients to set 90-day mental health goals.  Every 90 days you should take a three-day weekend and do something you’ve always wanted to do.  Whether you take three days to yourself or spend them with loved ones, make sure they are memorable.  If you follow the 90-day rule, then you are never more than 90 days away from a break.  The 30 days prior to your three-day weekend, you can get excited about the time off.  The 30 days after the weekend you can glory over what you did.  The middle 30 days you can plan your next escape.

The 90 day rule is one of my stress management techniques.  It fills my life with lots of good memories.  It helps me stay healthy.  Try it, I think you’ll like it so much that you may even decide to take four or more days at a time.  Americans live to work.  Europeans work to live.  Live now while you are healthy.  Be wellthy with memories and your stress level will diminish.

I’m glad to report that I’m back from “Failure,” and I’m working hard on losing my holiday weight addition and enjoying the “Wellthy” life.  I hope you’ll appreciate this article, first published last January, 2018.

Winter Break brings vacations, Christmas and New Year.  As usual, many of my patients have returned from their vacations and resumed their usual routines.  Some of my patients are having trouble getting back into their routine.

Where did you go on vacation?   A few of my patients went to Australia.  People who travel to Australia have such a great time that they don’t want to come back.  Another favorite destination is “Failure.”  Yes, too many of my patients take a vacation from healthy living during Winter Break.   They eat the wrong things, stop exercising, and, in general, over-indulge in excess. (Yes, that’s a redundancy.)

Like those who travel to Australia, those individuals who travel to “Failure” have a lot of trouble returning to their routine, healthy lives.  While living in “Failure” may be enticing, ultimately there is a price to be paid.  Sometimes that price is a financial one and sometimes it is a physical one.

While visiting “Failure,” my patients gain weight.  With weight gain, many will experience increases in their blood pressure, cholesterol, and blood sugars.  Some will experience back problems.  Others will notice that they get short of breath going up stairs.

The longer you stay in “Failure,” the costlier it gets.  As your blood pressure rises, you’ll need more medication.  Vacation in “Failure” long enough and you may even get a bonus stay in the Intensive Care Unit at your local hospital.  “Failure” must be a marvelous resort.   People whose vacation unexpectedly takes them to “Failure” have lots of trouble returning to normal life.

Well, Winter Break is over and no matter how much you enjoyed vacation; it’s time to get back to work.  If you are wallowing in “Failure,” find your willpower and work on losing that extra weight, eating appropriately and exercising.  Work on lowering your blood pressure/sugar/cholesterol.  Work on refining yourself and becoming truly Wellthy.

If you are having trouble returning to a healthy lifestyle, see your doc, join a gym, or read a book.  “Diets and Other Unnatural Acts” is highly recommended.  Search through this blog for success stories and read them.  Then work at writing your own success story.  I’ll be glad to publish it!

Doc, last week, I thought I was having a stroke.  My vision went from wavy to black then came back slowly.  I just thought I would mention it while I’m here.”

“Doc, last Sunday I had severe chest pain.  I thought I was having a heart attack.  It lasted 2 hours and then went away.  I’ve been achy and have not felt right since.”

“Doc, for the last few months I’ve noticed blood in my stool.  Sometimes it turns the water red.  Should I be worried?”

I hear some form of the above statements on a regular basis and I am always amazed that my patients respond to such potentially life-threatening symptoms in so nonchalant a manner.  While they obviously survived to tell their story, many don’t.

Unfortunately, people die at home while pondering the question, “Am I having a stroke, heart attack or gastrointestinal bleed.”  Their loved ones find them slumped over the kitchen table or lying on the floor.  Others are found in time, only to end up in a nursing home or as a cardiac cripple.  It’s the sad truth.

There is a golden period in which to salvage heart and brain from the ravages of stroke and heart attack, a time to stop the bleeding before you exsanguinate.  Why do people wait at home, pondering such an important question?  Sometimes, it’s simply denial.  “I exercise every day.  It can’t be my heart!  No one in my family has ever had a heart attack.”  Sometimes patients tell me, “I didn’t call because I didn’t want to bother you,” or “I felt foolish.  I was just being a nervous ninny.”  There are dozens of excuses for not acting on their concerns.

“I figured I would wait a while and see what happened,” is my favorite.  I want to respond with, “That’s a great idea!  Wait to see if you can lose your ability to speak, start dropping things or simply die with extreme chest pain.”  Yes, waiting to see what happens is a gamble.  It’s like rolling the dice.  Sooner or later, you crap out!

By the way, if you are alone and think you are having a heart attack, stroke, or start to hemorrhage, dial 911 while you can.  If you wait too long, dialing the phone may become an impossibility.  What have you got to lose?  Afraid you’ll look foolish by calling 911 when it’s really nothing?  Don’t be!  Be happy you are alive!

By the way, in my experience, 7 out of 10 times your intuition is accurate.  If you think you could be in trouble, you are!  As I always like to say, the life you save may be your own.  Be happy and “Wellthy!”

How much of a financial savings would it take to make you gamble with your health and wellbeing?  Would it surprise you if I told you some of your neighbors would jeopardize their health for a savings of $30 a month?  How about $20?  Or even $10?

It wouldn’t surprise me!  In the past, I’ve watched patients put their health on the line for as little as $10 a month.  Now please understand, these are not patients who are destitute.  They have jobs, homes, and go out to eat and to a movie on weekends.  These are people who have bought into what I call “The Insurance Mentality” or TIM for short.

People suffering from TIM believe that if insurance doesn’t pay for something that it is not worth having.  If their insurer tells them they will not pay for a particular medication, they call the office demanding to be taken off their current medication and switched to the insurer preferred product.  After all, the insurance company has their best interest in mind, right?  Wrong!  Their insurance company’s job is to maximize profits and make their stockholders happy.  My job is to maximize my patients’ health!

Unfortunately, the insurers are winning.  Emboldened by their newfound powers under Obamacare, The United Federation of Insurers of America (FU America) declared war on all expensive medications on January 1, 2014, papering the country with denials of medication orders and demanding that doctors and patients alike conform to the insurers select list of cheap medication.  The war continues today. No matter that a person has been successfully treated with a given medication for 5 years, they must surrender and change.

Those patients suffering from TIM immediately follow the edicts of the FU America movement and called in for their insurer preferred scripts.  Many were aghast to find they had to come in for an office visit but did so as FU America covered that visit.  All wanted to know if the switch was “safe.”

“Mr. X, you’ve done great on your Diovan for 3 years.  You’ll probably be fine on Losartan (the generic FU America prefers) but we won’t know until you try it.  I know that Diovan will cost you more so if you want to switch, we can try.”

Mr. X wanted to try so off he went with his new prescription and his trip to failure.  Yes, he reacted poorly to the meds and came close to staying at Good Shepherd Hospital.  He’s better now and back on his Diovan.  He learned a hard lesson but, in the end, he’ll be ok.  What’s your health worth?  Are you really willing to rock the apple cart to save a little money or would you be better off staying home, preparing your own meals and watching reruns on TV?

As many of my readers know, I often think of myself as a fireman, working to put out fires before they do serious damage.  My patients come in screaming, “FIRE!  HELP ME!”  Unfortunately, many of my patients are arsonists, actively feeding the fire I am trying to extinguish.  Being a doc/fireman can be awfully frustrating sometimes.

As a doc/fireman, I have a variety of fire extinguishers.  My main extinguishers are medications.  Others include an assortment of therapies (physical, occupational, and psychological).  A three-alarm fire requires not only my full assault with the above therapies but the help of others, my consulting group.

Unfortunately, the arsonists I treat often have their own ideas about how they want to put out their fires; and, many times, their unique demands only serve to fuel the fire that is injuring them.

Some patients refuse medications believing that pills are harmful.  It amazes me when a smoker refuses medicinal help due to an irrational belief that pills are toxic; yet, he voluntarily inhales hundreds of known toxins 20 times a day.

Some patients demand medication and shun therapy, even when therapy is a better alternative.  “Doc, I just want my tranquilizer, it solves all my problems.”  Not really!  In many cases, tranquilizers are firewalls, temporarily protecting my patient from being burned by the raging fire.  In the case of anxiety, the psychologist has a much better chance of eradicating the fire than I do.  In the case of a three-alarm blazing anxiety, my deploying medications along with the psychologist’s therapy is necessary.  “Doc, I ain’t seeing no psychologist!  They can’t help me”, means just “give me my pills”.  

Using the wrong extinguishers may cause as much harm as just allowing the fire to burn on its own.  Years ago, we had a fire alarm go off in my office.  Firemen streamed through the front door with axes in hand.  Luckily, there was no fire and no ax was used.  Those axes could have caused a lot of damage if used inappropriately.  Giving in to the demand for tranquilizers can lead to a lifetime dependency on those very medications.  Being a doc/fireman can be frustrating.

Still other patients come in yelling “FIRE, HELP ME”, then refuse all treatments.  They want something “all natural.”  What’s more natural than sitting with a therapist, talking about what ails you?  “I don’t want to see a therapist.”  “What about valerian, it’s all natural?”  “Pills”, published earlier this year, addressed these totally unnatural, unregulated, non-FDA approved, manufactured pills.  Despite the fact that no one really knows what’s in the capsule, what effects it may have on an individual, how the body processes it, and how it interacts with other substances the patient ingests, people have really bought into this form of witchcraft.  Being a doc/firefighter can be very frustrating!  By the way, I have a bridge for sale.  It’s all natural, made from wood.  It’s located in Long Grove.  Any buyers?

Being a doc/firefighter can be extremely rewarding!  I saw a smoker who was being consumed by a raging fire.  His ears hurt, his throat hurt, his lungs hurt, and he couldn’t stop coughing.  Just as the real firefighters and paramedics have to deal with victims of fires and just as those victims often succumb to smoke inhalation, my patient had succumbed to smoke inhalation.  His was no accidental fire! He actually lit his fire 20 times a day for the last 10 years!  I put out his fire and rescued him from smoke inhalation.  Once his burns are healed, he will never again smoke.  Why?  The answer is easy.  He loves his wife and children.  He would never cheat on his wife or children.  When I pointed out that he was cheating on his family 20 times a day, the expression on his face was one of horror.  He had never looked at it that way.  Sometimes, you win one!

Attention, arsonist!  Help me help you!  Do not feed the fire that is consuming you!  Help me help you by listening to the wisdom of my 30 years as a doc/firefighter.  Use all the tools available to you.  The life you save may be your own.

I recently published “Possible vs. Probable”. The premise of the article was that, while everything is possible, what is truly important is what the probability of an illness or outcome is.  Today, I want to apply the premise of “Possible vs. Probable” to the realities of getting old and being ill.

Mrs. “X” is in her 70s.  She has diabetes, high blood pressure and her kidneys aren’t up to par (renal insufficiency).  Mrs. “X”’s most pressing problem is her arthritis.  Her neck, low back, hips, and knees hurt all day long.  It takes Mrs. “X” “forever” just to get out of bed in the morning.  Mrs. “X” also worries about everything.

Mrs. “X” worries mostly about her kidneys.  Her kidney doc has warned her not to take any NSAIDs (ibuprofen, naproxen, etc.).  Theoretically, NSAIDs can adversely affect kidneys causing a decrease or worsening in kidney function.  Realistically, Mrs. “X” is in pain on a daily basis and NSAIDs are the treatment of choice for her arthritic pain.  Mrs. “X” knows that NSAIDs work as on the days she takes ibuprofen, she feels 10 years younger.

What should Mrs. “X” do?  Should she listen to her kidney doc and live in pain or use NSAIDs and risk further loss of kidney function?  Should she try other treatments?

Mrs. “X” does great on steroids.  She becomes pain free!  Theoretically, steroids can worsen her diabetes and hypertension, cause cataracts, osteoporosis, mood swings and an assortment of other problems.  The reality is that they make her better and without steroids or NSAIDs, she is crippled with pain.

What should she do?  She has tried acetaminophen and it has failed to offer any relief.  Narcotics constipate her and make her unsure on her feet.  Physical therapy did not help.

In my book, reality trumps theory every time.  Is it better to protect your kidneys, avoid possible worsening of your diabetes/hypertension and live longer in pain or is it better to relieve pain and potentially shorten your life?

I often find myself treating Mr. and Mrs. Xs who fit the above scenario.  A day with minimal or no pain is always better than ten days in pain.  Many of my patients go for quality over quantity.  What is remarkable is that most tolerate their NSAIDs or steroids well and do not significantly shorten their life or worsen their bodily functions.  Theory is not reality.

Because doctors believe in informed consent, because doctors are afraid of being sued for caring for their patients, they teach their patients about the theoretical problems a treatment may pose.  Because pharmacists have the same concerns as doctors, they glue and staple warnings all over Mrs. “X”’s prescriptions.  Unfortunately, patients often are scared by the warnings of theoretical doom and refuse treatment, leaving them to suffer day after day.

Remember, theory is not reality!  Remember, each of us is unique and how we respond to a given treatment is not preordained by scientific studies.  Life is about weighing risks and benefits and then hoping the decision you make is the right one.  When making decisions about potential treatments, the reality of today should receive much more weight than the theoretical tomorrow.

If you noted a sense of frustration in this article, you would be correct.  Our system of informed consent often backfires.  Rather than protecting patients from theoretical side effects and risks of treatments, informed consent often harms the patient it is meant to protect.  It’s frustrating to offer a patient relief from suffering and then, doing your duty as a physician, talk that patient out of doing what you feel is best for them.  Sounds schizophrenic? It is and therein lies my frustration!