FATIGUE

One of the questions I dreaded the most was, “Doctor, why am I always tired?”  Tired, fatigued, exhausted and lacking energy are among the many dreaded symptoms I heard almost every day.  Why did I dread this complaint?  Fatigue is a symptom of almost every disease known to mankind! 

In the article titled “Differential Diagnosis,” I reviewed how doctors formulate a list of possible causes for an illness, arrange those possible causes by probability of occurrence and potential for doing harm and methodically work through the list until an appropriate diagnosis is made.  The differential diagnosis for fatigue starts with “A” and ends with “Z”.  There are common causes of fatigue:  anemia; thyroid disease; sleep disorders including sleep apnea; depression; stress reaction; physical exhaustion; diabetes; hypertension; chronic fatigue syndrome; and COPD are but a few.

A typical office visit is divided into three parts: the interview, the exam and the planning stage.  The interview for the complaint of fatigue is often exhaustive.  The interview can also be frustrating as fatigue influences every part of a person’s life.   Doctors work with an interview tool called the “review of systems” (ROS).  The ROS is comprised of 14 organ systems with specific questions relating to each of those systems.  When dealing with a patient who suffers from fatigue, all 14 systems must be explored, and most patients have complaints in the majority of systems.  The doctor is often left with the “Chicken vs. the Egg” conundrum.

Now, do you understand why I dread this question?  To make matters worse, the physical exam seldom provides an answer requiring laboratory and other diagnostic testing.  While I am a puzzle solver and very experienced at solving this puzzle, each patient’s puzzle is unique and requires a novel solution and treatment approach.

So, when you complain of fatigue, and most of us will during our lifetime, recognize that the “Why” may be difficult to find, requiring extensive searching through your history, your physical exam and extended testing.  Be prepared for some frustration.  Be opened-minded about the various possibilities.  Recognize that one of the differential diagnoses is psychological and do not get offended if your doctor suggests you see a psychologist for testing.  At least, the psychologist’s tests don’t involve needles and KY Jelly!

Before seeing your doctor, ask the why, what, how, when and where questions about your fatigue.  Go through your own ROS (http://en.wikipedia.org/wiki/Review_of_systems).  In doing so, you may solve your own puzzle.  The more you question yourself, the easier it will be for you to answer your doctor’s questions.  While I am trained to solve puzzles by myself, it is easier if I have help.  Bring your significant other; he or she often has insights that are helpful.

One last request, if you could have a run of the mill anemia or thyroid problem, it would make my life easier! 

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FIVE THINGS TO KNOW

In 5 things that I want my patients to know, by Leana Wen, MDpublished today on KevinMD.com, Dr Wen states:

1. Antibiotics will not help the common cold.

2. A CT scan will not improve a headache.

3. Every test has potential side effects.

4. Lifestyle changes make a huge difference.

5. Aspirin is one of few medications that’s been definitively shown to help you.

Dr. Wen’s advice is indeed wise and in many instances, parallels the advice I have been expounding on in this blog for the last 2 years. Other things I want my patients to know include:

6. Immunizations work! Immunizations prevent disease and, while they have potential side effects, are very safe.

7. The Flu vaccine cannot cause you to get the flu, cannot give you a cold, and does not weaken your immune system.

8. Doctors want to help you get well and improve your health. We would not offer a treatment to you or your family if we thought that it would hurt you.

9. The only truly foolish question is the one you didn’t ask. Feel free to ask me anything without the fear of embarrassment, just not at 3 in the morning if it’s not an emergency.

10. Doctors have on-call services to assist you in an emergency/urgent situation when we are not in the office. Please do not call after hours to get a refill or dodge an office visit.

11. No two insurance policies are the same. Know what your policy covers and what it does not. 

12. Stress is a disease and is contagious. Learn to manage yours and don’t transmit it to others.

13. Donating blood is the gift that keeps giving! When you donate blood on a regular basis, not only do you help others but you help yourself build the ability to make new blood more efficiently.

14. ‘Chicken Steps” work. You can become the person you want to be by setting your course and taking one tiny step after another in the right direction.

15. Diets are truly unnatural acts.

16. Because you have never had something is no guarantee that you won’t get it. As you age, you are likely to have a lot of new experiences. Work hard to make them healthy experiences.

17. You can change for the better. Define who you are and then refine who you are.

18. Love more, hate less!

19. Thirty minutes a day of exercise is not too much to ask of your body. It will pay off in spades!

20. Enjoy today and every day. No one really knows what tomorrow holds. Count your blessings in the morning and at night.

My list could go on and on but I will stop here and spend some time with my family, Skype with my children, and count my blessings. 

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RESTORATION

I just saw an amazing sight:  a 1951 Ford Crestliner.  It’s amazing, in pristine condition and must be worth a fortune.  Can you imagine owning a piece of history?  I bet every head turns when it goes cruising by, proud owner at the wheel.

This particular Crestliner was all original, having been meticulously cared for over the last 63 years.  I imagine that the owner took it into the shop for regular tune-ups and preventative servicing.  When a part broke, he would do his best to repair it, resorting to using all original replacements only when necessary.

Ford sold a lot of Crestliners in 1951.  Have you ever seen one?  I doubt it.  Unlike the owner of the above-mentioned antique, most owners of cars do minimal maintenance, junking them when they age.  Junk yards across this country are full of rusting heaps of vehicles that once gleamed brilliantly.  A few will be meticulously restored.  Most will be turned into scrap metal and parts.

So, what’s all of this have to do with medical care?  I’ll tell you.  I’m a 1951 model that is currently being restored.  Unfortunately, I had neglected to take proper care of my body, making lots of excuses about why there was no time for diet and exercise, no time to take my body out on the road and run it.  I’ve got to confess, restoring one’s health takes a lot more effort than just preserving.

What model year are you?  DO OTHERS ADMIRE YOUR BOD WHEN YOU TAKE IT OUT OF THE HOUSE OR DO THEY SNICKER?  Are you showroom ready or heading for the junk yard?  Whatever shape you are in, start working on restoring your vitality.  Stop making excuses for not eating right and not exercising.  Trim down and take pride in what you have.  I guarantee you, it will be worth the effort!

By the way, I’m down 6 pounds, walking daily and finally sleeping.

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THE GOOD OLD DAYS PART II

I am now old enough to reminisce about the good old days. Back in the Stone Age when I started my practice, I would enter the exam room with a paper chart and a stethoscope, greet my patient and then sit down and have a face to face interview. Once the interview was completed, I would have my patient sit on the exam table, do a thorough exam and then return him to his chair and discuss my findings and plans. My patient and I would agree on a treatment or diagnostic approach and I would give him a handwritten summary and walk him to the desk and say goodbye. As his physician, I did not have to ask anyone’s permission to order a test or prescribe medication. Prior authorization meant I authorized the treatment prior to his leaving the office. The only authority who could challenge my treatment was the patient; and, since the patient was involved in the decision, treatment could be started immediately.

Flash forward to today. On average I would apologize to 12 patients a day. While I still walked into the room and personally address my patients, I would be required to address the computer that sits on the counter as well. It is hard to have a personal relationship with an 18 inch monitor staring you in the face. Medicine in the year 2019 is all about recording details and clicking that ever present mouse and keyboard. Our government, the insurers and the lawyers all agree that collecting data is what it is all about. If you do your paperwork, you must be a good doc. So, I apologized for using the computer and would try, as best I could, to have a face to face interaction with a real person, as opposed to an 18 inch screen. 

The patient and his/her doc are no longer capable of deciding, on their own, about diagnostic and treatment options. Insurers have usurped the docs’ responsibilities and require prior authorization before tests are performed or medications filled. Prior authorization means the doc authorize (write a prescription for) the test or medication that they then refuse to honor. Treatment is delayed until their staff and the doc answer a long list of questions proving to the insurer that you have failed on the insurer’s cheaper option or really, really need the test. If you have not “failed” on the insurer’s prescribed option, they may refuse to pay for your treatment forcing you, the patient, to either pay for the treatment out of pocket or risk failure. Again, my profession must apologize. 

How or at what point your doc, a board-certified physician, and you, a patient in need of care, lost control of our own destinies is beyond the scope of this article. We, the doctors and patients of America, continue to see our autonomy and rights slip away. The very core of medicine, the patient-physician relationship, is under attack on every front. While I took care of the children of the children I cared for during the early years of my practice, it got harder for those patients to remain with me as their employers change their insurance coverage every year. Policies are becoming more restrictive. In the past, I should not have had to say goodbye to a patient like Bill, a patient of 27 years. His employer had just changed his policy to an “open access plus” plan that was so highly restrictive that I refused to be a participant in it. “Open Access Plus” sounds great, doesn’t it? I told BiIl I was sorry to lose a relationship that had grown strong over the last 27 years but I could not function under such a restrictive policy! Bill and patients like him will be forced to find new docs as corporate America changes insurance policies and procedures on a yearly basis and use the word open when what they are selling is anything but.

I am saddened by the changes in my profession that have occurred over the last 40 years. I am fearful that the data the government and insurers collect from my computer will be used to further compromise physicians’ abilities to practice personalized medical care. While there have been many good changes, I find myself apologizing more often than not to those who suffer at the hands of modern-day medicine.

 I am torn between the sadness of no longer being in practice and the relief of no longer having to fight with the insurers, our government and the damn electronic medical record.  I’ve always said that if you can make something good come from something bad, you can lessen the bad.

I am glad to be able to speak my mind and tell my audience how bad it has gotten and how much worse “Medicare for all “will be.

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THE GOOD OLD DAYS PART I

I really feel really old. I find myself reminiscing about the “good old days” a lot recently. I’m afraid that modern medicine has become way too automated and impersonal! The computer seems to run everything, and it is a poor substitute for human judgment, contact and empathy.

A typical story goes like this.  I had a patient who was in trouble. His doctor was a University professor and expert in his illness. In the “good old days,” I would call his doc to confer on the best course of action and my call would be taken by a human. Yesterday, I got:

“Push one for English and two for Spanish.” This, in itself, bothered me. I was calling a university in Chicago, not Mexico.

“Push 1 if you are a physician or calling from a physician’s office.” I pushed 1 again.

“Our operators are busy, we value your services, please hold.” I heard the same message for the next 10 minutes. There was no option to leave a message for the doc. My phone tracts how long I am on a call and I’m not exaggerating. My patient needed help so I stayed on the line.

The doctor’s secretary answered and would not get the doc. “She’s in clinic. I’ll have her call you.” Four and a half hours later the doc calls; and, unfortunately, I missed the call. The doc left her office number leaving me no choice but to call back the same number I had such a bad experience with earlier.

Guess what happened. Yep, I was placed on eternal hold and waited 15 minutes until the doc finally answered. The pity is that this super specialist knows her phone system sucks but can’t do anything about it and frankly sounded like she could give a crap about it. Apparently, she is employed by the university and takes no responsibility for the negative effects on patient care her phone system causes.

I miss the “good old days” when docs were employed by their patients and could be reached by “dialing” a rotary phone and took responsibility for their offices and patient care.

On a side note, when I bought my phone system, the vendor told me I was nuts for not buying an automated attendant with my system. I’m glad I didn’t listen! A human answers my phones and always will!

Someone said, “Man plans, and God laughs.”  Well, I sold my practice to Amita.  My patients are now greeted by an automated attendant.  That’s just one more thing for me to be sorry for.

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WOULDA, COULDA, SHOULDA

I’m going to share a secret with you.  Men and women are not alike!  When it comes to health care, women excel.  Over the 40 years I practiced medicine, I found that women were much more proactive, coming in early in the course of a disease, seeking advice and treatment.  They are also much better at maintaining their bodies.

Men tend to take care of the car better then they care for their physical or emotional health.  Car vs. bodily maintenance will be a topic of a future article.  For now, I want to discuss the one place where men truly excel.

I’m referring to what I call the “woulda, coulda, shoudla” game.

I loved delivering babies.  I loved going to the newborn nursery and bedside to discuss the care of a newborn.  One of the things I discussed with the new mother was the afore mentioned game.  Becoming a mother is a beautiful thing with one exception.  For some reason, mothers take responsibility for everything, past and present and relive the past over and over again as if they could change it in some way.

The “woulda, coulda, shoudla” game starts here and is one of the worst games you can play.  In looking back over my lifetime, I can truly say that, of all my carefully thought out and researched personal decisions I made, half turned out to be mistakes.  Women look back in time and say; ”If only I had …., I shoulda done …., I coulda done …”. The point is that there is no way to win the “woulda, coulda, shoudla” game.  As a matter of fact, losing the game over and over again is harmful leading to regrets and depression.

Men play the “It is what it is game” and move on.  At the birth of a new mother, I tell them about this game.  I ask them to learn how to play the “It is what it is game,” from their husbands.  

The next time you start to play the “woulda, coulda, should” game, stop yourself.  Recognize that you can’t change the past.  REALIZE THAT YOU DID THE BEST YOU COULD OR IF YOU DIDN’T, FORGIVE YOURSELF AND MOVE ON!

It’s been said that living in the past causes depression.  Trying to live in the future cause anxiety.  Live in the present and enjoy life and be careful not to play a game you are sure going to lose.

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Mediterranean diet

According to an article published in “The Journal Of The American College of Cardiology,” a meta-analysis (scientific review) of 50 studies including 535,000 patients showed major health benefits from being on a “Mediterranean Diet.”  Among the benefits of this diet are:

  • Improved systolic and diastolic blood pressure
  • Improved levels of HDL cholesterol
  • Improved triglyceride counts
  • Lower blood sugar levels
  • Improved waist circumference.

The “Mediterranean Diet” is rich in vegetables, fruits, whole grains and healthy oils, such as olive oil.  A handful of nuts daily are an added bonus.  Red meats are limited to a few servings a month.  Eating fish and poultry at least twice weekly is advised.  Another bonus is the diet allows for the ingestion of moderate amounts of red wine.

I have addressed diets in numerous previous articles and will continue to do so as an appropriate diet is a mainstay of “Living Wellthy.”  The foundation of the “Living Wellthy” lifestyle encourages you to invest in your physical, nutritional, emotional and spiritual health retirement funds with the same fervor that you invest in your financial retirement fund.  You should set a long-term goal for your nutritional account and that goal should be the healthiest diet that you can maintain long-term. 

The “Mediterranean Diet” and others that I will write about in the weeks to come should be viewed as potential goals that can be realized by careful planning and sculpting of your current dietary habits.  Remember, your diet is based on your family’s dietary habits, your national and religious heritage and your personal likes and dislikes.  Your diet has been around for a long time and is, essentially, encased in concrete!  Rather than trying to radically change it overnight, slowly chip away at it and mold it into something much healthier.  Remember, the life you save may be your own. 

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DASH DIET

The “DASH DIET” (Dietary Approaches to Hypertension) is very similar to “The Mediterranean Diet” I wrote about yesterday.  “DASH” is all about your sodium intake and its effect on your blood pressure.  Studies have shown that the “DASH Diet” may protect against hypertension, heart disease, stroke, diabetes, osteoporosis and even cancer.

The main emphasis of the “DASH Diet” is maintaining your sodium intake at less than 2300 mgs daily.  The low sodium version of the “DASH Diet” restricts sodium to less than 1500 mgs daily.  As with the “Mediterranean Diet”, the “DASH” focuses on fruits, veggies and whole grains.  The “DASH” has fewer restrictions on red meats, fish and poultry.  A typical “DASH Diet” includes:

  • Grains – 6-8 servings per day
  • Veggies – 4-5 servings per day
  • Fruits – 4-5 servings per day
  • Dairy – 2-3 servings per day
  • Lean Meat, poultry, fish – Less than 6 servings (1 ounce/serving) daily
  • Nuts – 4-5 servings (handfuls) per week
  • Fats and oils – 2-3 servings per day
  • Sweets – Less than 5 servings a week
  • Alcohol – Males get 2 drinks per day; females 1 per day

The DASH diet is not designed to lose weight.  It assumes a daily intake of 2,000 calories.  To lose weight, limit yourself to 1500 calories per day.  Again, do not abandon your current diet as dramatic dietary changes are hard to maintain over the long term.  Instead, set a long-term goal and work towards that goal.   If you work hard at slowly changing old habits, you will be successful.  If you have hypertension, focus your efforts on reducing your salt ingestion.  I am a salt-o-holic and, after months of hard work, am now in the 2,300 mg range.  If I can do it, so can you.

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ASTHMA

Patients with asthma require the same routine yearly preventative exams as those without asthma.  In addition, they require daily exercise, maintenance of a smoke and toxin free environment and quarterly office visits to maximize their care.  Asthma has to be controlled!  In a previous article, I noted that ten people die every day from asthma.  That truly is a shame as asthma is controllable.    

People with asthma should have an “Asthma Action Plan”.  They should know what to do when their asthma is quiescent and what to do when it flares.  They should always be on guard even if they have “just a little asthma”.  There is no such thing as “just a little asthma”.  An asthmatic who has mild episodic asthma and has never had a severe attack could, at any moment, have a life-threatening attack.  Asthmatics should always have their rescue inhaler at the ready.

On a daily basis, patients with asthma should grade their lung health using the Asthma Control Test.   Scores above 19 are normal.  Scores of 15 or less demand attention!  Please see your doctor for advice and further care.

Even well controlled asthmatics should have quarterly or biannual medical checkups.  Those visits should include a careful review of your home ACT scores, activity levels and limitations, blood pressure monitoring, pulse oximetry monitoring (oxygen level), an exam of mouth and nasal passages, heart and lungs, as well as pulmonary function testing (spirometry).   

Yearly, patients with asthma should have spirometry, a complete physical with appropriate laboratory testing and other tests as dictated by age and severity of the disease.  

If caught early and treated aggressively, with avoidance of inhaled irritants, allergens, smoking cessation, exercise and medication (when necessary), the scope of the disease can be seriously limited.  As stated earlier, control is essential if we ever expect to lessen the impact of asthma on our children, ourselves and society.

Your lungs are precious.  Breathing air is essential.  Never smoke and if you smoke, stop smoking now!  Asthma often goes undiagnosed and is mistaken for recurrent upper respiratory tract infections and bronchitis.  If you have repeated respiratory infections, find yourself short of breath with exercise or simply cough too much, see your doctor.  A simple spirometry test can help diagnose asthma or COPD.  The life you save may be your own. 

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WELLTH

I always thought money was a vehicle, designed to get you and your family from one place to another in relative comfort.  Unfortunately, most of my patients treat money as a destination.  The problem with money as a destination is that you can never quite get there.  When is enough really enough?

Today, I met a truly “wellthy” man.  He is an executive in a large corporation with lots of responsibility and a salary to match.  He lived in a large home with lots of land and taxes to pay.  He drove a car befitting his status as a corporate giant.  He was wealthy financially but unhappy with his job.  Money was his soul destination until he realized he was on the wrong journey.

This brave sole decided to be “wellthy,” not wealthy.  He divested of his large house, mortgage, and taxes.  He’s living below his means now.  He has realigned his goals and started on a new journey with inner peace and happiness as his destination.  Downsizing his life has enabled him to begin the second leg of his journey to “wellth.”

His friends and neighbors probably think he is nuts.  After all, he was living the American dream:  big job, big house, family!  What’s this nonsense about job satisfaction?  If people enjoyed their jobs, wouldn’t they call it play?  

I think he is one of the sanest people I have ever met.  I think he is a teacher with a precious lesson to be taught.  He is young and energetic.  Why shouldn’t he go for happiness?  His critics focus on income as a measure of success.  They think it’s insane to give up such a good, income producing job.  My patient thinks being happy and content with his work product is more important than money.  So do I!

“Wealth” is an intangible, defined by each individual.  Some feel “wealthy” if they have $50,000 in the bank; others feel poor with a measly $4,000,000.  “Wellth” is a state of mind where a person’s physical, emotional, spiritual, and nutritional wellbeing is every bit as important as their financial solvency.  I think we would all be better off realizing that, without health, money is worthless.  That money is only a vehicle designed to help us find our “wellth.”  If money is your destination, change course.  If you can’t change course, stop along the way to take care of your other needs.  Don’t spend all of your health obtaining your “wealth.”

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