ROUND PEG IN A SQUARE HOLE

No, I haven’t lost it.  Today’s article is all about fitting a round peg into a square whole.  My profession is changing.  “Payers,” those entities that have taken on the responsibility for paying for and ultimately providing healthcare for my patients, want statistics.  They collect data on every visit, every medication ordered and filled, every test ordered and done (or not done).  If you are afraid of what Google and Apple are doing with your geographic data, you should be more afraid of “payers.”  The government, in the guise of Medicare, is the worst.

Protocols, for medical care, are being actively built and implemented on a daily basis. Information (data) is being harvested from every patient encounter.  That information is used to create evidence on what the least costly and, therefore, most effective treatment protocols are.  I am forced to follow these protocols every day.

A typical story goes like this; a patient needs a stat CT scan of her lungs to assure she did not have a pulmonary embolism.  Her insurer’s protocol requires a prior authorization for this potentially lifesaving test.  Failure to follow her insurer’s protocol would result in thousands of out-of-pocket dollars expense to my patient.  Delay in care could result in her life.  What to do? 

Protocols don’t take into effect an individual’s needs; they make an individual fit within the protocol’s needs.  Protocols are in the best interest of the “payer”, not the provider and his patient.  In “Normal,” published 2/28/11, I wrote that I had never met a “normal” or “average” patient.  I see individuals and they come in all sizes and shapes.  Protocols are devised to care for that fictitious, average, normal individual.

In “Are We There Yet?” (4/14/11) I wrote about a fictitious New York city in the year 2020.  There, everyone lived by protocol, from what they ate to when they died, protocol controlled everything.  Well, 2020 is just around the corner and we aren’t there yet, but I think we are certainly on our way.  Certainly, from a medical point of view, we are being pushed to sacrifice the personal aspects of care for the sake of cost control.

How do you fit a square peg in a round hole?  Try using a hammer, chisel or saw.  I’m afraid that the new world of medicine is going to be uncomfortable for most patients and downright painful for many.

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RENEW

Calls for refills are always out of control!  Every year, more patients are trying to avoid follow up visits by calling for refills on their medications.  They tie up the office phone lines, consume large amounts of secretarial and nursing time, and put themselves in harm’s way.  They plead for “just one more refill”; they promise to come in; they make excuses; anything not to have to spend time and money in my office.

I love making my patients happy!  I work hard to save them money.  I work even harder to keep them safe and out of harm’s way.  In “Your Doctor The Master Chef,” I explain how a chef prepares a delectable sauce by seasoning his dish, letting it simmer, and then tasting the dish, repeating the cycle until it is perfect.  Medications are like seasonings and good health is the recipe.  Your doctor, the chef, has to see you on a regular basis, both to adjust your medication and monitor your health to assure the recipe is right for you.

When I prescribe a medication that treats a chronic problem, I give the patient enough medication to last until his next visit.  I expect that my patient will see me prior to his/her medication running out so I will have time to collect and analyze any laboratory values needed to monitor the medication, evaluate the effectiveness of the medication, and refill the medication prior to the patient running out.  Each and every medication has expected benefits and potential risks.

Evaluating a medication’s benefit is critical.  If the medication is for elevated blood pressure and it is not controlling your blood pressure, something has to be done.  My nurse cannot take your blood pressure over the phone.  We have to see you in the office to evaluate your pressure.

Monitoring your medication for possible side effects includes both a physical exam and lab testing.  While the I-Phone can do many things, it can’t draw blood or help in examining you.  Refilling your medication over the phone may seem like the nice thing to do but it is often the wrong thing to do.

The best way to save money is to be healthy.  The expense of a follow-up visit is much less than the expense of letting a disease go under-treated or missing an adverse reaction at an early stage.  Help me help you!  Come in for your appointed follow up.  Put two weeks worth of your medication in a properly labeled medicine bottle; and, when you reach for that bottle, plan on coming to the office.  If your doctor requires fasting labs, then make sure you are fasting (water only) 10-12 hours when you come in.  Please make sure you drink plenty of water prior to coming in.  If you use a mail order pharmacy, plan on coming in 3 weeks prior to your refill.  Buying medications in small quantities locally can be very expensive.

Remember, the life you save may be your own.  Don’t cut corners when it comes to your health.  Most of all, be happy and healthy! 

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Sunshiny Day

Did you ever wake up with a song in your head. I did this morning. I knew it was gonna be a great day. The sun was out, the breeze was delightful and I am in paradise. The song by Johnny Nash goes like this:

I can see clearly now the rain is gone
I can see all obstacles in my way
Gone are the dark clouds that had me blind
It’s gonna be a bright (bright)
Bright (bright) sunshiny day
It’s gonna be a bright (bright)
Bright (bright) sunshiny day

(In fact, I felt great this morning.  My Parkinson’s was quiet, my back was better and my usual obstacles were nowhere to be found. Sure enough, there wasn’t a cloud in the sky.)

I think I can make it now the pain is gone
All of the bad feelings have disappeared
Here is that rainbow I’ve been praying for
It’s gonna be a bright (bright)
Bright (bright) sunshiny day

(My pain was gone!  My bright sunshiny day in Paradise was off to a great start.)

Look all around, there’s nothing but blue skies
Look straight ahead, there’s nothing but blue skies

I can see clearly now the rain is gone
I can see all obstacles in my way
Gone are the dark clouds that had me blind
It’s gonna be a bright (bright)
Bright (bright) sunshiny day
It’s gonna be a bright (bright)
Bright (bright) sunshiny day
It’s gonna be a bright (bright)
Bright (bright) sunshiny day
Oh what a bright (bright)
Bright (bright) sunshiny day

Unfortunately, my bright sunshiny day, and mood, didn’t last long.  I usually am at my best when I’m in Mexico.  I used to walk 15,000 steps a day.  Today I felt so good I decided to walk to the market with Renee, Dale and Brian.  I barely got started and my back and hip flared with pain.  My legs felt like gel.

I rode the trolley over to the market; and, by the time I got there, my Parkinson’s kicked in to add insult to injury.  I was major bummed out.  So much for my bright shiny day.  The nice thing about being in Mexico with Renee is that tomorrow will be another sunshiny day.  The song will still be in my head and, with a lot of perseverance, I’ll fight the hopeless feeling that overwhelms me when my legs turn to gel or freeze (or both).

Don’t put off the happiness. I certainly won’t!

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DEATH

The longer we live, the more people we know who die. Live long enough and all of your friends will be gone.  The good news is that if you are reading this, you must be alive.  I don’t know whether to be happy or sad for you.  Think about it.  Going to heaven with your previously deceased family and friends is a once in a lifetime experience.  It must be awfully good on the other side as no one ever comes back and complains.

Why do we mourn the loss of loved ones?  I’ve always fought death and hated going to funerals.  I cry at funerals.  I’m not supposed to.  I’m supposed to be there to support the family who has lost a loved one.  Many years ago, I went to the funeral of a dear patient and spiritual leader of the community.  I prepared myself for one of those sad and miserable experiences, expecting hundreds of mourners with feelings of profound loss.  Instead, I walked into a celebration.  This was not a wake, but a true celebration of Ray’s death.  I was dumbfounded.  

My confusion led me to seek answers from a longtime patient and friend who was standing near the family of the departed.  My patient explained that Ray had graduated from his earthly duties and, as a graduate of life, was now in heaven.  I was at a graduation ceremony and there was reason to celebrate.  Sure, everyone would miss Ray but everyone was happy he had matriculated and moved on to bigger and better things.

Ray’s funeral was a life changing experience.  I still cry at funerals but I view our earthly existence from a different perspective.  If Ray’s family and friends are right, then we will all meet up in heaven for a good time.  What a grand idea.  If they are wrong, then we will be pioneers much like the crew of the star ship Enterprise studying the great unknown. 

Either way, it behooves us to enjoy every day to its fullest and, when its our turn, accept whatever follows.

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CONSULTANTS

Consultants

I wrote this article years ago and it is still very relevant.  While I don’t practice any longer, the principals discussed in this article are universal.

Today, I want to spend a little time on the topic of specialty medical care.  First, I need to explain what I do.  I am a Family Practitioner, trained in general medical care and fulfill the role of PCP (primary care provider).  I am trained to know a lot about everything.  My predecessors, the general practitioner (GP, Marcus Welby, MD) did everything from delivering your babies, to operating on your appendix, to pronouncing your grandmother.  My training is similar.  I used to deliver babies.  I’m trained to take out your appendix.  I work hard at keeping your grandmother alive so I won’t have to pronounce her.

I know everything about a few things, a lot about a lot of things and something about almost everything pertaining to your health.  The most important thing I know is what I don’t know.  Knowing what you don’t know and where and how to find the answer is critical in healthcare.  My specialist consultants’ jobs are to know what I don’t know and to take over when you and I need them. 

Wise counsel is one of the most important tools in any endeavor, particularly so in medicine.  I use my consultants liberally.  Even when I know what the answer is, I may bring in a consultant for reassurance.  After all, I am human and capable of error.  My consultants are expensive!  Their time and skill set is highly specialized.  Their opinion is just as highly valued and may save your life.

In today’s medical environment, my consultants bring more than their opinions.  My consultants bring lifesaving technical skills as well.  My cardiologist can slip a stint into a closed artery and restore lifesaving blood supply to a dying heart.  My radiologist can block an artery to a tumor, killing the tumor and saving a life.

The insurance industry and Medicare want me to return to my Marcus Welby roots.  They want me to be a gate keeper, restricting your access to expensive care.  Can I function without highly trained specialists and expensive tests?  Of course I can.  I practiced in villages in Mexico where I didn’t even have electricity.  Should I return to the era of the GP and practice as your sole provider?  I think not!

You get what you pay for, right?  One of the best investments you can make is getting a second opinion from one of my chosen specialists.  By the way, I choose independent thinkers – doctors who, when necessary, won’t hesitate to disagree with me.  Debate among providers of care is healthy.  Often, there is no definite right or wrong way to accomplish a goal.  Finding the best way to health involves exploring many opinions.

“Knowledge is power” is a central theme of this blog.  Obtaining knowledge can be expensive.  According to me, expensive care leads to better outcomes.  Better outcomes mean better health.  

May you be so blessed as to never know the disease you prevented.

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SCREENING VS. PREVENTION

This blog is all about teaching patients how to care for themselves and interact with their docs.  A common misconception among docs and patients alike is that screening test are synonymous with preventative care.  They are not.

Prevention is something you, the patient, does to lessen the incidence of illness and injury.  Your doctor cannot prevent anything!  I can advise the cyclist to wear a helmet to prevent the consequences of head trauma but, if the cyclist does not wear his helmet, my advice is worthless.  Prevention is, by far, the best of medicine.  Preventing a heart attack by eating properly, exercising regularly and taking prescribed medicine when necessary is far superior to treating the damaged heart after a heart attack.

Screening is something you and I do in order to define what your risk of illness is and what needs preventative measures.  Self-exams are a form of screening.  No matter what any authorities tell you, self-exams are the key to preserving your health.  Physician performed physical exams and testing are key screening techniques used to predict your risk of developing an assortment of ailments.

Screening exams are worthless unless you are committed to doing what is necessary to prevent illness. To summarize, screening for disease is not the same as preventing disease.  Screening is the first step.  The second, and more important step, is enacting a game plan designed to prevent disease.  Your doctor will be happy to give you the advice necessary to enable you to succeed at preventing a host of illnesses.  You need to take his advice to heart and actively work at maintaining your health.  Working as a team, we truly can promote a “healthcare” system that will be worth its weight in gold.

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CHANGE

Sometimes things just fall into place.  Over the last 6 months, I have written on an assortment of topics.  Most of the time, my patients or the news provide me with ample material for future publications.  Last night, while flipping through the TV stations looking for something good to watch, I chanced upon two artists singing “Man In The Mirror” by Ballard and Garret.  For the first time, I actually heard the words and realized how important the message this song delivers is.

I was discussing the importance of the song with my first patient of the day and he introduced me to his morning prayer, “Dear G-d, I have a problem and it’s me!”  The lyrics to “Man in the Mirror” begin with:

“Ooh ooh ooh aah
Gotta make a change
For once in my life
It’s gonna feel real good
Gonna make a difference
Gonna make it right…..”

The chorus goes like this:

“I’m starting with the man in the mirror
I’m asking him to change his ways
And no message could have been any clearer
If you wanna make the world a better place
Take a look at yourself and then make a change, yey
Na na na, na na na, na na na na oh ho”

If we are to fix our broken medical system, we are going to have to make a change!  That change does not start with electronic medical records, with expensive testing and medications, not with visits to the doctor’s office, nor in the vitamin aisle of your local merchant.  That change cannot be legislated by any government nor is it coming from the insurance industry.

The change needs to start with “the man in the mirror.”  As long as people neglect their own bodies, fail to take responsibility for their own health and the health of their families, no amount of medical care or money will suffice.  

“If you wanna make the world a better place”, then for once in your life make a difference, make a change and feel really good.  Look in the mirror and decide that your health is the most important thing you own.  Start small; change something from unhealthy to healthy.  Feel really good about the change.  Then change something else.  Take responsibility for your own health.

Be happy, be healthy.  Then enlist your family, your friends and co-workers in a campaign to make a real change.  Health costs relatively nothing to maintain and a lot to lose!

If you are not sure what needs changing or what’s unhealthy, see your doc.  I’m sure your doc will be glad to assist you in your quest to be a healthy, responsible patient.  If getting healthy means taking medications, take them.  If being healthy means giving up vices, give them up.  In the end, you will be glad you did!

I’ve started with the man in the mirror.  I’m much happier with the man I see in my mirror today.  I have a ways to go.  It’s a long journey but worth it in the end.

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BLEEDING

Bleeding, from any part of the body, is abnormal and demands attention (unless it is from an expected menstrual period).  I am always amazed when I receive a call from a patient who has been bleeding for “awhile”.  The call usually occurs after hours or on weekends.  “Doc, I’m bleeding rectally.  It looks like a lot!  It started last week.”

I don’t know about you but I hate the sight of my own blood pouring out of my body.  The instinct for survival should cause an individual who is bleeding to seek help immediately.  What is amazing is the number of excuses my patients have for ignoring their blood loss.

“I have hemorrhoids.”  “I drank too much alcohol last weekend.”  “I thought it was because I fell down two flights of stairs last week.”  “I have a family history of a bleeding disorder.”  “I have irregular periods and didn’t think much about it.”

Bleeding is abnormal and “I think” is not a good enough answer.  Bleeding demands a definite answer (why) and treatment plan.  In my experience, hemorrhoidal bleeding is the most common cause of bleeding.   Bleeding hemorrhoids rarely cause significant blood loss.  The harm lies in the fact that patients who have hemorrhoids learn to ignore the bleeding.  Patients self treat by using suppositories and over the counter remedies and fail to ever mention their hemorrhoids to their doctors.  No one wants a rectal exam.  While the patient ignores his/her rectal bleeding, the unseen tumor that lies above the hemorrhoid grows silently.  It is a mistake to assume your rectal bleeding is simply a hemorrhoid.  Hemorrhoids are curses that demand yearly follow-up visits and, sometimes, more definitive treatments.

“I drank too much.”  If you are bleeding from the effects of alcohol, you are in big trouble.  Varicose veins of the esophagus from chronic alcohol abuse, tears in the esophagus from retching, and ulcers are all potentially life threatening causes of bleeding.  Please don’t ignore bleeding.

“I fell last week.”  If you fell and injured yourself causing internal bleeding, don’t call me; call 911.  If you cut your hand with a knife, pressure on the wound should stem the flow of blood long enough to get help.  There is no way to put pressure on a bleeding organ.  If you fell and subsequently have bleeding from your stomach or bowel, call 911!

If you have a family history of bleeding problems, seek help before you are bleeding.  There are tests that can help diagnose familial bleeding problems; and, then treatments and precautions can be taken.  Again, do not ignore bleeding.

“My periods are heavier than usual.”  Most women are familiar with their “normal” menstrual flow.  If your bleeding pattern changes and you are suddenly using an excessive number of pads, see your doctor.  Women with heavy “normal” menses may lose enough blood to become anemic.  Treatment may include iron supplements and hormonal manipulation.

Signs of anemia vary.  Often fatigue is the first symptom.  As anemia worsens, pallor (pasty yellow or white skin), shortness of breath, and even chest pain may occur.  Bleeding from the stomach often causes nausea, loss of appetite, and black tarry stools.  A gush of bright red blood rectally should be followed by a call to 911.  Bright red blood on the toilet paper demands a visit to your doctor’s office.

Err on the safe side.  If you are bleeding, see a doc.  If you are bleeding bad, see an emergency room doc.  If your friends are telling you look bad (pale), believe them!  Remember, the life you save may be your own.

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FEVER

Do you really want to treat a fever?  After all, isn’t fever a part of the body’s natural defenses?  The answers to these questions aren’t as clear cut as you may think.  Yes, fever is part of the body’s defenses; but, at times, it can be harmful. 

As with everything in medicine, what to do about fever boils down to the individual situation.  Each and every individual is unique; and each and every time an individual gets sick, his/her illness is unique.  In the old days, there wasn’t much that could be done for a fever.  Actually, many used to “sweat” the illness out by wrapping the infirmed in heavy blankets.  I always thought that Dorothy, in the “Wizard of Oz,” was hallucinating due to fever, her family waiting at her bedside hoping she would recover.

While fever can lead to dehydration, hallucinations, and seizures, most fevers will resolve spontaneously and are harmless.  Fevers up to 101 are generally well tolerated and may actually be helpful.  Since one of the risks of fever is dehydration, patients are advised to stay well-hydrated.  I recommend “sports” drinks for febrile illnesses, as they help replace essential salts often lost due to profuse sweating.  When the body’s core temperature goes up, so does the body’s metabolic rate.  “Sports” drinks are also a good source of carbohydrates.

Fever should be treated aggressively if there are any signs of dehydration.  One of the best ways to judge hydration is by measuring urine output.  In children, diminished urine output (dry diapers) is a potentially threatening sign.  Fever should also be treated aggressively if you have other, concomitant illnesses.  

In addition to hydration, acetaminophen and ibuprofen are the mainstays of treatment.  Ibuprofen can be used every 6 hours and acetaminophen can be used every 4 hours as needed.  Acetaminophen and ibuprofen can be used simultaneously when either product fails to adequately lower the temperature into a safe and comfortable range.  Remember, when treating fever, your target is under 101.

Fever without an obvious cause demands a visit to the doctor’s office.  I believe in erring on the safe side.  It’s better to be seen than be sorry.  Persistent fevers for days also require a visit to your doctor.  Shaking chills are a warning sign!

When bacteria is released into your blood stream (bacteremia), the immune system usually reacts strongly causing shaking chills.  If the bacteria survives your immune system’s response, sepsis (severe blood borne infection) ensues and is a life threatening event.  If you have shaking chills (rigors), see your doctor or go to the emergency room.

Remember, the life you save may be your own.   

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YOUR DOCTOR THE MASTER CHEF

YOUR DOCTOR THE MASTER CHEF

As a doc, I wore lots of hats.  Over the years, I have developed analogies for most of the things I do and for the things I want my patients to do.  Analogies help people conceptualize the complexities of medicine in a way that makes sense.

Not long ago, I had my chef’s hat on.  I was actually treating a young chef and found myself talking about food and medicine.  There is a direct correlation.  My office medicine cabinet is no different than my home spice cabinet.  As each spice has a specific taste and texture and effect on your body, each medication has a different personality and effect.  

Cooking is all about getting just the right mixtures of taste and textures and sensation to put a smile on your face.   No matter how many times you make a recipe, you have to season, then simmer, then taste, then season, then simmer, then taste, then season until you get it right.  Once you’ve gotten it right, you have to let your guests taste your version of what you believe is a perfect recipe.  I make an amazing chili con carne!  At least, I think it is amazing.  If I fed it to ten different people, I might get ten different opinions.  Some may think it is perfect.  Some may complain I use to much chili powder.  Some may complain I do not use enough chili powder.

When I cook with medications, I know exactly what results I am looking for.  When I was treating a case of newly diagnosed hypertension, I would go to my drug closet (spice rack) and pick out my favorite medication (seasoning).  I had made this recipe thousands of times but never for this unique individual.  I picked my favorite spice.  It is my favorite because it is often successful and rarely causes any adverse reactions.  I would send him home on one tablet a day and asked him to see me in 2-3 weeks.  In this case, 2-3 weeks is the simmer phase and the follow up visit is the taste test.  If his blood pressure is controlled and he has no distasteful problems, the recipe is good and I will let him simmer for 3 months before I take another taste.  If his pressure is not controlled or he does not like the recipe, I will adjust the mix by adding or removing medication.  Sometimes the recipe is so bad you have to throw it out and start from scratch.  Eventually, if my patient is compliant and works with me, we can achieve perfection.

As a chef, I take great pride in being the best on the block.  I am very particular when it comes to choosing ingredients, using the best quality available.  I like to taste frequently and adjust spices often in order to find perfection.  When I serve you chili, I don’t mind you adding some chopped onion, cheese or even salt. When I am cooking up a recipe for hypertension, I mind the addition of salt and prefer that you not add any other medications or nutraceuticals without my knowledge.  You know the old adage of too many cooks in the kitchen!

So, the next time you are in your physician’s office, imagine him wearing a chef’s hat.  Decide whether you are willing to settle for a mediocre dish or you want the gourmet version.  If you want perfection, go home and simmer and then follow up and let the chef taste and adjust.  You really should demand the best in your food and your health.  

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