Category: Uncategorized

October 17, 2019

Did you ever get the feeling that you were supposed to do something for someone, but you didn’t know what you were supposed to do or for whom?  I have.  In the past, solving this mystery was easy.  I was in the office 6 days a week and all I needed to do was sit and wait for that “someone” who needed special help to come in.

Now, it’s not so easy.  Last night I went to dinner with friends.  We were lucky, the waiter that we really like, had our table.  He’s remarkably good, entertaining and jovial.  Last night, he appeared to be dragging a little.

Yesterday, I published “Epiphany” and discussed how seemingly random events came together to give me a clear picture of something I had been pondering for a while.  Well, it happened again last night.  Two of my former patients (really, I consider them extended family) came over to say hi while the waiter was at the table.  Paul (I changed his name for confidentiality sake) recounted how I had saved/prolonged his life and thanked me for my care.

After Paul and his wife left, the waiter (Ron) confided in me that he was sick.   Apparently, he had been sick for a while and whatever he had was bad.  He’s under a doctor’s care and take lots of medicine.  He further stated that he usually is off Thursdays and that his change of shifts must have been fate! 

I explained that I also was on a ton of meds and chronically ill and, not wanting to delve further into his problems, gave him instructions on how to get to this blog.  I told him I blog in hopes of helping my former patients and others navigate through the complex world of medicine and illness.

If he is right and fate put my friends, wife and waiter together with a purpose, then somewhere in my prior articles or future articles, I’m supposed to provide him with the knowledge or support he needs. 

So, if you are out there and have a need, read on or leave a comment and I’ll respond.  If there is a topic you are interested in, let me know and I’ll try to address it.

Sometimes things just come together and paint an undeniable picture that you had never seen before.  Yesterday, after posting my blog about physician burnout and suicide, I read an article on KevinMd that mentions the switch from pay per service to a quality-based payment system.  When I finished reviewing Kevin’s daily articles, I came across an expose on Bit coins and how they function.  These seemingly unrelated articles started me thinking and led to an epiphany.

What became crystal clear was that my generation is responsible for the demise of the medical profession.  I helped kill the thing I loved, my calling.  Let me explain.

“Value is in the eyes of the beholder.”  When you are clothes shopping and find a shirt you love, you buy it.  Yep, you go to the cashier, pull out cash or a credit card and, having paid take your new shirt home.  Can you imagine going to the cashier and telling her/him that you left your wallet at home and you would pay for the shirt later or that your insurance company would pay a discounted amount if you send the bill to them? Of course not.  The store functions on a fee for service basis.  The store sets the price and you decide if the shirt is worth it.

Can you imagine pulling up to the gas pump and filling your car’s tank to the brim, then driving off without paying?  Or eating a meal at your favorite restaurant and skipping out on the bill with your leftovers and a bottle of wine?  Of course not! You would be arrested!

“But judge, I would have eventually paid for those services.”

“They should have sent the bill to my insurance first.”

“It’s only $10 dollars.”

“I never got a bill.”

My staff has heard it all.  If the clothes store, gas station or restaurant were run the way the medical system in this country is run, they would all fail.  Not only would the businesses fail, but the people who owned and managed them would suffer from burnout and their suicide rate would rise.

So, how did my generation kill the medical profession I love?  It’s all about setting a “value” on an item.  When I started in medicine, physicians and patients set a high value on their relationship and practice.  Some placed physicians on a pedestal.  It was a fee-for-service relationship much like in the examples of the retail world above.  I set the fee, the patient decided if seeing me was worth it (my value) and paid on the way out the door.  If patients had insurance, they would submit a claim and be reimbursed according to the policy limits.  Billing expenses were minimal, and my wife handled the paperwork and billing herself.

At some, my cronies and I fell into a trap.  We allowed the insurance company to insinuate itself between the patient and the physician.  We no longer set our value, the insurer and government did. Over the years, we have lost much of our value, not because the patients no longer valued us, but because the insurer/government/middleman took over and devalued us.  The more the insurer devalued and controlled us, the more profit they made; or, in the case of the government, the less they spent.  The more the insurers and Medicare took over, the more office expenses increased.  At the end, I had two nurses and four full time individuals in the billing department.  My income went down and my patients’ cost went up as did the insurers’ profit and control.

Had we stood our ground years ago, we would not be in the sorry state we are in now.  We find ourselves at another critical intersection.  If, as a profession, we don’t take a stand against a “value” based system, we will finish the job started years ago: the complete destruction and further devaluation of the medical profession.

Remember that if you do not set your own “value,” the insurers and Medicare will, and I guarantee you that what you and I deem valuable will not be what they deem valuable.  A “valued” physician will most likely be a physician who checks every box on the electronic medical record, provides the least expensive care while following the insurer or Medicare’s protocols and avoids unwarranted treatment courses that involve thinking, tests and referrals. 

In other words, a “valued” physician will hate his/her job, be burned out and at increased risk of suicide.  What a pity.

Would it surprise you if I told you that physician suicide is at an all time high?  Would it surprise you to find out that, by profession, more suicides occur among physicians than any other profession?  Not only should it surprise you, it should outrage you!  

When I was 13 years old, I told my physician that I was going to be his partner.  Dr Perlman told me that the medical field was changing, and I should entertain other professions.  When I was 18 and going to college, I again told Dr P. that I would be joining him in practice and he again warned me of the changes which were coming.

At 21, I called my doc to inform him that I’d be going to medical school and that I would be specializing in Family Medicine and joining him in the not to distant future.  Again, he warned me, telling me the changes he saw coming were bad. 

Unfortunately, he got sick before I graduated and had to sell his practice.  Sound familiar?  Dr Perlman was a visionary and his vision unfortunately was accurate.  My profession has gone to hell.  Not long ago, I asked myself why I failed to heed his warnings.  The answer was obvious.

For me, medicine was a calling.  One I had to answer.  Now, 40 years later, if your child asked me what I thought about her/him going into medicine, I would answer a resounding yes.  I would also repeat Dr. Perlman’s warning that medicine as I knew it has changed radically and not for the better.  What has not changed is the need for doctors who answer the call and care for those lives who have chosen to ask for help.

Since publishing “Sorry,” I have experienced an outpouring of love and respect from those who I cared for over the years.  The stories they tell, the thanks they give have been heartwarming.   I have cried, laughed and smiled knowing that medicine is truly a calling and now my patients are answering my call, a call for understanding as I exit their lives to care for mine.

Doctors need to learn or be taught how to take care for themselves as well as their patients.  I would love to teach this concept in medical school.  Perhaps, doctors should learn how to be patients prior to practicing medicine. I now know what it is like to be a patient and the view from this side of the exam room is radically different from what I learned in medical school and residency.

Yes, residency is barbaric.  If it were not for teachers like Drs. Edward Lack, Ken Miller, and William Arnold, I would not have made it through my residency.  The reality of the practice of medicine is, after residency, it is even more daunting.  Daily you hold your patients’ lives in your hands while having the government and insurance companies suck the life out of you with their electronic medical record demands, paperwork requirements and redundant requests for information already supplied.  

Unfortunately, the insurance industry will insinuate itself between you and your patient.  Yes, dealing with them will drain your energy, but know this:  if you and your patient team up and work as one, you will win the majority of the battles; and when you lose, you’ll know that you did the best you could. So will your patient.

You will lose patients and you will mourn their loss.  It is the nature of medicine.  And you will make mistakes, you are only human.  Forgive yourself, learn and move on.  If the pain of loss becomes too great to endure, follow the advice you would give a patient, quietly get counseling.  Write about your feelings and share them with other physicians and patients.  If necessary, do so anonymously.

Believe it or not, state medical boards will punish physicians for seeking counseling.  Isn’t that insane?  Insane, yes, but not a reason to commit suicide.  Letting your fellow physicians care for you during your time of need will help restore you.

The most powerful tool available for restoring a physician’s soul is hearing from her/his patients.  The letters and calls I’ve received have been incredible.  Perhaps, telling your physician how you feel while she/he is still caring for you would go a long way to reducing physician burnout and suicide.

Live wellthy.  Take care of yourself and others, and don’t give up!    

WEDDING VOWS

“I, ___, take thee, ___, to be my wedded husband/wife, to have and to hold, from this day forward, for better, for worse, for richer, for poorer, in sickness and in health, to love and to cherish, till death do us part, according to God’s holy ordinance; and thereto I pledge thee my faith [or] pledge myself to you.”

Wedding vows can be traced back to the 1500s.  Whoever wrote the original version of the traditional vows printed above must have been clairvoyant.   If he/she was not clairvoyant, he/she was smart enough to recognize that no matter who you were or who you married, crap was coming your way.

Yes, there would be good times and good health but eventually there’s going to be sickness followed by death.  We are forewarned on our marriage night and commit to sticking around through the crap to come.

By now you’re probably wondering where I’m going with this morose ideation.  Most people who live with a disability or chronic illness will eventually feel like they are a burden.  I can tell you it’s a horrible thought and not easy to dispel.

Imagine that you’ve been married 40 years and finally reached the point where your wife has to wipe your butt.  Sounds horrible?  It is! In many instances, it’s a reality.  Imagine you can’t take the trash out, shop for anything, dress yourself …. Yep, it happens and even the medieval author of the standard wedding vows recognized what was coming.

Let me ask you a question.  Was changing your baby’s diaper a burden?  Was shopping for baby food, clothes, furniture, highchair, … a burden.  NO!  Of course not!  Caring for your beloved baby was a privilege and joy.  You signed on for the task of raising your child at conception and you pretty much knew what was coming.

Caring for your beloved spouse, family member or aging friend is no different than caring for your baby.  Should your baby feel like a burden?  No, he/she should feel loved.  Remember this if you should become ill and disabled.

Hopefully, you’ve had many years of health and joy before falling into illness.  Use those memories to help you through the myriad of negative and maladaptive thoughts that will race through your head.

Also know that we live in technologically advanced times.  Bidets are affordable and can clean your butt for you.  There are a host of adaptive tools that will allow you to do things that once were done by healthcare aids.  There are “sock assists” that help you put your own socks on.  I have what I refer to as the ghost dog collar that helps me lift and cross my legs.  I have a dressing stick that assists in putting on my pants.  The list of home assistive devices is long and easy to find on Amazon.

As for me, I’ve been through the “burden” phase and do everything I can do independently, and then some.  Renee held my hand through the self-pity phase and pointed to the marriage vows, the good years we’ve had and the good years to come.   She has also stepped up big time in assuming the chores I can no longer do.

For those of you just entering the “I don’t want to be a burden stage,” you won’t as long as you do the best you can do, go to therapy as ordered and recognize that your spouse’s life has changed as much as yours.  Don’t forget to help and support them.

Why do we trust some pills and not others?  The answer often eludes me.  Patient “A” is quick to remind me that he does not want to take any medications.  His chart reveals that he is taking a multivitamin, Echinacea, Benadryl, saw palmetto, and Sam-E.  Aren’t they pills?   

According to the dictionary, a medication is defined as, “a drug used to treat an illness.”  My patient is treating his depression with Sam-E and his prostate with saw palmetto, despite the fact that he does not want to take “a medication.”  He is treating his poor dietary habits with multivitamins.  He is taking Echinacea on a daily basis to ward off colds and isn’t aware of the fact that Echinacea is a ragweed, something he is highly allergic to.  He is taking Benadryl to treat the side effects of his Echinacea.  For a man who does not want to take any medications, he is heavily medicated with over the counter garbage.

Why do we trust some pills and not others?  The F.D.A. regulates prescription medications.  The government requires strict adherence to F.D.A. standards requiring certification of a host of factors.  First and foremost, a prescription medication must be proven to be effective and safe.  Secondly, studies must be done to identify potential side effects, contraindications, and interactions with other medications.  Third and foremost, all company literature or advertisements about a medication must show a fair balance of information:  if you mention a positive, you must mention a negative.

Over the counter nutraceuticals are not regulated.  As long as they make no claim of treating any disease, they can say anything they want about themselves.  They are not required to show effectiveness, side effects, drug interactions nor contraindications because, officially, they don’t treat anything!  According to one internet site, Sam-e “promotes a healthy mood” a “revitalized mood”.  The site goes on to state, “These statements have not been evaluated by the Food and Drug Administration.” With regard to side effects, the site states, “Generally speaking, SAM-e supplements have been shown to be very safe, with no known side effects.”  What does “generally speaking” mean?  What are the possible side effects?  The site dodges this question.

The unknowing public is caught in the middle.  On the one hand, the doctor tells his patient to take a medication for his depression that comes with a three page list of possible side effects; and, on the other, the internet tells him that Sam-e will “promote a healthy mood” and “generally speaking” is very safe.  It’s no wonder the public doesn’t want to take medication but is willing to take lots of unproven, under studied, non-regulated pills and potions.

Why do people claim that their over-the-counter pills work so well?  Many neutriceuticals actually are medications with active ingredients.  Many simply deliver a placebo effect.  I like placebos; they are safe and, in some studies, show effects, both positive and negative, in a large percentage of people.  I worry about neutriceuticals that have active ingredients.  How will they react with my medications?  What are the unknown possible side effects that I should be monitoring?  How are they processed by the body?  What do I do if my patient overdoses on neutriceuticals?  Will my patient admit to taking them?

In the case of my patient on Echinacea, he is actually making himself sick.  He is allergic to the product he is taking and doesn’t know it!  In addition, Echinacea, when taken on a daily basis, may damage the immune system.  Many studies have found that Echinacea is ineffective at preventing or treating the common cold, yet it is marketed heavily (http://nccam.nih.gov/health/echinacea/) for the treatment of a variety of symptoms. 

Why do we trust some pills and not others?  The answer is easy; it is all in the marketing!  Snake oil salesmen have been successful throughout history.  Be skeptical of products that make fantastic claims.  Look for the following disclaimer, “These statements have not been evaluated by the Food and Drug Administration.”  Essentially, the merchandiser is telling you that his product is unproven and not approved to prevent or treat any disease state.  While I am not a fan of government intervention, someone has to independently assure the effectiveness, safety, and quality of anything you ingest.  That assurance cannot come from the company that is selling it to you.  The F.D.A. needs to step in and regulate the neutriceutical industry the same as pharmaceutical industry. Comparing apples to apples would certainly make deciding what is best for you a lot easier.  Forcing the neutriceutical companies to perform under the same standards as the pharmaceutical companies would result in the elimination of false claims and the unmasking of the snake oil salesmen who prey on the unsuspecting. 

October 4, 2019

I’m dumbfounded.  I’ve spent a lifetime pouring over medical journals and text, working at staying on the cutting edge of medicine.  Little did I know that much of what I needed to learn existed on YouTube (for free). 

This morning I came across a TEDx lecture by Tim Hague Sr. on the effects of Parkinson’s.  Mr. Hague, a nurse, developed early onset Parkinson’s.  His presentation is both scary, uplifting, moving and inspiring.

Tim and his son won the Canadian version of “The Amazing Race.”  He credits Parkinson’s for getting him the interview and subsequent casting call for the show.  In essence, he won the race because of and despite having Parkinson’s.

Mr. Hague raises the following question, “How do you relate to a new best friend that you hate?”  His new best friend is his Parkinson’s.  Parkinson’s becomes an ever-present part of your life.  It’s the guest that comes for dinner one night and refuses to leave.  It’s the guest that goes room to room through your house, trashing everything it comes in contact with. And, yes, it’s the guest that ultimately takes your life.

Mr. Hague’s answer is simple.  You “introduce friend Parkinson’s to friend Perseverance.”  According to Merriam-Webster, perserverance means “persist in a state, enterprise, or undertaking in spite of counterinfluences, opposition, or discouragement.” Mr. Hague adds the following: “with little or no evidence of success.”  

You get the point.  Friend “Perseverance” is a very important friend to have on your side in the fight against any chronic disease, especially one like Parkinson’s.  While I write about my Parkinson’s, please know that there are many disease names I could substitute in place of the name Parkinson’s that would have the same impact on an individual as Parkinson’s has on me.

What’s important is that learning how others survive with a “best friend they hate” can only help me (and you) persevere in finding the good in the midst of a swamp full of bad and YouTube is a good place to listen to the plight of others. Please share this blog with others.

On a regular basis, someone asks me, “Can I be perfectly honest with you?” I wanted to reply, “No, just be dishonest, I like it better that way!” “Can I be . . .” implies that, in past conversations, my patient has been dishonest. Dishonesty is a relationship breaker. Dishonesty leads to distrust and if I cannot trust what a patient is telling me, I cannot be effective; the doctor-patient relationship is terminated.

Am I being too harsh? Are there degrees of dishonesty that are acceptable? While there may be a place in the real world for partial truths and degrees of honesty, there is no room for dishonesty in the exam room. In June of 2011, I published “Three Things,” an article about the importance of being honest with your doctor and being honest with yourself. When surveyed about the three most important things a doctor can tell his/her patients, the most common theme was to be honest. Don’t lie.

Patients have their own reasons for hiding the truth. There are many reasons patients exercise various degrees of honesty. Some patients feel their actions make them look foolish; some fear the doctor’s scorn, some fear the answer to their problem will be too much for them, others are simply embarrassed. Sometimes, patients are in denial.  No matter what the reason, the doctor-patient relationship should be a partnership based on mutual trust and respect. In a relationship of trust and respect, there is no place for dishonesty.

Unfortunately, it’s a two-way street. There are times when I want to be less than totally honest. There are times when I want to “soft sell” the truth, knowing that the truth is going to hurt. After all, my job is to heal, not to hurt. Nonetheless, if I shelter my patient from the truth or mislead him, I break the relationship of trust and respect.

There are other times when family members ask me to spare their loved one the horrors of a bad truth. They want to lessen their loved one’s (my patient’s) pain and suffering. Telling the truth, the whole truth, can be a real problem. 

So, what to do? Risk the relationship of mutual trust and respect to spare someone pain? Then what happens when your patient needs honesty and discovers your deceit? It’s not an easy choice.

We are all humans, striving for the impossible goal of being perfect. The doctor-patient relationship is as imperfect as the two people who make up that relationship. Each has to recognize the other’s imperfection. Each has to strive to be “perfectly honest”. Each person has to realize how difficult it is to be “perfectly honest”, and that honesty can save a life, can take a life,  and can hurt!

I have chosen the path of seemingly brutal honesty, pulling no punches, for the vast majority of my career. I think people deserve the truth and that my job is to preserve the trust in the doctor patient relationship. There have been times when I have regretted that choice.

I hope my patients will choose the honest approach, no matter how difficult that choice. I hope they will understand how important knowing what is truly happening to them is and how the truth will ultimately impact their diagnosis and the success of treatments. I hope they recognize that the life they save may be their own!

I also hope that they will forgive me when I tell them what they didn’t want to hear, what hurts.  One last thing, think about what you want your doc to do and then inform him/her of your choice.

I’M SORRY

I read a very sad article on KevinMD today.  The author recounted how he had lost the love for medicine and the many ways he was sorry.  The article hit me as if I had taken a shotgun blast to the chest at close quarters.  For truly, I’m sorry!

I’m sorry I had to give up my practice of medicine.  I never lost my love for practicing medicine, but I had to leave my love behind.  Parkinson’s does horrible things to its victims.  It slowly, progressively diminishes its victim’s physical capabilities. 

I have “off” periods.  They are often spontaneous, and I literally freeze, have trouble walking or shuffle until I’m “on” again.  Then there is the fatigue, (whether from the disease or from the medication), that hits hard and stays for a while.  Naps have become frequent and non-refreshing.  My sleep sucks.  When the medicine wears off, my body stiffens and the pain sets in.

Add a heavy dose of degenerative disc disease, its resultant pain and practicing medicine is no longer possible.  I’M VERY SORRY!  I know many of you are lost.  You’ve told me of the many problems you are having.  I understand your frustration.  I’m sorry for your frustration.  You’ve told me how angry you are when you can’t get your meds refilled.  You’ve told me there are no physicians like me.  I’m sorry. 

Your new physician is not me.  They don’t know you or me.  They don’t know whether to trust my notes.  They may not understand your treatment regimen. They are going to want to see you.  I’m sorry.  You need to get to know your new physician and he/she needs to get to know you.  I’m sorry I can’t be there to care for you.

In most of the spy novels I read, the hero gets caught and tortured.  The villain wants to break the hero and force him/her to their knees.  The hero almost always says, “Do your worst, you’ll never break me.”  Unfortunately, I’m no hero and my captor has done its worst.  It stopped me from taking care of you and your healthcare needs.  It broke me.

I’M SORRY!!

Many of my patients use the internet to seek information about their health, diagnoses of illnesses and treatment options.  While the internet is an excellent source of valuable information, it is also full of garbage.  The garbage comes wrapped in pseudoscience, is sold as “doctor recommended” and is capable of doing great harm.  Sorting through the heaps of material is difficult, even for a trained physician.   What is real science and what is hype?  Sometimes, I don’t know!  During the last 35 years, I have seen the best of my science proven wrong.  So how does a lay person interpret the data delivered by Google and Bing?

There is no easy answer.  While discussing how to sift through the mountains of data you need to process to be a truly informed patient is beyond the scope of this article, learning the difference between a possible problem and a probable problem may be very helpful.

In the medical world, we believe in informed consent.  Informed consent means we tell you every possible consequence of taking a medication.  Ever listen to a pharmaceutical commercial on TV?  Product XYZ is touted as good for your heart and brain but may cause explosive diarrhea, excessive bad breath, uncontrollable flatus (farting) and a myriad of other things, including death.  After listening to one of these commercials, no sane person would want to take XYZ.  You can thank the lawyers for the absurdity of the disclaimer.

If the auto industry was required to advertise under the same rules as the pharmaceutical industry, car XYZ would be sold as fast and sexy with all the bells and whistles.  The disclaimer would remind the audience of national automotive safety statistics, stating car XYZ may cause death, dismemberment and a myriad of other horrific injuries we all know exist but ignore.  If a pharmaceutical company went to the FDA with a product that cured cancer but had the risk factors of a car, I doubt the FDA would approve it.

Anything is possible.  What is important is the probability that a possible side effect is going to injure you!  If XYZ causes uncontrollable flatus in 90% of people, taking it would be absurd.  If XYZ causes uncontrollable flatus in <1% of people, it is insignificant.  So, before you decide not to take the medication your doctor prescribes because of something you read on the warnings stapled to the package at the pharmacy, ask your doctor about the probability of your getting a side effect.  In general, if there are known side effects of significance, your doctor is going to warn you before giving you the prescription.

The following is a real telephone conversation:

“Dr. Segal, this is Mr. Z.  I’m mad at you!  I want you to know I found the reason I have had so many colds this year!”

“I’m sorry you are mad at me!  What do you think is causing your colds, Mr. Z?”

“The damn medicine you are giving me for my blood pressure.  According to the PDR, 32% of people taking product X get frequent colds!!!”

“Mr. Z, could you look at what the percent of people who got frequent colds while taking a placebo is?”  Dr. Segal asked.

“What’s a placebo?” replied Mr. Z.

“A placebo is a fake pill, it contains no active ingredient.”  Dr. Segal answered.

Mr. Z went back to the PDR, and called back a second time.  “Thirty six percent of people on the “no active ingredient” pill got frequent colds.”

“Wow, Mr. Z, if 36 % of people taking a placebo got colds and only 32% of people on product X got colds, then product X decreases the chances of you getting a cold.  Maybe the reason you get frequent colds is your smoking!  It may also be the reason you have high blood pressure and are on product X.”

Remember, what is important is the probability of getting a possible side effect.  Also, remember that “placebos” have side effects and risk!

“How do you feel?”  One of the most frequent questions I get is, “How do you feel?”  While the person asking the question is sincere in caring about how I feel, I get the impression that most of the time they want a simple “fine.”   Dealing with how I feel, or any other sick person’s feeling, can be depressing, especially if they haven’t been fine in a long time.

Dealing with “fine” is much easier, uplifting, and allows the individual asking the question to move on, confident that they showed their concerned and caring nature.  I know I’m being hard on a group of individuals who appear to be sincere but really aren’t.  Often, they have their own problems that are wearing them down and they really can’t handle any additional burden.

“Fine” is not a good answer if you really aren’t fine.  Lying to yourself and others often has real consequences, most of which turnout to be negative.  “Fine” cuts off your ability to get help from your family and friends.  “Fine” means that your abilities or disabilities will be misjudged.  “Fine” is a term that socially and mentally isolates the chronically ill patient.

So, what do you answer when someone asks, “How do you feel?”  I answer with a question of my own, “Do you really want to know?”  I don’t listen to what they say in response to my question.  I look at the expression on their face.  If they can take it, I let them know I feel like crap.  If they genuinely want to help, I tell them what crap feels like. 

If they are asking to be polite or proper, “I’M FINE” is just fine.  

One phenomenon of aging is that the vast majority of my social circle is not fine!  These days everyone I know is dealing with something.   The first 10 minutes of most social encounters consists of sharing how crappy we really are.  Now that I’ve put my thoughts on paper, maybe we should just say we are “fine” and move on.  Confusing?  What do you say when someone asks you how you are?

One last thought.  When I feel lousy, haven’t shaved nor showered in 48 hours,  have stains on my shirt and have obviously crossed into the blimp zone (if I get any larger the postal service may assign me my own zip code), don’t tell me, “You look great.”  If you think I look great, you either need an eye exam, to see a psychiatrist or are just full of sh.t.