“YOU’VE GOT TO KNOW WHEN TO FOLD THEM”

Can you believe it?  I’m finally out of things to say.  After publishing in excess of 2000 articles, I’ve reached the point where either I have covered all the aspects of medical care or I have a real writer’s block.  I’ve been struggling for weeks trying to come up with informative, entertaining and uplifting articles.  Last night, I asked myself the age-old question, “When is it time to quit?”

In my experience, most humans don’t know when to quit.  One of my most difficult tasks, as a family physician, was taking a patient’s license to drive away.  Men and women, alike, put up a fight.  Often, my patients would become verbally abusive; and, on occasion, they actually became physically threatening.   Many times, they would leave my practice.  Their families were afraid to confront them; and many times, they allowed their loved one to drive against my advice.  On occasion, the results were catastrophic.  I vividly remember one patient’s story.

Mr. V’s memory was bad.  As long as he did not vary from his daily routine, he functioned fairly well but once his routine broke down, he was in trouble.  One summer day I received a call from the Indiana State Police:

Officer – “Dr Segal, do you know Mr. V?”

Dr. Segal – “I certainly do.  He’s been my patient for 20 years.  Is he ok?”

Officer – “He’s fine.  He stopped at the fire station and asked them how to get to your office.  He showed them your card and stated he had a 10 am appointment with you.  It’s 4 pm here.  He’s on the southside of Indianapolis and doesn’t know how he got here.”

When Mr.V’s family told me that he refused to quit driving, I told them to take his keys away and sell the car.  They stated they could not do that to him.  Instead, they had to drive down to Indianapolis to pick him up (and they were the lucky ones).  They were lucky he didn’t die in the middle of a corn field or cause a major accident. They were lucky they didn’t have to go to a morgue to identify his body.

When is it time to quit driving? Work? Sky diving? Climbing ladders? Operating machine tools? There is probably a time when we should quit doing everything, even sex.

So how do we know when it’s time?  Certainly, when loved ones tell us it’s time to quit, we should, at the very least, listen to their advice.  We should weigh the risk of continuing to do what we want to do vs. the benefits of it.  We should assess our impact on others.  Perhaps, we should also discuss our thoughts and decisions with our physician and/or clergy. We should review all of our alternatives carefully.

Ultimately, when to quit whatever is a personal decision as long as it doesn’t adversely affect others’ health and safety. When the health and safety of others are at risk, family and friends have to step up and help their loved one find a way to gracefully and safely quit.  

When I started in practice, taking away someone’s driver’s license was crippling as he/she became isolated and dependent.  In today’s world, Uber can be at your doorsteps in minutes and can take you anywhere.  Finding alternatives to help our aging loved ones as their skill sets diminish and they need to quit is paramount to helping them age gracefully and safely.

So, if someone you love is too old to safely ________(fill in the blank), help them find a way to quit while maintaining their dignity and safety.  If you need to quit ________, don’t be stubborn or prideful.  Don’t refuse help, embrace it.

And by the way, have a sense of humor.  When it’s time for me to quit driving, I’m buying Lisa a chauffer’s hat and vest and sitting in the backseat.  I’ll be the world’s best backseat driver!

Here’s your music.  Kenny Rogers, “Gambler,” sums it up nicely.  “You’ve got to know when to hold them, know when to fold them.” Here’s your joke for today:

 A bus load of Senior citizens was traveling to a casino. Halfway into the trip, a little old lady walked up to the front of the bus and told the driver they had a pervert on the bus.

The driver told her he would check it out at the Casino. So she went back to her seat and sat down. Five minutes later a second little old lady walked to the front of the bus and told the driver they had a pervert on the bus … Since this was the second complaint in five minutes, he thought he had better check it out. He pulled the bus to the side of the road and walked to the back of the bus.

There he found a little baldheaded old man crawling around on his hands and knees. The driver asked, “What the hell are you doing down there?”
The baldheaded man looked up and said, “I lost my toupee and I’m trying to find it. I thought I had it twice, but mine is parted on the side.”

IDEAL OR REAL

I have spent a great deal of time writing about the ideal way to care for yourself and those you love. When I recommend a treatment course, whether it be diet or medicinal, I recommend the ideal approach. When I prescribe a medication, I recommend the ideal brand or generic, whichever is best. 

I recognize that there is often a difference between the ideal and the real. That difference is getting wider every day. The poor economy, the insurance industry, the government and the internet all are having a negative impact on our ability to live up to the ideal. Life, in general, and the practice of medicine have become compromises.

When is it ok to compromise? How much are you willing to compromise? What is the cost of compromise? These are all important questions. It is clear from looking at my parking lot that many of my patients will not compromise on transportation. They drive very safe, very nice cars. The price of those cars is often exorbitant, leading them to compromise elsewhere. Does it make sense to drive a Mercedes and compromise on medical care and treatments?

Case in point:  a Mercedes owner complained that he could not have a procedure because he had a high deductible and the test would be in excess of $2,000. Having the test is ideal; the real is something quite different. In his case, the answer was simple. His Mercedes has every safety feature imaginable and safety was the reason he bought it. He had been in a life threatening accident and wanted the best protection even if it was not truly affordable. The ideal test for his condition is a valuable safety feature for his health. Without it, he may be heading for a major accident. After explaining this to my patient in terms he could relate to, he relented and will find a way to afford the test.Make sure you inform your doctor when the ideal is truly not possible. Be ready to negotiate and compromise. In order to make the safest decision possible, find out why the ideal choice is the best choice. Find out what the risks of compromise are. Compare the financial, physical and emotional costs of both the ideal treatments and the negotiated treatments are and then make the best decision you can. Most importantly, be prepared to live with your decision and its effects on you, your family and friends. 

IT’S JUST A MIGRAINE

I’ve been headache free since retiring.  I used to get migraines as well as headaches from allergies, stress, and lack of sleep.  This morning, I woke up with a headache for the first time in over a year.  I have allergies and I’m certain that my headache is allergy induced and will go away shortly. One of the most common complaints I used to hear was, “Doc, I’ve got a migraine.  Can you prescribe something?  It’s justmy usual migraine!”   

True migraines can be much more than a headache.  As evidenced by Serene  Branson’s episode of gibberish during an on air news report, migraines can simulate a stroke.  What most people don’t know is that migraines can actually cause a stroke.

Over my years in practice, I diagnosed five patients with migraine induced strokes and two of those patients have residual neurologic deficits (loss of function or sensory changes).  Do you have migraines?  There are a multitude of types of headaches, including migraine, tension and chronic daily headaches.  Most people refer to any bad headache as a migraine.  It is important to know what type of headache you have as the treatment and possible consequences of a headache differ depending on cause.

If you are still reading this article, you or a loved one probably have headaches.  Don’t underestimate your headache.  Don’t put off seeing your doctor.  Please don’t learn to live with it or let it control your life.  We have excellent treatments for all types of headaches.  When you see your doctor, he/she will want to know the following things in order to help classify your headache and provide proper treatment options.

  1. How frequent is your headache?
  2. How severe are your headaches on a 1 to 10 scale?
  3. Where in your head are your headaches?
  4. What is the quality of the pain? Piercing? Stabbing? Throbbing?
  5. Describe the onset.  Does it build in intensity?  Is it sudden and severe?
  6. What makes your headache worse?
  7. What makes it better?
  8. Are there associated changes in your ability to think, speak, feel or move parts of your body?
  9.  What have you taken for your headache? 

Treatments for migraines and other headaches are often divided into rescue and preventative modalities.  Rescue medications are designed to help you stop a headache after it has started.  Preventative treatments, sometimes called controllers, are designed to stop the headache prior to its onset.  Obviously, in the case of the newscaster, it would have been better to stop her from losing her ability to speak.

If you have headaches, keep a headache diary.  Learn everything you can about your headache by collecting clues.  Read about headaches on WebMD and other reliable sources.  Once you have collected as much knowledge as you can, see your family doctor.  Let your doctor verify the type of headache and discuss treatment options, both for rescue and control.  Certain types of migraines may require consultation with a specialist and your family doc will help you find the right consultant.

One of the best, patient oriented resources I have ever seen is available online for free.  Dr. L. Robbins is the headache specialist I referred patients to during my years in practice.  His web site is an excellent resource for headache suffers.

Remember, read and learn as much as you can about what ails you so that you can be an effective member of your medical team.  The life/brain you save may be your own.

Here’s your music and a joke to brighten your day.

EXPECTATIONS

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

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

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

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

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

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

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

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

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

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

P.S. – I believe in miracles.  I have been blessed to see many miracles in the last 28 years of practice.  It is ok to have false or “fantasy” expectations, as long as you know that the only way they will come true is to receive a miracle.  It is not OK to sell yourself on false hope as the vast majority of time it will end in disaster.  

INFLUENZA VACCINE

As we live in an unpredictable world, I don’t often make predictions. However, 35 years of practice has taught me that the one thing I can predict is the severity of the local flu season.

The years that I administered my influenza vaccine to large numbers of my patients, we have a mild flu season. The years that I had vaccine left over at the end of October, we have a nasty flu season. Either way, I use up my vaccine.

In the past four years, my patients have gotten vaccinated early and we’ve cruised through the flu season. Will this year be a good year or bad year? In the next month, all of you should get your flu vaccine. Whatever you do, don’t forget the long lines, winding for blocks that accompany a major flu epidemic. Please don’t forget that the flu can kill.

So, get in soon and be proactive, or come in at the last minute and hope and pray that you didn’t wait too late. Good season or bad season, it’s up to you.

Here is your music and a joke. 

My dad told me never to go to a cheap, sleazy, dirty, raunchy strip club, because you’ll see something you really shouldn’t.

So, I went. 
And I saw my dad.

REFILLS

First published on March 20, 2015, this article is the answer to the complaints I’ve heard from many of you since I’ve retired.  It appears that your new docs are stricter than I was when it comes to refills.  Here’s how I felt about refills in 2015:

Please, don’t get mad at me! When I last examined you, I gave you instructions on when to follow up with me. I gave you prescriptions for enough pills to last you until our next visit. I told you to see me before you ran out. Now you are running out and being seen in the office doesn’t fit with your schedule.

Medications are prescribed for very specific reasons. Each medication comes with its own benefits and its own risks. Monitoring your medications for both effectiveness and harmful side effects is my responsibility. You are supposed to be my partner in this endeavor. I need your help!

Making me the bad guy is not in anyone’s best interest. I don’t like holding your refills as hostage to your next visit; but, over the last many years, I have come to the conclusion that putting off your doctor’s visit is a universal human trait. Everything is more important than following up with your doctor!

After all, you feel fine. I’m happy you feel fine. My job is to keep you feeling fine. If the medicine I prescribed for you is injuring your liver, there are two ways of finding the problem. My preferred method is to monitor you for liver injury on an appropriate schedule. The second way is to wait for you to turn yellow. Appropriate follow up and monitoring of potential side effects makes more sense than treating rare but serious side effects, doesn’t it?

Unfortunately, the electronic medical record and the “portal” make it too easy to dodge your follow up visit. Sending me an electronic request for a refill or having the pharmacy contact my office for a refill means never having to talk to my staff or your doc. In the end, you get mad at me. Your expectation is I will refill your medication without question, and you will eventually see me.

While I’d like to be your friend and play the role of the good guy, I have to be your doc. I have to make sure any treatment I give you is as safe and effective as I can make it and that means seeing you for appropriate follow up.

My recommendation is that you take an empty bottle of your medication and put 2 week’s worth of pills in the bottle and put it in your medicine cabinet. When you are down to your last 2 weeks of pills, it’s time to come in. Pretty simple, huh? Help me help you. The life we save may be your own!

Here’s your music for the day and a joke.

WHAT IF?

During the next few weeks, many of my Jewish family and friends will be busy preparing for the holidays, excited to be with family and friends, looking forward to the New Year.  The New Year brings many things, starting with the New Year’s resolutions.  While most of us look forward to a new beginning, hopeful that things will be better, many spend time pondering about the past and saying “what if?” and “if only I had”.

Thirty five years in practice has taught me that ruminating on the past and the “what if” question and the “if only I had” reply, is detrimental to your health.  After all, you cannot change the past.  While you are busy regretting past errors, you may be missing future opportunity.  A friend once told me that one of the most important moments in her life was when I helped her through a moment of self-doubt and self-recrimination.  She had made a decision many years ago that had long term consequences for her child’s health.  At the time she made that decision, it was the right decision.  Many years later, it was still the right decision, but when viewed through the “retrospectascope”, could be questioned.

All of us are called on to make decisions on a daily basis. As individuals and parents, who do not have a crystal ball with which to look into the future, we make the best decision we can.  All of us, when looking back in time through the “retrospectascope”, realize that some of those decisions turned out to be wrong, some foolish, and some absurd.  What is critical is to remember they were right at the time we made them.  

When you make a decision that affects you or a love one, take the time to gather as much knowledge as you can.  Follow your heart and your mind!  Give pause, then decide and carry out that decision with great care.  Later, if the decision turns out to be the wrong choice, live with it.  Learn from it.  Do not do the “what ifs”.  “What ifs” serve no purpose.  They lead to self-doubt, anxiety and depression.  They make you less capable and, therefore, more likely to err in the future.  Residing too long in the past steals your future.  Look forward to the future and all of its possibilities.

Here’s your music and a joke.

I bought some shoes from a drug dealer. I don’t know what he laced them with, but I’ve been tripping all day.

PROFESSION OR BUSINESS

First published in 2013, this article continues to be true.  Unfortunately, my cronies are retiring, and the private practice of medicine is dying.  Admittedly, I sold out in 2018 and went to work for a large hospital corporation.  I really had no choice.   As a private practice of medicine, I could no longer get reasonable contracts from the insurers and therefore could not survive financially.  My employer recognized my physical limitations and treated me well; however, the writing on the wall was clear. I would need to pick up the pace, see more patients per hour and satisfy the computers lust for data if I was to stay employed. 

July 2013 

Is medicine a profession or is it a business?  To us old timers, medicine is first and foremost a profession; a calling.  As such, the business of medicine has always come second.  Unfortunately, neglecting the business side of medicine has led to my profession’s downfall.

Fast forward to current times.  Medicine has become big business.  Companies such as Walgreens have led the charge.  Obamacare has led to the creation of Accredited Care Organizations owned by corporate entities and poised to suck every available penny out of my once proud profession.  Physicians, Nurse Practitioners and Physician Assistants have become corporate America’s service technicians and patients have become cost centers to be controlled and serviced in mass.

What’s behind the changes in medicine?  Profits!  America’s leading healthcare companies have figured out the business end of medicine and are going at the business full gun.  Pharmacies are now doing acute and chronic care in their Quickie Clinics.  Does anyone see a problem here?  I certainly do!

In past articles, I have written about the ethics of selling cigarettes in a facility that administers care and medication to sick smokers.  Corporate America has taken greed to a whole new level.  Apparently, it is OK to help someone develop chronic obstructive lung disease and then treat him for his chronic illness for the remainder of his life.  

The treatment of chronic diseases entails more than just writing a prescription. It entails helping the patient develop healthy lifestyles.  Will the store front practitioner who is treating a patient for diabetes walk her through the store and show her everything she shouldn’t buy or will the sale on large bags of Reese’s Pieces catch the patient’s eye and will he/she end up with several bags of the sugary delight in their cart?   Will the three 12 packs of Coke for $9 sale be the diabetic shopper’s reward for purchasing his/her healthcare at such a convenient location?

Will the store front practitioner walk the hypertensive safely out of the store avoiding the racks of salt-laden chips and pretzels?  I think not!  Instead, the store designers will continue to set up food gauntlets designed to lead the customer to the most profitable products and fill the corporation’s coffers.

The business of medicine is the end of medicine as us old timers know it.  Ethics and morals will change and it will become completely ethical to sell an obese individual a diet pill, a six pack of Millers, chips, pretzels and candy.   If you can sell cancer sticks in a place of health, hell, you can do anything!

TELEMEDS

First posted August 31, 2013, this article, like everything else, has changed radically since the onset of COVID.  (My current mindset can be found between the parenthesis.)

Would you hire a painter and ask him to paint your house blindfolded?  Would you call your auto mechanic and ask him to repair your car over the phone?  Would you ask your attorney to draw up your will without sitting down with him and discussing your needs?  Of course not! (However, you might ask a doctor to treat you over the phone.)

So, why would you call your doc and ask him/her to treat your body over the phone?  There are reasons:

  • “I’m too busy.”
  • “I’m too sick.”
  • “I don’t have the money.”
  • “The wait’s too long.” 
  • (“I’m afraid to be around other people who might give me Covid.)

These are among my favorites!

“But, doc, it’s just a cold!  I don’t have time to come in.  The last time you gave me the Z-pack.  I promise I’ll come in if I don’t get better.”

Mr. C’s cold turned out to be heart failure.  Yes, Mr. C has a cough and congestion.  He also had swollen legs, a cough that worsened when he laid down and an EKG that suggested that Mr. C had suffered a recent heart attack.  Caring for Mr. C over the phone may well have been a fatal mistake. 

Mr. C was too busy to come in.  He had lots to do around the house and was having trouble finding time to do it all.  He also was not very productive as he was short of breath and weak. His heart was having trouble supporting any physical activity.

Mr. C was too sick to come in.  He didn’t know how right he was!  When you are too sick to be seen, you really need to be seen.  If you are too sick to come in, it may be time to call the paramedics.  

Mr. C didn’t have the money to pay his co-pay.  Mr. C drinks a lot.  His congestive heart failure is the result of too much alcohol.  At the price of a fifth a day, it’s no wonder he can’t afford to see the doc.

And yes, the wait is too long.  Mr. C called the office to get his Z-pack.  The front desk had to answer that call and take a message.  The message had to be routed to a nurse who then called Mr. C to tell him to come in.  The front desk had already told him to come in and he had ignored them, asking to talk to the doc.  Mr. C ignored the nurse’s advice, telling her he was sure that “Stu” would take care of him. For some reason, patients think calling me “Stu” infers that they are my personal friend.   My friends don’t call me “Stu.”

Ultimately, I had to call Mr. C.  By the time I called Mr. C, it was too late for him to be seen.  I told him to go to the emergency room.  He ignored me and showed up the next day.  Shortly after being seen, the paramedics picked up Mr. C.  His wait time was short.  Everyone else’s wait time was excessive.

Not only is phone medicine potentially harmful, (Still true, but practicing medicine can be harmful) it is very time consuming.  With the bad economy, patients are trying to avoid coming in to be seen in ever increasing numbers.  Patients are putting off rechecks and instead asking for refills over the phone.  Today, I had 40 refill requests and 20 phone requests for care (I’m sure it’s the same or worst today).  Some of those patients desperately needed to be seen.  

So, what’s a doc to do?  My practice is designed so that my patients can come in when it fits their schedules.  Yes, some days the wait may be an hour or more, but your needs will be attended to.  I see patients six days a week.  In return, I try hard not to treat my patients over the phone.  When my front desk tells you to come in, please don’t ignore them.  When my nurses tell you to come in, you can be sure you need to. (My front desk exists only in my dreams.  I hated making sick people wait, but I would rather they wait than having to cut patient’s visits short.)

Your doctor needs your help. Work together to provide the best care possible.

Here’s your music and a joke.

Having sex in an elevator is wrong, on so many levels.

FORD CRESTLINER

I once 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 69 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!