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.

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.

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. 

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.

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. 

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.”

ANXIETY

It’s never too late to learn!  Yesterday, I saw Mr. X.  Mr. X has been seeing me for the past 20 years.  He is in his 70s and has been diagnosed and treated for a major anxiety disorder for as long as I have known him.  Despite the best that my profession has to offer him, the best medicine, counseling and behavior modification techniques, Mr. X continues to be anxious and worry about everything.

“My knee hurts.  Do you think it could be cancer?”  Mr. X has seventy-some year-old knees and they are worn out.  “My shoulder hurts.  Do you think it’s a heart attic?”  Mr. X carried some heavy boxes from the garage to the attack over the weekend.  “I had a headache two days this week.  Am I going to have a stroke?”  Mr. X’s worries have gotten worse over the years.  In retrospect, the harder I try to alleviate his fears, the worse he gets!

It’s never too late to learn!  Yesterday, I had an epiphany.  Mr. X is a professional worrier.  He worries the way some people play golf, shoot pool or play bridge.  He is the Tiger Woods of worry.  Worry is woven into every facet of his life.  It is part of his social being.  In his younger years, he worried about work, paying the bills and his children.  His worries were less threatening.  As he aged and retired, his worries turn inward, focusing on his physical wellbeing.  His worries have become increasingly more threatening over time.  It’s one thing to worry that your painful knee is arthritis; it’s quite something else to worry that your knee pain is cancer.  

My mistake has been trying to take away his worries.  Doctors are trained to alleviate pain and suffering.  When a patient’s knee hurts, we are taught to diagnose the problem, treat it and provide for future care.  When a patient worries excessively, we do the same thing.  We try to remove the worry.  In the case of a professional worrier, when you say, “Don’t worry, it’s not arthritis.  It’s just your age.  It’s just  a minor sprain,” you take away a benign source of worry and open the door to a malignant worry.  “Could it be cancer?”

Live and learn!  I should have told Mr. X he has arthritis.  He would have been much less threatened by arthritis than by cancer.  I’m learning!  I talked to Mr. X about his worrying and his need to focus on less threatening worries.  I suggested that he buy a lottery ticket and worry about whether or not he would win.  I suggested that he should worry about what winning would do to his life.  I suggested other things he could worry about.

Not being a psychologist, I consulted with Dr. Lapporte, one of my colleagues.  Dr. Lapporte is one of the psychologists who has treated my patients for decades.  I wanted to make sure my new treatment approach was valid and safe.  He concurred, stating that “distraction” was a viable approach.  I think I will prescribe more “distraction” in the future.  It’s cheaper with far fewer side effects than medication.

For those of you who are professional worriers, find something harmless to worry about.  “Will it snow today,” is an excellent place to start.  As you become better at choosing less harmful things to worry about, work on developing healthy worries.  “Will I have time to exercise today?”  

Most of all, be happy and healthy!

SMOKERS

In the past, “Medpage Today” featured an article proclaiming that men who smoke at the time of being diagnosed with prostate cancer did not do as well as those who never smoked or quit 10 years earlier.  My first impression was a resounding, DUH!  As those of you who read this column regularly know, smoking is linked to multiple cancers.  Oxygen is a vital molecule and anything that decreases your oxygen intake is going to harm your health.

Smokers don’t get it and I don’t understand them.  There is a mountain of evidence that smoking cigarettes and cigars not only causes cancer and COPD but leads to a host of other illnesses.  Why do people continue to smoke?  Don’t they believe the evidence?  

Do you know any smokers?  Four of my best friends smoke (three guys and a gal)?  The effects are obvious to everyone but them.  It’s frustrating but I can’t help them.  They won’t listen to anyone.  Do you know the frustration I’m talking about?  Perhaps we should start a support group for friends and families of smokers.

Perhaps a support group would serve as a think tank where we could develop novel approaches to helping smokers see the light before they die and see that other light.  My friends tell me they are going to die from something, so it might as well be smoking.  I don’t think it would be so bad if they died suddenly.  I would miss them but could celebrate the life we had together.  Unfortunately, most smokers die slowly, whittled away by COPD or cancer.  It’s agonizing to watch!

If they read this column, they are going to be pissed.  They hate when I nag them.  I’m pissed.  I work hard, seven days a week, to preserve my patients’ health:  they throw it away.  They love those damn cancer sticks more than life itself.  They love their smokes more than they love their children and grandchildren.

Again, I must ask, why are cigarettes legal?  What is wrong with our society and our government that allows us to sanction the slow and purposeful destruction of life?  Until we answer these questions, our children are at risk!  “We owe our children three things: example, example, example.”  Be careful what example you set!

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.

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!