SMILES

Yesterday was a lousy day. My trip to Tennessee to visit my brother was at its end.  He is recovering from a stroke and I hated to leave him.  I also hate going to the airport (I used to love flying the friendly sky) as there are always delayed flights which leads to angry people. Angry passengers mean tension and stressed filled hours in the waiting area and on the plane.

In fact, the early flight to Chicago was delayed 2 hours and they had room for Renee and I.  I was hesitant to switch flights as I was in no mood to deal with others’ frustration and anger.  Nonetheless, we switched.  Sitting at the gate I realized, to my amazement, that there were no angry, complaining passengers.  If they had spiked Kool-Aid, I wanted some.

So, why weren’t people angry, frustrated, acting out and pumping up their blood pressure as usual?  The answer became obvious when I noted that the flight attendants, M.W. and B.H., were smiling.  Both had disarming smiles.  It’s hard to have a bad day when someone is smiling at you, engaging you while sincerely apologizing to you and keeping you updated on conditions. 

Once on the plane I looked around the cabin and found lots of smiling passengers. Apparently, smiles really are contagious and the flight crew had infected everyone.  So, what does this have to do with health?

In my case, they helped alleviate some of the sadness I was feeling as I left my brother to head home.  My depressed mood was lighter and my anxiety about being in a tin can with angry individuals vanished.

I have been a doc for 40 years and the one thing my patients and colleagues agree on is that stress causes illness.  I’ve seen people who looked like they were going to stroke out screaming at gate agents and flight crews.  I’m sure some have. 

All this brings me to my point.  Many of my patients seek relief from stress in a pill.  Today, it was obvious that the treatment for stress is to find a great smile and spend enough time with it to let it infect you.  Your job is to nurture that smile and pass it on!

I hope United Airlines recognizes how precious these two flight attendants are.  I certainly do.  If you work for United Express, pass this article on.

Personal Responsibility

While this article was written in 2011, it represents an average day in a docs life and accentuates the point made in yesterday’s article.

All right, I admit it!  I was grumpy today.  I started the day 45 minutes early; and, by the time we opened, I was 30 minutes behind.  As very sick patients came through the door, I got further and further behind.  Not one patient had a simple problem today.  Everyone needed lots of time.  The further behind I got, the grumpier I became.  I don’t like to keep patients waiting.  There is a bright side to being grumpy.  My staff lobbied my wife to take me on a short vacation.  I’m going to see my grandchildren this weekend.  I should be grumpy more often!

Today’s topic is taking responsibility for your own health.  Today’s patients wanted me to fix years of neglect.  I treated an asthmatic who was angry because her cough has not gone away after 6 weeks of office visits and multiple treatment failures.  She blames everyone and everything other than her pack a day smoking habit.  She wants to see an allergist; it must be allergy related.  She wonders if gluten in her diet might be causing her cough.  

I treated a man who complained of erectile dysfunction who blamed it on his wife and not his heavy daily intake of alcohol and food.  Did I mention he is obese, hypertensive and has diabetes?  Today, I saw a fatigued mother of four who insisted her fatigue must be something medical rather than face the fact that she smokes, never exercises and binges on caffeine and chocolate.  Today, I treated a woman for headaches and sleep problems.  She did not want to know why she had headaches and can’t sleep; she just wanted pills.  She didn’t want a diagnosis as that would mean dealing with her many reasons for depression.  She would have to take responsibility for some of her bad choices.  It was one of those days.

Taking responsibility for being grumpy, smoking, drinking or eating excessively is the first step in getting healthy.  Taking responsibility for bad choices is the first step to healing.  The second step is doing something about it.  Changing lifestyles can be hard, but it also can be very healthy.  If you are ill, have health care issues that need work or are just unhappy, look first at the obvious causes, then at everything else.  When you can’t figure it out or you can’t change, see your doctor.  Hopefully, he is not having a grumpy day!

WHY?

Everyone is interested in the “whats” and “whens”.  What do I have?  What are you going to do about it? What is going to happen to me? When will I feel better?  When can I go back to work?  While the “whats” and the whens” are certainly important questions to ask, the “whys” are the most helpful.

Today, I had a lengthy conversation with one of the brightest individuals I have ever met.  Conversing with him is intellectually stimulating.  During our conversation, he mentioned that most people skip the “why” and race to fix a problem before truly analyzing the issues involved.  It dawned on me that the “why” in medicine is often more important than the “what, when and where” questions.

While I can’t always answer the “Why?” of illness, the true path to health lies in finding the “Why?” and preventing it.  Over the last few days, I have been trying to focus on the known “whys” of illness.  “Why aren’t I getting well?”  Answer, “You keep smoking and the smoke is destroying you airway.”  “Why do I need all of these medications for my cholesterol and blood pressure?”  Answer, “You are not on a DASH diet; you are eating fatty red meats, salt loading and not even trying to change your sedentary lifestyle.”  “Why am I having problems getting an erection?”  Answer, “You are massively overweight and out of shape.  Sex might actually kill you!”

The answers sound harsh.  Reality is sometimes harsh.  The only way to stop the cascade into illness is to find the answers to the “whys” and then do something to change.  Am I frustrated?  Yes!  I often refer to myself as a fireman, pouring water (medication) onto a fire, trying to put it out.  My patients are often arsonists, pouring fuel on the fire and yelling at me to put the fire out.  As I increase my fire extinguishers (medicines), I get yelled at, “I’m on too many expensive medications.  I’m spending $500 a month.  You have to do something.”

I have witnessed the success of those patients who have found their “whys” and then done something about them.  On 11/23 and 11/30/10, I wrote about remarkable patients who found their “whys” and accepted the responsibility of doing their parts in healing themselves.  I have lots of success stories!  I also have lots of failures.  The failures frustrate me.  How do I motivate people to find their “whys”?  How do I convince my patients to tackle their problems head on, to take personal responsibility for their wellbeing? And, above all, how do I find my “whys” and what can I do to improve my health!

I’m working hard at answering my “why” and dealing with it in a constructive way.  Are you?

TOO MANY MEDS

When I was in training at Lutheran General Hospital, my fellow residents and I used to meet in the cafeteria to commiserate and eat lunch.  One of the most frequent topics of conversation revolved around how the older attending physicians tended to prescribe way too many medications.

Our teachers were dinosaurs and we were the new king of the universe.  We marveled at how the old guys would prescribe 4 medications for an illness, followed by another 4 medications to take care of the side effects of the first four, and then a few more meds to counter the side effects of the 4 meant to treat the side effects of the first four.  Is your head spinning yet?

We swore that we would never do anything that foolish!   After all, we were the new generation of enlightened docs armed with the latest and greatest medications ever invented.  Jump forward 30 years and meet the dinosaur version of Dr. Segal.  Wisdom and age showed me that the old guys I was so quick to criticize knew what they were doing.

Ron, the waiter, stated that he was on too many medications.  I’m on ten, and yes, several are designed to treat the side effects of others.  I’m sure that today’s young residents in training would criticize my treatments.

As a young doc in training, I did not realize how complicated aging can be.  Each of my meds are essential.  Without my Parkinson’s medication, I’d sit frozen in my chair 24/7.  One medication causes nausea and one counter acts the nausea.  One medication potentiates the other.

One treats my hypertension and one treats the swelling in my legs.  One of the medications treats my arthritic joints and another protects my stomach from the stomach damage caused by the anti-arthritic.

While I complain about taking “too” many pills, I am thankful I have them.  I am also working hard at taking off some weight and increasing my exercise.  Hopefully taking off 25 pounds will improve my BP and joint pains and allow me to stop taking some of my meds.

So the next time you bemoan the expense and inconvenience of taking a lot of pills, count your blessings.  Medication, when appropriately prescribed, can save your life.

FATE

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.

EPIPHANY

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.

PHYSICIAN SUICIDE AND BURNOUT

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

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.

PILLS

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. 

TEDx

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.