VIRAL vs BACTERIAL

Often, the most difficult part of my job is deciding whether my patient has a viral or a bacterial infection. The second most difficult job is explaining to a patient who has a viral infection why an antibiotic will not work. Patients suffering from respiratory tract infections (URI) want me to cure them. They want antibiotics, the supposed cure-all! In my early years in practice, it was impossible to differentiate between a virus and bacteria. Antibiotics were considered relatively harmless and everyone who suffered from a URI received one. Since my patients got well (because of or despite taking an antibiotic), they grew to believe that, without an antibiotic, they would not get well. Over the last decade, antibiotic-resistant bacterial infections have dramatically increased due to the overuse of antibiotics. In the decades to come, appropriate use of antibiotics will be imperative.

In the real estate business, it’s “location, location, location.” I often hear, “Doc, I’ve got a sinus infection and need an antibiotic.” “Doc, I’m coughing up green sputum and need an antibiotic.” Sinusitis, bronchitis, tonsillitis, pharyngitis, gastritis and cystitis are all infections in certain locations within your body. The easy step in diagnosing an illness is determining where the infection is. The hard step is determining what “bug” (virus vs. bacteria) is causing the infection at the given location.

“Bugs” can all cause the same symptoms. A sinus infection, complete with facial pressure, green discharge, fever and chills, can be viral or bacterial. A viral sinus infection is treated with symptomatic measures and eventually goes away by itself. Once your body recognizes the virus, specialized killer cells (lymphocytes) are produced and then hunt and kill the virus. Antibiotics assist your body in getting rid of bacterial infections. Once your body identifies an invading bacterium, it makes specialized killer cells (neutrophils) that eradicate bacteria.

In the early stages of any URI, mucoid secretions are clear. As the infection worsens, they often turn yellow, grey then green. Green is actually good. Green is the color of white cells (lymphocytes or neutrophils) engaging the enemy. Green means your body has found the invader and is attempting to heal you. Mucous, in itself, is a problem. It nurtures and shelters the invading “bug.” Symptomatic treatment is aimed at helping you clear mucous. Mucinex is my favorite agent. My instructions also call for saline nasal sprays and the ingestion of copious amounts of fluids. Please avoid orange juice. While it contains vitamin C, it also contains citric acid. The acid content further irritates the throat and increases mucous production.

So, how do I determine if you have a bacterial or viral? As stated above, it’s not easy. Bacterial infections tend to cause higher fevers and tend to be associated with more severe physical findings. Viral infections tend to cause severe symptoms with milder physical findings. In the early stages of a communal illness, diagnosis tends to rely on highly educated guess work. That may sound shocking, but it’s true. Once I have seen 10 or more cases, it becomes easier. The disease takes on its own personality and becomes predictable. 

I used to rely heavily on the ability to do blood counts in the office as an aid in diagnosing viral vs. bacterial infections. Low white counts are usual for viruses and high white counts are seen in bacterial infections. Normal white counts may indicate an infection with a mycoplasm infection (modified bacterium/bug).

In person, it is difficult to accurately diagnose a URI or any other medical problem. Diagnosing over the phone is often impossible. Sometimes, it takes several visits to solve the mystery of what is infecting you. One reason I keep an open, extended-hour schedule is so that you can easily be seen. Please come in when you are sick. The life you save may be your own!

PREVENTION MAKES SENSE

What’s easier; caulking and painting your house’s exterior or letting it rot and eventually replacing it? The answer is simple, isn’t it?

What’s easier; checking and replacing the brakes on your car when they are worn or dealing with the carnage when the brakes fail? Again, the answer is obvious!

So, what makes sense; taking care of your body by eating the right foods, exercising and seeing your doc for yearly physicals and routine maintenance or letting your body go to fat, your belly sag over your belt and your muscles atrophy from disuse. The answer should be obvious, shouldn’t it? Unfortunately, it’s not!

Many of my patients take their health for granted! They feel well! They’ve never been sick a day of their lives. They work hard at making a living but invest little in staying healthy. Then catastrophe hits and they are sick! Their blood pressure is elevated. They are diabetic or worse; they have a heart attack or stroke. Recovery is a bitch!

It’s no secret. It’s easier to maintain your health than to restore it once you’ve lost it. So, this year, work hard at maintaining your health. Make sure your spring-cleaning list entails cleaning up your diet, tightening up your waistline and exercising. The life you save may be your own.

FIND, FIX, FINISH

I’m reading Brad Thor’s book, Full Black. In the book, a “former Navy SEAL Team 6 member turned covert counterterrorism operative Scot Harvath,” joins an ultra-secretive, counterterrorism group whose motto is, “Find, Fix, Finish.” His job: save the United States from the horrors of a massive terrorist attack.

I instantly liked the motto, “Find, Fix, Finish;” and, while I do not have SEAL training, as your doc, my job is to thwart attacks on your health by a wide variety of terrorists, known as infections, diseases and addictions, or to limit their damage and help you heal. I think I like being a covert operative better than being a chef or CSI technician. It sounds sexier!

The three “f’s” start with “find.”  “Finding” what is going to hurt you or what is currently hurting you is critical. Many of my articles have dealt with the art of diagnosis. Just as Scot Harvath depends on his team to root out the villains, you, your family and your doc need to work together to uncover any hidden villains lurking in your history or actively harming you.

The “fix” is designing an appropriate treatment regimen to protect you from harm and repair any damage already done. Treatment is not synonymous with medication. Treatment starts with appropriate lifestyle changes, diet, exercise and giving up unhealthy habits, to name a few. Lack of compliance with treatment protocols often lead to disaster.

Today’s article is about the “finish.” It’s the “finish” that is often lacking in medicine. While I often write about diagnosis and treatment, Thor’s book has made me focus on the real problem: getting the job done once and for all. Too often patients try to comply and fail to follow through. Many times they stop short of their goals. While “finishing” is not always possible, it is worth making every effort to accomplish the goal. 

When my patients do “finish” their job, it is a sight to behold. Recently, I wrote “Wow.” The two patients depicted in this story “finished” their jobs and shed their medication. Finishing the work you start is an integral part of success! 

The next time you go to your doc, work through the “Find, Fix, Finish” protocol.  Remember, if at all possible, you want to finish the job. “Finishing” means getting your blood pressure into a normal range and then doing whatever is necessary to keep it there. “Finishing” means going on that diabetic diet your doc recommended and make it your own diet, not something you are doing to lower your blood sugar so that you can resume your old bad habits. “Finishing” means never smoking again. “Finishing” means sticking with your new exercise routine.

What job do you want to “finish”? What job needs to be “finished”? Take the first step. Tell your doc it is time to finish the work you need to do to be healthy and ask him for his help.

HOW TO EVALUATE WEB SITES

We’ve all done it.  We’ve all purchased that miracle cure being sold on the internet.  The ad usually starts with “What doctors won’t tell you,” and ends with “You can have this life saving miracle for just 4 payments of $49.95.  Shipping is free.”  How do you know what’s true and what’s bullshit? 

In “How to evaluate health websites,” published in 2013 by Kenneth Lin, M.D., Dr Linn does a nice job discussing the potential problems with biased internet sites.  While this article is somewhat dated and some of his hyperlinks no longer function, it is still worth reading.

Why am I writing this article?  On a daily basis, I saw patients who had been misled by highly polished internet sites selling snake oil.  “Doctors recommend product X,” “Proven in over 100 clinical trials,” “Made from the finest, all natural ingredients and proven to help with . . ,” are all impressive headlines used to gain an individual’s trust.  Unfortunately, the consumer often does not realize that words such as “Doctors,” “Clinical,” and “Natural,” are actually meaningless.

Let’s look at “Doctors recommend product X.”  What kind of doctors are they?  Are they doctors who are shareholders in the company?  How many doctors are “they?”  Do they recommend it because they sell it?  Are they even medical docs?

“Proven in over 100 clinical trials” sounds good but is often meaningless.  Who ran the trials?  How many patients were in the trials?  Were they open label or blinded?  Did the FDA approve the trials and review the results?  

My favorite is, “Made from the finest, all natural ingredients and proven to help with . .”  Imagine I am a soybean farmer.  Do I sell my finest soybeans to a company that is going to encapsulate them, or do I sell it to a high-in grocer who caters to the Japanese community?  So, I sell my finest to the high-in grocer, my next finest goes to the producers of tofu and soymilk.  What do I do with the remainder, the damaged and bruised portion of the crop?  Yep, I can sell it to an industry that pulverizes it and sells it in cans of powdered protein.  Yes, it comes from the finest crop.  It just happens to be the part of the finest crop that I used to discard as waste.

Remember, if it’s too good to be true, it probably isn’t. If you do decide to buy product “X” let your doc know you are taking it.  Better yet, discuss it with your doc before you buy/swallow it.

So, take what you read on the internet with a grain of salt.  One of my favorite sites is from the Mayo Clinic.  Another favorite site is FamilyDoctor.org.  Many of our most reputable medical centers have educational web sites that you can probably trust.

NEVER ASSUME

You know the old saying, “When you assume something, you often make an ass out of you and me? In my world, assumptions are bad. Ever notice that I discuss my findings and plans with you and then give you a written summary of my findings and plans? 

I can’t afford to assume that you understand me. I can’t afford to assume that you will remember what I said. If I assume that you and I are on the same page and we are not, it can lead to catastrophe. If you do not understand what your doctor is telling you, stop him/her and ask more questions. If you do not say anything, the natural assumption is that you’ve got it! If your doctor does not give you a written summary of the visit, ask for one. The written summary of your office visit is one of the few benefits of the electronic medical record.

Ever notice that I repeat what you say to my nurse and to me? Often, I will read my nurse’s note to you and ask if it is accurate. Do not assume that what you say is what your doc heard. Communications between individuals is often lacking. One of my favorite quotes is, “I know that you believe you understand what you think I said, but I’m not sure you realize that what you heard is not what I meant.”

During your visit with the doctor, both parties should take the time to make sure they are on the same page. One way to assure better communications is to plan for your visit in advance. Write down the questions you need answered and the points you want to make in advance. Once you have your list, prioritize your needs as the doc may not have time to address all of your concerns at one visit.

Do not assume that your doctor has all the answers. Your doctor’s job is not to know everything; his/her job is to know what he/she doesn’t know and how to find the answer. Do not assume that there is always an answer to your problem. There are problems that have no answer. There are problems that have no solution. 

The true art of medicine is in listening, communicating, and finding a way to deal with those problems. In today’s world, everyone is in a hurry. No one is willing to pay for time and no one is willing to wait. The number one complaint about my practice is wait time. I’ve always been perplexed by that complaint because the walk-in system means you will be seen on the day you need to be seen, not on the day an appointment is available. Yes, patients often wait an hour or two in my lobby or exam room. It takes time to listen, more time to communicate, and even more time to make sure that everyone is on the same page.

Help me help you! Prepare for your visit in advance. Stop me if you think I’m not getting your meaning. Stop me if you are not getting my meaning. Make sure you get a written visit summary before leaving. Actually, read that summary and make sure you understand it. Read this blog. It is designed to teach you to help take care of yourself. Send this blog to your friends and relatives. You may save a life.

WOW, THEY DID IT

During the last few weeks, I’ve been writing about taking control of your health through knowledge, partnering with me to accomplish a healthy lifestyle.  I’ve written about the doctor-patient relationship and characterized that relationship as often being similar to the fireman-arsonist relationship.  Today, I want to share with you the story of two patients who took charge of their lives and changed their lives for the better.  One willingly, the other after I thoroughly pissed him off.  Today was a great day!

My first patient (Number One) of the day had been given a diagnosis of diabetes, hypertension and elevated cholesterol; and he is on multiple medications including insulin.  He followed my instructions and took command of his health rather than letting his health take command of his life.  Forty-two pounds lighter, he is rewarded for his efforts by feeling younger.  He no longer needs insulin and I suspect most of his medication will eventually be stopped.  I applauded his efforts and sent him on his way feeling like I had succeeded as his doctor and mentor.

As a physician, I love to see my patients flourish.  I think of myself as a benevolent teacher and enjoy seeing my students prosper.  While my first patient took my teaching to heart, my second patient did not.  Patient Number Two was markedly overweight, diabetic, hypertensive with high cholesterol and neuralgia (a painful malfunction of the nervous system).  Number two was on three medications for blood pressure, two for diabetes and two for neuralgia.  My efforts to help number two understand the immensity of his problems included:  I tried education and instruction; fear mongering; and guilt.  I TRIED ANYTHING ELSE I COULD THINK OF IN ORDER TO MOTIVATE MY PATIENT TO TAKE CONTROL OF THE ILLNESSES PLAGUING HIM.   It seemed nothing would work.  At last, I let him have it and royally pissed him off.  That worked!

Patient Number Two proudly came in for a yearly physical today, having lost in excess of 100 pounds.  Medications were no longer necessary.  The diagnosis today was not hypertension, not diabetes, not neuropathy.  Today, the final diagnosis was “HEALTHY”!  

It’s a pity I had to piss him off but it was worth if in the end.

STORM WARNINGS

While I would like to believe that I am better at predicting storms than the weather- man, unfortunately, I am not.  If you are wondering if I’ve lost it, I haven’t.  Once upon a time, my first patient of the morning left the office by ambulance.  After taking a careful history and performing a thorough exam, my assessment was that he was in imminent danger, much the way the weatherman declares a tornado/storm alert.

Yes, a major storm was in the making, one we docs call sepsis.  Calling in the paramedics is the equivalent of calling up the National Guard.  As always, they responded quickly and efficient, securing my patient against what could have proven to be a major tempest.  The next day, my patient is much better.  The storm has blown over and, thanks to G-d, was nowhere near as devastating as I had predicted.

Unfortunately, there are times when medical storms strike fast and appear from nowhere.  No matter how good my patient and I are at practicing preventative care, there are many occasions when medical twisters touchdown in our lives wreaking havoc.

So, what can we do?  In the case of a severe weather alert, most of us get busy securing our homes, checking on our flashlights, making sure we have gas for our generators and snow blowers and fill our pantry.  We check on our loved ones and neighbors and then hunker down for the night.

In the case of a medical alert called by your doc, respond promptly, heeding his advice.  Don’t argue as it wastes time.  If the doc says, “Call 911,” call 911.  Take proper precautions.  If your doc warns of an approaching storm in the form of a future heart attack/stroke/diabetes, take action by improving your lifestyle, complying with medication and seeing the specialist when recommended.

Yes, my predictions are often wrong.  When I warn of impending doom and it fails to develop either due to your precautions or not, I’m one happy camper.  Now, if I can only figure out how to predict those sudden acts of terror that occur when illness is lurking in the wings but invisible to the modern medical eye.

MEDICINE BY PROXY

Medicine by proxy is growing rapidly in the United States and I don’t like it!  It’s just not healthy, unless you are the employer/insurance company/ Medicare.

According to Wikipedia, Proxy voting is a form of voting whereby some members of a decision-making body may delegate their voting power to other members of the same body to vote in their absence, and/or to select additional representatives. A person so designated is called a “proxy” and the person designating him or her is called a ‘principal’.’”

In the case of medical care, the “principal” is my patient and the “proxy” (in past times, the physician was the “proxy”) is now the insurer/Medicare.  While proxy voting may work well in the political world, it fails miserably in the medical world.

First, let’s look at how a proxy works in the political arena. “Principals” and “proxies” should have closely aligned goals and aspirations.  If I designate my neighbor as my proxy for a neighborhood association meeting, I know my neighbor will vote both on and in my best interest.  If my neighbor and I disagreed about what was in my best interest, I would never grant him my proxy.

Now, let’s explore a medical proxy.  Patient A buys an insurance policy with Charge’em and Screw’em of America (CSA).  Patient A signs on the dotted line, having no real idea what he is buying and what his rights are.  He also doesn’t know what rights he signed away.  Patient A expects that the medical care provided by his doc will be covered by his new “proxy,” CSA.

CSA’s goal is to make a profit!  Their goal is to cover as little medical care as they can and immediately start exercising their proxy.  How?  Let me explain.  Patient 

A has hypertension that is well controlled on Exforge and high cholesterol, also well controlled by a medication called Crestor.  CSA does not want to pay for either medication as they will cut into the company’s bottom line, so they exercise their proxy by refusing to pay for Patient A’s medication or by requiring a mountain of paperwork from the patient and his doc.  

CSA, the proxy, inserts itself between the patient, the pharmacist and the patient and often is successful in forcing a change in the patient’s care.  Many times, the change is financially costly to the patient (increased number of office visits and additional testing to stabilize the patient on the new med), as well as medically harmful.

So, what’s a guy to do?  You’ve got to have insurance, don’t you?  Of course, you do; but you should know everything about your insurance coverage and your rights under your policy.  You should also recognize that your insurance company does not have your best interest in mind!  You should not allow them to dictate your medical care.

Freedom has a price!  In olden days, people had a Christmas fund where they socked away money for next year’s presents.  It’s time to establish a Health Savings Account where you sock away money for next year’s medical expenses.  Going to the dinner and the movies next weekend?  Maybe a quiet meal at home and a Red Box movie would be just as fun and the money you save can be put away for future health needs.

If you are going to choose a healthcare proxy, chose your doc, not CSA!  If there is a safe and less expensive alternative, trust that he’ll find it!   Most of us are acutely aware of our patient’s financial problems and the cost of healthcare.  I didn’t go to medical school to bankrupt my patients!

MEAN PATIENTS

MEAN PATIENTS GET WORSE CARE

You know who you are, or do you?  I was fairly lucky.  Over the years, I had relatively few mean patients. On the other hand, my staff had a fair number of mean patients.

Why the discrepancy? While it was easy to be mean to my staff, it was relatively hard to be mean to me.  I never understood the logic behind pissing off my staff.  My staff controlled the flow through the office.  If you wanted to see me, you had to go through them.  Yelling at them, insulting them and being overly demanding not only ruined their day, but ruined my day as well.  Trust me, you want to see a healthy and happy physician.

I was trained in conflict management and never hesitated in pointing out inappropriate behavior.  Disarming an angry patient was usually easy, but it was always time consuming.  Wasting clinical time was always a pity.  It’s no wonder that mean patients get worse care as half of the visit is spent resolving whatever is making you mean.

Click on the hyperlink to see a Zdogg video on this topic.  I particularly like Zdogg’s advice on how to interact with your doc.  Your doc’s office staff is there to help you.  Be kind to them.  Remember, if you don’t like how they do things, discuss your issues with the office manager or the doc.  In my office, Renee, the insurance companies and I set the policies and my staff followed them. 

1984

Renee and I opened Lake Zurich Family Treatment in 1984.  We were broke and the banks did not want to lend us any money as NO ONE HAD HEARD OR, OR COULD IMAGINE A WALK-IN FAMILY PHYSICIANS OFFICE.

Our attorney and financial advisors were sure that we would have a negative cash flow for 2-3 years.  Despite such dismal projections, I signed the lease and construction began.  My earliest patients met me while we were still under construction.  I worked at Northwest Community’s ER during the day and installed ceiling tiles and laid flooring at night.  

It was summer and the TCBY was open.  People would stroll into the office and ask me if I knew anything about the new doc hose practice was opening soon.  I told them that I personally knew Dr Segal and he was a great doc. I also told them that he was pretty good at installing flooring and ceilings.

The landlord met with me and informed me that someone was working in the building at night and the union was threatening to shut down the site.  He was surprised to find that the “someone” was me.  When he told the union crew that the night worker was the doc and that the doc was broke, they stopped working on the rest of the shopping center and finished my office.

In those days, being a doc garnered a lot of respect.  Being a doc who would get his hands dirty garnered even more respect.  When times were bad, I could always look at the exam room floor and smile, knowing what I was capable of creating.

One of the individuals who strolled in late at night when I was working as a laborer was Tom, the local independent pharmacist.  Tom welcomed me to the community and taught me how important it was to have a family pharmacist on a patient’s healthcare team.  Tom would call me if my patient failed to pick up his/her prescription or if someone had a problem with their meds.  He would also help those who could not afford their meds.

When Osco opened, Vicki (a pharmacist) assumed the same role, becoming a vital part of many patients’ healthcare team.  Over time, things changed.  The Oscos of the world, insurance carriers and pharmacy benefits managers (PBMs) put Tom out of business.  The major pharmacies started rotating multiple pharmacist through their stores and the family pharmacist became extinct.  With few exceptions (the pharmacist at Marianos in LZ), a major part of a person’s healthcare team disappeared.

WHAT A PITY!!!

Once again, ZdoggMD has done a brilliant piece on the modern-day pharmacy.  Please click on the hyperlink and listen to what he has to say.

In the next few days I’ll write an article on “Pay For Performance” and the shift from medicine being a calling to medicine becoming big business.  Stay tuned.

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