LIVE THE WELLTHY LIFE

How much of a financial savings would it take to make you gamble with your health and wellbeing?  Would it surprise you if I told you some of your neighbors would jeopardize their health for a savings of $30 a month?  How about $20?  Or even $10?

It wouldn’t surprise me!  In the past, I’ve watched patients put their health on the line for as little as $10 a month.  Now please understand, these are not patients who are destitute.  They have jobs, homes, and go out to eat and to a movie on weekends.  These are people who have bought into what I call “The Insurance Mentality” or TIM for short.

People suffering from TIM believe that if insurance doesn’t pay for something that it is not worth having.  If their insurer tells them they will not pay for a particular medication, they call the office demanding to be taken off their current medication and switched to the insurer preferred product.  After all, the insurance company has their best interest in mind, right?  Wrong!  Their insurance company’s job is to maximize profits and make their stockholders happy.  My job is to maximize my patients’ health!

Unfortunately, the insurers are winning.  Emboldened by their newfound powers under Obamacare, The United Federation of Insurers of America (FU America) declared war on all expensive medications on January 1, 2014, papering the country with denials of medication orders and demanding that doctors and patients alike conform to the insurers select list of cheap medication.  The war continues today. No matter that a person has been successfully treated with a given medication for 5 years, they must surrender and change.

Those patients suffering from TIM immediately follow the edicts of the FU America movement and called in for their insurer preferred scripts.  Many were aghast to find they had to come in for an office visit but did so as FU America covered that visit.  All wanted to know if the switch was “safe.”

“Mr. X, you’ve done great on your Diovan for 3 years.  You’ll probably be fine on Losartan (the generic FU America prefers) but we won’t know until you try it.  I know that Diovan will cost you more so if you want to switch, we can try.”

Mr. X wanted to try so off he went with his new prescription and his trip to failure.  Yes, he reacted poorly to the meds and came close to staying at Good Shepherd Hospital.  He’s better now and back on his Diovan.  He learned a hard lesson but, in the end, he’ll be ok.  What’s your health worth?  Are you really willing to rock the apple cart to save a little money or would you be better off staying home, preparing your own meals and watching reruns on TV?

As many of my readers know, I often think of myself as a fireman, working to put out fires before they do serious damage.  My patients come in screaming, “FIRE!  HELP ME!”  Unfortunately, many of my patients are arsonists, actively feeding the fire I am trying to extinguish.  Being a doc/fireman can be awfully frustrating sometimes.

As a doc/fireman, I have a variety of fire extinguishers.  My main extinguishers are medications.  Others include an assortment of therapies (physical, occupational, and psychological).  A three-alarm fire requires not only my full assault with the above therapies but the help of others, my consulting group.

Unfortunately, the arsonists I treat often have their own ideas about how they want to put out their fires; and, many times, their unique demands only serve to fuel the fire that is injuring them.

Some patients refuse medications believing that pills are harmful.  It amazes me when a smoker refuses medicinal help due to an irrational belief that pills are toxic; yet, he voluntarily inhales hundreds of known toxins 20 times a day.

Some patients demand medication and shun therapy, even when therapy is a better alternative.  “Doc, I just want my tranquilizer, it solves all my problems.”  Not really!  In many cases, tranquilizers are firewalls, temporarily protecting my patient from being burned by the raging fire.  In the case of anxiety, the psychologist has a much better chance of eradicating the fire than I do.  In the case of a three-alarm blazing anxiety, my deploying medications along with the psychologist’s therapy is necessary.  “Doc, I ain’t seeing no psychologist!  They can’t help me”, means just “give me my pills”.  

Using the wrong extinguishers may cause as much harm as just allowing the fire to burn on its own.  Years ago, we had a fire alarm go off in my office.  Firemen streamed through the front door with axes in hand.  Luckily, there was no fire and no ax was used.  Those axes could have caused a lot of damage if used inappropriately.  Giving in to the demand for tranquilizers can lead to a lifetime dependency on those very medications.  Being a doc/fireman can be frustrating.

Still other patients come in yelling “FIRE, HELP ME”, then refuse all treatments.  They want something “all natural.”  What’s more natural than sitting with a therapist, talking about what ails you?  “I don’t want to see a therapist.”  “What about valerian, it’s all natural?”  “Pills”, published earlier this year, addressed these totally unnatural, unregulated, non-FDA approved, manufactured pills.  Despite the fact that no one really knows what’s in the capsule, what effects it may have on an individual, how the body processes it, and how it interacts with other substances the patient ingests, people have really bought into this form of witchcraft.  Being a doc/firefighter can be very frustrating!  By the way, I have a bridge for sale.  It’s all natural, made from wood.  It’s located in Long Grove.  Any buyers?

Being a doc/firefighter can be extremely rewarding!  I saw a smoker who was being consumed by a raging fire.  His ears hurt, his throat hurt, his lungs hurt, and he couldn’t stop coughing.  Just as the real firefighters and paramedics have to deal with victims of fires and just as those victims often succumb to smoke inhalation, my patient had succumbed to smoke inhalation.  His was no accidental fire! He actually lit his fire 20 times a day for the last 10 years!  I put out his fire and rescued him from smoke inhalation.  Once his burns are healed, he will never again smoke.  Why?  The answer is easy.  He loves his wife and children.  He would never cheat on his wife or children.  When I pointed out that he was cheating on his family 20 times a day, the expression on his face was one of horror.  He had never looked at it that way.  Sometimes, you win one!

Attention, arsonist!  Help me help you!  Do not feed the fire that is consuming you!  Help me help you by listening to the wisdom of my 30 years as a doc/firefighter.  Use all the tools available to you.  The life you save may be your own.

I recently published “Possible vs. Probable”. The premise of the article was that, while everything is possible, what is truly important is what the probability of an illness or outcome is.  Today, I want to apply the premise of “Possible vs. Probable” to the realities of getting old and being ill.

Mrs. “X” is in her 70s.  She has diabetes, high blood pressure and her kidneys aren’t up to par (renal insufficiency).  Mrs. “X”’s most pressing problem is her arthritis.  Her neck, low back, hips, and knees hurt all day long.  It takes Mrs. “X” “forever” just to get out of bed in the morning.  Mrs. “X” also worries about everything.

Mrs. “X” worries mostly about her kidneys.  Her kidney doc has warned her not to take any NSAIDs (ibuprofen, naproxen, etc.).  Theoretically, NSAIDs can adversely affect kidneys causing a decrease or worsening in kidney function.  Realistically, Mrs. “X” is in pain on a daily basis and NSAIDs are the treatment of choice for her arthritic pain.  Mrs. “X” knows that NSAIDs work as on the days she takes ibuprofen, she feels 10 years younger.

What should Mrs. “X” do?  Should she listen to her kidney doc and live in pain or use NSAIDs and risk further loss of kidney function?  Should she try other treatments?

Mrs. “X” does great on steroids.  She becomes pain free!  Theoretically, steroids can worsen her diabetes and hypertension, cause cataracts, osteoporosis, mood swings and an assortment of other problems.  The reality is that they make her better and without steroids or NSAIDs, she is crippled with pain.

What should she do?  She has tried acetaminophen and it has failed to offer any relief.  Narcotics constipate her and make her unsure on her feet.  Physical therapy did not help.

In my book, reality trumps theory every time.  Is it better to protect your kidneys, avoid possible worsening of your diabetes/hypertension and live longer in pain or is it better to relieve pain and potentially shorten your life?

I often find myself treating Mr. and Mrs. Xs who fit the above scenario.  A day with minimal or no pain is always better than ten days in pain.  Many of my patients go for quality over quantity.  What is remarkable is that most tolerate their NSAIDs or steroids well and do not significantly shorten their life or worsen their bodily functions.  Theory is not reality.

Because doctors believe in informed consent, because doctors are afraid of being sued for caring for their patients, they teach their patients about the theoretical problems a treatment may pose.  Because pharmacists have the same concerns as doctors, they glue and staple warnings all over Mrs. “X”’s prescriptions.  Unfortunately, patients often are scared by the warnings of theoretical doom and refuse treatment, leaving them to suffer day after day.

Remember, theory is not reality!  Remember, each of us is unique and how we respond to a given treatment is not preordained by scientific studies.  Life is about weighing risks and benefits and then hoping the decision you make is the right one.  When making decisions about potential treatments, the reality of today should receive much more weight than the theoretical tomorrow.

If you noted a sense of frustration in this article, you would be correct.  Our system of informed consent often backfires.  Rather than protecting patients from theoretical side effects and risks of treatments, informed consent often harms the patient it is meant to protect.  It’s frustrating to offer a patient relief from suffering and then, doing your duty as a physician, talk that patient out of doing what you feel is best for them.  Sounds schizophrenic? It is and therein lies my frustration!

Why?  Why won’t you tell me why?  I need to know!  If I know, I can help!  I’ve been practicing medicine more than half of my life.  You would think I would know why, but I don’t.

I’m frustrated.  I’ve learned so much, studied so hard and worked all my life to provide the best care I can.  No matter!  Unless I can find this last piece of the puzzle, it may all be for naught.  Why?  Tell me why!

Why won’t you take care of yourself?  Is a little exercise too much to ask for?  Is cutting back on bacon and salt so hard that it’s worth cutting your life short?  Life is so precious!

Why must you harm yourself?  Sure, smoking is an addiction.  Shouldn’t living “well” be an addiction?  Isn’t the risk of cancer enough of a threat?  Tell me why you won’t listen to your body.  You cough every morning.  You’ve been coughing for months.  You want a cough medicine.  You’ll take a cough medicine, but you won’t stop smoking.  Why?

I’m frustrated.  I don’t get it!  You’ll take medicine for your diabetes, blood pressure or emphysema but you won’t take care of yourself.  You’ll suffer through surgery and chemotherapy for your cancer, but you won’t take care of yourself.

Proper diet and exercise is the one prescription you won’t follow.  Why?  Why suffer at your own hand?  Why make your family suffer?  Why?  Please tell me why.

Surfing the net for knowledge is one of my pastimes and last night I struck gold.

“A not-to-do list for those with chronic pain or illness” by Toni Bernhard, JD instantly caught my eye!  Coming off a miserable week of back pain, I could use some advise even if it’s from an attorney!  Here goes(taken from her article):

• DO NOT say “yes” to an activity if your body is saying “no.” 
• DO NOT call yourself names or otherwise speak unkindly to yourself.
• DO NOT try a treatment just because someone said it cured him or her.
• DO NOT wait until the last minute to get ready for something.
• DO NOT strive for a spotless living environment.
• DO NOT “shop ‘til you drop.” 
• DO NOT wear uncomfortable clothes.
• DO NOT think about pleasures from your pre-illness life, freeze them in time, and assume they’d be as much fun today.

I want to thank Mrs. Bernhard for her sagely advice and add a few of my own:

• DO NOT tell someone to take the day off, go home and take it easy when they appear to be in better shape than you are.
• DO NOT sit too long in any one position and expect to be able to stand up gracefully.
• DO NOT try to fool your patients.
• DO NOT fail to thank those who show their concern for your wellbeing.
• DO NOT get short with your coworkers and spouse.

Chronic pain or illness is no fun but how you choose to live with it can make a world of difference.  Oh yes, there are two more big “DO NOTs” for your list:

• DO NOT forget to follow you doctor’s instructions.

Last but not least, DO NOT give up hope!  An answer may be right around the corner.

Regret is a harmful emotion. Regrets are best avoided. It’s one thing to regret buying a stock that plummets; it’s another to regret that you ever smoked because your chest x-ray shows a large tumor. 

People often don’t appreciate what they have until they’ve lost it. When you’ve lost your health, you will regret its loss for the rest of your (shortened) life. Not long ago, I wrote about non-compliance. Imagine that you were supposed to take your medication every day. Your doc prescribed the medicine because, without it, you would be at risk of having a heart attack. Imagine you decide that medications are expensive, bad for you, and that you are going to use all “natural” over the counter pills to treat yourself. 

Now, imagine you wake up in the coronary intensive care unit. Your doctor tells you that you suffered a cardiac arrest (died). You try to ask him a question but gibberish comes out. The doc explains that you are stable; but you were without oxygen for too long and you have suffered hypoxic brain damage. You’ve had a stroke. You realize you can’t move your right hand and leg. You’re alive, and, for the first time in your life, you understand what being healthy was all about. 

You understand that you may never walk, work, drive, or even make love again. You understand that you will have to take medications, go to rehab, have full time help, and learn to live a new life. You understand that you should have never stopped your medication. You will regret that decision for a very long time. 

Every day, I plead with patients to take their medications, get their colonoscopies/stress tests/ x-ray, done. I plead with them to stop smoking and drinking. I ask them to give up cholesterol, sugar, and other goodies so that they can be healthier. I write articles (over 625) aimed at helping them understand how important their health is. 

Every day, my patients tell me they are going to try to care for themselves. I hate the word “Try”. To me, try implies failure. I ask them to work at being healthy. I explain that the stakes are high, often to no avail. You don’t know what you have until you lose it. A healthy person cannot imagine what it is like to lose his health. A healthy person cannot imagine how much “regrets” hurt! 

Life is full of regrets. Do everything within your power to be healthy. Live a “wellthy” life by investing in your physical, nutritional, emotional and financial wellbeing with the same fervor as you invest in your financial health. Work with your doctor. Learn all you can learn. Follow your doc’s instructions. Don’t fall for the hype of the “all natural” neutraceutical world. If you don’t believe you need a treatment or a test, discuss it with your doctor. 

Staying out of trouble is much better than getting out of trouble. Remember my favorite blessing, “May you be so blessed as to never know what disease you prevented.” Be “Wellthy” and live a long life without regrets. 

I just read 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.

Several 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 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 40 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.  

Medically speaking, what’s a guy to do when there is no right answer?  My patient’s solution is often to ask me what I would do given his particular circumstance.  He isn’t happy when I respond with, “I truthfully don’t know!”

In reality, I always know what I would do.  I’d gather knowledge, see consultants, and explore every possible option to its fullest.  Then, most probably, I would still not be sure what I would do unless I was in the situation myself.  “What’s a man to do” is a very personal question with many, nonscientific factors to be taken into account.

Case in point.  I’ve counseled many patients with prostate cancer.  I know all the treatments available and the pluses and minuses of each approach.  The common options include “watchful waiting”, some form of radiation, surgery, or a combination of the latter two.   

What’s a guy to do if he has prostate cancer?  This is one disease where the answer is difficult and the stakes high.  Several years ago, I had an elevated PSA (screening test for prostate cancer) and an abnormal prostate exam.  While waiting for my biopsy results, I got a chance to look at all the options from a patient’s point of view.  I now know what I would do if my biopsy was positive, but my decision-making process was unique to my life and what I feel is important.

I counseled a patient with a precancerous lesion of his colon.  A routine screening colonoscopy revealed a polyp (tubular adenoma) that could not be fully removed by the gastroenterologist and has the potential to become a cancer.  Again, his options were watchful waiting with careful follow-up versus a surgical resection of part of his colon.

What’s a man to do?  Watchful waiting means yearly colonoscopies and biopsies.  In my early days as a doc, I saw a young lady with a slightly abnormal mole on her back.  I started to advise a watchful waiting approach when I realized that I was watching to see if she might develop a malignancy.  After I explained my reasoning, I removed the lesion.  The pathology report came back as an early stage of melanoma, a particularly nasty cancer.  Since then, I have not been a fan of watchful waiting.  Luckily for my patients, I surrounded myself with conservative surgeons who provide a nice balance to my aggressive surgical leanings.

Colon resection is no picnic, either.  To have a colon resection for a lesion that may never turn cancerous carries its own risks and expense.  What’s a guy to do?

In the business world, it’s called “due diligence”.  According to BussinessDictionary.com, due diligence is a “measure of prudence, responsibility, and diligence that is expected from, and ordinarily exercised by, a reasonable and prudent person under the circumstances.”  A reasonable and prudent patient, when presented with a disease that does not have a clear cut treatment option, needs to collect all the information he can to define his options, the risks and benefits of those options, and the costs; then he has to make a decision and live with its consequences.

Life’s a bitch sometimes.  Making decisions is hard work and you know you’ll win some and some you’ll lose.  What’s important is being able to live with the results of the ones you lose.  If you did your best to answer all the questions, to weigh all the choices, you’ll be able to live with your losses.  If your decisions were ill-informed and hasty, not only will you have to live with your losses, you will have to live with regret, as well.

Until they invent a “retrospectoscope”, a man has to work hard to understand his situation, to know in his heart that what he chooses to do is right at the time, and to accept his account, whatever it is.

I’ve always said that, if you can make something good come from something bad, the bad wasn’t so bad after all.  Somebody once said, “man plans and G-d laughs”.  At least I’ve given G-d some good laughs over the years. 

In the morning, I often feel like the pilot of a 747, getting ready to start up his engines and going through his pre-flight list.  Renee, my co-pilot, has her own list and, often, we check each other’s list.  It goes something like this:

“Gas, check, more than needed this am! 

“Fluids, check.  Better drain the system before it develops a leak.” 

“Waste dump, check.  Overdue by 3 days.  If not performed soon system will go critical.  Consider procedure 13, suppository.

“Landing gear, check.  Creaky but adequate.  Improve after first 10 steps.  Renee, where’s the Aleve?”

“Back, check.  Working good this am.”

“Neck, check.  Not working so good.  Where is the Aleve?”

“Heart, check.  BP, check.  Windshield, check and foggy.  Where are my glasses?”

Pilot to co-pilot, “All systems go.  Check your list.  Central computer, check. No headache.  Chassis, check.  No back pain.  Ventilation system, check.  No cough.  To hell with work, how about I take you out for a spin?”

“OK!, I’ll get serious. Time to wash this baby off and take off for the rest of today.”

  Sometimes, getting old can be complicated!

The flowing article has been published several times over the past few years.  It is even more appropriate today than it has been in the past.

Originally published on March 5, 2011, this article ranks in my all-time top five viewed publications.  As insurance and Medicare become more restrictive, medical luxuries become more important.  With the recent move to brand many tests and interventions as unnecessary, what was once cutting edge and “necessary” now falls into the realm of luxury.  The statisticians look at what is “enough lives saved” in their quest to define necessary.  PSA screening is no longer “necessary” as not enough lives were saved for the cost of the test.  If your life is saved by a test of intervention, doesn’t that qualify as “enough?”  “Medical Luxuries” addresses the word “need.” 

The word “need” means different things to different people.  In an earlier article, I referred to “need” as the new four letter word.  People overuse and abuse the word “need”.  In my practice of medicine, I defined three levels of need. 

A level one need is critical and worth fighting over.  I saw level one needs two to three times a week.  Level one needs are exemplified by the 60-year-old hypertensive male who has chest pain.  He needs to be in the hospital now!  He needs to go by ambulance now!  His life depends on it.  When he refuses to follow my advice, I dial 911.  When he is at home and refuses to heed my advice, I call 911 and his wife.  Level one needs are absolute! 

Level two is where I spent the majority of my time.  My job was to inform you why you needed whatever it was you needed, what the benefits and risks were, what the expense was and how soon I think you should get it done.  I then left it up to you to decide if and when you were going to do it.  I might disagree with your decision but respected it.  A routine colonoscopy is the standard of care at the age of 50.  It is a level two need.  (If you have a family history of colon cancer, it is a level one need.) 

Level three needs are luxuries and the topic of tonight’s article.  Luxuries are needs you can do without but can do better with!  In medicine, a luxury is anything that is either unproven (but promising), not standard of care, or not covered by insurance.  We live in a peculiar world.  I have patients who won’t get a chest x-ray ($200) because their insurance won’t cover it.  They drive to the office in a BMW but won’t spend $200 on their own health.  I have patients who eat at expensive restaurants every weekend ($50 per person) yet want an inferior generic because the branded cost is $100 per month.  The insurance world has convinced us that if, they won’t pay for it, either you don’t need it or it is too expensive to afford.  

Luxuries can save you money and your life.  Several years ago, I was called in to the hospital to see a very sick patient at 5 a.m.  I dressed quickly, jumped into my car, backed out of the garage and slammed into my daughter’s car.  I had not spent the extra money to buy back up sensors when I purchased my car.  My decision had consequences.   I had to tell my daughter I smashed her car.  I had to pay for her repairs, as well as mine.  What seemed like a luxury item at the time turned out to be more of a necessity than I had anticipated and a costly error in judgment as well.  Luckily, the patient did fine. 

So what are luxury medical items?  Cardiac Scoring is a good example.  It measures the calcium load in your coronary arteries and predicts coronary artery disease.  A healthy 50-year-old male with no family history of heart disease is buying a luxury when he gets one.  Insurance won’t pay for it and technically he doesn’t need it.  So why get it?  Most of us are healthy until we are not.  If his results are normal, he gets peace of mind.  If his test is strongly positive (it happens to the healthiest of us), he may well have saved his life. 

Every year there are unexpected deaths in our community.  Could the purchase of a healthcare luxury, an annual physical, an EKG, blood test or x-ray, have saved their lives?   I would like to think so.  The next time your doc asks you to get a test or buy a medication that is not a covered benefit, think twice before you dismiss the idea.  Times are tough and money is tight; but, if your roof was leaking, you would find a way to get it repaired.  I often use analogies to make a point and my favorite has to do with your house.  Your house is very important; and, when it needs repairs, we find the means to do so.  Your house shelters your body; your body houses your soul.  Do everything you can to protect your body and keep it fit for many years to come.