Dr Beckwith's Blog

What does the patient really want?

2011-11-20T10:17:00.000-05:00

Sometimes the patient tells the doctor what she wants up front. But sometimes the patient's real reason for seeing the doctor is not apparent. Here are some examples:

A man with shoulder pain mentions in passing during the visit that he'd like some Viagra samples.

Stated reason for visit: Shoulder pain
Actual reason for visit: Erectile dysfunction

A woman with back pain mentions in passing during the visit that she thinks she can't work any more due to her back pain.

Stated reason for visit: Back pain
Actual reason for visit: Disability

A young man with a sore throat mentions during the visit that he'd like to be tested for sexually transmitted diseases.

Stated reason for visit: Sore throat
Actual reason for visit: STD testing

It's perfectly okay for patients to give any reason they like for their visit when they call to make the appointment. And it's understandable that the patient doesn't want to tell the nurse the real reason for the visit. But when the doctor comes in the room, I think it's best to be up front about the main concern.

The reason is that the patient is more likely to get what she really wants if she's up front about it.

What often happens is that the patient only reveals the real reason for the visit after we've already spent 15 minutes working on other problems. Then when I find out the patient's real concern, I have to put off working on it until the next appointment. The patient is upset not to have gotten his real concern addressed, and I'm upset because the patient is upset with me. If I spend the extra time handling the patient's actual reason for the visit, the other patients in my office are upset with me for having been kept waiting. It's a lose-lose proposition.

So, to get the most out of your doctor visit, tell the doctor what you really want.

Socialized Medicine

2011-05-15T07:48:00.003-04:00

All day long I see patients who can’t afford to take off work, can’t afford the appropriate work-up of a problem, can’t afford transportation to the doctor’s office, can’t afford the necessary treatments for a problem, etc.

Here are some all-too-frequent examples:

A patient without health insurance because he’s self-employed needs surgery for a pinched nerve in the spine but has to live in pain.
A patient whose health insurance doesn’t cover the necessary cholesterol medicine has a heart attack as a result.
A patient on Medicare who has diabetes can’t afford the appropriate kind of insulin, so her diabetes is not optimally controlled, and she develops nerve damage in her feet, eventually requiring amputation of toes.
A patient with a high-deductible insurance plan who avoids going to the doctor because, up to her $3000 deductible, she has to pay full price for all medical services.
A patient with several chronic conditions, to include diabetes, hypertension and migraine headaches, avoids going to the doctor because his employer would fire him if he didn’t go to work every day.

I would really like it if:

When a patient presented with symptoms, the patient could afford the appropriate testing to figure out the problem.

Every time I diagnosed a patient with a medical condition, the patient could afford the appropriate treatment, to include

Medication
Seeing a specialist
Physical therapy
Surgery

When a patient required frequent doctor visits for optimal management of medical conditions, the patient could afford to take off work, and could afford transportation to the doctor’s office.

Some sort of socialized medicine is the answer to this problem.

The way to make socialized medicine work is to include financial incentives for taking care of your health. For example, for:

Keeping your weight down
Not smoking
Attending doctor visits as scheduled
Taking your medication

The conservative approach of having people pay for all of their health care doesn’t work, because it just motivates people to avoid going to the doctor.

Thus, universal health care is not enough. Requiring everyone to have health insurance is a nice first step, but socialized medicine is the real answer.

Somatoform Disorders

2011-03-27T07:32:00.000-04:00

Somatoform disorders are medical conditions characterized by physical symptoms that have psychological causes. There are 5 somatoform disorders.

Hypochondriasis. A hypochondriac has a physical symptom which has a benign physical cause, but immediately suspects that the cause is something much more serious than the actual cause. For example, a hypochondriac might have leg pain and assume it's due to bone cancer.

Somatization Disorder. People with somatization disorder have severe physical symptoms with no identifiable physical cause. These folks have severe anxiety, but are not sufficiently in touch with their emotions to see them as emotional; rather, their emotions are experienced physically.

Conversion Disorder. In this medical condition, a psychological trauma is converted into a very real physical symptom. For example, a mother sees her child murdered and immediately becomes blind. There's nothing wrong with her eyes, but she can't see at all.

Pain Disorder. These patients have chronic pain with no identifiable physical cause. This is different from somatization disorder because the pain is not necessarily caused by anxiety. For example, a patient may have back pain after a motor vehicle accident; but then, months later, long after the pulled muscles should have healed, still has pain. It's as if the mind had gotten into the habit of being in pain.

Body Dysmorphic Disorder. People with this condition are obsessed with some aspect of their physical appearance which they consider to be flawed. Michael Jackson is often quoted as an example of a patient with this disorder. People with body dysmorphic disorder will sometimes have plastic surgery to correct a perceived defect in their appearance, when no actual defect exists.

Somatoform disorders are notoriously difficult to treat. The reason is that, if the doctor informs the patient that s/he has one of these disorders, the patient feels threatened. For example, if I have anxiety, and my anxiety manifests as back pain, and my doctor tells me that my back pain is just a manifestation of my anxiety, then my anxiety has no way to express itself any more. I will feel invalidated by the doctor, and frustrated. After all, if I had had the psychological insight to deal with my anxiety directly, I would have done so. The back pain is my only way of coping with my anxiety, and now the doctor has taken that away from me.

By the same token, if the doctor gives the patient with somatoform disorder and back pain a pain medication, the back pain will probably not be relieved. If the back pain is relieved, however, the patient's anxiety is still there, and now has no way to express itself. So it will manifest in some other way--for example as depression, or fatigue, or insomnia.

What I've found is that, if I simply develop a good rapport with my patients, and be a good listener, then their problems improve over time no matter what I do. Go figure.

Sometimes a little humanity is more effective than a lot of medicine.

The Importance of Vitamins

2010-12-05T16:45:00.000-05:00

Frequent complaints I hear in my practice include:

Fatigue
Muscle pains
Joint pains
Depression
Anxiety
Headaches
Weakness
Leg cramps
Skin problems

These symptoms and many others can be caused by vitamin deficiencies.

Of course, all of these symptoms can have other causes as well.

It turns out that, even with a fairly good diet, you can easily develop a vitamin deficiency. For example:

Patients who routinely take antacids can develop vitamin B12 deficiency, since the absorption of vitamin B12 from the diet depends on an acidic environment in the stomach.

Vitamin D requires sunlight. Not getting enough sunlight can cause vitamin D deficiency, resulting in weak bones (osteoporosis). I don't know about you, but the only time I get any sun is walking to or from my car.

Therefore, I recommend that all of my patients take a multivitamin daily. And, if you suffer from fatigue or chronic muscle pains, I suggest you take a Vitamin B complex as well.

The Courageous Ones

2010-11-27T10:15:00.001-05:00

The truly courageous among us are those who have been diagnosed with a terminal medical condition, yet find it within themselves to carry on.

I have quite a few patients with terminal illnesses. They are an inspiration. Whenever I am in the same boat, having seen their example will help me to face the same situation for myself.

After all, we are all going to die some day. Some will die unexpectedly, but most of us will have some warning. That warning might be a curse more than a blessing, since the anticipation of death is by far worse than the actual experience of dying.

So thank-you to all of you who have faced death courageously, and inspired the rest of us to find the inner strength and faith to do the same.

Purity of Spirit

2010-11-14T10:18:00.002-05:00

All human actions could be divided into 2 categories: those with ulterior motives, and those which are pure of spirit.

In our daily lives, we encounter many examples of impure actions: The politicians telling us what we want to hear (rather than the truth), the insincere sales person buttering us up to make a sale, our son complimenting us so we'll let him use the car. Even sincere communications often have ulterior motives: Fishing for a compliment, for example.

I would venture to postulate that the highest and best actions are those which are pure of spirit. I believe that we should endeavor to lead our lives at the highest possible level.

Having said that, what kinds of actions are pure of spirit? What kinds of actions should we strive for?

It turns out that the actions which are pure of spirit are not necessarily the huge, gigantic, world-shattering actions (like achieving world peace, engineering an arms reduction deal, discovering a cure for cancer). These huge accomplishments may or may not be pure of spirit.

But if you want to lead a life pure of spirit, all you have to do is do things which have no ulterior motivations: The simplest and most direct example of this is to help someone.

For example, you're walking down the street and see someone in need. You stop to help. It takes 15 seconds out of your day. That's an action which is at the highest possible level. At that moment, you are as good in God's eyes as the holiest monk.

I can walk down the street thinking that I'm something special because I'm a doctor and make a certain amount of money and have a certain level of intelligence etc. But then someone opens a door for me and allows me to go first, and I realize that that person is on a higher level than I am, and it humbles me.

I think when we get to Heaven we're going to find that everything is upside down. The people at the highest level there are going to be the people whom we don't even notice in our daily lives--the person watering the plants, the person running the vacuum cleaner, the person preparing our coffee, checking us out at the grocery store, etc. The people at the lowest rung of the ladder in Heaven will be the CEO's, the politicians, the lawyers, etc. (Well, maybe the lawyers won't be there...)

The Down Side to Pain Killers

2010-10-24T10:54:00.000-04:00

As a doctor, I like to relieve patients' pain. Pain is an awful experience, and it's tragic if the doctor could just prescribe a pain medicine to take away the pain but is reluctant to do so. So, in the right circumstances, I do not hesitate to prescribe a pain medication to my patients who are in pain.

But sometimes, when a patient is given pain medicines, the patient's general health declines. The patient becomes dependent on the pain medication, no longer tries to get healthy, and turns into a generally helpless and pitiful human being. It's a sad thing to see.

This doesn't happen to everybody who's on pain medicines. Not at all. But it happens to some people.

What I'm talking about is not addiction. It's just a natural consequence of being ill with chronic pain and being on pain medicines. And it occurs on a subconscious level, so it's not a conscious decision the patient makes to become a helpless person.

Here is an example: The patient has pain, sees the doctor, gets a prescription for a pain medicine, the pain medicine takes away the pain. The patient returns for a follow-up visit. The doctor asks, "How is your pain?" The patient thinks, "Well, if I tell him my pain is all gone, he won't give me more pain medicine." So the patient says, "It's a little bit better with the pain medicine, but it's still there." And the patient makes a point of walking slowly as if he were in pain (even though on the pain medicine he's not in pain any more).

It's just a sick role that the patient adopts in order to make sure that he continues to get the pain medication he needs. It's not an entirely illogical thing to do either, if you think about it.

But this helpless sick role can permeate the patient's whole personality, and infect every part of his life. For example, instead of using the relief provided by the pain medicine to do his job, the patient starts to think about applying for disability.

The solution to this problem of pain medicines killing a person's spirit is for the doctor to do more than just prescribe pain medicines. The doctor should also focus on the patient's entire health as a human being, for example enabling the patient to work at his job without pain, to be able to play with his children without pain, etc.

Pain medications can be a life saver, but we need to make sure they don't kill the patient's spirit, and make his general health worse instead of better.

Missed Opportunities to Get Healthy

2010-08-15T11:50:00.000-04:00

After practicing medicine for 17 years, I'm getting pretty good at helping people to get healthy and stay healthy. This includes helping people lose weight, get their cholesterol down, their blood pressure normal, their blood sugar normal, to no longer be depressed or anxious, and many others.

If you take all my patients, however, only a small percentage of them actually are willing to do what it takes to optimize their health.

For example, I might meet a new patient, assess his health, find that he has hypertension not optimally controlled, diabetes not optimally controlled, depression, headaches, fatigue and arthritis in the knees.

So I say to him, "Here's what I'd like to do: Put you on a blood pressure medicine, put you on a medication to relieve your depression. Once your depression and blood pressure are controlled, your headaches will likely go away. At that point, we'll put you on a diet pill and a diet and exercise regimen to get your weight down. This will help the pain in your knees. Losing weight will also help your blood pressure, at which point you may be able to get off the blood pressure medicine. It will also help your diabetes, and we may even be able to cure your diabetes if we get your weight down low enough. In the mean time, you should avoid eating sweets."

The patient responds, "Oh I don't think my blood pressure is that high, and I don't like to take medicines. And there's no way I could go without putting sugar in my coffee, I don't like the way it tastes without sugar."

So here I am, willing and able to help this person, but he doesn't want my help.

Happens every day.

I used to try to convince my patients to accept my help. But that created unnecessary stress, and I didn't enjoy my job.

Now, when a patient doesn't want my help, I just say okay, and go on to the next patient.

The patients who really want to get healthier are enough to make my day, and keep me going.

How to Handle People

2010-07-10T20:43:00.001-04:00

I walked into a restaurant, where two teenage hostesses were standing there talking. I said, "Hello, ladies!" They perked up, and one said to me, "Hello! You look nice today!"

I was not accustomed to getting such a positive response from the hostesses at this particular restaurant.

After some thought, I realized that the reason I'd gotten such a positive reception, is the way I started out the encounter. By saying, "Hello, ladies!" I put their subconscious minds into the mode of, "Charming man talking to attractive women, who behave like ladies". Now they had to respond in a manner consistent with the role I expected them to play.

In other words, I manipulated them.

But it's not so bad to manipulate people this way. By understanding how people's minds work, you help them to be the kind of people you want them to be.

Heretofore, I'd done it the other way around. I'd waited to see whether people were nice, and when they weren't nice I was disappointed.

Now I'm being pro-active, starting out by giving people subtle cues to be nice, receptive, etc. Whatever I need them to be in the situation.

So I'm transitioning from being a person who's frequently disappointed by the mean-spiritedness and pettiness of people, to being a person who can get anybody to be nice to him.

Pretty cool, huh?

Every Day is a Vacation

2010-07-10T20:27:00.000-04:00

Recently I took a few days off, but scattered about--a day here, a day there. And as is my custom on my days off, I came in to the office to answer a few messages, sign a few charts, etc.

Then sometimes I would be back at work seeing patients, and I would get confused, start to think that it's a vacation day.

And realized that, when I thought it was a vacation day, even if it was a work day, I enjoyed my job a lot more.

So now I consider all days to be vacation days. And I'm having a lot more fun.

Overwhelm

2010-05-15T09:12:00.002-04:00

This week I've been overwhelmed.

Some patients seem to think that if they tell the doctor about all the stressors in their lives, he will be more sympathetic. In my case, this just makes me feel burdened by their troubles.

For example, the patient presents with migraine headaches. We discuss the character and frequency of the headaches, etc. Then, while I'm typing away on my computer documenting the history, and deciding on a treatment plan, the patient starts telling me about his daughter getting arrested for shoplifting, his wife having an affair, his verbally abusive boss, losing his job, losing his house, having to go on unemployment, etc. After a couple minutes of this I'm feeling more and more depressed, and unable to function. How can I help patients if they're dumping all their (non-medical) problems on me?

I wish patients would just say, "I have a lot of stress in my life, and this is making my migraines worse." Then I would sympathize and we'd get back to the medical problem at hand.

Another source of overwhelm this week has been patients who want to squeeze as much medical care out of a 15-minute visit as they can.

It's not uncommon, for example, for a patient to fail to follow up in 3 months as requested at the last visit, but instead return 9 months later, and expect me to handle 6 or 7 issues in a single visit. After problem 3 or 4, I tell the patient I don't have time for anything else, and then the patient gets angry and thinks I'm a bad doctor. "The doctor said he didn't have any more time for me." One patient recently wrote a complaint letter saying, "I don't want to tell the doctor my problems and have him tell me he has other patients waiting."

I think I do more for my patients than most doctors do. I take pride in being a good doctor, for being thorough and pro-active. But there's only so much one person can do.

Many patients understand this very well. They're appreciative of my help, and willing to make follow-up appointments to handle problems we couldn't get to that day. These patients make my job a sheer joy.

Unfortunately, this week I had more than the usual number of the other kind of patients.

Morality vs Religion

2010-04-25T07:44:00.000-04:00

For me it's a daily anguish to see both the lack of morality in the people around me and the narrow-mindedness of the religious.

Other drivers tailgate me and cut me off, as if to say, "You're not important, get out of my way, me first." This is un-Christian, right?

But most Christians are no better. They want to turn the United States into a theocracy, with prayer in schools. They want to take away the rights of atheists, people of non-Christian religions, and gays.

On the one side are amoral members of the me-first generation, to whom other people have no importance other than as obstacles in the road.

On the other side are the fundamentalist Christians who are intolerant of any other ideas.

Stuck in the middle are people like me, who think people ought to just be nice to each other.

Rabble Rousing

2010-04-11T08:39:00.000-04:00

In my opinion, the new health care bill is a good thing.

When everybody has health insurance, everybody will be healthier. Instead of waiting until they're deathly ill and going to the ER because they have no health insurance, people will visit their primary care physician whenever they're sick (hopefully even before they get sick for preventive medicine visits).

It's too bad that the politicians whose party is not in power feel that they have to disparage the efforts of the party that is in power, in order to ensure that they will get re-elected. We need to all work toward improving our society, not just tearing down the opposition party. The founding fathers of our country did not envision political parties. The two-party system evolved later on, and is one of the most destructive innovations ever conceived.

The politician who gets elected is the politician who is better at criticizing the opposition. The winner is the one who sows the greatest discontent. Rabble rousing is the valued skill in our society.

Let's rise above this low level of existence. We should ask, "What do we want to accomplish?" The next question is: "How will we accomplish it?"

If we just walk around disparaging the efforts of people who are trying to make things better, we're part of the problem.

Let's all be part of the solution.

Misconceptions

2010-03-19T09:43:00.002-04:00

Here are some common misconceptions of patients:

I don't eat too much. If you eat less, you will lose weight. If you "hardly eat anything" and still don't lose weight, then you are still eating too much. After all, if you stopped eating altogether you would lose weight. So there must be some amount of food less than what you are eating (but more than nothing) which would result in weight loss.

I'm taking too many medicines. There's an idea that some people have that medicines are bad for you. While it's true that medications can have harmful side effects, doctors prescribe medications to people to help them. A doctor would not prescribe a medication unless s/he believed it to be beneficial. Also, many medications are only necessary because the patient has led an unhealthful lifestyle (usually eating too much); in this situation blaming the doctor for prescribing too many medications is doubly inappropriate.

But I feel just fine. Many serious medical conditions have no symptoms at all. Examples include high blood pressure, chronic kidney disease, pre-diabetes and high cholesterol. Patients who only seek medical attention when they feel bad are in for a rude awakening when their undetected medical conditions bite them in the ---.

The doctor didn't do anything. This is a frequent complaint after an emergency room visit. But ER doctors are only there to make sure the patient's life is not in danger. As soon as the ER doctor has determined that your life is not in danger, she will send you home. This is her job. To tie up the emergency room with non-emergent medical problems would be an inappropriate use of health care resources. To actually solve your problem, you would need to see your regular doctor.

I can't lose weight because I can't exercise. Even if you can't exercise, you can always lose weight by eating less.

I'm a bad person. This is the real thought behind all resistance to getting healthier. For example, if I say that the patient needs to lose weight, the patient thinks I'm saying that he's a bad person because he's overweight. If I say that the patient needs to avoid sweets, she thinks that I'm saying she's a bad person for eating sweets. Etc. Every person is by nature good, because every person is a child of God. The doctor visit is not an opportunity to be criticized for not taking care of yourself; rather, it's an opportunity to get healthier. And the healthier you are, the happier you will be.

Refills Made Simple and Easy

2010-03-12T08:54:00.002-05:00

When you need a refill, contact your pharmacy.

If there are no refills left on your prescription, your pharmacy will then contact the doctor for you.

This works for mail-away pharmacies as well.

You've already mailed your initial prescription in to the mail-away pharmacy. However, you don't need to mail your refills in too.

Once your pharmacy has the prescription on file, you can simply request refills directly from the mail-away pharmacy. The pharmacy will then contact your doctor for a refill authorization.

There are 2 ways to contact a mail-away pharmacy to request refills:

By Phone
By Internet (on the web site of the mail-away pharmacy)

This way, you don't have to keep mailing in prescriptions all the time, or taking them to your local pharmacy.

(Another advantage to this approach is that it saves trees.)

Pretend Therapy

2010-01-24T15:03:00.000-05:00

You know how young children spend a lot of their time pretending? Well, I think this is an untapped resource for adults as well.

Crazy people do this all the time. Of course, they don't realize that it's pretend. For example, a person with bipolar disorder might think that he's a secret agent. He goes into a shopping mall, imagining that he is seeking out spies. He believes he has ninja martial arts skills. He feels invulnerable. He believes himself to be able to handle any threat. He also feels valuable as a person--no insecurities plague him the way they do the rest of us.

Let's say your boss is being a jerk toward you. Well, the next time you go to work, imagine that you are secretly the president of the corporation, pretending to be an employee in order to gather information about management styles. You have the power to hire and fire at will.

Your experience of your a-ho boss will be different, I guarantee it.

Indifference Toward Vice

2010-01-10T11:54:00.000-05:00

One of the Yoga Sutras of Patanjali recommends indifference toward vice.

This means that we should endeavor to not be affected by the negative actions of others.

In police drama shows such as Law & Order, in every episode there is inevitably a conversation between the police detective and the criminal. It's a verbal sparring match, in which the criminal is trying to get the detective's goat, and the detective is trying to prove himself superior to the criminal.

This has always seemed silly to me. If I were a police officer or detective, as soon as I obtained evidence of the criminal's guilt and arrested him, I would just ignore him. He doesn't deserve my time and attention. He's just not worth it.

This I think is the way we should deal with all the people in our lives who would like to bring us down to their level. Just ignore them. They're not worth your time and attention.

Hierarchy Diagrams

2010-01-02T09:12:00.002-05:00

I don't know about yours, but my brain is a bunch of hierarchy diagrams.

Some examples:

If a patient has a cough, it's either infectious or non-infectious.

If it's infectious, it could be:

pneumonia
bronchitis.

If it's not infectious, it could be:

asthma
emphysema
acid reflux
medication side effect
post-nasal drip.

There are 4 classes of medications to treat hypertension, using the mnemonic ABCD:

A = Ace inhibitors and ARB's (e.g. Benazepril, Diovan)
B = Beta blockers (e.g. Atenolol, Carvedilol)
C = Calcium channel blockers (e.g. Diltiazem, Verapamil, Amlodipine)
D = Diuretics (e.g. Hydrochlorothiazide)

Classical music is divided into:

Baroque (e.g. Bach, Handel, Vivaldi, Mozart)
Classical (e.g. Beethoven, Brahms)
Romantic (e.g. Chopin, Rachmaninoff)
Modern (e.g. Stravinsky, Cage)

Books are divided into:

Fiction
Non-fiction

Food is divided into:

Carbohydrates
Proteins
Fats

People are divided into:

Nice
Not nice

Computers are divided into:

Mainframes
Servers
Desktops
Laptops
Notebooks
Netbooks
Handhelds

Hierarchy diagrams are extremely useful.

Hierarchy diagrams help us remember things. As a doctor, I have to remember a scary mass of facts. If they weren't organized somehow in my brain, retrieving them would be an impossible task.
Hierarchy diagrams are comforting. It's reassuring to know that there are 5 kinds of so-and-so--not 4, not 6 or some other number. And this is a fact I can rely on.

If you don't already use hierarchy diagrams to organize your life, I highly recommend them.

Making a Contribution

2009-11-21T08:27:00.001-05:00

When I was in college a good friend of mine, who had been raised in Bolivia, when talking about career plans of college students, would ask, "What contribution do you plan to make?" To George, one worked to "make a contribution" to society. I've always thought this was an admirable point of view.

It's amazing to me how many people in our society could work but don't. The bottom line is that the many are being supported by the few. In my opinion, everybody who can work should work. Everyone needs to make a contribution.

This is not only the right thing to do. It's also good for a person's physical and emotional health, to be making a contribution every day.

Not working is destructive to the spirit. Every day I see people who have gradually slid into a helpless outlook. In many cases, their health problems are more the excuse than the reason.

I am not by any means referring to those in our society who cannot work. Of course there are people who are legitimately disabled, or who are caring for children, or who are retired after a lifetime of contributing.

It's interesting to notice how someone who is employed in a fulfilling job will fight tooth-and-nail in the face of an illness or injury to get back to work as soon as possible. In contrast, the patient who is not working, or who is working in a boring job, will magnify his symptoms, exaggerate his disability, and generally delay his recovery in order not to have to return to work.

Why do some people have boring jobs and others have fulfilling jobs? Could it be that, when they were in high school and their parents told them to study so they could get into a good college, and they chose to go party with their friends, or play computer games, or send text messages, could this be when their choice of a life of drudgery was made?

When I was 35, I was unhappy, in a boring job. I decided to go back to school. I got a night job so I could take pre-med courses, then applied to medical school, spent 4 years in med school and 3 years in residency. Then at the age of 45 I began working in Hagerstown, Maryland as a family practice physician. And I'm still here.

There was a time in my life when I was so depressed that I found it difficult to go to work each day. Often I would call in sick, not realizing that my real sickness was depression. I felt alienated from society, cut off from all that was good in the world.

So I know how impossible it can seem to pull oneself out of the bottomless pits of inertia, inactivity, and despair that constitute the lives of so many people in our society.

Making a contribution is the opportunity that constitutes living in a free and affluent country such as the US of A. It's also an obligation. But, most importantly, it's a privilege.

Let's all make a contribution. Starting with studying hard in school, choosing a fulfilling career, getting and staying healthy, getting a job, and sticking to it even when times are hard.

Laziness

2009-09-19T21:21:00.003-04:00

Patients have a fear of being cared for by an incompetent doctor.

But competence is not usually the issue.

In my opinion, when a patient doesn't get the best possible care, it's more often due to laziness.

Here is a sample scenario. This is fictional, but not far from reality:

Mr. X, an 18-year-old young man, goes to see his internist, Dr. A, on Friday afternoon about a painful lump in his groin. The doctor examines him, and finds an abscess.

Dr A knows that the abscess needs to be incised and drained. This is a procedure which could be done right there in his office. But Dr. A has a golf game in an hour, so calls a local surgeon.

The surgeon, Dr. B, says this is not a surgery case. "Since it's in the groin it's a urology case, you need to call the urologist". So Dr A calls a urologist, Dr. C, but Dr C is in his car headed for the theater, and says to send the patient to the ER.

The patient goes to the ER as instructed, waits 6 hours to be seen. The ER doctor, Dr. D, listens to his story, examines him, and calls the urologist on call. This is a different urologist, Dr. F. Dr F tells the ER doctor to call a surgeon. "This is a surgery case, not a urology case".

So the ER doc calls a surgeon, Dr G, who is currently out to dinner, and instructs the ER doc to call the hospitalist doctor to admit the patient, and he'll see the patient the next morning.

The ER doctor calls the hospitalist, Dr H, who says that this 18-year-old patient is actually a pediatrics case, so the ER doctor needs to call a pediatrician to admit the patient.

The ER doctor calls the pediatrician on call, Dr I, who is asleep. Dr I is upset that he's being called about a patient who is not even his patient. But he sucks it up and comes in to the ER to admit the patient.

Meanwhile, about 10 hours have passed from the time the patient presented to the first doctor with the abscess. When Dr I arrives to see the patient, Mr. X not only has an abscess (much worse than it had been when he originally presented to the office of Dr A), but now he also has shaking chills. This means that the infection has spread to his blood stream. The patient's blood pressure is now dangerously low, meaning that he's in septic shock.

The ER doctor runs to the bedside, gives the patient antibiotics and fluids, and the blood pressure rises. But now the pediatrician says he can't admit the patient. "This patient belongs in the intensive care unit".

So the ER doctor calls the ICU doctor, Dr J, who refuses to admit the patient, saying, "This patient isn't sick enough for the ICU. After all, his blood pressure is normal now."

Finally, the ER doctor is able to convince the pediatrician to admit the patient.

The next morning, the surgeon, Dr G, comes in and sees the patient. He is alarmed by the deteriorated condition, yells at the nurses (as if it weren't his fault in the first place for not coming to see the patient the previous night), takes the patient to the OR, and incises and drains the abscess.

The patient makes a full recovery.

What does the patient think of all this? He thinks that the surgeon is his hero. He thinks that the surgeon is the only doctor who took care of him who knows what he's doing.

In reality, there were only 2 good doctors involved in the care of this patient: the ER doctor and the pediatrician.

(Incidentally, the pediatrician doesn't get paid by the patient's insurance company, because the insurance company says he's not the patient's doctor.)

Baseline Expressions

2009-09-09T08:37:00.001-04:00

A Baseline Expression is the expression a person has on his face when he has no expression on his face.

You can tell a lot about a person by his Baseline Expression.

Here are some examples:

Some people look like they've been abused all their lives, and are just waiting for the next bad thing to come their way.
Some people look like they're hostile toward everything and everybody.
Some people look happy, with a positive outlook.
Some people look cynical, like nothing's going to disappoint them because they're not expecting anything anyway.
Some people look sad.
Some people look perpetually amused, like they've just heard a good joke and would love to share it.
Some people look excited, like they're looking forward to what they're about to do.
Some people look kind and benevolent, like you could trust them with your feelings.

What is your baseline expression?

A corollary to the Baseline Expression is the expression people wear when they encounter strangers, such as when you're walking in the mall and someone meets your eyes. I call this the Stranger Expression. Some examples:

Hostility
Distrust
Fear
Arrogance
Friendliness
Compassion

What is your stranger expression?

Good Health is an Obligation

2009-09-07T20:52:00.001-04:00

I frequently hear excuses for why patients have been neglecting their health.

I've been under a lot of stress lately.
I've been on vacation.
I've been taking care of a sick uncle.

But the fact is, taking care of your health is a social obligation. Like putting on your clothes before you leave the house, or brushing your teeth, or paying your taxes, or not killing anybody.

Can you imagine:

Your boss comes to work naked, saying, "I've been under a lot of stress lately".
A corrections officer at the prison leaves the gates open, saying, "I've been on vacation".
A customer at Wal Mart walks out without paying for something, saying, "I've been taking care of my sick uncle".

There is no excuse for not taking care of ourselves.

Making Your Bed

2009-09-04T08:13:00.005-04:00

Let's say you wake up in the morning and see that your bed's unmade. You make the bed. You get it just right, all the corners lined up, the pillows fluffed, the bedspread without wrinkles. You stand back and admire your handiwork. It makes you feel good.

By making the bed, you have accomplished 3 things that make life worth living:

You straightened up something that was in disarray. You put something in its place. When everything is in its place the way it should be, it gives one a sense of security.
You completed a job which needed to be done. This gives one a sense of accomplishment.
You performed a creative act. People who notice the nicely made bed might ask, "Who made that bed?" And you could say with pride, "I did it."

But by making the bed, you've done much more than those 3 things:

Later on, when you get home from work and see the beautifully made bed, it will make you feel good. It will raise your energy level.

Other people who see the nicely made bed will also have their moods lifted. So by making the bed you have made a contribution to the lives of all the people who will see the bed that day.

And both you and those other people who will see the beautifully made bed, by virtue of having your energies raised, will have a rosier outlook, will accomplish more, will contribute more to the lives of others.

When you take this approach to every single task in your day, to every single task in your life, you really begin to reap rewards.

And the people around you benefit from your meticulous approach to life.

So make your bed. And make the world a better place.

Get Your Numbers Right for Optimal Health

2009-08-30T00:16:00.007-04:00

To achieve and maintain optimal health, get your numbers right:

LDL (bad cholesterol) under 130.
HDL (good cholesterol) over 40 (man), 50 (woman).
TG (triglycerides) under 150.
Blood sugar under 100 (fasting), 140 (post-prandial).
Weight under ideal body weight plus 10%.
Abdominal Circumference under 40" (man), 35" (woman)
Average Blood Pressure under 140/90

For more on these, follow these links:

Family Practice Dull?

2009-08-27T07:27:00.002-04:00

Lots of medical students choose specialties other than internal medicine and family practice, thinking that being a generalist is dull. Here are some diagnoses from my past 2 weeks of patients to contradict this idea:

Chronic Paroxysmal Hemicrania

Osteosarcoma

Bipolar 2

Sacral Fracture

Cocaine Use

Dyslexia

Rectal Prolapse

Erythrasma

3rd Degree Burn

Anosmia

These are all diagnoses which I made myself, rather than problems which the patients had already been diagnosed with by specialists.

Of course, interspersed among all the unusual diagnoses are plenty of sore throats and poison ivies. But I tell you what, when I get the simple cases, I'm happy. It's a relief to have something easy to deal with.

When the Doctor is Rude

2009-08-23T10:47:00.003-04:00

Sometimes I'm rude to my patients.

I admit it.

I'm constantly working to be nicer, but I'm not a finished work.

Here are some examples of things I've done lately that were rude:

The patient interrupts me when I'm talking, so I say, "Let me finish..." That's rude.

I ask the patient a question, and the patient's answer is not exactly what I asked. So I say, "That's not what I asked." That's rude.

I don't want to be one of those doctors who only have patients who are nice enough to not get upset when the doctor is rude. Patients shouldn't have to put up with rudeness from their doctor.

Of course, all of us are working constantly to be better people.

The reason I'm posting this is to let those patients of mine who read my blog and to whom I may have been rude know that I realize it and am working on it.

False Accusations

2009-08-07T07:35:00.002-04:00

A young man tells his girl friend he wants to split up. She gets mad, calls the police, and tells them that he threatened suicide. Six uniformed men show up and forcibly drag him to the ER, where he is held for 24 hours against his will. The whole time, he insists that he is not suicidal, and his ex-girl friend is just being vindictive. Unfortunately, even if the police and the ER personnel believe him, there's nothing they can do. It's the law.

Someone calls my office anonymously and says that a patient of mine is selling his Percocets on the street. What do I do? Most likely I will discharge the patient from my practice, even though I have no proof, and even though the person might be lying. Because there are plenty of other doctors out there, and I don't want to be prescribing opioids to a drug abuser.

In many cases the caller is being honest and has good intentions. But a certain percentage of such calls are doubtless malicious. Sometimes it's just that someone is pissed off at the patient for some reason, but sometimes it's because there's a child custody case pending and they want to make the patient lose custody of the children.

It's a damn shame that some malicious person can make trouble for a good person, but I know of no good way to handle the situation that is completely fair.

Great job!

2009-07-16T09:04:00.003-04:00

I sometimes wonder what it is that brings people in to see me over and over again, when each visit consists of me hounding them to optimize their health.

I try to be as pleasant as possible about it, but surely my patients dread these visits, where I'm telling them they need to lose weight, stop smoking, take their medicines, etc. Not only that, but each visit costs the patient money.

Finally today I just realized what it is that keeps them people coming back: It's their commitment to their health.

A patient may not succeed in losing weight or quitting smoking, but simply returning to the doctor and being reminded of these things demonstrates an admirable commitment to good health.

And for people who have the most difficulty doing what the doctor recommends, it's even more admirable. Because for them, it's harder. Yet they keep coming back.

Great job!

Finding ways to say YES

2009-07-05T07:58:00.003-04:00

Being a human being, is a privilege and a joy.

But so much of our lives seems to be about drama.

Someone gets their feelings hurt, lashes out, hurts someone else's feelings, then before you know it we're making ourselves even more miserable. We cut ourselves off from others. Enemies are made. Then we don't feel safe, because now the universe isn't benevolent any more.

And the joy of being human is lost.

This is the Hindu idea of Karma. Negativity begets negativity.

The answer is to break the downward spiral by not reacting to the negativity of others with more negativity.

Sometimes we create negativity needlessly. Such as when we say no, when we could just as easily say yes.

As a health care provider, I say no many times each day. Some of these no's are appropriate. Others are not. It's those inappropriate no's which are a measure of my personal limitations. Finding a way to say yes to people who come to one in need is a great way to work on one's humanity.

After all, being in a position where people come to you for help is a privilege in itself.

Why are Europeans thin?

2009-04-19T08:39:00.003-04:00

I just returned from my first-ever trip to France. Spent a week in Lyon. Had a great time.

During the entire week I spent in France, I probably saw about 5 overweight people. Can you believe it?

I often advise my overweight patients to avoid bread and sweets, but the French eat bread and sweets often.

I'm convinced that the reason they're thin over there is that they don't eat as much at every meal as we do.

If you go to a French cafe, the people are sitting around talking, drinking tea or beer or wine, and snacking on a croissant or something. They're not eating sweet rolls, and they're not eating huge meals.

Yesterday I went to Olive Garden and ordered linguini with meat balls, and a salad. I got a bowl of salad with about 4 servings of salad in it, from which I served myself a bowl of salad, followed by a second and a third. There was still salad left in the big bowl when my linguini came. I realized right then that I was already full, but since I'd ordered it I ate about half the linguini.

So essentially, in one meal, I ate about 2 complete meals--and still left half the linguini uneaten.

In Europe I would have been served a single small salad and about half the linguini that I was served at Olive Garden.

So now I have this theory that we in the U.S. are fat because we eat too much. Go figure.

Getting Younger

2009-03-28T18:15:00.008-04:00

It seems to me that getting healthier is the same thing as getting younger.

===

If a patient is 25# overweight, has pre-diabetes and hypertension, then loses 25#, no longer needs BP meds, and gets a 2-hour glucose tolerance test and discovers that the pre-diabetes has resolved, isn't it reasonable to say that s/he has gotten younger? I think so!

===

After all, if your health improves, then you'll live longer.

===

So let's all get younger (instead of older)!

Universal Healthcare is Inexpensive

2009-03-15T11:24:00.003-04:00

I think President Obama has it right when he says we need to revise our nation's healthcare system to reduce costs.

According to the World Health Organization, France has the highest-quality healthcare in the world. Yet they spend less per capita on healthcare than we do here in the U.S. Here is a list of selected countries' healthcare costs as a percent of GDP as of 2006:

U.S. 15%
France 11%
Germany 11%
Canada 10%
U.K 8%
Japan 8%

Yet these countries have universal healthcare, and we don't!

So it is possible for every single person in our country to have health insurance, and actually spend less money on healthcare than we do now.

The reasons for this are complex, but among other things are explained by 2 facts:

1. Emergency Room care is expensive. A patient can go to the ER and spend $1500 easily, whereas comparable service in my office would be about $130. Patients who have no health insurance go to the ER.

2. People without health insurance delay going to the doctor until they are very ill. From then on, you're playing catch-up--trying to get their diabetes controlled, dealing with the heart disease resulting from untreated hypertension, dealing with kidney failure, etc. These are expensive diseases to treat. If these people had health insurance, they'd find a primary care physician and be diagnosed much earlier. They might even avoid these medical conditions in the first place, by appropriate preventive medicine measures.

So three cheers for Barak Obama and his efforts to reform our healthcare system.

I'm Everybody's Friend

2009-02-05T16:26:00.004-05:00

My new motto is "I'm everybody's friend".

The idea is to have every patient who comes to see me have a positive experience.

Some co-workers have told me that this is an unrealistic expectation, because patients sometimes need to hear things they don't want to hear, and sometimes patients wants things they shouldn't have.

But I think there's a tactful way of saying no.

The bottom line is: The patient is the boss of his or her own health care.

What got me thinking about this is, I noticed that I always go out of my way with little children to make them have a positive experience--blowing up balloons, etc. So why don't I do the same thing with adults? Not blow up balloons, but make them have a positive experience.

So that's what I've been doing this week, and for the most part I've succeeded.

We'll see whether I can keep it going.

The start of a typical day

2008-11-15T08:42:00.007-05:00

8:00 Ms. B arrives early for her 8:15 appt.
8:14 Mr. A arrives 14 mins late for his 8:00 appt, is shown into a room.
8:15 Ms. B complains to receptionist that Mr. A got to go in first. Receptionist explains that Mr. A's appt was before Ms. B's appt.
8:15 On way to room to see Mr. A, Dr is told that Mr. X is on phone with chest pain.
8:20 Ms. B is shown into a room.
8:25 On finishing phone call with Mr. X regarding his CP, Dr goes to Mr. A's exam room. Mr. A has list of 5 problems he wants addressed.
8:30 Mr. C arrives on time for his 8:30 appt.
8:40 After addressing first 3 items on list, Dr tells Mr. A that he'll need to do the other 2 on his next visit. Mr. A is displeased, says that if his disability form isn't completed today he'll lose his job. Dr says he should have brought that item up first, now regrettably there's no time to address it. Mr. A goes up front to complain to office manager.
8:45 Dr goes into room to see Ms. B, now 45 minutes behind. Ms. B is visibly angry. Dr apologizes for keeping her waiting. Ms. B says she doesn't know why she's there, was told she had to come in. Doesn't see why she should have to come to the doctor when she feels fine. Dr explains that all patients with diabetes need to see the doctor every 3 months. Ms. B asks why. Dr explains. Dr reviews pt's labs, notices that cholesterol is high despite dietary changes, suggests a medication. Pt says she doesn't like to take medicines. Dr explains that a high cholesterol causes heart attacks, suggests pt cut back on meat, dairy products and eggs. Pt says she hardly eats any of those. Dr says, "Then medication is the only other option". Pt reiterates she doesn't like to take medicines. Dr refills patient's prescriptions. Pt is displeased that the doctor doesn't put 3 refills on each 90-day Rx. Asks why. Dr explains that if he put 3 refills on the Rx's, pt would not return for a year, and needs to be seen every 3 months. Ms B accepts the prescriptions and walks out in disgust.
9:15 Dr goes into room to see Mr. C, still 45 minutes behind. Apologizes for keeping him waiting. Mr. C says, "Hey, don't worry about it, Doc, I know you're busy." Dr smiles and shakes Mr. C's hand, grateful for the nice patients.

You can't please everybody

2008-11-13T04:59:00.004-05:00

The patient tells me about a problem. I type what he says into his chart, asking appropriate questions. While I'm typing, he's thinking, "Hm, well, he's not saying anything, what am I supposed to do? Well, I guess I'll tell him about another problem." So he tells me about another problem. I'm still typing up the previous problem, but I don't want to tell him to wait because people don't like that. So I keep typing up the previous problem, and simultaneously try to remember what he's saying about the second problem. I make appropriate sounds of acknowledging what he's saying. Then the patient thinks, "Well, he's not saying anything, so I guess I'll tell him about another problem." But I'm still typing up the first problem. So now I'm trying to hold the fact of 3 problems in my head. Then I just have to say, "Hold on there, dude, you're 3 problems ahead of me, give me a second to catch up, okay?" But this makes the patient upset, and he thinks I don't care about him, that I'm not a nice doctor, etc.

Here's another scenario: The patient tells me all her symptoms. I'm now typing into the computer, thinking about her symptoms, trying to figure out how to approach the problem, trying to figure out what the causes of her symptoms might be, what tests to order, etc. Since I'm not saying anything, she thinks, "Hm, he's not saying anything sympathetic, I wonder if he cares? I wonder if he really understands how serious this problem is." So she starts to tell me how terrible the problem is, how it's destroying her life. Then she tells me all the terrible stressors in her life, and how in addition to all those stressors this medical problem is just making things worse. I'm now listening to a terrible tale of woe, and getting more and more distressed all the time. This is getting really painful, and meanwhile I'm unable to think about her medical problem because I'm so sympathetic to her suffering. So I say, "Okay, give me a minute to think about what to do about this," but that just makes her irritated and impatient. She's thinking, "He doesn't care about me."

The common denominators in these 2 scnarios are my silence while I'm thinking or typing, and the presence of the computer in the room. When I'm thinking, the patient thinks I'm not doing anything. When I'm typing into the computer, the patient thinks I'm ignoring him.

Unfortunately, there's no good solution to this problem. I have to think. While I'm thinking, I can't talk. To think effectively, I have to not listen either. But I know from experience that when the patient speaks I have to listen, or I might miss something really important. So for me to think effectively about the patient's problem, there has to be silence.

Also, I have to type into the computer. The computer is the patient's chart. It's also where I go to look up recent test results, to read what consultants have reported, to see what I did on the patient's last visit, to see what medicines the patient is taking, etc.

Some patients understand that when I'm paying attention to the computer I'm paying attention to them, since I'm looking at their chart and thinking about their case.

Some patients understand that when I'm not talking I'm thinking, and they're not uncomfortable with silence.

Fortunately, I'm more committed to the health of my patients than I am to making them happy. If that weren't the case, I'd listen sympathetically, make a lot of eye contact, not type into the computer at all. Patients would love me, but I wouldn't be solving their medical problems. I wouldn't be a very good doctor.

But I want to make everyone happy. It hurts me when patients are unhappy with me. So I'm a good doctor who helps a lot of people, but daily has to deal with the disapproval of the people he's trying to help.

Actually, I'm not unique. This is the dilemma that all doctors go through, for one reason or another. It's not always the computer that's the problem, or the doctor's silence. There are lots of things that patients can be displeased with which have nothing to do with the doctor's competence. And a sensitive doctor will be taken aback by the patient's displeasure and to a certain extent be less able to do the job he needs to do to help the patient as a result.

On the other hand, should a patient never express displeasure with the doctor? That's no solution either. Sometimes, I learn some of the most important things about the patient's problem when the patient gets upset with me. And patients should always feel free to communicate with their doctor. This is also the time when I can learn how to be a better doctor and a better person.

So I try to let people know I care about them, and at the same time ask them politely to slow down, or give me a second to think about their problem, and just hope that I'm not offending them. And when they're offended anyway, I try to just realize that that's what being a doctor involves, and you can't please everybody.

Only patients who want to be healthy need apply

2008-11-02T07:47:00.017-05:00

What are your medical goals? Do you want to get healthier than you are? If so, how much are you willing to do? Are you willing to:

See the doctor regularly
Lose weight
Stop smoking
Take medication
Exercise
Be on time to doctor visits
Keep all appointments with doctors
Eat a healthy diet

I have many patients who are not willing to do some or all of the above.

I believe that patients are the bosses of their own medical care. A patient who doesn't want to do certain things is okay with me. But I don't necessarily have to be that person's doctor, either.

The problem is that health care involves a lot of work. If the patient is not willing to do anything, then the doctor has to do more. This puts a strain on the doctor's resources. In effect, the patient is saying, "I don't want to do anything, Doctor, so you need to do more."

It may seem that the doctor should be willing to do more, since he's being paid for his time. But it doesn't work like that. Here are some examples:

The patient doesn't want to go to the doctor more often than once a year. She brings with her a long list of complaints. The doctor now has an unpleasant choice to make: either tell the patient she needs to return for another appointment to address some of her issues, or take more time with the patient and keep his other patients waiting.

Under Medicare's new Pay for Performance program, doctors incur financial penalties from Medicare for not keeping their patients healthy. A diabetic who isn't willing to stop eating sweets, for example, will cost the doctor money.

The patient who only wants the doctor to write prescriptions for a sore throat, and doesn't want to take care of himself, still has to listen to the doctor's suggestions to lose weight, get blood tests, stop smoking, etc, and has to say no to each of the doctor's suggestions. This is unpleasant for the patient, so the patient gets irritated with the doctor. The doctor's feelings are hurt because the patient doesn't seem to like him. The doctor doesn't have the option of not making those suggestions, since if he did not make them he wouldn't be a good doctor. The patient thinks the doctor is unpleasant, the doctor thinks the patient is unpleasant, and the whole interaction is unsatisfying for both parties.

So I've decided to not see patients who are not willing to take care of themselves.

Helping people get and stay healthy is a wonderful experience. I thoroughly enjoy helping people all day long. There's no better job in the world. But there are so many patients out there who would like to be healthier, who are willing to do whatever it takes, that I don't need to waste my time on patients who aren't. It's as simple as that.

Moving from Helpee to Helper

2008-09-07T13:47:00.003-04:00

One way to see whether you're getting healthier is to ask yourself: "Am I a helper or a helpee?"

If you are healthy, you can help others in your life. If you are extremely unhealthy, you will be spending all of your time seeking help from others.

Some patients I see are healthy enough to help others, but are for some reason committed to being helpless. Some patients I see are very unhealthy, but still manage to focus on helping others.

So it's partly one's attitude.

Patients who want to be healthier might want to examine their lives to see whether they are primarily a helper or a helpee. No matter where you are on the continuum, you will benefit from moving closer to the helper end of the spectrum.

Poor Customer Service

2008-08-29T05:44:00.004-04:00

I had a bad customer service experience at my car dealership this weekend. When I arrived (for my 5000-mile maintenance appt) there were people standing around waiting expectantly for one of the attendants to notice them. There was no organized way of figuring out who was next in line, so all of us customers were eyeing each other with suspicion. The attendants didn't seem to care about us. Finally, one approached me with a list of appts. I told him my name, but I wasn't listed. Apparently my appt had been forgotten. I waited around for 10 more minutes, then left in disgust.

This is not much different from the experience some of my patients have at my office. They arrive on time, only to find that the doctor is 45 minutes behind schedule. Talking to other people in the waiting room, they discover that 2 other patients have appts at the same time they do. Sometimes they get fed up and leave in disgust. When they do wait it out, they sometimes find me to be distracted, in a hurry, or paying more attention to my computer than to them. Or I help them with 2 problems but tell them I don't have time for a third.

My experience at the car dealership has caused me to be more sympathetic to disgruntled patients, and to resolve to make my patients' experience at their doctor's office rewarding rather than frustrating.

This is something that I feel is well within my capabilities. Some doctors would not agree. They would say that, with the state of modern managed care, a doctor cannot survive financially without seeing at least 4 patients per hour. This means 3 problems will never be addressed in one visit. Also, since patients will come in with emergencies, there's no way you can avoid keeping patients waiting sometimes.

However, even when a patient has to wait, I can be gracious enough to apologize for the delay when I walk in the room, and listen sympathetically to every problem. Most patients are willing to tolerate occasional delays, if after their wait they are greeted by a sympathetic doctor who really is interested in them and wants to help them.

Since I started working on my manner with patients, I have been pleasantly surprised to find that, when you make an effort to make the other person's experience more rewarding, you make your own experience more rewarding as well.

You may wonder, "Well gee, after 10 years in practice, why didn't he learn this years ago? Why don't they teach doctors to be sympathetic to patients' complaints right from the beginning?"

It's true that there is very little if any training in bedside manner. This is one problem. Medical schools and residency programs really should start training future doctors in how to make patients' experiences with health care providers more positive.

However, there really is a huge problem staying financially viable when you are a primary care doctor these days. You simply cannot take adequate time with each patient and still stay in business. So your doctor is sitting there trying to be sympathetic to your problem, while at the same time he's thinking about the 3 patients who are already in rooms impatiently awaiting his arrival. He cannot book 2 patients per hour and spend 30 minutes with each patient, because then he wouldn't be able to pay his office staff, pay his rent, etc.

Finally, the doctor's first allegiance HAS to be to the patient's health. There are many doctors out there whose first allegiance is to the patient having a positive experience, who are loved by their patients, but who don't keep their patients healthy. A doctor who is always nagging you to lose weight, to stop smoking, etc is a better doctor than one who always tells you what you want to hear.

It's taken me 10 years of practice to find a way to have all 3: financial viability, optimal health care, and happy patients. I don't achieve this goal with every patient encounter--far from it--but I think I've figured out how to achieve it now. Each day my skills improve. And with each satisfied patient, my job becomes more enjoyable and rewarding.

It's difficult to be nice all the time

2008-08-24T19:48:00.005-04:00

A doctor should be nice to patients at all times.

Unfortunately, this is easier said than done.

Because I want everyone to be happy with me, when a patient shows displeasure with me I tend to get upset. Sometimes I deal with this by confronting the patient about the problem (which has the advantage of being direct but can put people on the defensive). Sometimes I deal with it by closing down emotionally (which leads the patient to conclude that I don't care about him or her).
And sometimes, despite the best of intentions, I'm actually rude.

Patients' reasons for showing displeasure for the doctor vary widely. Here are just a few:

The patient was already having a bad day before arriving at the doctor's office.

The receptionist was rude to the patient.

The patient had to wait a very long time for the doctor.

The patient just doesn't like doctors in general.

The patient is upset about something the doctor did in the past.

The patient thinks the doctor is incompetent.

The patient is dissatisfied with the care being received from the doctor.

The patient thinks that showing displeasure with people is the best way to get them to help.

The doctor pays more attention to his computer than to the patient.

I would love to be able to make everyone happy, give the best possible health care, and keep the practice financially solvent, all at the same time. Unfortunately, these 3 goals are sometimes incompatible. For example:

The patient wants me to address 4 problems on a visit and there's only time for 2. Spending extra time with one patient would make other patients wait (they'd then be unhappy).

The patient wants me to prescribe narcotics despite a history of narcotics abuse. This would endanger my medical license, and then I wouldn't be able to care for anybody's health.

The patient wants me to be on time, even though doing so would mean not addressing emergencies as they arise during the day. People would die.

The patient wants me to declare her to be disabled even though I don't think she is. This would be unethical. I would make the patient happy, but my integrity would be sacrificed.

The patient wants me to fill out a disability form but not charge for the service. The practice would go out of business if free services were routinely provided.

The patient wants me to prescribe a medication over the phone without seeing him. In most cases this would not result in the best medical care, and in some cases would endanger the patient's life.

The patient wants me to have reviewed her entire chart before every visit, so that I never have to look anything up. This would make a 15-minute visit take 30 minutes, and the practice would go out of business.

The patient wants me to spend the whole visit making full eye contact, devoting all my attention to her, and not entering anything into the computer. I would then have to spend 15 minutes after the visit entering everything into the computer, making a 15-minute visit take up 30 minutes of my time. The practice would go out of business.

Recently I cut way back on my schedule. I'm now seeing about 30 patients less per week than I used to. That way, I can spend more time with the patients who need extra time, and not make people wait so long.

I'm also making a concerted effort to be nice to every single patient, no matter how displeased with me the patient gets. Some days I succeed in this endeavor, some days I do not. Each time I am not nice to a patient I feel bad about it, and resolve to do better next time. If any of the readers of this blog has any suggestions on how to keep one's cool in the face of displeased customers, I'm open to hearing them!

One Secret to Enjoying Life

2008-08-14T20:46:00.009-04:00

In our modern world, one source of stress is having to live by the clock.

It's helped me a great deal to eliminate insofar as is possible the need to hurry.

Allow enough time for each of your tasks. Try to set it up so that you can take extra time if you want.

Just having an unlimited set of time laid out before you which you can fill any way you want is quite relaxing and rejuvenating. I think this is one reason why we enjoy weekends and vacations so much.

The person who is at a very high level of self-actualization enjoys each and every minute of the day, concentrates fully on each and every task. It's impossible to be in the here and now if you're worrying about what you have to do next.

Know Your Medical Conditions

2008-07-20T18:29:00.002-04:00

In your medical chart, the doctor can see your

Medical Conditions

Medications

Allergies to Medications

Surgical History

Family History

I am often surprised to find that a patient does not know what his or her medical conditions are, and does not know the names of his or her medications.

If you do not know these things about yourself, then just ask your doctor to print out a copy of your medical conditions, medications and allergies.

In any case, I suggest you go online and set up a Personal Health Record. For example, you can do this inside of Google at https://www.google.com/health/p/.

Interrupting Patients

2008-06-20T16:54:00.002-04:00

Recently a very nice patient of mine complained to my office manager that I interrupt too much.

As a result of getting this valuable feedback, I decided to go a whole day without interrupting anybody--as an experiment. By midday, I had discovered that I was interrupting everybody constantly. It was a much bigger problem than I had imagined.

Since then I have made a point of not interrupting people--either patients or anyone else. I still slip up from time to time.

As a result, I have found that people enjoy my company more, and I enjoy their company more. My job--which I already enjoyed thoroughly--has become even more rewarding. Instead of just getting along with patients, I'm actually having quite positive interactions, and even feel that some of my patients are my friends as well as my clients.

Artificial Sweeteners Cause Weight Gain

2008-06-01T08:55:00.003-04:00

WASHINGTON — Want to lose weight? It might help to pour that diet soda down the drain. Researchers have laboratory evidence that the widespread use of no-calorie sweeteners may actually make it harder for people to control their intake and body weight. The findings appear in the February issue of Behavioral Neuroscience, which is published by the American Psychological Association (APA).

Psychologists at Purdue University’s Ingestive Behavior Research Center reported that relative to rats that ate yogurt sweetened with glucose (a simple sugar with 15 calories/teaspoon, the same as table sugar), rats given yogurt sweetened with zero-calorie saccharin later consumed more calories, gained more weight, put on more body fat, and didn’t make up for it by cutting back later, all at levels of statistical significance.

Source: http://www.futurepundit.com/archives/004997.html

Clean the Gunk out of your Carburetor

2008-04-26T09:41:00.003-04:00

Many patients think that statins are unsafe. Statins are drugs used to lower cholesterol. Examples include Lipitor, Crestor, and Zocor. (The generic name always ends in "statin"--Lovastatin, Atorvastatin, Pravastasin, etc.) Such drugs have 2 significant side effects--muscle cramps and elevated liver enzymes. The muscle cramps aren't so scary, but the elevated liver enzymes tend to put some patients off. Which is a shame, because if your cholesterol is high, then taking a statin is one of the best things you could do for yourself. I take one myself every day.

The liver has the job of breaking down poisons that you ingest. The body considers any medication to be poison. Thus, the liver breaks down medications. Some medications are harder for the liver to break down than others. Statins are an example of this. That's why we do blood tests periodically to check the liver enzymes on any patient who is taking a statin. If the liver enzymes start to rise, we stop the statin. The liver enzymes come back down to normal. There's no danger in the small amount of liver enzyme elevation we commonly see on statins.

I liken statins to STP, the stuff you pour in the carburetor of your car to clean the gunk out of the engine. Cholesterol is the gunk in the body's engine. Gunk (cholesterol) clogs the works (arteries), so that your engine (heart) can't get enough gasoline (blood) when it needs it the most. This results in heart attacks. Clean out the gunk and you'll live longer. It's as simple as that.

Discharging Patients

2008-04-16T23:17:00.009-04:00

Sometimes it becomes necessary to discharge a patient from my practice.

Here are some reasons this can occur:

The patient is discontented with the services I provide.
The patient upsets a member of my staff.
The patient doesn't pay his or her bill.
The patient fails to show up for appointments at my office.

Not every doctor is right for every patient. The same qualities in me which are so appealing to many of my patients are irritating to other patients. Examples are:

My commitment to optimizing my patients' health. Not everybody wants to get well.
My use of computers. Many patients find my use of a computer distracting.
Bringing patients back for frequent doctor visits. Many patients don't want to go to the doctor any more often than absolutely necessary.

Fortunately, there are many primary care doctors in my community. Patients who are not a good fit for my practice style still have plenty of other doctors to choose from.

Take a Quiz

2008-03-20T02:32:00.002-04:00

Go to http://123facts.com/ and take a quiz on any trivia topic of interest. Several of the quizzes there were written by me. This is one of my favorite web sites, and one which you might find amusing. Some of the quizzes are on medical topics.

Nice Patients

2008-03-14T06:20:00.002-04:00

Some patients make my day. These are the patients who have a positive attitude, treat other people with respect, and are genuinely interested in becoming healthier.

Some patients are less enjoyable to treat, though I care for them just as thoroughly. Some people seem to think it's a crime to smile. Some seem to be resentful about having to be at the doctor's office to begin with. Some are distrustful of doctors; apparently they think doctors are out to get them or something (rather than help them live long and healthy lives).

When I first meet a patient who seems distrustful, hostile or downright impolite, and after patient communication and evaluation, discussion of options, etc, the patient begins to open up to me, and relaxes, it's very rewarding for me as a doctor. I figure such patients have had bad experiences with doctors in the past.

Some people are just grumpy, though, and there's nothing I can do to change them. Someone was joking that we should allocate one day a week dedicated to grumpy patients, see them all on the same day. It would have to be a Friday though, because I'd need a couple days to recover!

Why do patients sometimes sabotage their own healthcare?

2008-03-09T11:01:00.006-04:00

Some patients don't get the best healthcare they could from their physicians because they put up roadblocks to their treatment. Here are some examples:

"I don't want to take cholesterol medicines because they can damage the liver." (This is a misconception.)
"I don't like to take medicines." (I've never understood this one, perhaps someone can explain it to me.)
"I don't like to go to the doctor."
"I don't want to take that medicine because my friend had a bad experience with it."
"I don't want to take a medicine every day. I just want something I can take when I have symptoms." (But the medications you take as needed are often more dangerous than the ones you take every day.)
"I'm not willing to lose weight."
"I'm not willing to quit smoking."
"I'm not willing to stop eating sugar, even though I have diabetes."
"I want to lose weight, but I'm not willing to eat less. I barely eat anything now."
"I don't need a colonoscopy. I don't have any symptoms." (But cancer in its early stages has no symptoms, and a colonoscopy can prevent colon cancer.)
"I stopped taking all my medicines. I was taking too many pills."

As a result of these roadblocks to care, I am unable to help some patients as much as I help the others.

Side Effects

2008-03-02T19:58:00.002-05:00

Side Effects are just things that drugs might do, not things that they will do.

Patients often tell me they don't want to take a medication I recommend because of the side effects.

When this happens, I wonder whether they understand that side effects are only possible, not probable.

For example, let's say a drug has a 1 in 100 chance of causing muscle cramps. I tell the patient this, and the patient says, "Oh, well, I have enough muscle cramps already, I don't need more", and declines the medication.

Go figure.

Alcohol Excess

2008-02-26T05:37:00.007-05:00

The safe limits of alcohol consumption vary by gender. The following is the maximum number of alcoholic beverages per week, per day and on any single occasion:

Per week: Man: 10 Woman: 7
Per day: Man: 2 Woman: 1
On any single occasion: Man: 4 Woman: 3

If you customarily drink more than any one of the above limits, then you are drinking too much for your health, and should reduce your consumption to the safe limits.

Cheaper Drugs

2008-02-23T20:32:00.003-05:00

Your doctor is understandably more concerned about your health than about your pocketbook. In the rush to take care of her/his patients' medical problems, the physician may not pay much attention to prescribing the least expensive medications. But there is something you can do to ensure that your drug costs are minimized.

Bring your insurance company's formulary to each doctor visit. The formulary is the list of medications covered by your insurance company. A formulary typically has 3 tiers, or levels of cost of drugs. First-tier drugs are generics, these are the cheapest. Second-tier drugs cost more. Third-tier drugs cost the most.

So bring your formulary with you to each doctor visit, and ask the doctor when s/he prescribes a medication whether there's a lower-tier alternative on the formulary.

Also ask your doctor to go through the list of medications you take on a regular basis to figure out whether any of them can be replaced by lower-tier alternatives on your formulary.

Universal Healthcare Coverage

2008-02-10T11:15:00.000-05:00

The prospect of universal healthcare raises fears of government interference in medical care, higher taxes, and lower pay for physicians. Yet none of these would be an issue if we simply extended Medicare to all citizens.

Medicare already exists, and is a system which works. When my patients over 65 come see me, they have an insurance plan--Medicare. From my point of view, this is the same as any other health insurance. The care I provide for these patients is the same as the care I provide for all my other patients.

Extending Medicare to all citizens would not increase healthcare costs at all. The money that patients' employers now pay into their private insurance plans would simply now go to Medicare.

Health care costs would actually decrease. Patients who now go to the emergency room for their health care because they have no health insurance would now have insurance, and would go to office-based physicians for their care. Emergency care is much more expensive than ambulatory care.

Patients who now only go to the ER for health care, and only when they're seriously ill, would now see a primary care physician on a regular basis. So their medical conditions would be detected and managed much earlier. So they wouldn't have a chance to worsen to the point of needing dialysis, hospitalization, and other serious and expensive complications of inadequate health care.

Of course this will never happen, because the huge private health insurance companies have a powerful lobby in Washington. If we put all citizens on Medicare, the health insurance companies would go out of business.

Doctors Should Get Sick Too

2008-02-08T04:13:00.000-05:00

Doctors should get their patients' illnesses sometimes.

Every illness that I experience gives me more compassion for my patients.

If you haven't actually suffered from an illness, you can't know what it's like.

An excellent example of this principle is psychiatric illnesses, such as depression and anxiety. People who say that depressed people should just talk to their friends (instead of taking a medication, or seeing a psychiatrist or counselor) have no idea what psychiatric illnesses are. Depression is being unable to see life as anything but hopeless, no matter how hard you try. Anxiety is being filled with fear 24 hours a day.

Another example is pain. If you haven't experience pain so bad that you've actually seriously considered suicide as a way out of it, then you may not think that a patient's pain is any big deal. Some doctors actually refuse to prescribe strong pain medications for their patients, for fear of addicting them to narcotics. While it's true that drug addiction is a common problem, so is severe pain. A good doctor relieves his patients' pain.

Itching is another example of this principle. A really bad case of poison ivy can drive you absolutely nuts. Most people have no idea. All they've ever experienced is a mild itch of some dry skin, for example, or a mosquito bite. Itching can be so bad that you can't pay attention to anything else, can't concentrate, can't even function in society.

Even something so simple as being on a daily medication has made me a better doctor. So many days I forget to take my medication. Used to be, when a patient said to me that he would forget his medication some days, I used to get frustrated. Now I just think, "Man, it's really hard to remember to take your medicine every day."

My Personal Approach to Using Phentermine

2008-02-06T04:58:00.000-05:00

I like to tell my patients that you have to meet phentermine halfway. You can't just take it and think, "Hm, I'd like a pizza. I guess that phentermine isn't working." You have to ask yourself, "Can I live without the pizza?" Before taking phentermine, perhaps the answer was no. After taking it, the answer is yes. That's the difference that phentermine makes.

Also, for me, eating small amounts doesn't make a lot of sense. When I sit down to eat a meal, I want to eat. So for me, skipping meals makes more sense than eating small meals. I know that this does not agree with most authorities, who say you should not skip meals. But whatever it takes to lose weight and stay thin is more important than not skipping meals, in my opinion.

What I do is this: I never eat breakfast anyway (not hungry in the morning). My first meal is lunch. I take my diet pill after lunch, and then I don't eat anything the rest of the day.

Foreign Language Patients

2008-02-02T20:21:00.001-05:00

In addition to English, I speak fairly fluent Spanish, pretty good French, and passable Russian.

So, if you're looking for a doctor, and you speak one of the above languages natively, come see me! I'm always looking for more opportunities to practice my other languages.

Good Health Is A Work of Art

2008-01-25T03:30:00.000-05:00

The management of a patient's health is the gradual but steady optimization of health parameters. For a doctor, this can be an aesthetically pleasing activity.

The healthy patient has the following values within the normal range:

Cholesterol
Triglycerides
Weight
Blood Sugar
Blood pressure

The healthy patient also has little or none of the following:

Worry
Depression
Pain
Insomnia
Fatigue
Addictions

When a patient first comes to me, he or she may have some of the above factors out of whack. I see my job (partly) as helping the patient to optimize these parameters. With patience, persistence, and teamwork, the patient and doctor work together over time to get the patient as healthy as possible.

This is an effort in which both the patient and doctor can take pride. Optimal health truly is a work of art.

Being Part of the Solution

2008-01-23T01:28:00.000-05:00

Those who are in service professions (such as health care) can take great pride in the help they provide to people by the work they do.

But sometimes we make things worse instead of better.

This can happen when we allow our personal agendas to get in the way of helping people.

When a person in need (in my world this is called a "patient") goes to someone whose function is to help, and only gets roadblocks or attitude, this is inappropriate and counterproductive.

The question we have to ask ourselves is, "Am I part of the problem, or part of the solution?"

The Doctor As Pill-Pusher

2008-01-19T17:21:00.000-05:00

I freely admit that I'm a pill pusher.

Often the solution to a scary medical problem is to take medication. We have so many miraculous medications available today.

Many patients hate to take medicines. Yet medications can do so much good!

Here are some examples:

One pill a day can bring high blood pressure down to normal, and avoid stroke, heart attack, blindness, erectile dysfunction, and kidney failure

One pill a day can bring high cholesterol down to normal, and avoid a heart attack

One pill a day can transform depression and anxiety so severe as to make one contemplate suicide into enjoyment of life and freedom from stress

One pill a day can break one's addiction to food, and allow one to be thin again

It's easy to lose weight

2008-01-15T17:41:00.000-05:00

The vast majority of chronic medical conditions are caused by excess weight. So, if you want to live a long and healthy life, get thin and stay thin!

My favorite way to get thin and stay thin is to take diet pills and eat a healthy diet.

A healthy diet is, above all, a low-calorie diet. There are a thousand ways to achieve this. Some examples:

1. Don't eat when you're not hungry.
2. Keep busy.
3. Substitute no-calorie or low-calorie foods for your favorite foods. For example, a cup of coffee with milk might take the place of a whole meal, since caffeine can fight hunger. Drink diet drinks instead of soft drinks.

Avoid foods which raise your blood sugar and, thereby, cause rebound hunger 2 hours after you eat them. These are high-glycemic-index foods, which can be characterized as "white and fluffy" -- sugar, bread, pasta, etc.

The diet pill I prescribe is phentermine. It is a stimulant which reduces your appetite. It is most effective if taken along with an antidepressant in the SSRI class, such as Prozac. However, it can be effective alone.

My personal approach is to have a decaf plain latté for breakfast (just milk and espresso), eat a large lunch (no sugar or bread, but I do eat pasta), then take my diet pill. For the rest of the day and night all I consume is unsweetened iced tea, since the diet pill has taken away my appetite.

Patients' (Unreasonable) Expectations

2007-12-28T20:14:00.000-05:00

It's difficult for a primary care doctor to satisfy all patients' expectations.

What do you want from your doctor?

Here are some expectations that I meet with daily:

1. The doctor should not tell me to lose weight.
2. The doctor should see me once a year and handle all my problems at that one visit.
3. The doctor should listen to me when I ramble on and on without interrupting me, even though there are other patients waiting, but still take the time to handle all of my issues.
4. The doctor should not prescribe a bunch of medications; I don't like to take medicines.
5. The doctor should be willing to see me even if I show up 45 minutes late for my appointment; after all, I often have to wait 45 minutes to see him.
6. The doctor should see me whenever I call, not tell me to go to the emergency room just because I call on a Friday afternoon when his schedule is full.
7. The doctor should meet me in the emergency room whenever I have an emergency.
8. The doctor should renew my disability papers even if he doesn't think I'm disabled.
9. The doctor should fill out forms for me even without seeing me.
10. The doctor should prescribe medications to me without seeing me, so I won't have to go to his office; after all, I know what's wrong with me.
11. The doctor should lie for me so that I can take off work when I'm not sick, get out of paying a plane ticket, do day care even though I have a drug abuse history, etc.
12. The doctor should leave certain things out of my chart so that I won't have to pay higher insurance premiums, such as asthma, depression, and chest pain.

Any patient who wants his or her doctor to do any or all of the above should find a doctor other than me. I pride myself on being a good doctor. But I will never be a doctor who does whatever the patient wants.

The 15-Minute Doctor Visit

2007-11-23T07:11:00.000-05:00

Why are doctors always in a hurry? Why can't I come to the doctor once a year, save up all my medical problems, and get them handled in a single visit?

The answer is "managed care". Insurance companies reimburse doctors based on certain criteria. These criteria are satisfied by a 7 1/2 - minute visit. Thus, any primary are doctor who sees patients for longer than 7 1/2 minutes on average is giving out free services. Free services are okay from time to time, but a doctor's office will not be able to continue helping patients if its balance sheet is red.

My visits are scheduled at about 12 minutes on average. Some visits are longer, some shorter. The other day I spent over an hour with a patient. Sometimes, there's an emergency, and that's just what it takes. But if it's not an emergency, I keep the visit down under 15 minutes, and bring the patient back more frequently.

So, if you have medical insurance, and you have several medical problems to address, don't be surprised if the doctor brings you back for frequent visits in order to handle them all, rather than taking care of everything in a single visit.

There are doctors out there who do not accept insurance, who charge for their time. A 30-minute visit costs twice as much as a 15-minute visit. But the patients are expected to pay in full at time of service, and the doctor does not bill the insurance company.

Personally, I'm quite happy with the system in which we work. I like seeing lots of patients each day, handling 2 or 3 problems in a 15-minute visit, getting a lot done, and bringing patients back frequently. I find this quite stimulating. But many patients don't like feeling rushed.

This system is particularly frustrating for the son or daughter of an elderly patient, who might live an hour away, and has to take time off work to drive all the way here to pick up his father and bring him to each doctor visit.

This situation is a result of the way our health care system is structured by the insurance companies. It isn't because the doctor doesn't place importance on the patient's time, or doesn't care about the patient.

The Struggle to Remain Compassionate

2007-11-22T13:12:00.001-05:00

We all struggle to maintain our ability to be compassionate. It's especially challenging for those in health care, because we deal with people in crisis all day long. But this is a daily struggle for people in all professions.

I think that the soul of compassion is respect. I don't quite understand this, actually. Perhaps someone can explain it to me. But when I look at another human being with respect, it makes it much easier for me to help him or her.

So I endeavor to be respectful toward all of my patients.

In spite of these efforts, however, there are times when my compassion reaches its limit. An unkind word slips out. I don't do everything I could do for a patient. Afterwards, I feel ashamed. But then I resolve to do better, and ask God for the strength to be a better person next time.

This is the essence of personal growth--at least in the health care professions!

Diet Pills

2007-11-18T19:04:00.000-05:00

I'm now prescribing diet pills again. The diet pill is phentermine, which works best if taken along with an SSRI (such as Prozac, Lexapro, Celexa, Zoloft, etc) but which can be taken alone as well.

Chronic Fatigue Syndrome and Fibromyalgia

2007-11-18T18:57:00.000-05:00

CFS and Fibromyalgia are two aspects of the same disease. This disease is a dysfunction of the hypothalamus. I'm currently taking a course from Dr. Jacob Teitelbaum (http://endfatigue.com), so that I'll know how to treat these syndromes.

I'm very excited about the prospect of helping my patients who have CFS and/or fibromyalgia.

Chronic Fatigue Syndrome is characterized by debilitating daily fatigue, brain fog, and insomnia.

Fibromyalgia is characterized by generalized achiness.

Is your life a hurricane?

2007-10-19T22:16:00.000-04:00

Our emotional state affects our physical health.

To be physically healthy, make sure you are striving to be emotionally healthy as well.

How to be emotionally healthy is a subject which would take volumes, but some strategies are:

(a) Don't take on other people's problems and responsibilities.
(b) Pamper yourself.
(c) Get plenty of sleep.
(d) Avoid stress-inducing substances, such as sugar.
(e) Get rid of toxic friends.
(f) Find a job you enjoy, and where people treat you well.
(g) Manage your budget well; don't spend more than you make.
(h) Keep your living space clean.

Over the years I have had patients whose health could not be improved because the stress in their lives was causing them to be in crisis mode 24-7.

If your world is turbulent, endeavor to be the eye at the center of the hurricane, where the seas are peaceful.

From The Inside Out

2007-09-17T19:15:00.000-04:00

The logical approach to the world is to work from the inside out.

1. We should first take care of our spiritual health. (For example, be a good person, always tell the truth, etc.)
2. Next we should handle our emotional health. (For example, don't obsess about things we cannot change, seek professional help for depression or anxiety, avoid unhealthful relationships, etc.)
3. Next, our physical health. (For example, don't overeat, don't smoke, exercise, and see the doctor regularly, etc.)
4. Next, our family.
5. Next, our work place.
6. Next, our community.
Etc.

Most people go the other direction. They live in their work place and family, and only after much persuasion by me (their physician) do they consider handling their physical and emotional health.

But it's only after having a healthy self that we are able to help other people. To put it another way, it's on a foundation of spiritual, emotional and physical health that we are able to build a healthy and prosperous life.

Good and Bad Fats

2007-09-16T22:24:00.000-04:00

Good Fats:

Omega-3 Fatty Acids
Polyunsaturated Fats

Bad Fats:

Saturated Fats
Trans Fats
Omega-6 Fatty Acids

Health Grades

2007-09-03T08:19:00.000-04:00

The government is in the process of grading the health care provided by physicians. This is called P4P -- "Pay for Performance". Medicare will be giving those physicians who provide the best health care a bonus at the end of each year. This program is not yet in place, but a preliminary program called PQRI -- "Physicians Quality Reporting Initiative" is.

But the grade that the doctor gets is also your grade. For example, let's say you have diabetes, hypertension and high cholesterol (a very common constellation of conditions), and your HbA1C is 8, your average BP is 140/90, and your LDL cholesterol is 120. Your diabetes, your BP, and your cholesterol are all poorly controlled. If we were to assign letter grades to your health care, we might give you a "D". So the doctor's "D" is also your "D". After all, it isn't just the doctor who is responsible for your health; you are too.

Of course, some patients' health is poorly managed because the doctor is doing a poor job. For example, the doctor might have told the above patient that his diabetes, BP and cholesterol are all "just fine". In that case, what's the patient to think? How can the patient know that he has more work to do if the doctor is telling him he's okay?

So it isn't always the patient's fault that his health is poorly managed.

But deciding at whom to point the finger diverts us from the real issue: how healthy are you really? What can you and your doctor do to optimize your health?

And to know what needs to be done, you first need to know where you are. So health grades are a good thing. Doctors resist them (for example because they're arbitrary, based on faulty data, etc) and patients will resist them (they'll blame the doctor, say the standards are unreasonable, etc). But in the end, if you want to be healthy, grades are a good way to see where you are and where you need to be.

The Doctor's Commitment to the Patient's Health

2007-08-24T07:15:00.001-04:00

If your doctor's a pain in the ass, it could be that he's committed to your health.

I'm suspicious of doctors who are very popular with their patients. Some of these doctors are undoubtedly excellent physicians, but many of them are just good at telling patients what they want to hear.

Of course, you can't be an effective physician if you are always getting on your patients' nerves with your constant suggestions that they lose weight, stop smoking, etc. But to give them the idea that it's okay to continue with their unhealthful lifestyles is downright irresponsible.

I strive to be as tactful as possible with my patients, while I encourage them to become healthier.

But when it comes right down to it, a good doctor has to be more committed to his patients' health than to getting along with his patients.

Fatigue

2007-08-24T07:05:00.000-04:00

A frequent complaint I hear every day is fatigue.

Whenever a patient complains of fatigue, I order lab tests to check for the following:

Anemia
Mono
Thyroid Abnormalities
Vitamin B12 Deficiency
Diabetes
Urinary Tract Infection

These are only some of the causes of fatigue. Here are a few others:

Depression
Anxiety
Obesity
Heart Failure
Emphysema
Insomnia
Sleep Apnea

Of course, if you don't tell the doctor you are fatigued, he won't look for a cause!

"It moves right through me."

2007-07-01T20:51:00.000-04:00

Patients with diarrhea often say, "Everything I eat goes right through me." By which I suppose they mean that what they just ate came out the other end.

However, this is a misconception.

It actually takes about 2 days for the food you eat to completely traverse the digestive tract. It's probably less if you have diarrhea, but not THAT much less.

When patients say, "It goes right through me", what they're expressing is the frustration of having diarrhea every time they eat something.

This results from the GASTRO-COLIC REFLEX. This is a natural neurologic mechanism in healthy people, which causes the bowels to move shortly after a meal is consumed.

Because of this frustration, patients with diarrhea will often refrain from eating or drinking anything, because they don't want to have a bowel movement.

This is a BIG MISTAKE. The major danger to your health from having diarrhea is getting dehydrated. It's very important to drink large quantities of water to replace the water lost through the bowel movements.

And the water that comes out in the form of diarrhea is not by any means the same water you just drank!

How to lose weight

2007-06-17T09:45:00.000-04:00

For most people (but not all), the difficulty losing weight is hunger. If we didn't get hungry, we wouldn't overeat.

Some day there will be a pill you can take which will reduce your appetite. You will get on the scale, see that you're 5 pounds over your ideal body weight, and take the pill every day until your weight drops to the desired weight.

Unfortunately, we do not currently have such a pill. Such medications are in development, they're just not ready for prime time.

In the mean time, there is something that you can do to reduce your hunger. Stop eating foods that make you hungry.

The foods which make us hungry are sugars, starches, artificial sweeteners and salty foods. Anyone who eats sweets (even artificially sweetened foods) knows that such foods are addictive. Starches are addictive also, because they are converted very quickly by the body into sugar. Saltened foods such as chips and peanuts are addictive as well.

Starches are the 5 white foods: bread, rice, potatoes, pasta and bananas. Of these, the worst is bread.

The Dr Beckwith Diet consists of eliminating sugar, artificial sweeteners, bread and chips.

There are other ways to lose weight. For example, Weight Watchers is quite effective. The Weight Watchers idea is to count your calories, and not eat more than your allotted calories each day. Weight Watchers simplifies this process by using a point system. There is also an excellent support system. At the time of this writing, the cost of Weight Watchers is $11 per week, which I think is quite reasonable.

SlimFast works well also. This is a dietary supplement which satisfies you but does not contain a lot of calories.

The reason I like the Dr Beckwith Diet better is that it eliminates hunger cravings, making weight loss effortless. I personally follow my diet, so I practice what I preach.

Lose weight to reduce your blood pressure

2007-06-17T09:39:00.000-04:00

In a recent study, the best way to reduce blood pressure was found to be weight loss. The reduction in blood pressure resulting from weight loss is a linear relationship. This means that the reduction in blood pressure is exactly proportional to the weight lost. If you lose a little weight, your BP will drop a little; if you lose a lot, your BP will drop a lot.

Speaking from personal experience, I was diagnosed with hypertension and had to go on 2 medications to get my BP under control. I promptly lost 15 pounds. Shortly, I had to go off of one of the medications. Two months later I was getting dizzy, so had to go off the other BP med. My BP is now perfectly normal without any medication.

My example above illustrates an important principle. There is a lag time between life style changes and effects on the body. After you lose weight, it may be a few months before your blood pressure drops the full amount.

Kids are some of my favorite patients

2007-06-17T09:33:00.000-04:00

Many adult patients with children do not realize that family doctors see children. Family doctors see patients of all ages, including newborns.

The difference between a family medicine doctor and a pediatrician is that pediatricians know more about the care of children. A pediatrician's care is appropriate for children who have less common medical conditions such as Down syndrome, congenital heart disease, and diabetes. For children who are relatively healthy, a family practice doctor is an excellent choice.

The reason we're called family medicine doctors is that we see the whole family!

Welcome to my new blog!

2007-06-16T14:24:00.000-04:00

Welcome to my new blog.

In future posts you will find ideas about optimizing your health, thoughts on the latest medical breakthroughs, and comments about medical news.

Enjoy!