Category Archives: Uncategorized

The Most Natural Treatment for Constipation

In the middle of an otherwise complicated visit, an older woman reminded me of a very basic treatment for constipation that she discovered 40 years prior.  It involves no medication, no special diet, and no unpleasant bowel regimen.  It does, however, require a certain maturity of character.  This technique demands assertiveness, social bravery, and a measure of self-assuredness that might be difficult to hone.  In Clint Eastwood’s movie The Good, The Bad, and The Ugly, there is an iconic line that goes: “When you have to shoot, shoot.  Don’t talk.”

So let it be with moving the bowels.

My patient told me that most of her life she was embarrassed to go to the bathroom in public places such as school, and then later work.  She would hold her bowel movements against the tide of peristalsis telling her to relieve the pressure.  She didn’t want the boys to know that she too defecated, or the popular girls to snicker at her as they seemingly excreted nothing but perfume and wavy hair.

By missing her body’s natural signals, by resisting the natural rhythm that wanted to move things along, she would back things up, creating the preconditions that would cause discomfort, immobility, and intestinal dysfunction later in the day as she struggled to make things happen on a socially convenient schedule.  And once the train stayed off the tracks for too long, a pattern of dysfunction became normal.

This may have done lasting, permanent damage to her system.

The bowels move materials using coordinated, progressive contractions, moving like waves through smooth muscle.  The assembly line moves in synchrony, and can be triggered to start going by the thought of food, ingestion of food, and circadian rhythms.  The gastro-colic reflex is a well-known example.  After receiving food in the stomach, the rest of the gastrointestinal system gets a cue to start moving things along.  It is best to ride the wave.

As my patient matured, and cared less about what people might think about her retreating to the bathroom on cue, she began riding the natural waves, at work, at home, wherever.  After completing an appropriate medical evaluation, colonoscopy, and gastrointestinal evaluation showing things were ok, she decided to get back to basics.  A typical morning might be eating breakfast, drinking some coffee, and then 1 hour later like clock work getting up and heading to the toilet when the feeling began.  Bosses, boyfriends, barbies be ignored.

After a while a certain understanding was reconnected between her behaviors and her parasympathetic nervous system.  A circadian rhythm also kicked in, and the whole show became a natural symphony.  OK, so maybe not that beautiful, but I digress.

In addition to drinking plenty of water, exercising, getting fiber from fruits and vegetables, perhaps constipation for some people can be thought of as a social timing problem.  Like brave actors who go out upon the stage under the bright lights and overcome their anxieties about being watched, scrutinized, and exposed, we should ourselves go with the natural flow, following our bodies’ rhythms and reflexes no matter how embarrassing.

I think this is particularly important for young girls, who are held to higher standards of propriety and appearance, encouraged to cloak themselves and their bodily realities more than boys.  For boys, by contrast, pooping and flatulence can even be celebrated as a sort of social currency.  But that is another topic for another post!

When you have to shoot, shoot.  Don’t talk.  Go to the bathroom.  It might help more than you think.

 

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The Self-Defeating Logic of Gym Memberships

I belong to a local gym.  I’m supposed to go there to exercise.  I pay $40 a month for the privilege, but I would estimate that I actually get to the gym twice a month.  This failure to find the necessary time to work out is by itself a self-defeating, exercise-discouraging proposition.  By equating exercise with a third-party gymnasium, do we undermine our very notion of healthy activity?  Should not getting to the gym = not exercising?  Here are some ways to correct this fallacy of inherent defeat.

If you conflate healthy physical activity with a time and place that is not readily accessible, you unwittingly place a firewall around succeeding.  For example, I worked until dinnertime last night, had to run home (drive in a car, that is), and take care of domestic duties for the rest of the night.  By the time I might consider going to the gym it was already 11:00 PM.  Therefore yet another day of physical inactivity because there was simply no way to fit in the 1-1.5 hours needed to execute a trip to the local sweat house.

Are we exercising less because of this faulty logic?  Like other activities we outsource, ultimately there is a loss of efficiency and joy.  Look at cooking.  For some people making dinner is just too time consuming.  They rely instead upon take out, half assembled meals, or processed food.  The food infrastructure in the fridge collapses – no garlic, no basic ingredients, rotten milk… so that when a quick meal is desired, it actually takes more time to find an edible assortment of ingredients that could pass as a meal.  Better to cook your own food most of the time, and keep a healthy, steady supply chain coming from the grocery store.

Exercise does not have to entail purchasing a right to machinery, group psychology, and a physical location separate from the rest of your daily life.  As this Wall Street Journal article shows, some boutique gyms are charging upwards of $30 dollars for an individual class, with no coupons or discounts.   Outrageous and expensive.

Here are some ways that you can get the cardiovascular benefits of exercise during the day, without settling in to an unhealthy lifestyle that can’t find the large chunk of time needed for the gym.  Several goods apps and websites exist that demonstrate home exercise routines using no equipment other than your own body.  My favorite is a free site called Darebee, which has countless exercise routines and videos to demonstrate proper techniques.  For a while I was doing these exercise almost once a day, sometimes scattered in between patients, or at night after the manic clock of efficiency can be turned off.  Some of these exercises like the burpees may have contributed to a groin pull I sustained, so remember your age and realistic fitness level!  Just go for a walk once a day, anytime, anyplace.

Taking the stairs, getting up and walking around the house/office at least 2-3 times per hour, and even fidgeting at your desk can help immensely.  One study found measurable benefits to circulation by tapping your toes and moving your feet up and down while marooned at a desk all day.

The gym is also covered in germs.  I heard a recent podcast, can’t recall the source, that described a recent study showing more harmful bacteria on the average free weight than on the average toilet seat!  Always wash your hands at the gym, and long pants seriously recommended.  But I digress…

So in summary, if you are in a busy, time-contrained phase of life, the old habit of equating “getting to the gym” with “getting exercise” is flawed.  It will actually make you unhealthier and more frustrated and defeated.  To maintain that gym membership as the only avenue for working out is a modern fallacy.  Instead, stay active as much as possible during the day, from fidgeting to stretching to walking to running.  If you can make it to the gym, that’s awesome and I must admit that I am jealous.  There are surely a lot of reinforcing psychological benefits to group exercise, as well as having access to better equipment.

On your mark, get set, stand up and move around a little!  Inspiring.

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medical work horses

How To Be More Efficient As A Primary Care Doctor

As an overextended physician in my 40’s, with a family life and a daily sense of exhaustion, I have given up the quixotic dream of helping to change healthcare in this country. I’m just trying to survive each day, along with my patients, and to be an efficient and helpful primary care doctor.

If you too have accepted that our healthcare system is a bloated, unfixable, disappointing mess, and that you are just a squirrel trying to get a nut each day, then read on for small tips on how to survive, nay thrive, within the sad drama that has become the modern office visit.

Resolve that someday, when perhaps you are better rested, better informed, and the industrial-capitalist-insurance-forprofit model has eaten itself alive, perhaps then you will return to your passionate dreams about how to be a better doctor and craft a better medical world. In the meantime, here’s an atomic bomb shelter model to survive.

1. See patients in one room
I used to carry a laptop from room to room, fumbling around and drifting from place to place to see patients. Stop that. Set up shop in one room, and plan on being there for most of the day. Get a comfortable chair. A green plant. A mug of coffee and a water bottle. One room facilitates the rest of this list as you will see. Patients can be brought back and their visits begun in an adjacent room. When you are ready for them, leave your room and ask them to kindly join you next door where you’ve been preparing for their visit. Unless they are extremely old or frail, they will get used to the shtick, and come to expect it.

2. Take 1-5 minutes to review each chart before starting the visit
I used to feel so bad about running late that after finishing with one patient, I would burst into the next room, as if punching a time card, and apologize to the patient, barely knowing whom I was seeing next. Forget that. It doesn’t serve you or the patient to be unprepared for the visit. You will make mistakes, be unfocused, and look like you don’t remember them.

Instead, sit in your little home base with the door closed. Review the last visit or two. Jot down some quick reminders on an actual piece of paper. Among the 15 complaints from last visit, which ones still need attention? I write down chief complaints and quick to do lists. (Last visit – Chest pain, ?stress test done. Elevated alk phos. Bone scan ok. ?paget’s. See rheum. DM2. HTN. Colonoscopy scheduled? Dysphagia, needs EGD. Etc)

Review imaging tests. Jot down loose ends. Review specialist letters’ conclusions. Review recent labs.

Scan vital signs. Did they lose 20 pounds since last visit, unintentionally? Is the BP 180/100? Bad to miss that.

3. Set up the assessment and plan
Yes, do this before the visit. I know you haven’t even seen the patient yet, but unless she is here for a quick same day visit, she’s going to have her own agenda and priorities as soon as you open the door. If you don’t crystalize your own agenda before you are juggling hers, the visit is going to be even more of a struggle.

List 5-15 chronic or recent problems on the chart’s assessment and plan before even seeing the patient. If there are major tasks you know the patient needs, or has failed to complete, order them before seeing the patient. Chest pain, didn’t get stress test, you’ve already ordered it. You can always delete it.

Once the visit has begun, you can add new complaints and diagnoses. Sometimes the visit can become unruly, and finishing with a problem list 10-20 issues deep is exhausting. But 99214’s and 99215’s result, diligent care is achieved, and everyone is happy-ish.

4. Small talk is good, for a small time
This hurts the most. I love knowing my patients as human beings, appreciating their stories, legends, quirks, bravery, and fears. But this is survival mode, and if you are in a saturated situation with kids to pick up by 6 PM at school after-care, then you must stay on point after a brief detour into humanism.

This really sucks.

5. Let the patient’s agenda come first
You may or may not see the patient holding a tangible list of problems in hand, but what you don’t want to do is take over from the beginning, force your way through your pre-planned list of 5-15 items, and then find out they have 6 more. “I know you are here for a check up today, and I have a lot of questions to review with you from recent visits, but I want to give you the floor first. How are you? What can we help with today?” It sounds like family medicine softness. Kind of deadly. But it is actually eastern Zen philosophy combined with German engineering – letting the visit pass through you without resisting its true motivations, yet holding onto an invisible scaffolding beneath.

Once you’ve handled the patient’s biggest concerns, your preplanned list may already overlap with theirs, making the additional dump of your diligent reminders easier. Don’t drag this part out. You’ve already done the work from prior visits. Lung nodule, due for CT Chest, reminder and script given.

6. Demand enough time
Modern primary care visits cannot be reasonably accomplished in less than 20 minutes. Demand 20 minute visits for chronic care, and 30-40 for the most complex patients, hospital follow ups, new patients, and most “preventative physicals” which end up being chronic disease management with USPTF essentials added in. 15 minutes is disrespecting you and the patient, and making money for someone else anyway. Plus, with better care 99213’s are rare, so it evens out or you come ahead in terms of RVU’s and that stuff.

7. Smile, breathe, laugh if you can
It really helps. But don’t force it. A smiling or laughing doctor at the wrong time is creepy and unnerving.

When rechecking a blood pressure, walk the nervous patient through some calming, deep breaths, and while telling them to relax their muscles, you do the same. No laughing at this time.

8. At the end of the visit, give a narrative outline
Sometimes patients won’t let you talk as much as you need to. They are excited, nervous, or just talkative. You have to wrap this up in a tidy manner for you and them. “So I understand what you’re telling me. I’m going to tell you my impressions about what is going on, then review some diagnostic tests we may or may not want to do to figure this out, and then we’ll talk about treatment options.” That way they know to give you some space to help them. “After that, please ask any questions you have, and then we’ll run through a quick summary of your old issues with some reminders.”

Bring more structure to the visit as it progresses. Hopefully, it is satisfying for you and the patient. Making order out of chaos is what humans do, even if the laws of thermodynamics still prove everything we do ultimately creates more disorder. Alas…

9. Get up and escort patient out at the end of the visit
This is good manners. It is also a ceremonial display that this dramatic interaction has reached its natural conclusion. It stretches your legs, helps your back, and alleviates pressure on your hemorrhoids. Just kidding. Maybe not.

10. Return to your room, close the door
With peace and quiet, finish your note, organize your thoughts into coherent, thoughtful, narrative documentation. I insist on speech-to-text dictation (Dragon medical dictation software). I refuse to click on boxes or try to cram the patient’s complex story, overlapping ideas, and fluid assessment and plan into templates provided by most electronic medical records. It’s not human, and it’s bad. Enough said.

If I’m running more than 30 minutes late, I will stop finishing each note. Instead I will then move on to the next patient’s chart and start the whole pre-gaming process all over again. Leaving the full documentation of the visit for the end of the day, or “lunchbreak” whatever that is, is a total bummer. But it happens.

In between patients, take a deep breath or 5. Close and rub your eyes. Do some tai chi poses, or practice a minute of mindfulness stuff. It really helps, and maybe your first heart attack will delayed.

11. Noble sacrifices will be made
This part is optional, depending on how badly you need to get out on time and pick up your kids, or walk your dog. Consider sacrificing small talk with colleagues. Eat your lunch in that bunker of a room while reviewing the 25 phone calls that have come in for you while you were seeing patients. Put on some music. Stretch. This is a sad departure from those you work with. Optional.

12. Delegate
You can’t do it all. Don’t feel bad. Your mission is to be the doctor. Medical assistants and front desk personnel should be there to support the whole enterprise.

Good luck. Hopefully this will make you a more efficient, more diligent, better doctor within the horrible confines of a typical, busy primary care practice. There is no one-size-fits all. But this approach works for me. I bring significantly less work home, and achieve greater productivity than my colleagues.

I’m soldiering on, muddling through, being a workhorse. These are not visionary pointers, and there is little inspiration in them. But until the larger struggle is won against our broken healthcare system, some of us choose to survive within the system, while others set up systems of care that are off the grid with concierge practices, ideal micro practices, or some other funky model for cash.

It also helps to have a photo depicting a rustic, mossy cabin in the woods posted somewhere.

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specialized facilities africa

We Should Construct Specialized Ebola Facilities in the US. Now.

The US should be ready to build facilities, akin to what the military has been setting up in West Africa – specialized Ebola hospitals with moon suits, free-flowing bleach solutions, and brave healthcare workers who have been properly trained, and will be properly compensated for their risk.

Conventional hospitals have failed to protect at least two healthcare workers from contracting Ebola, despite what sounds like fairly diligent safety precautions. The nurse in Spain, and the nurse in Dallas just diagnosed today, both practiced stringent precautions and wore protective gear. It has been postulated that a single Ebola virus is enough to transmit the infection between close contacts.

And, while the CDC director assumes there was “a breach in protocol” to explain the nurse’s infection, this is not reassuring to any healthcare worker who knows how impossible it is to achieve perfection in the care of sick patients. Doctors, nurses, medical workers – we are not trained, prepared, or equipped to deal with something like Ebola.

And even with buddy systems and moon suits, any human being lacks perfect motor execution when disrobing. And the disrobing protocol in this country does not even include being sprayed/bathed in a disinfection solution prior to disrobing – something done in Africa for years. This is outrageous.

Even with regional Ebola treatments centers, the diagnosis and triage of potential infections will likely continue to be through the conventional health system, as false scares will certainly outnumber true diagnoses. But once a diagnosis is made, that patient needs better care, and workers need better protection than all the reassurances thus provided by the CDC and WHO and hospital protocols.

The four hospitals in the country commonly cited by the news as having high containment units do not have sufficient beds to handle Ebola if it picks up speed and numbers. The death toll among healthcare providers in West Africa is much, much higher than the average population. It would be here, too.

The Ebola epidemic continues to grow exponentially in Africa. Today we have the luxury of hyper-focused contact tracking and supervised quarantines in the United States, but these efforts take considerable resources and attention, and will fall apart if the disease count grows. Such is the terrifying power of exponential math.

It is not a good idea to have Ebola patients in conventional hospitals like Texas Presbyterian. Conventional hospitals are already a nexus point of the worst antibiotic-resistant contagions in the world. We need to enlist the help of groups like Doctors Without Borders that really know how to protect their staff, and we need to start thinking about containing and treating this infection outside the normal hospital box.

Build it, and hope they never come.

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Obama’s Foreign Policy Is Linked to a Healthy, Restrained Immune System

ObamaForeignPolicyWith 58% of Americans disapproving of Obama’s foreign policy, mounting Ebola virus deaths, and flu season around the corner, I think it is important to synthesize an overlapping theme between how our country fights perceived threats, and how our bodies successfully or unsuccessfully fight disease. In short, I think Obama’s continued restraint and use of soft power is evidence of a good prognosis for the country.

In this analogy, our bombs and military are the most caustic weapons of the country’s immune system, akin to a fever of 105 degrees and impending sepsis. Does “nuke them all” work?

Diplomacy, espionage, surveillance, economic sanctions, and other soft tools of foreign policy can be likened to low grade temperatures, coughing, mucous, and all the other less dramatic symptoms of immune system activation.

Considering medications is a stretch, but stay with me. Cholesterol-lowering medications called statins actually do more than lower our lipid levels – they mildly hamper the immune system and reduce inflammation. Intuitively this would seem to be a bad thing when fighting a war inside the body against an invader. But statins are increasingly suspected to be a beneficial kind of weakening force that paradoxically might save us from an immune system run amok.

Is Obama like Lipitor?

Consider influenza. Often young, healthy people with robust immune systems are at increased risk of dying from pandemic influenza simply because their immune systems launch such powerful attacks that the body cannot withstand the friendly fire.

One study found that patients hospitalized with influenza were 54% less likely to die if they were taking a statin medication. It is postulated that statins modulate and dampen the inflammation unleashed by the immune system, thereby limiting collateral damage.

Another study published in the journal Critical Care recently found “that early treatment of sepsis patients with a statin reduced the occurrence of organ failure (a complication that often kills Ebola patients) by 83 percent.” An opinion written by two medical doctor/professors appeared in the New York Times this week calling for a trial of statins in those dying of Ebola for this very reason.

ISIS is a cancer, surrounded by other diseased states. Putin is MRSA. The Middle East is the Middle East. I’m glad we don’t have Bush and McCain running in with their hands unwashed to try and save the day. I’m glad Hillary isn’t trying to do her best Clint Eastwood.

So far Obama seems to be managing these illnesses like a well-restrained immune system. Even though we disapprove of his foreign policy, a majority of Americans want to stay out of these foreign conflicts – putting Obama in no-man’s land in terms of chasing approval ratings.

Personally I’m much more worried about the planet’s fever, the looming environmental catastrophes, and being on the front end of the greatest mass extinction the Earth has ever known.

Push fluids with ISIS. Only send in bombers and troops to Ukraine prn, and start World War 3 if America is terminal in the ICU. But for now I salute the commander for swallowing his bitter pills, sneezing and hacking up mucous, and enduring the taunts of weakness from viral media on behalf of the country’s health.

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If You Don’t Look For It, You Will Miss It

Death leaves an invisible silence, a wrenching disappearance of love’s voice and presence.

Your father held you in your first moments, poured his love and life into your cup, and told stories that created a fabled purpose from the dull chaos.  And then he was no more.
photo

Are loved ones gone forever when they die?

They live a new, unselfish life within the murky, star-forming nebula of our memories.  We conjure them in moments of anxiety, sing along with them in the music they loved, and see how they once adored us as we tuck our children into bed.  And beyond our perceptions, they exist as nothing and everything.

And if we don’t keep a keen eye on the outside world, we may miss them there as well.  On a birthday I looked down and saw this dirty little puddle.  I paused, noting that it was heart-shaped.  And as great art can move mountains within us, so too can dirty puddles speak for the dead:

I love you.

it said.

~

In the moment my father died there was a beautiful, September-like sky, crisp and blue like the month he entered the world.  He shone in the sunlit footprints of his granddaughter as she ran down the sandy beach, brimming with her young life, a torch of his own.

My father jammed the electromagnetic waves of the police trying to call my cell phone to tell me of his demise.  Four times I answered the phone to static, which has neither happened before nor since.  Stay in this brilliant moment a little while longer, son. I’m with you and your family over this warm beach blanket as I join the sky, reveling in your daughter’s giggles.  Remember nothing in the universe has produced a greater sound.

We are of the world when we are born into it, why should we not remain of it when we die?

Look for your loved ones, hear them, sense them, and hold on in inexplicable ways.

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Is Thanksgiving Actually a Misguided Holiday?

auroraI used to think of Thanksgiving as the supremely humble, agenda-less holiday most deserving of our celebration. As an American adaptation of harvest festivals found in other cultures, it seems at once natural, secular, and modest.

Yet as I called a lovely woman a few days before the holiday to inform and counsel her that she has cancer, the notion of millions of others “giving thanks” rang hollow, selfish, self-referential, and arrogant.

The turkey on her table was unexpectedly as rotten as the necrotic mass in her pelvis, and her many arriving guests were suddenly interlopers in her nightmare. Perhaps there is a better way to frame the loaded notion of “giving thanks” that does not presuppose blessings, special entitlements, and personal good fortune.

The act of giving thanks necessarily involves a transaction between an actor and a receiver. Giving thanks is a reaction to something bestowed. This problem of agency is what makes Thanksgiving fundamentally flawed.

An unseen God known via faith can be thanked, but to do so takes a egotistical leap over the woman with cancer. What has she received from this same God? Instead, giving thanks seems most appropriate for the transparent exchange, such as that which occurs between human actors helping one another.

So what notions would be most honorable, most worthy of our sacred celebration? The best abstract ideas I could come up with would be reverence, humility, wonder and awe.

Reverence for humanism, the natural world on Earth, a newborn child’s silky head, the brilliance of the stars, and the capacity of love.

Humility that grasps our frailty, our inherent flaws, and the acceptance that every action we commit, even those considered altruistic, is ultimately self-serving.

Awe at the enormity of the universe from galaxy to gluon, the stubborn and heroic perseverance of life, comets from the Oort belt grazing the Sun, and the beauty of snow flurries falling as we exalt in the pleasures of sharing pumpkin pie.

If we were all equally blessed, or if there were some rational justice that determines who suffers, then we should say “thanks.” Otherwise I think a good prayer before the feast should focus on the ideas of reverence, humility, and awe… and to give thanks to those who journey along with us.

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