Tuesday, October 23, 2012

Hanging out with Hatred

     Spining Chaos always has a Calm Center

 To make ends meet, outside the office I work at an Immediate Care Center.  (Insurance reimbursement makes it impractical to spend more than 15 minutes of face to face time figuring out a personal strategy for lifestyle change - thus the reason everyone gets a scripted "one size fits all, this is what you have to do before next years annual visit").  No wonder the research this year says wellness check ups dont make a difference in life span!  So here I am working at a cough, cold, sprain clinic with a very expensive EMR (computer based medical recording system) that decided to crash.  So the staff at the front desk worked diligently to contact the IT guys on a sunday-yeah right!  In the mean time, I was so elated inside waiting to turn on the speed.  Why?  Any patient who has been to a clinic with paperless EMR knows the feeling of the doc facing the computer screen and spending little time looking at the patient unless you have good typing skills or know where to intuitively click boxes and scroll.   Any doc using EMR knows how frustrating it is to have to click off boxes in order to fulfill the criteria to get reimbursed for the evaluation and treatment planning and having the whole ritual take time away from patient care.  So here I am, a great excuse has been laid in front of me to ditch the computer and just write down the history, physical and treatment plan on paper.  I could usually finish with pen and prescription pad faster than it takes to click print and walk the patient to the printer.   I pulled some blank paper out of the copy machine, got my script pad and started charging down the hall chewing up one visit after the next.  It was so liberating to get people cared for, explain why they were sick and come up with a treatment plan on how to get better and not have to wait for the plan to print up at the nurses station.  Usually on a sunday, there is an after lunch crowd of sick people (referred to as the "after church group" since as church lets out, every family that has a sick kid stops off at the immediate care for an evaluation hoping to get better by monday morning school bell)  We actually didnt have much of a back up as I was really able to fly through the paperwork.  Alas.....good things come to an end.  The tech guy called and said things are fixed....and the system was up but some of the rooms where slow as molasses so.....back to pen/paper(yay!).  I ended up reverting back to full EMR (boo!) toward early evening and the whole immediate care slowed down again.   (one lady in the waiting room commented that is shouldnt be called immediate care since it was anything but immediate-I agreed but if we were 2 hours behind, the ER was 4 hours behind so I was still the lesser of two evils)

     So why do I call this hatred when it seems that I was on cloud 9?  Well, as the crowd in the waiting room started to gather with the reintroduction of the EMR system, the natives became restless.  It was such a contrast to greet families with joy (paper) vs greeting people that start the conversation with "I thought you forgot about me" (EMR).  As I opened more doors with a wave of heat, crying kids and adults falling asleep waiting, I had to do more explaining of why we were backed up, calming down, and patients at that point felt very entitled and were demanding things like personally calling the script in (calling in a script takes about 5-10minutes of waiting time on the phone to the pharmacy.....doesnt seem like much right?  If I crank out 20-30patients a day, spend an additional 5-10minutes each with a phone call, for the unlucky patient at the end of the day-thats a potential 3 hours of waiting.)  So if I am not "grounded from stress" before starting  my shift, I could easily develop a pissed off attitude like "why the F are you coming here when you should have been to your doc last week" or "get over the pain and get back to work you wimp" (at Danada Family Medicine in the 90's, I remember working with a hug ice pack on my shoulder every hour from a full thickness rotator cuff tear for weeks dealing with the pain just to get through work)   But I didnt let the hatred rule my day, I worked and did it fast.  The EMR was inching its way back into my life over the course of several hours.  Most patients I got cooled down and gave a plan for feeling better.  I am pretty sure I still have some data entry I have to catch up on but the hell with the computer.  The entire day was a testimonial that EMR may help insurance companies keep an eye on what is being charged but it only slows down the practice of medicine. Helps a little for the doc regarding making notes legible, does nothing for the patient except making the wait longer as the clicking and printing takes forever.  It still comes down to whats between my ears that figures the right questions to ask, figures the right tests to help with the diagnosis, and the right solutions to the problem.   If the patient is irritated, I become defensive, the relationship is strained before we start and that effects what is between my ears and how I use it to help suffering. 

I always tell teens that emotion is contagious.   If you hang out with a drunken mob, you will assimilate the irrational behavior of the mob.  If you hang with an abusive significant other, you will imbibe the abusive tendancies of the other.  If you watch the reporting of "yellow journalism" you will be swayed in your thinking to become entangled in the conspiracy theories of the reporter.  If you are with a room full of meditators, regardless of your expertise, you will feel the wave of relaxation experienced by the group.  If you are with a group of people looking to change the world, you will think outside the box and come up with answers.  It takes alot of practice to not let emotions around you dictate your actions.  One of the things Deepak Chopra teaches is you cannot control your environment, the only control you have is your reactions to it.    Herb Benson taught me, Deepak taught me, Andy is teaching me....meditation and the relaxation response set the ground work for longevity, health and disease free living.  Learning to be "bullet proof" to external stressors is difficult, usually need someone to teach.  If you initially invest in a good teacher it will set up for effortless development of personal practice on your own at your pace.  (one of my classmates from the Chopra Center)

Thursday, October 18, 2012

Listen to your "Inner Doctor"

- Tea and pumpkin bread while waiting for my car to be finished.
     Driving my car on the highway, I feel a cresendo/decresendo vibration with the left front tire.  I brought it into my local Sears Service Center (cheap) to save money worn tires while checking out suspension they said everything is ok but you need new tires.  Went on with my new tires and got back up to 55mph and here comes the shake again.  Need a "higher" level of experience so brought it to my Volvo dealer (expensive).  No problems seen, suspension checks out even with a local test drive.  Ok.....all in my head.  Get back on the road, shake is worse.  I jack it up and get under the car.....check out bushing, shocks, brakes, every thing looks good.  Pull on the tie rod (little metal connector that connects wheel to steering) and the thing is about to fall off.  Bring it back to Volvo and rejoice in my discovery, mechanic gets it in the air, I get called back and he says-"theres nothing wrong, what exactly are you worried about?"  Proud as a peacock, I estutely go straight for the tie rod and say, "is this normal?"  Oh sh_t, says my mechanic and they begin work.  I was thankful they at least allowed me to walk into the garage, under the car and check things out. 

     Today a study from Denmark (Cochrane Review) was released saying wellness check ups didn change the overall odds of death.  As docs, we hope to impact the health of people we see.  One of the most sacred times to establish and develop rapport and trust is the coveted annual check up.  Patients who see me know my preference is to rely on history taking to figure out a plan to optimal health.  As I have pointed out in previous blogs, my job is to get you from point A (now) to point B (optimal health, with minimal suffering).  In my heart, I feel the road blocks to point B will not be obvious.  Certainly if cholesterol or blood pressure is high -easy..... work to bring things to normal human levels.   But if all "looks ok", still have to extract that crucial bit of information from the patient/the driver about how things feel in day to day activity/driving?  What is the reaction to stress/driving fast?  What exactly are the average activities/driving habits that may speed up death/mechanical failure?  This takes a keen ear to comprehend how the patient/driver is relaying the story, a creative architect to construct a plan to change, a politician to softly suggest change without insulting the masses, and a coach to know what will probably work in fighting disease with the strengths and weakness of the individual.  Economics will always have to play a part and in todays insurance based health care model, reimbursement for being a good detective is not rewarded.  In fact, production line medicine is probably the only way to keep an office afloat considering malpractice insurance, price to maintain EMR (electronic medical records), salaries for staff needed return phone calls, discuss results, attain authorization for MRI's/PT/Prescriptions. 

     People coming to see me, want to make a change but also want to stay within the constraints of "what insurance pays for".   I have to always bring the bad news; "your insurance will not pay for being healthy, but it will pay for your medicine and surgery once you get really ill!"  I used to be able to send patients with high blood pressure, high cholesterol or obesity to my registered dietician when I worked for Central DuPage Hospital and I would work with her and make some "baby-step" changes to point B.  Now I have to encourage folks to pay out of pocket to see RD's that used to be the first line in treating the above diseases (times are tough so its a hard sell).  Way too much bad information on the internet to do it properly on your own.  [Had a guy come in with cholesterol issues and said adding fiber may help/he said he did that last year with no change in blood tests.  When asked how he did it, said he started eating 1 bowl of oatmeal daily and that was the extent of it- I said that was a good start- now just eat about 16 bowls of the oatmeal and you would have reached true suggestions for proper intake-people need customized programs from knowledgable professionals!]

     Dont be confused with the information being released now.  The person trained to sniff out medical disease is good at what s/he was trained for.  The caveat is even when the tests seem normal, if there is something you feel is off with your average daily activities, express yourself as best as you can to a person that knows you and has the patience to listen.

Saturday, October 13, 2012

How to change a culture?

Another Filipino couple came in for guidance on health.  She had no insurance but wanted to continue taking the medicines her doc in North Carolina started 2 months ago for blood pressure, cholesterol and sugar.  She was on 3 expensive new meds for BP, one standard statin for cholesterol and cheap med most likely for type 2 (late onset diabetes).  No old blood tests to show me, unsure about her numbers, just about finished with meds and unsure which med was for which problem but she seemed to have an allegiance to the doc she met.  So I had to work backwards and elicit has much history as possible (with my primitive knowledge of Tagalog-the major dialect in the PI)   She didnt have any immediate risks for heart attack or early death at the age of 72.  Parents were in their 90s at time of death and most of the 10 siblings alive.  She was thin, ate typical Filipino dishes and was caring for her grandkids.  I asked if the doc tried any other drugs first and she said these were the first she ever "ate".   So I am assuming the doc went straight to the top of the heap regarding expense.  Also sounds like she was never given guidance on healthy food choices or changes.  (usually the first thing to do in first diagnosing diabetes-unless sugar was dangerously high).   And now I have to repeat expensive blood tests that will probably hit the 300$ range just to see if I can get her numbers lower with diet manipulation.  (there are even supplements like krill oil, Coq10, red yeast rice, plant sterols, fiber that have a great track record in lowering cholesterol test results and will come out alot cheaper than the prescription meds dont believe me?-Dean Ornish's work on reversing heart disease with group therapy, mostly plant based diet, yoga and exercise has been approved since 2010 for bypass candidates on medicare.....thats without taking medicine)  As I posted in a blog about loving pork, speaking with a popular TV cooking host, it seems as if viewers are more interested in "home cooking" and not concerned about substituting quinoa for rice, wheat berries for bread, fish for beef.  This is the standard thinking for many patients that are first to immigrate to the US.  Their kids, the first generations here are easier to convince of changing eating patterns.  So how do I get the oldies to keep traditional food but buy into manipulating macronutrients?   Here it goes-Seven Strategies to be applied over seven days:

1-Meatless Mondays.....traditional US approach to cutting back total volume of weekly red meat.  Have to be creative 4 days a month, not much to ask-discuss fav "alternative" dishes on sunday before going grocery shopping. 

2-Fish Fridays...............same US approach to decreasing red meat, try to stick with roasted or baked.  With no other options ok to add fried but ask to use good quality oils with high smoke points (consider grape seed and organic non gmo canola since olive oil doesnt tolerate high temps)  The best fish for high omega 3 content will be Sockeye Salmon, Sardines, Herring, Anchovies, Mackerel, Alaskan Halibut, Alaskan Salmon.  Watch the farmed fish as they usually have pesticides and antibiotics. 

3-Cut the Kanin (rice)...rice is essential to every meal in the traditional Filipino kitchen.  Certain rice is known to have a very high glycemic index.  (the speed at which the food group is digested and absorbed to raise blood sugar)  There are some rice species that have a low GI.....like jasmine or better yet, basmati.  Decreasing the GI or speed which food gets us our sugar highs will allow the pancreas to survive decades without turning into a diabetic gland.  In easier terms, lower GI means longer full feeling.   Decreasing volume will decrease total calories consumed at the end of the week.  An option Ron Bilaro personally uses is to substitute wheat berry for rice.   Yes texture is different as well as taste but the choice still gives the meal substance and the whole wheat is a great fiber that pulls cholesterol out of the circulation.  (....and Ron tells me at 40+, this is the healthiest he has ever felt)  Real world application of this is to cut down on breads and potatoes-when was the last time you went to a restaurant starving and gobbled 2 orders of bread before the meal even came out, then ate the whole meal since you "paid for it".   1/2 cup of cooked rice per meal only!!!!

4-Fill up with Prutas (fruits)........as a tropical country, Pinoys are very familiar with seeing a variety of fruits in the market all year long.  The problem is if you are in a northern US state, fruit will have to be transported a distance (2000 miles sometimes) so you may have to shop at specialty stores in winter (Whole Foods Market, Marianos, Mexican or Asian grocery chains).   Pick 2-3 servings of Prutas per day to eat for breakfast and lunch.

5-Garnish with Gulay (vegetables).........this is where we can excel due to the wide variety of veggie dishes sauted and accented with spices.   Many times a meal in their own right.  Turkey/chicken can always be substituted for beef or port in the meat accented dishes.  As stated above, the older Filipinos will probably not go for this knowing the texture is "different".    But then again, dont tell them and let's see if they notice.  Trickery can be easy with dishes like Bolabola (meatball and vermicelli in clear broth) or even Lumpia Shanghi (Filipino eggroll).  A special mention goes out to the use of Tokwa (tofu).  Asian culture is big in using tofu (bean curd) in many dishes and health benefits have been repeatedly studied with positive results.  Just try to avoid the processed tofu and stick more with whole soy foods and natural soy products (non genetically modified)   Pick 3-4 Gulay servings per day.

6-Salad or Sopas (soup)...................in summer cool with salad, in winter warm with soup.  Both smaller side dishes or as main entre will help with satiety.  Keeping the stomach happy releases hormones of love and satisfaction.  (oxytocin and serotonin....sound familiar?  This is the same action you get with zoloft and prozac without the side effects!   Good to balance the decrease in rice. Hint: it allows you to feel satiated/full so you don't attack the rest of your meals and eat like a hungry animal.

7-Fat-busting Fiber...............yes, fat does give a sense of fullness and it is important in inflammation.  Goals in the last decade have been to increase awarenss of the imbalance of too much omega6 and too little of omega3.  Our grain raised cattle and pork have a terrible abundance of omega6 in their diet......you are what you eat so unhealthy slow moving pig/cow will pass onto you the same crap it eats.  Recent WPRI.com article has revealed the plight of the American farmer for the price of grain feed.   This article (click here) speaks of one American farmer feeding bulk "2nd hand" candy to fatten up cattle before slaughter.  Owner Joe Watson says his cattle are healthy with the new feed.....notice Mr Watson's weight in the interview.   So if you happen to eat Mr Watsons cattle, do you really think that yummy tasting prime rib is giving you anything that will help fight cancer and heart disease?  Read on adding fiber/grain sources to the tune of 25grams for women or 35 grams for men daily.   If tastebuds are not happy.....well at least take an omega 3 oil supplement (fish, krill or flax) as a daily regime until your next cholesterol and sugar blood test.  Click here to calculate daily fiber suggestions for your age.

Make the portion smaller, make the plate seem like it's holding alot of food (smaller size/contrasting color to food/dividers on the plate-forgive me Emily Post) and have something to refer to in measuring volume that can easily be referenced in future meals.  (For example, a small tea cup on the table will remind one of how much cooked rice is allowed in a meal....then theres the idea of having tea to slow the whole feast down so as not to devour everything then feel unsatiated.)   Timing is always important, even if there is no hunger for breakfast or lunch, it is important to stimulate the digestive tract to produce juices and enzymes, there is a physiologic cascade that begins and prepares the body for the next meal and activities of the day.   I have alot of truck drivers that come in thin as a rail, coffee and tobacco users that say they only need to eat dinner.  I tell them it is certainly a cool skill to be able to push away hunger but this is not a regular human schedule, they should do what they have to do to work however.........the body is going ask you to pay the price of poor nutrition sooner or later.    If its later, it will be so incidious that you wont notice how much damage has accumulated until an event has already occurred (diabetes, stroke, heart attack or early cancer)   The longer you wait, the bigger the mountain to climb.

The above measures are just a frame work for an average Filipino diet but if you break it down, the concept can be applied to any culture (short of the occasional vegan or wheat allergic patient.)   Read through, see how you can substitute dishes from your heritage, combine with nutrition in your locale and reliable dietary facts available from your doctor or registerd dietician.  (just need to ask for help and commit to change.....stick with it until the next season and enjoy the differences!)

Happy eating! Healthy living! Mabuhay! (Long life!)

Friday, October 5, 2012

  (click here if you love pork)

Had a discussion with Filipino TV chef Ron Bilaro (Adobo Nation on TFC).   I told him the recent uptick in young couples from the Philippines (30-40's) coming to see me.  As with most folks in that age group, I usually find high BMI (measurement of body fat), elevated blood pressure, elevated cholesterol.  Of course most are "shocked" to find they now have risk factors for heart attack and stroke!  Yet everyone proclaims they feel great!  And I applaud the fact but also say that my training is to forecast how to get from point A to point B.  The former is how lifestyle is now, the latter is how a well balanced lifestyle should be.  Standard medical practice is to say we should lose weight, exercise daily and lower cholesterol.  DUH.....if it were easy then everyone would have done it by the time they walk into my exam room. 
The realistic approach, (which is what I love about Integrative Medicine) is to plot out a path to point B, embrace the strenghts of the patient, his knowledge base, home life, likes and dislikes; then design sustainable steps to get the lifestyle change to occur.  If it were as easy as giving a prescription for a pill and rechecking blood tests in 3 months then saying "you are good, see you next year" then by golly, heart disease would have been wiped out 18 years ago when the first statin was released.   Dont get me wrong, these meds work for people with advanced heart disease.....but to slam everyone that is found with cholesterol issues with meds and not first work on diet/nutrition/food addictions......like putting a bandaid on a gunshot wound. 
Anyway......I was asking him if he build me a data base of mostly vegetable dishes from around the Philippines that my average middle age couple might be able to substitute 5 nights a week instead of a braised meat dish and not feel like they are being robbed of their heritage just to live life in the place with streets paved with gold.  Anyone that has been to a Filipino party will attest to the sight of a dining room table decked out with mostly brown colored dishes.  Lechon (roasted pig), Lumpia (eggrolls), Pancit (noodles) and steamed rice with lecheflan (sugary desert) for desert.  One of the problems with most households I visit is these feast foods will be served 5 days a week.  (not specifically the above but usually a saucy, salty braised meat dish with large volumes of rice).  Combine that with the fast foods available within 1/2 mile of most suburban/urban neighborhoods and you have the makings of -33% of all adults being obese. 
This isnt the norm for all Filipinos, neither is it the norm for 1/3 of the American families but it is thought to be a reason for the growing epidemic of obesity in the US. 
Ayurveda (Indian healing) has a dictum that for every area on earth, there are common diseases that occur.  Within that same area there will also be a harvest that treats the disease.   Perhaps Ayurveda didnt expect food to be so processed that it causes an addictive "high" when ingested or that food could be transported 2000 miles away so you can "indulge" any time of the year.  My mom used to send me 3 16inch long "Big Johns Cheese Steaks" double stacked with strip steak and dripping with American cheese, mayonaise on an Italian roll when I was in college and everyone in the dorm used to gather round and feast on my care package every month of the year. 
The bottom line with my project is to fine tune allowing patients to feel empowered yet satisfied to maintain a lifestyle that will get them to point B.  If I just say stop eating meat and increase your ingestion of rabbit food (as my brother in law refers to my lunch) most will feel robbed, and give in to the taste and smell of steak/hamburger/lechon before the 3 month time when I recheck blood levels of cholesterol.  Social media, TV adds, billboards.....for Gods sake, even the atmosphere around tailgate parties from a mile away will be drenched with the smell of hamburgers, hotdogs and barbque.  (like having alcholic hang out in a liquor store)
To me for a change to be sustainable, it has to feel good, taste good and you have to be able to show it off with pride, and this isnt one size fits all. 

(click to see the addendum post from 10 12 12)