Monday, December 24, 2012

I wanna be the tortoise.

In the fable the tortoise and the hare, the tortoise is depicted as a wrinkled old man short of breath, blunted face, 1000 yard stare, carrying his home on his back, not allowing the events around him to change his demeanor.  The hare is the anxious, sarcastic, egocentric, gaunt individual who thinks he can improve the world around him with his version of living.  In the clinic:

-Mr tortoise always talks about metaphysical interpretations of his universe.  Seems to only engage when asked about philosophy.  Prefers organic when he can get it, otherwise nutrient dense foods and supplements.  Very slow pulse rate and seems to close his eyes when not involved in conversation....but he isnt dozing off.  Family history reveals his parents are still alive and only positive is a cousin with anger issues that snaps.  Minimal disease present in close relatives.  Cholesterol excellent.  He works as a teacher with no financial investments, simple shell for a home, with minimal possessions.  Enjoys breathing exercises, long walks, and stretches alot.  Maintains visits when he can get in every 5-10years and has no complaints.  Doesnt offer much information, somewhat withdrawn and occasionally doesnt come out of his shell, but overall healthy. 
-Mr Hare has clear genergalized anxiety.  Boarding to the point of paranoia about always thinking about abduction from UFO's.  Comes in for physicals annually and averages a visit a month for symptom control from multiple medical problems.  Eats alot of green but prefers processed foods for "energy".  Sleeps poorly probably from urinating so often as he constantly drinks from his bottle.  Has a dermatitis issue that flares up with season change or stress- always scratching.  Possible over the counter nasal spray abuse as every time he comes in, his nose is constantly twitching.  Complains of restless leg and has to constantly thump is lower extremity to feel better.  Seeks out companionship and tends to involve himself in relationships that only cater to massaging him.  Practices polygamy and is not sure of how many children he has.  Fast heart rate and high blood pressure but excellent vision and hearing for his age.  Possible irritable bowel disease in an issue with defecating anywhere.  Family history reveals a very short life span for close relatives.  Very wealthy with multiple investments always thinking about saving for next season with a few savings accounts he doesnt remember and cant find.  Likes gardening and veggies.  There is a question of abuse in a witness seeing him pick up is child by the neck.   Earlier life was behind bars but cleared his record and now well loved by his young social network and often visits gradeschools.

I essentially advised the tortoise to avoid hiking near roadways,  try to increase fluids and avoid the sun.  I would like him to join social groups but he doesnt seem interested (truthfully I have trouble deciding his gender since its not obvious on physical exam).  Told him ok to continue seafood diet but avoid foods containing too many parasites and worms. His diet his high in calcium so we postponed a bone scan for now.  I suggested he come in for physicals whenever his deductible has been met but he says only has catastrophic coverage so probably wont see me for a few years.  He does visit a chiropractor regularly for neck issues.

I had to get Mr Hare into therapy immediately so referred him over our behavioral health department.  Kept on talking about the Mayan calendar, the end of the world and how he had multiple underground sites that he was prepping.  Told him to change his diet as the processed pellets he eats were too high in binders that was causing him the stool problems.  Had to schedule him for a consult with the STD clinic at county hospital since he didnt have insurance due to preexisting medical disease and jumped around from job to job.  Will address drinking problem next week and after he sees therapist to start mind body programs and lower his heart rate.  Have to postpone the relflux and sleep study for next month after his shots.  Ran out of time this visit but as he will be seeing multiple providers, I will try to coordinate care.  Until then ok for continued exercise as he seems to love long races and competition. 

Interesting how these two characters are companions but at polar ends regarding healthcare.  Guess with out one the other cant exist.

Friday, December 21, 2012

The Screen

I received notification from my high school that a childhood friend passed away. Tony happened to be my college roommate as well. In the season of giving, it is sad to hear about loss though from every fire emerges life. As a physician, the event of passing-on always becon’s the question, could this have been prevented. The neighborhood doctors was the guy who knew the family, was available if you walked over to his house and would take care of everything from diaper rash to dementia. In the millenia, primary care doctors are thought to be where patients enter the insurance based medical maze to look for disease and stop it. (My perspective of the current system is me entering a hamster wheel of healing, trying to give undivided attention to detail, package a plan for life change, then jump back on and see the next soul that I stumble upon) It is not uncommon that as I formulate a diagnosis, tests and give reassurance, patients comment "this is the most time a doctor has spent listening to me". It is nice to get validation I am doing the right thing to heal people but I'm not here for validation! I became a doctor because of an innate urge to serve humanity. The knowledge base imbibed over the 25 years of training has taught me the essential message within the symptoms of suffering is the answer to its resolution. Problem: how to extract the right information in your annual 15minute visit and reverse life threatening disease?

You can’t.

Medical insurance penalizes doctors for spending "excessive" time in a patient visit. Most patients only have catastrophic medical insurance coverage that covers annual physical exams and nothing more. (What policy holders don’t know is that your doctor is not allowed to address chronic issues during the yearly meet and greet) This glorified visit has been truncated to be a history review; a physical exam, cursory blood tests and the statement- "don’t smoke, get some sleep, eat right, lose weight and start exercising for the next 12 months". Being on the receiving end of getting a mountain of information and only having 15 minutes to climb it, I have experienced some visits that are difficult and some that are effortless. Here is my formula to take advantage of a "wellness screen" (aka annual physical) where both patient and doctor walk away fully accomplished.

1- Expedite the transfer of information with a summary of symptoms (if you are suffering from something that is concerning to you). Write the diary in chronological form and keep it 1-2 pages large font. You will have to be poetic in descriptions but editorial in cutting out crap. Have pertinent test results available in chronological order (accordion folders are good) but don’t just hand this folder over (very overwhelming to the person that accepts the gift); when doc reviews your narrative, s/he will ask for certain tests if needed-highlight dates of testing so you can reference, pull out and show. Films are good to have but too bulky to manipulate during a physical exam and take too much off the clock to hold up and review. (Too many ingredients in the soup will obscure the essence and make it unpalatable.)

2- Stay focused on short answers to questions of inquiry. There is a tendency in chronic suffering to answer a question with "…this was preceded by…" or "…and then I developed…" leading to another problem. Western medicine docs think in single systems so jumping from digestive to respiratory to hormonal would lead to half-ass fact finding (ultimately leading to half-ass solutions)

3- Spouses (guys) usually need the partner present to make sure primary concerns are addressed in the end. This is especially true if the patient was prodded to get a checkup all the while thinking life was good. (Some don't realize how the depth of their problem effects the family.)

4- Have a list of prescription medicines, doses and times per day; supplements with ingredients and times per day and your average dietary intake per day all listed. If I can scan your "pills", I can tell you what interacts and where you don't have to spend alot of money. (As I tell my patients, if I can save you 50 bucks a month, use it to get a massage or go buy a healthy dinner!)

5- Keep up to date with medical problems suffered by relatives. This is a neon sign that helps docs figure what is in the family genetics or childhood surroundings that may lead to development of disease. (ie, if heart disease is in the family-doesnt matter if you are an athlete, we should work up your heart.....statisticians will say likelihood of heart attack is low but if you are the lucky guy/gal who is hiding a widowmaker, I have to console your family while 911 is rushing you to the hospital.

6- Research from reliable sources (Medscape, DrOz, DrWeil, WebMD) on hot topic items. Usually the buzz in social media will surround release of new information or new controlled trials. May involve a medicine you are taking or a symptom you are dealing with. It never hurt to ask for a specific test to find disease early but you and your provider have to be prepared on what to do with the results. Caution: just because your doctor writes an order doesn’t mean it will be paid for by insurance. The insurance pencil pusher will always tell my patients "as long as the doctor writes a diagnosis of maintenance/routine, it will be covered. Yeah right, I write it, then the lab says they can't run it with a "routine diagnosis code"; you get a $200.00 per test bill and there goes your life savings.

7- Ask to change into a gown before the doc enters the room so you can save time and encourage direct visualization/examination versus having to excuse yourself, change, reenter, get on the table ……When a physician is running 30minutes behind, 3 minutes of idol waiting in the hallway is stressful while other patients are peeking out of the room wondering "when am I going to be seen?". During a physical exam, if you arent ready to show, I am skipping over it and just handling big ticket items-this may miss a skin lesion or tell tale signs of thyroid deficiency......

8- Expect to come into the office for follow up discussion of results and further planning. The old thinking of no news is good news just actually means doc never got your results and didn’t call. Also know who the contact person is in the office to communicate with the doc. Modern medicine doesn’t allow time for docs to call back and answer questions personally, there is usually one person s/he trusts to relay messages and plan. (Don’t take it personally, providers are usually in and out of the hospital, office or surgery and if you insist on a personal call back, in most cases it will induce resistance or you will be placed in a long cue that gets buried in a pile of unanswered messages.)

This sounds like you have to do a lot of work to get a routine annual physical…..and you do! Unless you are not the average American with prehypertension, prediabetes, slightly overweight with elevated cholesterol, working 40-50hours weekly, and not meditating on a regular basis, you have to be your own advocate for staying healthy and living until 90-disease free and happy. If you have an Integrative Medicine physician, or an old school doc who knows how to listen-grab hold and do what you can to see them annually (no matter what the statistics say about maintenance physicals) Some docs that offer membership for a retainer fee (like a lawyer) essentially take care of steps 1-8 so you don’t have to worry about it-this is good if you can afford it. Bottom line is that if your gut tells you it's time to make a change, you are probably carrying a few medical risks already. Even with something like my Mom's  pancreatic cancer (that has a poor prognosi)s, or in Tony's case I am sure a few extra years would have been appreciated by his kids. I believe any properly trained doctor can help you template a change or find disease early, but it starts with the precious face to face time of a wellness screen.
(Anthony J D'Angelo, DMD)

Tuesday, December 18, 2012


How many traffic lights had to coordinate, how many sales people had to schedule to be switched, how many buyers had to estimate the needs for a local Tucson store, how many store clerks that have hiked the grand canyon had to be working......all this on the day I was just going to the store after a day of lectures at the Arizona Center for Integrative Medicine. 

My story starts with the 2 year fellowship I finished on the week of 12/12/12.  This was with the AZCIM (famed postgraduate school started by international author Andrew Weil)  I was accepted to the 2011 class.  Before starting, mom was diagnosed with pancreatic cancer.  I tried to continue studies but had to withdraw.  I was convinced to just postpone starting and join the following years' class.  (miracle 1)  I just happen to fit in nicely with the group of healers, residents, nurses and physicians from the 2012 class.  I also gave my mother one of the last moments of a parent being proud of a child's accomplishments....I feel this helped her pass into heaven.  Jump forward 2 years, I finished my didactic studies and flew to Tucson for graduation week.  I had planned to graduate on Friday and drive straight to the Grand Canyon to see the Colorado River.  Before flying out, weather was clear and not to cold so I packed hiking/camping equipment for hot days (water storage and shade) and cold nights (thermals and sleeping bag/tent).  Only took one rain gear as an outer shell and left everything else at home in Chicago The City of Cold Windy Snowy Hikes.  As I camped out at Catalina State Park, I was using a Jetboil outdoor canister gas heater and was running low on fuel.  Decided to take a trip to REI but just as I turned the corner to the building, remembered my credit voucher wasn't good till next day so aborted and made a U turn (miracle 2).  Cutting through a parking lot to head home, I saw this small strip mall and a tiny store that caught my eye (miracle 3).  Went in for peek and started talking to one of the sales I was leaving, he mentioned to another associate I was hiking the Canyon.  Guy said, "theres a snow storm coming" (miracle 4).  I mentioned when I last checked the Weather Channel, there were clear sky and no moisture.  He brought it up on store internet and to my bewilderment, 3-5 inches of snow to arrive the night I arrive and the day I hike down.  Not only did I pack inappropriate gear, I had no snow shoes, no crampons (snow spikes) and non waterproof boots.   After confirming the arrival of the first snow for the Canyon this month/season, I called around for crampons as I figured these were most important and useful tool if I ran into danger on he incline going back up.  Out of all the stores in Tucson, one store had one pair left in my size (miracle 5). 

Graduated from AZCIM, headed out to the Bright Angel Lodge.  Yes... ran into the snow storm but was able to unload and bed down before the chill and ice set in.   The next morning, 4 inches of snow and low cumulus clouds obscured any chance of me seeing trail or vista.  Was able to wrap my boots in Target Store plastic bags to prevent soaking my socks and used my walking sticks and headlamp to find my way down for the first 2 hours.  It was painfully slow but as the day progressed, snow stopped and softened.  Had a great time in the base of the canyon.  Hiking back up toward evening started to freeze all the wet snow.  The slippery footing and 10 hours of aching calves made for a very slow climb and with 2 hours of hiking left, I was wondering how am I going to get back up with no rangers around to help, phone drained, and temperature dropping fast with what felt like a Lake Michigan fridgid wind blast.  BLAM!!!! I broke out the crampons and like getting a new lease on life, every step was now locked in, and legs didn't have to "work" to maintain balance since spikes pierced the top layer of snow, the middle ice sheet and the bottom mud pie.  It was like I had magnetic shoes and was walking up a steel wall.  If not for the last set of crampons, from the last store in Tucson, warned by a passing salesman, at a small store I had no intention of buying from, and a hiker that just happened to be listening to the local weather forecast, and my last minute memory about store credit that didnt kick in until the next day....I would have had a dangerous hike out of an icy Canyon that has taken lives.

My trip was already planned to happen the way it happened long before I bought my plane ticket.