Thursday, October 24, 2013

Diet and exercise wont work.

Had a patient go for PAP smear from her "primary care Gyne" in Barrington IL.  Incidental high blood pressure and cholesterol noted at visit.   I suggested first trying diet and lifestyle change with introducing exercise.  Upon recheck 2 weeks later doc says with a smirk- "...well how long do you plan on doing this?"  [before starting medicine]  "Your BMI is normal and since your not overweight, diet and exercise wont work"
BMI Calculator

WHAT THE F@#$!!!!  How dare this "primary care Ob/Gyn" make the suggestion that lifestyle change doesn't work.  Guess she didn't read the Lyon Heart Study, The Lifestyle Heart Trial, Framingham Heart Study.....   If it wasn't for my patient seeking me out, starting an exercise program (hasn't exercised since high school 35 yrs ago), learning about affordable nutrition (works 2 jobs as health care provider and mom), learning the value of slowing down to notice joy/feel grounded (high speed Internet life).....she would have taken the advise of this well established physician in the Barrington Community and started medications without changing harmful practice. 

I teach my UIC medical school students that 80% of a diagnosis can and should be made with history taking.  That means prying open a patients life with properly asked questions to find out what has brought her to this point after 50 years of living.  Blanket statements of "eat healthier" and "eat more veggies" doesn't work for the average American.  In fact the government has increased suggested serving amounts since the old suggestions didn't change overall death rates.  The minimum level of blood glucose had to be lowered to call more people "prediabetic" since old threshold levels didn't decrease the diabetes epidemic.  The food pyramid had to be changed to the food plate since people found the old idea too hard to follow.  The majority of patients placed on hypertensive medicines have not been educated on the basics of the DASH diet which is the first intervention step in treating diagnosed hypertension before medicines are prescribed.

Link to National Institute of Health Info

There is a place for high blood pressure medicines, there is benefit for cholesterol lowering drugs, there is a need for quadruple bypass surgeries.  Isn't it cheaper to practice healthy Thinking/Eating/Activity prior to the 10 dollar blood pressure medicine, the 30 dollar statin and the $60,000 bypass?  

Food for thought while you take your medicine this morning.   Here is my medicine:


Saturday, October 5, 2013

 Flew back from Wyoming hike sitting next to a COO from some large hospital group from the South East.  She had some nice ideas about the health and wellness of the nurses but I think her bottom line was dollars and profit.   You can get to feel good intentions and bad intentions after conversing with enough people that are emotionally on the edge (most of my patients).   I don't mean that in a bad way, I just believe disease is different now than 20 years ago.  I saw a lot of people in their 40s with the beginning presentation of a single disease process.  Now with modern technology, we are screening people earlier to find these "pre" disease states and placing people on "pre" treatment.  That is with family history of anything, if you are a little overweight, a little hypertensive and a little high on cholesterol....time for pharmaceutical intervention!  Docs don't have time to counsel on nutrition (and in my opinion my colleagues don't have enough knowledge to make good suggestions), registered dietitians don't get reimbursed for "pre" counseling so no appointments can be taken.  No one is willing to go see a psychologist or counselor for stress management or guided imagery teaching ("...I'm not crazy doc!")   So my average 40 year old is now coming in with 10 years of 2-3 medicines when back in the 90's I used to be the one who would start them on a pill.  And yes everyone is still heavy, under rested, over intoxicated, over stimulated and under exercised. 
     So this 30 something Chief Operating Officer was trying to tell me how they just built a wellness center for the "nurses" and they offered acupuncture and massage.  I didn't want to tell her I opened up the Central DuPage Hospital Wellness Center and helped design the physician community interactions along with my sports medicine clinic to get the community to become aware of the endeavor.  These things are just a write off where people can join a large club for a nominal fee and have subliminal advertisements galore of the hospital every time you use a machine.  Not to mention the rehab patients can also take advantage of a discounted membership.  All this at the expense of millions of bucks for another hook the hospital can use to pull you to them vs the other guys.  I went along with her philanthropic tone and said I work for the Immediate Care Centers in my area as my full time career.  I also exercise my calling by working an Integrative Consulting Service where I see 1 patient for 60 minutes initially and 30-45minutes for follow up just so I can extract the vital info needed to create a person program of wellness....or plan an anti-inflammatory lifestyle. 
    She immediately said a few doctors in her area do "Concierge Medicine" as well.  I asked her what she thought that meant.  "When you take cash as a retainer for physician services and make house calls".  I said I take cash since the reimbursement from insurance for 30-60minutes of counseling wouldn't even pay for my malpractice insurance.  (1/3 monthly goes to rent; 1/3 to taxes; 1/3 to malpractice leaving me with no profit...thus the need to work a "real job"-but I love designing a way out of conventional medicine!)  It is so dynamic to hear what people think of their diseases, find out the priority at this time, emphasize strengths, let go of weaknesses and think of another way around what is to some people an insurmountable obstacle.  This is Integrative Medicine popularized by my mentor Andrew Weil, and supported not by my colleagues but more from the community.  People are tired of taking more and more medicines with very limited happiness in outcome (not everyone but a majority).   Concierge Medicine, Boutique Medicine is totally opposite.  This is where a doc that has a large following, splits off from group practice, picks 500 of 2000-3000 patients and charges them an annual retainer so they can stay in his small panel of patients.  S/he usually still will charge insurance for office visits (double dipping insurance?) but give out his personal phone number for faster access and I guess makes house calls!?!? 
      I don't need no stinking house calls.  Who the hell has time for that.  I am not here to pamper anyone or deliver medicine with a bow tie and silver platter.  If you come to me for what I spend my own money learning in 4 additional years of training....there aint gonna be pussy footing around.  I will listen, construct and help apply a life plan that very few doctors will be able to do.  I don't want to waste your time or my time if we are just here for fluff and to see who knows more about the most recent episode of Dr Oz.  Mercola charges an arm and a leg but I hear he knows a lot.  Andy Weil and Deepak Chopra don't see patients anymore as they are winding down their face to face time.  What me and my fellow graduates from post grad training do is provide a service that is hardly filled but desperately needed.  It is just to hard to break away from the paycheck and lifestyle afforded by being employed by a hospital.  You can make a good living with medical insurance but the bottom line is numbers.  Numbers for my COO like being in the black, and numbers for my docs as in you have to see 1 person every 7-10 minutes.   (No this mandatory electronic medical records thing didn't make things more efficient, it just slowed down face to face time between doc and patient to make sure notes were legible enough to get the most reimbursement)   Even if my handwriting was illegible, I could get a diagnosis, treatment and follow up planned in 1/2 the time it takes for me to listen, type, print, get a signature and discharge.  And now with the Affordable Care Act, a whole bunch of folks that were previously uninsured and unhealthy will be coming in for "free" wellness screenings and supposedly getting healthier since it is covered.  A healthier US means less obesity, less cancer and less heart disease.  Oh....wait....there aren't enough primary care docs to take care of all these people!!!  So they can just go to the ER for the 1st decade of this Obama Care, hopefully there will be more doctors coming out of school to fill the primary care gap. docs want to do primary care cause it pays so low compared to surgery and you are a slave to a hospital system that say see patients every 7-10minutes!!! 
    This COO wont get the idea of living the anti-inflammatory lifestyle cause she is trained in dollars and cents and IMHO that doesn't translate to compassion and healing.   The two will never meet.  I am just thankful I have the opportunity to have one foot in both worlds.