I am witnessing a duality in creating my "ideal medical practice".  Corporate medicine uses structure to design a healthy community.....reimbursement, budget, staff, department. building, campus.  I am using anecdotal success to design......learned information applied in real time to my salaried position.  (sounds like a watered down version of my practice but in the eyes of professional regulation, I am a family medicine doctor just like any other).

My experience with hospitals is when large hospital joins larger hospital system.....reputation brings volume (more doctors ask for privileges to practice, local business align with hospital, patients set allegiance with hospital name) and volume brings profit.
My experience with healing is all patients possess the appropriate way to improve suffering but it must be teased out of the tangled mess acquired over decades (spiritual, physical and nutritional baggage).

So can the medical model work to end suffering.  No, it can control suffering... and in a few cases successfully reverse (like what you see with visits to Mayo Clinic....people sign up, get evaluated by intake doc, speciality doc, testing doc, summarizing doc.....in a few days to be send back to place of origin with homework for the local healers.  In my opinion its nothing fancy, just the impeccable timing and focused communication among several aligned physicians with a captured audience.  A well functioning local hospital can have the same success when large departments are cohesive, testing is not redundant and patient is willing to go from department to department in a single well designed plan.

The problem I experience with hospitals in the last 20 yrs is -there's poor communication between departments, between doctors, between testing facilities.  It brings excessive testing, excessive prescription use, prolonged suffering and sick days at work....this all culminates in less energy by the patient to make the visits, and be engaged in being their own advocate for finding the endpoint.  (we have all experienced this in calling the phone company to dispute a bill, getting an automated phone menu, repeating the voice commands then being switched to punch dial for a department, finally speak with a live representative describing the problems, being placed on hold to only repeat your autobiography to a fresh person who promptly forwards you to a manager extension that goes to voice mail.....kinda get the wind taken out of your sails by then right?!?! ) So imagine someone labeled with irritable bowel syndrome, fibromyalgia, non differentiated connective tissue disorder, chronic pain, obesity, metabolic syndrome........

The fix was supposed to be the primary care doctor role.  In the 90's we were given the title of "gatekeepers" to arbitrate if and when a specialist was to be seen.  Patients were very unhappy with being told, you can't go to him (not in network) or I do not believe you need that test yet (direct to consumer advertising pushes the most expensive test or pill with little to no benefit over standard).  Insurance companies acquiesced to the masses and gave more options for patients and doctors.  I remember in residency, to take care of all the insurance forms and call backs, an entire department had to be created to handle the paper chase man-hours....and this is from a speciality that receives the smallest reimbursement of all departments.  I have worked for 6 hospital systems in 2 different states and I am always told by corporate that primary care offices "do not make money".  So if you tally the budget and payments received, most primary care offices are in the red.  But....hospitals can sustain primary care practices for the trickle down profit of blood tests, surgical procedures, imaging tests, rehab......when all these things per reimbursed properly, the hospital can justify keeping primary care doctors around.

Q-can the average primary care doctor be an advocate for the suffering patient with a tangled mess of acquired decades of baggage?
A-yes.  If....the doc is well versed with using different tools to untangle.  (Maslow's Hammer 1966, if all you have is a hammer, everything looks like a nail)  Imperative is the ability of the doc to negotiate the truncated patient visit with the exact set of questions.  If we all doctors had 60 minutes to do a quid pro quo,  I believe even the untrained person could design a decent direction for patients to proceed to better health.  We don't have 60 minutes, we have 10 (maybe 15 if you argue to the corporation that issues your salary.....you have a dedicated panel of patients that are satisfied!!!)  What Can I do in 10-15minutes?  Listen ...but interrupt if you give too much information ...all this so I can extract just enough story-line to justify writing a prescription to turn suffering temporarily down a bit.  Disease management as my guru Andrew Weil calls it.   So requirements to successfully be an advocate for creating a local Mayo Clinic experience is 1-visit time and 2-integrative medicine training.  Neither of which we are afforded as a primary care doctor coming out of residency training.

In attempting to create an Integrative Patient Care Practice (a local Mayo Clinic type center), one would have to lay out a structure to "corporate" for allocating budget.  It would have to be strategically placed in the hospital campus to anchor the new department as a destination medical specialty.  It would have to hire talented ancillary care to help with lifestyle change.  That's a lot of planning and proposal based on  anecdotal evidence from a doc that "doesn't see as many patients as an average family medicine practitioner", "practices medicine but also does that cooky acupuncture (needles or something like that)" and "teaches yoga, eats organic veggies like a hippy".  Sarcastically this is what I experienced as I went to corporate in the past, presented my vision of a Lifestyle Center and was immediately met with questions like what is the budget, is this viable for the economy of the area, who will we have to hire (even had one head walk out of the meeting early)  Difficult questions to answer for a concept that doesn't exist.  I don't blame them, this is the language they don't speak.

So for my patients who follow my blog, have no fear, I know what has been working for 20yrs and I have refined my personal life be healthier husband/father/son and it has afforded me a better spyglass to see into patients "tangled mess".  All the cool experiences I have lived through helps me avoid Maslow's golden hammer law, just in the last 10 months of my return to working for a hospital, I have seen countless patients coming in with weight loss 20-40lbs.  This as the result of educating new patients last spring about how to lower cholesterol medicine dose, wean off 1 of many blood pressure pills, or exercise with walking.  The beauty of inspiring a "way out" is you fill the sails with wind by empowering change with knowledge.  Ultimately my heart says to do whats right for my patients but my paycheck says I have to do what's right as a salaried Family Medicine provider. (I Got This!!!)

yin and yang

Hot and Cold, Anger and Calm, Adrenaline and Serotonin......there are extreme opposites that exist to emphasize and support each other.  Can't have one exist if there weren't the other.  So if you think about the majority of reasons people show up to the ER being linked to the stress response it would be valid that teaching the relaxation response would keep our ER's empty!!!  Ah but no one learns this relaxation response until catastrophe occurs and then the mad scramble to find a healthy lifestyle.  Granted there are the few who I meet in yoga class/at a retreat/on the trail/in sanctuary/watching a sunrise or.......at a beach sunset that were blessed to have experienced the Serotonin High (click for link) at a young age and continue to chase the feeling for a lifetime.  You know when you meet the lucky ones, just seems like they are so magnetic, at peace, and just living and enjoying-(downright enviable!)  And here's the cool thing; human brains are hardwired to be attracted to people, events and circumstances that emulate this.  Genetics decided that the species will survive with love as a group so it is built into the DNA to feel very "on top of the world" when you accidentally place your "experiential toe" in the pool of happiness.

It's the ego that we entertain in youth (and sometimes into adulthood), that convinces the brain that the experiential thing that pulls us to share/smile/do things for others - isn't as important as getting something and keeping it, not giving back or contributing.  It's the ego that contemplates that you are the center and all things happy are placed on earth to serve you.  This self serving tendency makes you want to accumulate and horde, you are separate from others, "you are number one", "you deserve a break today", "this Bud's for you".....but the pseudo-rush-feeling one attains from the Adrenaline High is very fleeting and usually leaves you feeling kinda charged but at the same time- kinda needing to get recharged or more as the feeling isn't fulfilling for long.

This is the difference between material happiness and experiential happiness.  Both will work to trigger an emotional wave but usually the experiential thing (like me hitting the summit of Half Dome (click for link) will far outlast the purchase of a sports car or a big screen tv.  In fact there is something called the Hedonic Treadmill where you accumulate more "things" to keep the happy only to find the "thing" you purchased doesn't reward your DNA for long- resulting in a temporary fix making this unsatisfied spiritual nomad seek out another material thing.  Even in economics, the Easterlin Paradox says increased income does not correlate with increased happiness.

I believe that those who haven't tasted the nectar of the serotonin high will go for the next best short term easy emotion that even a child can cultivate....anger/stress.  I think deep inside most Americans will seek out terrifying news, "jump scare scenes" in horror movies, big noise, flashy lights...shock value stuff that is hard to look away from.  There is a definite rush associated with reckless behavior-but again....fleeting.   And to extend this concept to food, people who want fast emotional reward will also find it comes easily with smell and taste.  Processed food will usually give the same rush as shock tv  = rapid emotional turn on followed by a feeling of empty and the need for another "hit".

The built in "lysine contingency" (from Jurassic Park) to humans is -if the individual is exposed to an environment of continuous stress/anguish/hostility/poor calories....the species' DNA says surroundings are not supportive for prosperity so the individual will develop disease and die early.
(Please see my last post The Walking Dead -click here)

Has stated in the title, both extremes have to exist.  The Adrenalin Rush is a useful thing,  but not sustainable ......and for a good reason in that the species can use it to fight off saber tooth tigers, run from fire, seek shelter in thunder, move away from spiders.  Fast and furious response, then off.  In contrast, the Serotonin High makes people come together (literally) help others, provide service ........everyone gets a lump in the throat and a sheds a tear when watching young kids get reunited with parents that have been away a long time.   Having an act of kindness done to you generates massive amounts of serotonin and oxytocin.  Even witnessing the previous act of kindness will make you generate serotonin.  Ever wonder why a person coming home from vacation or a retreat is on cloud 9 for a long time after the experience has finished.  It is hardwired into our genetic code to to seek serotonin inducing activities and places that will allow the best odds for the species to survive.

So why don't we teach this to people as a form of "preventive medicine"?  China did this centuries ago in the form of large industry stating everyone that has a job must practice a form of serotonin inducing activity during the work day-Qi Gong/Tai Chi!!!  The end result was to have a more peaceful work environment, efficient workforce, healthy employees-less sick leave!   That was along time ago but if you even pass by an Asian household now, you may be witness to a grandparent doing some type of "swimming in the air" movement while standing in the driveway.  That is the old Asian guy getting his daily dose of serotonin!  Because he was blessed in younger years to experience the Serotonin High, he continues practice well into his 70's and 80's.  It makes him feel good most of the day, its easy to do, no side effects and requires no copay.

So is it worth carrying high adrenalin levels and suffering the side effects of the reflux medicine, the blood pressure medicine, the anxiety medicine, the palpation medicine, the IBS medicine, the headache medicine?  NO! ..NO!..NO!

More importantly, is it worth keeping daily serotonin at a therapeutic level using refreshing sleep, yoga, qi gong, meditation, hiking, exercise, laughter, healthy food?    Yes! ..Yes!.. Yes!    

When is it too late to begin a healthy lifestyle change?

I gave a talk today to try and inspire some of my patients onto a healthier lifestyle.   I remember communicating with Steven Devries, an integrative cardiologist who tries to get his pre-cardiac stent patients to make a lifestyle change before going to bypass.  I used to think the concept of integrative preventive medicine was only limited to primary care doctors since my specialty couldn't bill for hospital based procedures -thus the only tool at our disposal was prescription medicine or life-coaching.  With the 15 minute visit not being adequate time to educate .....our only go to was the prescription pad.  Fast, powerful, easy to swallow and most important......paid for by insurance!!! But wait.....what if a patient asks about diet and exercise?  "Well John, I can send you to a registered dietitian for 60minutes of education, design, empowerment.....oh.....but your diagnosis of increase weight, high cholesterol, high blood pressure and prediabetes doesn't cover the visit with her".  We have to wait until your heart attack occurs or you are a full blown diabetic before giving you the education to reverse disease.  Doesn't make sense!!!  But has a hired doctor for a large corporation, I have to be productive compared to other docs.

Or do I?

I thought instead of seeing different patients individually then repeating the same answers.....why not have them all come at the same time!!!!   (of course they have to kinda resemble each other as far as type of medical disease)  But aren't the most common diagnosis all rooted in the same problems-nutrition/stress/immobility?  I decided to see a group of patients at the same time, teach healthy eating and "fire off" answers to the questions that resonated from the group - How to Design the Change in Life and Where to Start.  At the fellowship of Integrative Medicine with Andy Weil, doctors are essentially given the permission to spend 2 years reading and learning about using nutrition, mind body medicine, and parts of ancient whole healing systems (like yoga an Chinese medicine) to take care of the imbalances most people are suffering from.  These imbalances are driving the per capita spending from $5000.00 per person about 5 yrs ago to $8000.00 more recently. So I was able to get some good education across (I think?) and design good take home points that all could use for their individual medical problems.  I called it Weight Loss and Lowering Cholesterol.  I should have called it Weight Loss/Lowering Cholesterol/Reversing Prediabetes/Improving Obesity/Reducing Blood Pressure Medicine/Helping Menopause/Caring for Metabolic Syndrome/Fighting Cancer.  That wouldn't fit on the first slide.  Not only was I able to give more in depth info, I was able to introduce a personal trainer/nutritionist to our group and have her chime in additional "real world" pointers to each person in attendance!

Pouring this information into someones cup will only work if the cup is held with the open side up.  If I have someone that doesn't want a "refill", I don't give it.  Since taking over this primary care practice in Jan 2015, I have found most people didn't want to change getting their refills every 4-6months and some were not ready or willing to start experimenting with cooking more, buying from the farmers market, going gluten-free, enrolling in an exercise place.  In fact some people got angry and offended that I would suggest conservative options instead of medicines (see the angry review on www.vitals.com).  This is because the trusted way people have been interpreting "being healthy"- is to take a prescription.  Their thinking is if I suggest exercise, counseling and food prep then take the prescription drugs away and ......that would bring on disease!!!  I feel that other doctors are DISEMPOWERING patients by puffing up the value of prescription fixes and not mentioning natural ways to reverse disease with eating and movement.  So back to my original intention....I used to think it was just the primary care doctors role to advise lifestyle change since we had no procedure training and couldn't do stents or bypass or irradiation of tumors or insulin pump insertion.....but....I heard Steven Devries speak of Dark Leafy Greens and exercise and the diet used during the Lyon Heart Study.  Now it isn't just primary care, the concept of healthy lifestyle and evidence based change has trickled down into the specialists fields!!!  (there's hope after all....)

One of my old patients (an open heart surgery patient) came to the group visit today.  He and his wife are living proof of lifestyle change leading to positive results.  He was told by his cardiologist if he didn't have another surgical procedure, he would be dead in 4 years.  (-threat incentive)   I remember seeing his cardiac numbers a few yrs ago and was a bit worried that going conservative may not reverse his disease in time.   We pushed on, I watched him while his cardiologist continued to give the obligatory  finger pointing saying that once the heart muscle is damaged it can never be retrained to beat healthy.  First we did supplements to feel better, then supplements to fix deficiencies on blood testing, then exercise to take advantage of the supplement positive effects, then nutrition to remove the need for supplements.  Now at 72, he has been deemed a miracle according to the cardiologist, he inspires people 1/2 his age (and out-exercises a lot of them!!!)  He has dropped down to a healthy weight even lower than what he was in high school.   I asked to see muscle size and this is what this 72 yr old open heart patient showed me:

Even at the age of 72 where some people are accepting death, John is making changes to live a healthy life, has thrown away all his cardiac medicines and (....the clincher) avoided the high risk procedure he was told would get him past the 3 yr deadline given by cardiologist.  He looks good, feels good, is helping his wife get healthy and is living proof that change is worth it.....it's never too late.

WALKING DEAD

Walking Dead

    The practice I was asked to absorb in January has the typical population patterns for rural America but I have been able to care for quite a few more senior citizens which I consider an honor.  I have met some great 80 yr olds -very active at home, in the garden, in the neighborhood.  I unfortunately have also adopted a large army of middle aged patients with an equally large surplus of prescription medicines.  Anyone who knows me can attest to the fact that I use prescription medicines but I usually make a good run at conservative measures first ….(unless symptoms are severe).  In some cases when the disease presenting in the patient is advanced, “I go straight to big guns” and not worry about throwing rocks at the problem (although rocks can win a war too).  The complication is when first meeting these patients, they come in for refill…appalled that they have to schedule an “expensive office visit” just to have me re-up their 4-8 prescriptions for another 6-12 months after viewing the usually normal blood tests.  Little do my patients realize is that I may be ordering cursory blood tests like the preceding doctor, but I am also piecing together a plan of lifestyle change that usually starts with looking for deficiency.  Average primary care doctor coming out of residency can read the scientific journals and keep an eye out for flagrant red flags (high blood pressure, high cholesterol, high sugar, anxiety, depression, hot flashes and impotence) and divvy out a prescription for each of the problems found.  By stabilizing the metric that was found abnormal, the doctor has done his/her job and can reevaluate in 6-12months.  This was probably ok for the 90’s when the population was less obese and drug companies were just starting direct-to-consumer advertising.  Now that we have DVR’s, DVD dispensers at the pharmacy, addictive TV on demand, fast food restaurants that deliver without you moving off your couch or out of your car, obesity going from 1in5 to 1in2……I do not think JUST STABILIZING the abnormal metric (bp, cholesterol, sugar, panic, sadness, the change, ED) with 1-2 prescriptions will work to hold off progressing disease. 

    I was able to do that in 95 and watch the progression of aging and disease presentation and when a patient would outrun their temporary prescription and still have symptoms, then I would get specialists involved with 2nd opinions to instill fear and perhaps that would get people to change lifestyle.  I would embrace exercise and nutrition but the only thing that was big back then included Richard Simmons, The South Beach Diet and weight loss pills.  Bariatric medicine started in the millennium and everyone that was unsuccessful with their own lifestyle remodeling was getting their stomach cut.  It was getting so hot, I remember an 18 yr old coming to my office asking for surgery before I left CDH (I didn’t agree with the way medical insurance encouraged dis empowering patients).  This is my biggest contention….I believe just doing minimal with STABLIZING a symptom or measurement is not enough.  Once the acute problem is neutralized, then the architect is supposed to evaluate, look for weakness in structure, anticipate failure and redesign.  I admit when looking at patients I sometimes will put on my “invisible glasses” and see through the patient to look for flaws that may have contributed to current disease manifestation.  With Andy Weils foresight in offering education to doctors and Deepak Chopras knack for defining modern medicine with ancient healing…I am very comfortable with designing and redesigning different ways to break the mold and get back to feeling young again.  

    THAT’S IT!!!  Feeling young.  I always wanted to make my patients live to 90 with as little medicines and surgeries as possible….but….since starting back into primary care and true wellness, I have been blessed to see some 80 year olds driving to their appointments on their own, living independently, taking few medicines…..and most of all-smiling and happy enjoying life and giving back.  In reading Dan Beuttners Blue Zones and the population studies he presented, living to 100 is more common in other parts of the world.  No, I don’t mean the American version of 100 (nursing home, incontinent, immobile and in a vegetative state), I mean European, South American, Asian centenarians that look like how the current US 70 year olds appear.  I can’t really do much for the current patient that comes in at 70-80 with end stage diseases…..but I can do something for the middle age folk that are on their way to a long, painful and demoralizing retirement.  (…some already forced to stop working and apply for disability!).
This is my picture of the current middle age American:

-Overweight

-Stressed with life

-On 3 to 5 medicines

-Still with aches and pains

-Not able to exercise

-Poor sleep

-Alcohol dependant

-Postponing falling in love again (I don't mean singles, I mean married people seeing spouses on the weekend and occasionally in the bathroom before bed)

     When I hike or run or work out in the gym, everyone seems so blunted with emotion (and that is the portion of society trying to make a change!!!).  I will sometimes decide to walk through a mall or grocery and just smile.  I will force eye contact and flash a smile to as many people I can.  Last time I went to Jewel Osco to buy office flowers, it seemed like everyone was walking around like they were near dead or wounded.  Big belly, bad knees (from the big belly), achey back (from the altered moving knees), lack of hair (from poor sleep due to pain medicine), cart full of large volume processed food (due to craving from the pain medicine and poor sleep), refilled prescription in hand (to control the side effects from the first prescriptions).  What kind of existence is this!?!?!?!  Most people really have to reach rock bottom before they are inspired enough to change life….I see that places like Cancer Treatment Centers of America have been able to capitalize on this.  Here they get people with live or die choices that no longer have a choice-they have to change.  CTCA also has done more than just getting like minded western trained doctors together…they hire on the team- mind body medicine, traditional chinese medicine, yoga, naturopathy, herbal and plant based medicines….all to increase the chances people will get to 100 and be loving life.  

     Don't just be content with filling out the medicines to satisfy algorithms and control symptoms. This is disease management at best -creating a society of Walking Dead.  "Health Care" is taking someone off balance and getting them back into balance, feeling healthy no matter what age.  I love the way Chris Crowley gets it in Younger Next Year.  He and Dr Henry Lodge give a template of how to enter into your 40’s, 50’s and 60’s feeling like you did in college…..and maintaining that level of youth.  When sitting in the room with a new patient, I try to inspire patients into change without making them feel guilty.  The problem is most people don't realize that as years go by (now it’s more like months) the medical community and advanced medical testing will find more and more things abnormal that will only be fixed with another medicine or surgery.  If you look in the mirror and tell yourself, I will work on that stomach tomorrow, or I’ll indulge in that extra portion of highly processed food "cause I deserve it", or I don’t have the money for those vitamins this year…..it is a matter of time before you walk around slower, make poorer choices, and start losing the feeling of happiness. 

     Modern medicine will not allow you to die outright, you will have a stent here, a joint replacement there, a medicine to control emotional outbursts, a medicine to help you get to sleep, a medicine to wake you up, a medicine to help the heart work, a medicine to cool down digestive fire………YOU WILL BECOME THE WALKING DEAD so dont just wait for the signal that it's too late...........look for a sustainable change now.  

Perform action without regard for the fruits of action. -Bhagavad Gita

Being "well centered" allows for a tolerance to the forks in the road.  There will always be decisions to make on the journey to a summit.  Of course you have to commit to a summit to begin with.  At the Chopra Center's Yoga Teacher Training we are taught to live our purpose in life.  Sometimes it will be obvious- what we were put on the earth for; other times it will take journey to find it.  Either way, if we have connected with that ever lasting energy of nature/the universe, our time on the path will be effortless.  The difference between investing hours of our lives to a project vs effortless ease in living in the moment is light years apart.  It is not the belief that you don't care but more of accepting the next fork in the road as part of the journey.  Both ways of seeing a goal will get you to a summit but the latter will get you there with less expression of disease and disability.

When CEO's come to see me for "check ups", most are educated, well read and have embraced problem solving skills that have launched them into the current state of "success".  The question I have is if in their "success", are they feeling fulfilled.  Most are missing something inside although they are surrounded by material reminders of their journey.  No question that it's cool to have expensive stuff that only a few humans will ever glimpse, but how long will deep happiness last holding onto that temporary object.  (...it's more of a caution to note when the interval between requiring the next object shortens-red flags should go up!).  I remember my guru saying "we buy things we don't need with money we don't have to please people we don't like".   I don't expect patients to take a life of celibacy but I do believe that neutralizing objective reward with a practice of contemplation will keep one foot in the real world but the important foot will be connected to a sense of oneness.  If you haven't taken a yoga class taught by a good healer then you probably can't fathom the value of silent mindfulness.  There is usually an aha moment with people that sit down with the intention to remain in quiet for some time.  I teach my guy patients (males are very visual and can comprehend a concept better with data/facts) that relaxation and spirituality can best be demonstrated by the "floating on a cloud" feeling you exude during the first few days of coming back from vacation/nature.  You can see it in the blogs and post of people back from vacation.  Energy in words, actions, attitude for a few days.  That is the serotonin high on a trip that started when you unplugged and just learned to be in the moment.  The high is usually maintained with just a shared thought, story or reflection on feeling really good.  When people feel good serotonin and oxytocin are released into the blood stream.  These feel good hormones help little RNA/DNA, white blood cells, digestive system, brain tissue do what their dharma (purpose in life) was programed for-survival and continued existence.  When every cell is working efficiently, people feel creative, fast problem solvers, have great sleep, and appear emotionally attractive during the serotonin high.  The sense of ecstasy can be reproduced even without being in Punta Cana or Yosemite or with friends and family.  But it takes practice, regular practice to be able to reproduce that state of happiness without having to fly across a continent.  The more you practice the deeper you get in a shorter amount of time.  After a while you end up not caring about time because during your regular practice, the serotonin and oxytocin secreted by all 3 trillion cells of your body work with maximum efficiency in the "sanctuary of time" you create.   When the factory is buzzing, you product is good!

Science has tried to reproduce the feeling with SSRI's (Zoloft, Paxil, Prozac, Effexor...) medicines to synthetically increase serotonin.  They work for the worst cases of mood disturbance but usually mild to moderate depression gets the same amount of a bump in serotonin with meditation, St Johns Wort, sunshine and counseling.  What I have experienced is when you're doing what you were born for, time stands still, serotonin is endless, your investment in any action is infinitely rewarded.  In the journey to my summit, I used to question if all of my efforts of burning up time would be worth it to accomplish a goal.  I was always focused on the goal and it made me insatiably anxious that I was "burning up daylight" and possibly going down the wrong path.  My aha moment was attending a seminar at Harvard by the author of the Relaxation Response.  I realized that there were other doctors that were "great listeners" both their own cellular intuition and the patient's ailments.  Herb Benson showed me that there was validity to mindfulness, energy based medicine and the idea of letting go and trusting in some unseen "pull" that guides you to fulfill dreams.


So picture the Steve Jobs of the world, setting a summit, launching on the journey and staying unshakable in the moment of decision making at their fork in the road. Then imagine the CEO that seems financially successful but looks stressed, unapproachable, and unhealthy with some form of substance abuse.  (I don't name anyone but you can probably think of someone in an executive or managerial position that may be great at what s/he does but also looks 20 years older than his highschool classmates ).  Initially it seems counter intuitive to let go of a dream but I think back to what Deepak taught me-detaching yourself from the outcome doesn't mean you dont care, it just means being open to when "something" will happen and knowing the next step to take.  Think of it this way:

                                          -you can hold tight on the stick and chase the carrot

                                                                                       or

             

                  -you can throw the carrot into the abyss before your journey trusting you will find it again

It works for a while then stops....

I always wondered why patients say "the prozac worked for a while then stopped....my psychiatrist had to switch me to another".   "The GI specialist started me on Prevacid but my gerd flared up again and he tried nexium".   "The pain doctor put me on a a vicodin and I was pain free for a while but now I'm on oxycontin (oral morphine)".   The blood pressure pill was helping but for some reason he had to give me a stronger one after a few years".   In the short visits spent with patients in the immediate care setting, I would see this over and over; along with a typical 30-40year old with a list of 3 meds. 40-50year old with 4 meds/2 vitamins, and a 50-60year old with 5meds/3 supplements.  Oh....I make it a hobby to ask about weekly activity and relaxation practice-same answer: no time for "exercise" and "I'm not stressed out".  I don't usually have the time to go through quid pro quo about nutrition knowledge but my hot button there is to look at weight/BMI and that's the answer to eating style.

Returning to primary care office work (seeing patients routinely and getting follow up vs the take care clinic band aid work) I can see a repetitive occurrence of people leading unhealthy lives; coming in for short fix prescriptions; coming back with temporary but unsustained response; going onto multiple rx management, eventually being sent to the specialist care for BIG medicines or surgery.   On the flip side- around every 20th patient is taking my advise for beginning a relaxation practice, switching to some form of nutrition practice, starting a supplement and fixing sleep.  I had a lady with severe symptoms of hypothyroid/fibromyalgia/sleep disturbance see me last month very frustrated with previous docs....made a few recommendations like the aforementioned and 1 month later she is a different person.  (that is one of the fastest turn arounds yet!)  My pessimistic self says maybe it is all placebo and just the fact that I told her she will get better orchestrated the flip of her switch.   My optimistic and evidence based self said she is getting better because she removed herself from poor nutrition practice, supplemented for deficiency, started breath work and templated a healthy schedule of sleep and exercise.   Bottom line is -doesn't matter how it happened, I just have to help guide change and keep the ball rolling.

I feel that in most cases, the reason pills give a temporary response is because no one changed the unhealthy thinking/eating/activity of the person taking the pill.  New drug will give a nudge to the system.  Forcing the brain to simulate happiness: the gut to stop secreting acid: the body to ignore inflammatory signals from twisted body parts....but if no change is made to the "body part" then this magnificent machine called the human body will find another way to send signals saying SOMETHING IS NOT RIGHT!!!.  At least until a different medicine is used to suppress the annoying alarm.  Better than spraying foam on the kitchen fire is turning off the gas main.

A patient yesterday said she was worried before she came in that I was a Family Medicine doctor and not Internal Medicine trained.   She went on to say"....but I can tell you are different and that makes me feel hope".   I believe telling people their "blood tests say the medicine is working,  see you in a few months" is reassuring.  I feel guiding people to develop sustainable changes in areas they didn't recognize needed change -is empowering.  Pulitzer prize winner Dr Siddhartha Mukherjee said "Physician honesty need not equate with hopelessness".  He was referring to life ending disease.  As a primary care doctor I deal with life altering disease but the same fundamentals are in play - don't just surrender to the disease and wait -empower people to live life with hope.

Push back check out time please

The other day in the office, one of my favorite 80+ yr oldie's came in to see me.   She was quick witted as usual but after checking out, she started "checking out".  First she started slowing down her snail pace to almost a stand still.  Then she remained silent while standing (this is one of those souls who makes play by play commentating like she is talking to a radio audience...."it's cold", "it's so white out", "that will take forever"......)  Then as I sat her down the well known slump of death started.  It's when a human that was previously made of flesh and bone suddenly is a 110 lb bag of melting ice.  You would be surprise at how difficult it is to carry someone when there is no life, turgor, or blood flowing through the body.  I'm pretty fit but as I picked her up like a sleeping child, she started sagging like gravity was pulling body parts between my arms.  Got her up on an exam table and had her in semi flat (in the field if someone passes out I place them in trendelenburg with head down and feet up to pour life restoring blood into the brain but with her age, I wasn't sure if she was having a stroke out so I rigged this first aid position).  Blood pressure was really low and she was unresponsive so I asked relatives if she was DNR-they said yes and after some debate, we decided to postpone calling 911.  As I mentioned hospital and IV ...she suddenly started speaking with a muttering in a barely audible voice.  I went closer and she said "I don't like the hospital".   Huumm.......I decided to get her grand daughter on the phone and asked the kid to say hello.  Guess what, grandma started talking louder....albeit her blood pressure wasn't reflecting any level of what I would consider normal for a human, in fact it was still dropping.  I was very uncomfortable with keeping her in the office; because the experience I have working in ER's the resources available to  orchestrate resuscitation in second and begin a diagnostic work up makes it temping to use the God Complex to say I can fix this.   But then...my Dad popped into my head (-being guided by my favorite mentor).  He told me...wait.  So I continued to observe, provide comfort and just reassure the patient I was there for her.   I felt like I was back in med school where I was the "human cardiac monitor" and had to repeat vital signs every 10 minutes and assess color, turgor, heart sounds, neck veins, level of consciousness to determine what the cardiac output was; preload, after load, cerebral perfusion, peripheral perfusion - all the basics of human physiology which will give just as much information as a $10,000.00  monitoring system in the ICU (yes, this is why a 10 minute trip to the ER for a fever and Tylenol will cost you and your insurance a thousand bucks).

Bag-o-Jello suddenly started to take human form again, voice strengthened, color returned, blood pressure was normal.. then she said she wanted soup (probably the brain triggering the need for fluid volume and salt?!)  I asked her how she felt and she said I'm OK, can I go now?  What the #@$@, such a resilient generation this lady was born into.  I told her she had to take it easy because she just went through a life threatening experience.  She just said "I'm hungry" as if nothing just transpired over the last 60 minutes that in my mind was like an eternity.  She got back up, finished checking out at the front desk, proceeded to the parking lot and left with her care giver.  I heard her say in a loud voice...."it's so cold!!".  They went on to eat Sinigang and Lechon at a Filipino restaurant (2 pork heavy traditional meals!).

The hour  of "back country" monitoring this tough but delicate lady was more than a a review of basic physiology and wilderness medicine.  More importantly it showed me that sometimes there is more to lifesaving than just running protocols and algorithms....the human soul ultimately decides when it's time to check out.  Learning to listening to it is good for the patient and the healer.

Living with Disease

When I work shifts at immediate care centers, as I am going through my questions and answers to template an idea about who my patient is.  In medicine we follow this concept that Lawrence Weed developed in the late 60's called POMR.  (modern version is called the SOAP note) It's a way of organizing data collection while speaking with patients so a clear understanding can be made of the problem.  He created it due to the complexity of medical conditions in patients.  In 1969 he wrote:

"...accept the obligations of meeting many problems simultaneously and yet to give to each the single-minded attention that is fundamental to developing and mobilizing his or her enthusiasm and skill, for these two virtues do not arise except where an organized concentration upon a particular subject is possible."

-an old SOAP note (note _OAP to left margin)

So the doctors of today are not dealing with anything new when it comes to tackling the "laundry list" of issues that patients arrive to the doctor with.  Many of my contemporaries claim current society is so overexposed to processed food, biased television/internet news, unhealthy work hours, lack of exercise, alcohol/drug consumption and now over utilized prescriptions that the health care of today that the modern day patient is different than yesteryear.  Guess what....no matter what kind of plate you put the meal on - its still a meal.  I will always teach my medical students, the importance of establishing rapport first.  Get the trust of the patient and you will figure out the answer in the ailment.  The problem I see with going to the doctors office today is that there is a concept of hurry (no doubt started with medical insurance industry "streamlining" billing) to limit a visit to a diagnosis.  So no longer are we treating Joe Schmoe, we are now taking care of a high blood pressure reading or an elevated sugar or a month of feeling depressed.  Doctors are being encouraged by an industry to label a visit with one bullet diagnosis.  Savvy doctors will list down several diagnosis to attain maximum reimbursement for services rendered but the problem I see is docs concentrate on claiming "I found diabetes in you with your blood test" or "your X-ray says arthritis" so much so that we tend to make an la carte treatment plan based on a list of 3-5 diagnoses and hope the treatment "takes" when the patient come back in a few weeks.....100% better.  So.... if I send a Porsche with strut problems to a Chevy volt mechanic and he tries to fix what is basically a suspension issue-it will probably not perform like it did before.  On the same analogy if an automobile just has a loose nut...most mechanics can tighten the nut and stop the rattling.  But......human nature is to wait until the lose nut has caused a cataclysmic suspension failure resulting in cashing in your 401K to fix the problem.  There is nothing like the experience of being given a long list of things that have to be fixed when you thought it was just a loose nut.  I guess it's the same way with an annual wellness screen, you go in healthy, you come out with an inventory of what is abnormal and "has to be fixed."

As medical insurance steps in the make the visit to doctor and hospital an affordable event, they need an algorithmic way to translate SOAP diagnosis into something they can reimburse (and not just trust the doctor is billing properly for expertise rendered during a visit)  Here comes ICD coding.  As a patient you leave the doctors office with 3-5 ICD codes.  This is what it has come to, you are now an accumulation of codes.  Even as I call my specialists to let them know of my patient I am sending, the conversation usually starts as: "...I have a 76 year old Alzheimer's patient with depression and subdural bleeding on Aricept and Lexapro coming to see you for non control of symptoms."  The answer will usually be: "...add Namenda over the next month and I will see him in the office for further adjustments then".   I hope and pray that during the 30minute visit with the specialist, my consultant will see more than a few ICD codes in the exam room, and try to give expert advise on better options for treatment.    The back room event that occurs is the specialist with a booked up schedule will rely on my ICD codes in building up opinion, possibly do some "fancy" testing to refute or support the codes and stream line additional treatments.  Doc will then have the patient come back after another month or two (booked up schedules!) or come back and see me.   So goes the typical "spin" of going to the doctor/hospital.

If you look at why ICD was created...it was to record causes of death in Europe.  Like a registry.   Since the 1700's it has changed from International Lists of Causes of Death to the current WHO adaptation of International Classification of Diseases-10th revision.  The original lists were compiled as population studies for figuring out why kids were dying early and scientifically devise an intervention for this large group.  Great application....and it probably was key in curing many childhood diseases.  My bias is that when you use population information and apply it to the individual....it doesn't guarantee success.  In a broad sense you may prolong life for the species but only at the sacrifice of ignoring suffering from the individual.   The Ecological Fallacy points out that the outcome of the individual is not determined by the outcome of the group (my truncated version).  In medicine when someone breaks through the usual statistics of a certain disease; specialists call it an "atypical reaction"/lawyers call it a missed diagnosis/laymen would call it a miracle.  What ever it is called, its the demonstration of the human cell/energy to attempt repair and survival.  I believe if you provide the soil for DNA to "do its thing" it will continue forever.  Science says cell replication ends at about 70-80 years of life.  Living an unhealthy lifestyle (bad soil) will bring death sooner (Standard American Diet).  Living a healthy life will push back death (The Blue Zones of Sardinia, Okinawa, Nikoys and Ikaria where people are leading productive lives into their 100th year of life).

So how do we become a centenarian?  I don't mean an American Centenarian-(nursing home, bed bound, depressed, diabetic, demented, cancer-ed, bypassed, dialyzed, catheterized, emaciated)....I mean a centenarian from one of those previously mentioned places in the the world.  No question we have to live with a diagnosis and try to neutralize each ICD-10 code with the best protocol treatment plan possible.   My calling is to think with an Integrative Medicine mind.  I would attempt to "reverse" what ever brings you into the doctors office.  The problem is knowing when to go.  If you are listening properly to the cues your life is giving you, it will be easier to recognize abnormal change.  This requires knowing what is normal.  This requires education.  There are so many ways to empower with knowledge; books, seminars, hospital lectures, DVDs, Cd's, internet.  From former to latter you have to be weary about reliability of the information.  Once you recognize the cues, then see the propelyr trained healer, you should be able to revert your "flare up" to "status quo".  The same knowledge that helps get out of temporary illness should be used to determine if your lifestyle is going to sustain you.  My patients have a choice to change their disease manifestation for the best chance at arriving to their 90th birthday.  By living with disease, it doesn't mean taking the prescribed medicine for the ICD-10 code and going about your business.  It means always looking ahead to that "miracle", always trying to provide your DNA with fertile soil, it means adjusting the loose nut before your suspension crashes.  It usually means seeking out the advise of someone who can vacillate between using the awesome power of modern medicine and the awesome potential of ancient wisdom.  Don't ever just settle for being a disease controlled on medicine because the likelihood is......another disease/code is coming-listen for the cues.  

Destination Disease

Listening to Joel Osteen he began today's sermon with a story:
-two lumberjacks were working away in the bitter cold and one said I have to take a break and sharpen my axe.
-the other said I have no time for that and continued to chop away
-1st guy comes back after 3 hours with a razor sharp axe and slices through more wood in faster time than the guy with "no time"

In many of the 50-60 year olds that come to see me (CEO's included) I present a lifestyle plan to change and get back to feeling health and wellness.  Many times the plan I create encroaches upon the "untouchable" 50-60 hour work week.   I certainly try to design a change that is gradual and sustainable but it is usually first accompanied by resistance until I let them know that if they embrace "sharpening their tools", the 50-60 hours of work will be performed more efficiently to the point of creating time to indulge in more healthy endeavors....that in turn will open more creativity/more productivity/better sleep/faster problem solving (you can see the positive cycle of events that usually follows).   I also have some obese, hypertensive, emotionally drained, cortisol depleted moms that care form 3-5 kids and don't even have time to carve out for 5 minutes of breath work.  (I even obliged a mom who came desperate for help but unwilling to risk changing her unhealthy routine...saying ok, how about if we combine breath work during your daily potty break.....she said "can't do it"!  I pointed out her speed of speech, her emotional fragility, and difficulty with finishing sentences without distraction....if she could harness her own practice of calm-her duties may just become an iota more efficient; providing her with at least more poop time instead of splash and go.)

Whether its running a company or running a household, we get into a rhythm that seems to carry us from breakfast to bedtime.  It would seem that we have reached our destination in life with the only routine available; and deviating from it could end up a disaster.  But the realization I point out is the disaster is already occurring when my 50-60 year old looks like a 70-80 year old, weighs 50 pounds heavier and average, is on 3-5 medicines, and considering a divorce lawyer since the counselor didn't help.   Running a company or running a family takes a lot of talent and making it to that point has its rewards but my point is that there is still alot of learning to occur.  It is said that most Americans after high school will not read another book from cover to cover...ever!  Learning is not period in life...it is a way of life.  There will always be more knowledge to impart to even the most well read people.

The act of "sharpening your tools" goes for doctors as well.  I had a priest come to my wife's office blessing (Dental Radiance) and he asked me about L Arginine for cholesterol lowering.  Of course I dug a bit deeper in the short time I spent with him, and turns out he was placed on a statin after a few years of "trying on his own" with diet.  The medicine helped drive his cholesterol down to 150 (good!) and he said his HDL was good at 65 (mediocre if you ask me) but his last 2 blood tests showed "enzymes were high" and doc wanted to take him off the statin since his cholesterol levels were good in the last few years.  I wasn't there for the conversation he had but I wanted to question his doctor as to what the hell he was doing suggesting statins before nutrition change.  When I queried the Father on his fiber amount or if he was on an omega 3 fish oil or which nutrition author he was following....didn't have much of an answer except he tried to switch veggies for meat but was unsuccessful.   So just bringing realization to his fork in the road, I said if the nutrition practice he adopted before the statin didn't help; and after the statin he didn't continue any great switch to vegetarianism....how can stopping the cholesterol medicine now be met with anything else but the same high blood test results as before.  It was at the request of his chiropractor to consider L arginine during the next 3 months while his doctor wants him on a break from liver damaging statin.  The chiropractor had a good idea to think in terms of nutritional deficiency but this should have been the doctor inquiring on: the lifestyle of a priest, his exercise routine, his wine indulgence.  But guess what.... most doctors reach this pinnacle of medical knowledge and just do the basic minimum in keeping up with CME training as per requirements of board certification and maybe the occasional visit from a drug rep who is promoting her newest statin with great results from a study funded by the same company.   What if we allowed CSA vegetable delivery or Whole Foods Market into doc offices for pushing produce on doctors "backed with evidence" in some of the oldest studies (Framingham, Lyon, Nurses Health)....I think docs would make stronger suggestions for meals, dishes, nutritional practice.   But alas, the docs have no time; trying to break even with the vast number of patients to be seen, refills to be faxed, procedures to be performed to make up for the stagnant salaries we get compared to the diminishing reimbursements paid by medical insurance.   Who has the time (2-3 years) and the money (30-40,000$) to "sharpen their tools"?   Joel Osteen was right, the apparent disease is thinking when you arrive at destination, all the work is done.   I feel the answer is always stepping back, reassessing your purpose in life, honing your skills then reapplying them for the benefit of yourself and those around you.....you will never over-sharpen an axe.