Friday, January 9, 2015

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 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 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 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.  

Saturday, January 3, 2015

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 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 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 will never over-sharpen an axe.