I had the opportunity to work side by side with another doc (gently "older" than me) the other day.  I was doing a physical on an Air Marshall and he wanted to sit in.  (These physicals are like "executive physicals" from the 80's that encompassed everything short of a colonoscopy- we have to make sure these government employees are ready for anything and fit to perform.  As I was reviewing the Marshal's chart, I didn't see much of a problem short of the usual extra 30 lbs, scant scalp hair and few screening test abnormalities but I started asking my salvo of questions to make sure past and family history were devoid of risks for a premature departure from the job of crime fighter.  I  brought up the few abnormalities and along the way threw in a few fun fact suggestions for nose congestion, reflux, hearing problems.....  He seemed to resonate with a few and started asking questions seemed to be interested in my few comments so I would give him more info then move onto the next body part......then more info.....so I could see he was hungry for info/guidance.  In fact, what started as a simple review of tests and updating chart notes soon became counseling on using omega 3 oil and turmeric for the early arthritis in his ears (yes the 3 bones in there get arthritic from shooting a firearm for years) and cutting back on alcohol and considering stopping since he had some signs in his life of dependence.  Then he opened up to both of us about chest pain for the last few months!!  I appreciated his candor and took it that he was subconsciously concerned but at the same time he was always aware we were the doctors licensed by the government to flag Marshals unfit for duty.  I am used to this as when I interview someone past 10-15 minutes, they usually open up and I find the juicy information that would have been missed on standard medical history taking.  This is the info that helps shape the personal lifestyle change I create.  I figure if we take extra time to figure how they got to this mess/at this decade of life, we can plan around addressing the cause of disease and not just treat it. 

The other doc was perplexed as to why he was giving so much information.  My colleague kept on saying that was very odd.  (I was just snickering to myself, "that is the way you do it doc!")  Truthfully I saw a man that wanted to get some help for drinking and was having problems controlling his teenage daughter-the hearing wasn't a concern, neither was the chest pain.  Well, I sent him to an Ear Nose Throat specialist and got him to the hospital for a stress test. 

I don't always have the luxury of extra time with patients but I can always continue next time.  This is the trick I learned from Medicare.  We are supposed to tell the patient after the first or second complaint that they have to follow up for guidance of the next few complaints at a later time since I only have time to address 2 major symptoms.  (...and this is your grandpa who has 10 pills twice a day from 3 different specialists and may questions about the side effects to a few of the expensive pre-approved drugs.  If I have to, I will guide my patient to concentrate on the major issues we in the medical community would be concerned with to continue functioning independently while we let go of any low grade nuisance symptoms. 

So even some of the established docs don't have the right idea about how to really empower people to change the cause and not just address the symptoms.  Shop wisely!

Fork in the Road

I am awestruck with how the Universe shows itself every time I stop resisting.  It's like hiking a path at night, I know the journey is out there but I can only see what my lamp illuminates.   The forces I fight are not "the dark side" luring me to play, they are my feable attepts to try and control for every variable for the future.  Lamenting in the past can cause depression, worrying about the future can cause anxiety.  It takes effort to maintain but I try to live in the present. 

I did this in 2005 when I was sick of a new hospital administration stringing me along and saying its going to be alright as long as you sign a very legally binding contract for 5 years and you keep up with a some MGMA statistic (info pools of large medical practices and how many patients you are supposed to see to be average)   If I worried about the future, I would not have been able to leave and start this journey to present day.  No question it was hard work to survive the finger pointing from established docs and job interviews with newbie graduates, but I let that stuff go and just grabbed onto any solid step that was placed in my path.  Herb Benson from Harvard, Deepak Chopra, Andrew Weil all were part of the universes plan for me to give back.  I can confidently say a career of being a medical doctor was just a stepping stone to my true calling of healer.  I am honored to have met these world leaders and take bits and pieces of their practice philosophy to evolve mine.  I consider myself a neophyte but wonder if I too am supposed to be influencing those that I come in contact with. 

Had some free time before another hospital orientation so I stopped by Whole Foods Market.  Saw a young premed student I spoke with briefly in the recent past.  She congradulated me on getting an appointment to teach at the University of Illinois Medical School.  (have to chuckle that after years of being ridiculed as a foreign medical school graduate from the Philippines, now I am being asked to teach by the same people who pushed my application to the bottom of the pile)  Last time I spoke with her, she was deciding on which school to pick-UofI or Uof WI Madison.  Immediately I started rattling off about Madison WI.  Richie Davidson -founder of the Center for Investigating Healthy Minds (most famous subjects include Matthiew Ricard and The Dalai Lama) is a huge proponent to mind-body medicine "the new Herb Benson" of the millenium, built his multi million dollar facility there along with Dave Rakel -previous fellow of Andy Weil, now Director of the UW Integrative Medicine Fellowship.  Something special about this place-poised for being a center of healing.  I leaned a little to UofI since I am now an appointed teacher/tutor there but considering the fact that she knows so much about nutritional supplements (employee of WFM) she already has a step above all medical school candidates-she understands how food can heal.   I was so happy to hear she made a choice to move and continue premed in Madison!  I saw the reservation in her face about the stress of moving.  I then reflected on where I am now and wondered if I had the same look back in 2005.   I've moved my family into 2 states, 3 different houses, applied to a new hospital every 3 years.  The difference is the career keeps me appealing to hospitals that want experienced docs (for standard pay) so there is always a job.  The difference is the calling brings me to a more beautiful vista with every move forward.  It seems like a logarithmic unfolding of some master plan the universe has in mind.  It's daunting to know that while I consider myself a student, I will have to start teaching my style of healing and help others get to this point.  My courage is fueled by the fact that even now, someones application is being placed at the bottom of the pile and that person may be responsible for my family, my patients, my community.

 

Performing a Favor for someone:

"You are an Expert at something you know nothing about"

 

Giving a word of Advise:

"You know nothing about what you are Expert at"


-DrRic

 

Brain washed to fail

Last post I spoke of doctors being taught to use a hammer.....and consequently everything looking like a nail.

For those patients who come in with numerous prescriptions for diagnosis after diagnosis.....then more prescriptions for side effects from the first set, perhaps its not the fault of Dr Hammer.  It may be the insurance company and the drug advertisements have convinced people they are the "nails".   Viagra improves your marriage.  Statins stop heart attacks.  Hydroxycut makes the fat melt off in 3 weeks.  Cymbalta takes the pain away.   Vaccines are harmless.  GMO doesnt have to be labeled.  Gastric bypass gets you back to high school life.  You deserve a break today.  This bud's for you.  Your approved for a home mortgage even if you don't have a job. 

There is the compassionate view of everyone working to better humanity....then there are people who take short cuts.  Its not everyone otherwise our species would have died off long time ago.  Unfortunately, there are people who like to take advantage and ride the wave, survive at the expense of others.  Doug Lisle coined the phrase the "Pleasure Trap" where humans can be swayed to take the easy way out.  Maintaining a whole food plant based diet will have its merits in giving the user an overwhelming feeling of health and wellness  (dont care what my bodybuilding friends say about needing animal protein!).  Having processed foods can "concentrate" the pleasure of eating into a compact package that gives the same feeling without the fiber, nutrition, time prep, love and community.  If not trained to note the benefit of fiber, nutrition, kitchen family prep....the brain will want you to go "straight to guns" (Tom Cruise in Top Gun) instead of setting up the shot safely.  Then the brain will always want the quick short cut leading to obesity, deconditioning, cravings, food addictions......just to please the pleasure center of the brain without considering the consequences. 

I believe this is why I usually get 30-40 year olds in my office looking for a way to get off the medicines accumulated just in the "last few years"-as if disease just sprung up as they entered into the decade without any relationship to the improper living from high school and college.  Change is soooo difficult but postponing it is like a downhill truck with no brakes....the longer you wait to run off the road, the more damage will occur.  Change takes more than one visit, it is a learning curve that has to be done gently but effectively with several teachers.  I may be able to construct a campaign for winning the war but the battles I leave to my warriors.  I think the best successes for damage accumulated in the medical insurance disease maintenance model are treatment plans outside standard paradigm.  It sounds like an up sell but medical insurance does not pay to get you healthy, it pays to stabilize and manage your disease.  (I remember a patient saying I did a "bait and switch"- saw her and took the standard insurance reimbursement then sent her over to non insurance providers in the same office.  She was right but insurance doesnt pay for nutritional guidance, personal exercise, relaxation therapy and alternative healing therapies.......It Pays For Medicine!!!!)  Western Medicine in the rare case it reverses what you have-some lymphomas, congenital heart valve problems, cataracts to name a few but the majority of medical diagnosis are maintained and accumulated over an average lifespan.  What's worse is if you get a diagnosis and your doctor looks statistics up, you will be treated like the average no matter how healthy or poor you live.  Cures are thought of as chance miracles and why waste time with giving "false hope".  Lets look at miracle cures.....when a billionaire goes outside western medicine or people refuse and step away from their insurance doctor and come back from asia with a cure. 

We devalue -nutrition, relaxation and community (usually the basis to healing in indigenous systems like traditional chinese medicine, ayurveda, american indian healing).  We hold high -material possessions, drugs, surgical corrections.  I believe it stems from exposure to symptom-only bandaid care made popular by the people selling the bandaids.   If only we spent Superbowl money on TV ads for Deepak Chopra teaching meditation, Wayne Dyer teaching empowerment or Andy Weil Educating on nutrition!!!  Watching PBS programing isnt as channel surfing eye grabbing as 10 seconds of an Xbox, beer comercial with the prettiest girls wearing little to no clothing.  Advertisers bank on the fact that if you suffer from disease (adhd/sleep deprivation/chronic pain/economic and emotional instability) your brain is under stress and will grab at fast relief of pain.  When I get a patient that works 60+ hours per week-guaranteed s/he has multiple problems and wants a short fix stating s/he cant stop working since not having the current salary would lead to death.   Then the V8 momement comes up that "the lifestyle is the disease".    As Deepak once told me, we spend money we don't have to buy things we don't need to please people we don't like....and I think this is the root of poor health. 

Messin with God

Was at a relatives house last week for a birthday celebration and met a national treasure who was visiting from the Philippine Islands. The 90 year old in the picture above. Sweet lady, quiet but when engaged in conversation, comes alive with smiles and hugs. She was walking around as my brother in law says with zero gravity; taking a cautious step, holding onto furniture, stepping with the other foot, advancing her feel for the next piece of furniture.... I sensed she was observing and enjoying the camaraderie. I always ask an elder about lifestyle to figure out what I can take out of life to hopefully propel me to the same age without many failures. Seems she just didn't go to the doctor! (Also lived in a northern town in the PI that is known for indulging in less meat and more veggie dishes.....please see my youtube video on switching to a whole food/plant based diet)

During my short stint in Orlando FL (while I was riding out my 18 month restrictive covenant with Central Dupage Hospital after leaving the "new administration") I would run into many 80 year olds getting around on golf carts. Only difference was these guys were on a slew of medicines and a bit overweight. (please see my youtube video on BMI) So what was the key to this great grandmother surviving past alot of her younger contemporaries? Not sure. I have my guesses but not what I'm writing about today.

While here, she was brought to the doctor for something small but ended up being placed on 2 medicines. The blood pressure medicine I can understand. At her age, chances for stroke are high so keeping bp low is good (unless it makes her dizzy and fall) But here is the surprise. The doc checked her cholesterol and said she should be on a statin (a cholesterol lowering medicine). Let me break it down for you:

-lady lives through Japanese occupation of the Philippines
-lives through a dictator
-lives through a revolution
-gives birth to and raises a large family
-avoids going to the doctor save a cold or cough
-avoids immunizations
-avoids PAP smears and mammograms
-eats a mostly plant based diet
-works her share and stays active
-keeps a low body weight
-makes it to 90

-then a doc in the US says he found an elevated cholesterol while she is visiting and suggests she would live longer by lowering cholesterol with a medicine? He probably didn't ask the bullet points above....I wasn't there and cant blame hime since if all you have is a hammer, everything will look like a nail. What Andy Weil and Tierona Lowdog taught me over the last 2 years was that it takes a great detective to extract the right clues from the interaction between patient and healer. (What more if you have time constraints of 10, 15 or 20 minutes!) Ask the correct questions, have a true healing purpose inside your words and be genuinely involved in finding a path to wholeness.....the answers will reveal themselves on what is best for this person. If being pragmatic and following algorithms for designing health are so right, then why is the US in this predicament of spending so much money per person yearly (6000-8000 dollars each!) and 1 in 3 are obese. (take a count of 3 people in line at your next dinner and observe how many are overweight)

-make sure your doc is listening to your answers, make sure you are listening to the messages your body is sending you, make sure you do all the research on a medicine, its benefits and side effects before you or your loved one start, make sure you work to achieve maximum healthy living and have as many odds stacked in your favor when you make the lifestyle change. Goal is to try and get to 90, be happy and have a community behind you. 

(for the flipside to this click here)

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.

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)