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Medical Mythbusters | August 8, 2016
Sometimes that’s how I feel. I am by no means a lone voice crying out in the woods in talking about the exaggerated benefits of statin therapy, the limited data to support dietary sodium restriction, the modest and controversial benefits of aspirin therapy for primary prevention but it sure seems like it.
I write today about birth and death. The birth of dietary guidelines and the death of common sense. I know you think the government is careful and thorough in all things…I mean look at how well Obamacare is doing, our war against terrorism, our carefully balanced budgets etc. Well, the dietary guidelines were crafted years ago…perhaps the government was somehow better, more honest then. Sorry to disappoint but read on.
I will write more about the cholesterol con in further posts but today I focus on dietary guidelines. In 1977 the United States Select Committee on Nutrition and Human Needs convened a consensus panel… (one of the participants quipped that if there was real consensus they wouldn’t need a panel) That panel concluded… despite the lack of any real evidence that dietary fat caused heart disease and obesity. Interestingly enough for you history buffs the chair of the committee was Senator George McGovern. The panel’s guidelines became the Dietary Goals for the United States and the instructions were to eat more carbohydrates and less fat. Specifically the guidelines said you should consume 55-60% of your calories from carbohydrates! As the great Dr. Jason Fung points out in his book “the Obesity Code” the American Heart Association’s guidelines in 1995 “Americans should eat six or more servings of breads, cereals, pasta and starchy vegetables and to choose fruit juices and carbonated beverages as your liquids of choice.” Six servings of bread? Carbonated beverages as the liquids of choice? This seems laughable ! How can this be a real recommendation? The results of these recommendations? Heart disease did not decrease significantly as was predicted but obesity has increased to “epidemic” proportions. Current recommendations are still based on misguided interpretations of research done years ago. There is almost no scientific basis for the current guidelines. For a an absolutely superb video on this subject… check out Dr. Peter Attia on youtube or his website “the eatingacademy.com”. His common sense, easy to follow review of massive amounts of historic and current data…the same data some of the guidelines use to make their recommendations and so much of the conflicting data that has been ignored will completely convince you of the errors of our current thinking.
Just from a common sense standpoint… who could believe that such completely natural things like eggs and butter could be deadly and you should instead use this alien yellow substance in a slightly different yellow colored plastic container. We were told the fat in milk is bad for us… not a shred of evidence to support that and instead we became a nation of soda drinkers or just as bad… juice drinkers… if, as is typical, the juice contains high fructose corn syrup. We all learned to cut off the fat from our steak while at the same time consuming more nitrate containing bologna and hot dogs. We were told that breakfast was the most important meal of the day which is worse than nonsense since the typical american breakfast consists of some cereal product. News alert… there is no healthy cereal period. It’s all processed carbohydrates. It’s the worse thing you could put in your mouth in the morning. The worse thing. I recoiled in horror the other day when I learned that a relative of mine was so proud of the fact that they had the same thing for breakfast every day… Cheerios. First, wouldn’t a little variety be nice? Who really wants to eat the very same thing every morning ? Well I could understand if the results were impressive but let’s just say the Cheerios have left an impression on my relative. A BIG impression.
So yes I am saying that eggs and butter and steak and milk are very healthy foods. The idea that you should substitute one fat for another is flawed. The one exception is trans fats… completely manufactured fats for the most part. You avoid trans fat and processed sugars when you avoid processed foods. Anything out of a box is processed. Many current dietary guidelines say to limit saturated fats and substitute fats like linoleic acid will cut down the risk of stroke and heart attack.
Now it gets interesting because recently data from the Minnesota Coronary Experiment which looked at just this question has been reexamined. As published in Cardiology Today July 2016 (hows that for current data!). The data are very damning for the guidelines. This was a double blind study involving almost 10,000 people They wanted to see if substituting linoleic acid for typical fats would cut down on cholesterol levels and heart attacks and death. Those are some easy to understand endpoints. Dr Zaomora and colleagues found that the change in diet did indeed lower cholesterol but it had no mortality benefit whatsoever. The change in diet did not decrease deaths. In fact the researchers found that as the cholesterol level lowered the risk of death actually increased! At autopsy the group on the linoleic acid died were found to have twice as many heart attacks as the regular diet group… twice the number of heart attacks!
Now I don’t trust metaanalysis data (where multiple trials are lumped together to try to find significant findings) as much as I trust the double blind trials like the one above but the same investigators included the above trial and 5 other trials and found there was no association between serum cholesterol and BMI. They found no association between cholesterol lowering interventions and heart disease mortality or all cause mortality. This is pretty damning stuff! This analysis is saying that cholesterol lowering drugs have not shown any benefit in terms of how long you will live!! This is not the only trial that has shown this. A recent paper looked at trials in high risk patients… the elderly, people with diabetes, people with kidney disease, and people who have had bypass surgery and the vast majority of these trials showed no benefit in terms of all cause mortality. Even in high risk patients… taking a statin will lower your cholesterol nicely but just doesn’t have an impact in terms of how long you will live. We will talk about relative risk and absolute risk and the number needed to treat in subsequent articles but even the most “convincing” data from a recent trial showed that a thousand people have to take the pill for years and only one person might actually live longer…that’s not very convincing or encouraging to me.
Unfortunately when you show data that disputes the current “Cholesterol is bad…if your cholesterol is high you must take a pill” dogma usually the establishment just rejects it. For example when Dr Willett …chair of nutrition at Harvard… was confronted with the evidence that changing the fats in your diet was either unhelpful or actually harmful..evidence from a large trial done using what we think are the best research methods available… his response was “this report adds no useful new information and is irrelevant to current dietary recommendations…” How do you argue with a person who won’t even acknowledge the basic data?
Well you and I have had 40 years or so of dietary brainwashing and it’s going to take more than one column to help you come into the light. For some great summer reading on this from much better and more knowledgeable doctors than myself look to Dr. Malcolm Kendrick , Dr. Peter Attia and Dr. Jason Fung.
Lest you think me a lone nut job… well I may be a nut job but I am not alone in my distrust of much of what we have been told…let me end with a quote from someone more prominent and public than myself…”It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgement of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of the The New England Journal of Medicine” Dr. Marcia Angell. Until next time…yours in gentle scepticism.
Original Published in Table Hopping Night Life Magazine, August 2016.
Forget the Obits Skip to the Memoriams | July 7, 2016
Sure I used to scan the obits every day when we had a newspaper that was delivered daily. I guess that dates me…I remember when we got the newspaper delivered twice a day, a time when we only had 3 channels on TV, when you had to go to the library if you wanted to research something. If my arms were a little shorter I would be reminiscent of a T Rex.
So, in this modern age you can get the obits on your smartphone but there seems to me to be something unseemly about the ability to “swipe right” to leave the obit almost like you do with a dating site. It’s just not the same on line.
If you do peruse the obituaries..a practice I know is common… one of the things you notice is that there seems to be times of year with more deaths than others. Especially around the holidays. I guess that speaks for itself but I still don’t understand it. Are some people holding on to having one more Easter with the family? I understand holding on for a grandson’s graduation or a niece’s wedding but when someone you love passes away on a major holiday it sets up immediate conflict in the cortex cerebral. You want to celebrate or at least observe the holiday for its sake and you want to give the departed their due as well…celebrate / mourn…celebrate / mourn…this is what I mean about the conflict. What I am saying here is that all other things being equal you should try to avoid keeling over on any major holiday or at any major family gathering. I’m not saying go quietly ….quite the opposite let’s go out celebrating but lets not share the memory of your passing with Passover. I think you, of all people deserve your own day. So yes I am saying that you should avoid dying during the Holidays. All of them. Still leaves plenty of other days. Obviously , most people don’t have any choice about when they die but a surprising number of people do. You know who you are.
When you read the obits in print form you can often see some people have lengthy columns and others have just a few lines. Does a longer column mean a more important life? How many inches will your column be? T.S. Elliot wrote in his poem, The Love Song of J Alfred Prufrock that we have measured out our lives in coffee spoons.Do we measure out our deaths in inches of newspaper column? The obits reflect what a person accomplished in their life…what they did and when. What they don’t reflect are the emotions surrounding their life…for that you have to read past the obits to the memoriams. These are the remembrances posted by those who remain and remember the loved one usually at the anniversary of their birth or death. These can be positively gut wrenching. A good gut wrenching can be a positive and therapeutic thing. To experience strong emotion without having some direct involvement is the stuff of Greek Tragedies. Reading these memoriams can really help you remember what’s important in life. It seems disrespectful to use any actual quotes from the memoriams but suffice it to say these are heart and gut wrenching postings. And that’s precisely why I read them. I don’t read the obituaries and say to myself…I would like a long column about my accomplishments and achievements. I can be dispassionate about the deaths of strangers. I read the memoriams and say to myself I hope my life impacts others as deeply as these people have done! You can’t possibly read these postings…some of which use standard phrasing and many are very personalized…and not stop and think and feel. I find it a very powerful exercise. Thats right…I read the memoriams to help me stay mindful about the life I am living now .
Steven Covey the author of the bestseller “The seven habits of highly effective people” wrote that one habit of success was to begin with the end in mind. It’s difficult to accomplish anything if you don’t know what you want to achieve in the end. He recommended extending this idea not to a project but to your life as a whole. He recommends that one day a year you go to the cemetery and just sit and ponder. You will be in the grave eventually…what do you want to accomplish between now and then. Who do you want to have an impact on. What will you be remembered for and by whom? Instead of just going through the motions…stop and think about your life and where it’s heading…be mindful of your words and actions.
As a physician I write about this because I think an awareness of our mortality is a healthy thing and the memoriams are a daily poignant reminder of how our lives can impact others. I dare you to read a few memoriams and not feel something. Until next month…get well stay well.
Original Published in Table Hopping Night Life Magazine, July 2016.
Chronic Care Management (CCM) You Want It & You Want It Now! | June 6, 2016
I have written separately about the way that Medicare and other insurance companies are going to change the way they reimburse doctors. The government wants to move away from paying a doctor or physician extender a fee for each visit and moving towards paying for measures of performance. These include the percentage of patients that have had a mammogram, the doctors immunization rate, their hospital readmission rate..their management of heart failure etc…These seem like good ideas but ,as always, the devil is in the details. One of the ways that Medicare intends to reimburse doctors is based on the management of the patients chronic medical conditions and this part is called the CCM program. Although I am no fan of a lot of things about Medicare I am a big fan of this program and once you hear about it you will be as well.
Listen, I don’t have to try to sell you anything here. This is not my program. I have a program..SignatureMD …this has nothing to do with that. This is a first ever available extra level of coordination of your care, This is a program crafted by Medicare which finally acknowledges the tremendous amount of work it takes to really coordinate care properly for patients with multiple chronic illnesses. This is not for the young , or the healthy…They don’t need their care co¬ordinated. When you start seeing more than 2 doctors regularly you qualify. When you have multiple caregivers changing medications or ordering tests you qualify. When you have two or more significant health issues on an ongoing basis you qualify. You get the idea.
Chronic Care Management means your primary caregiver is taking extra steps to have someone check up on you regularly and actively so that we know you are not missing medications, appointments etc,. You have a dedicated person overseeing all your visits. This involves making sure all the providers and whatever family members the patient has designated have all the same information. This involves more transparent but HIPPA etc compliant access to the patient’s medical history. This involves following up on all the appointments and reviewing independently all the records. This is a person reaching out to the patient on an ongoing basis to minimize the screw ups that could have serious consequences. Do I have to go there? Last month’s British Medical Journal suggested that medical mistakes could be the third leading cause of death in America. Really?! This program could significantly impact that likelihood and its covered by insurance. !!
If this is now available and you are eligible why wouldn’t you give this a try? For the doctor this is extra work and there is an extra charge. . Most, if not all, of the cost is covered by Medicare, Medicare Advantage and Blue Cross / Blue Shield. This is an available, covered, upgrade to your medical care that could save your life or your mother’s life… if you are a child living out of town or across town worried about your momma! Accurate information , easily accessed, can make an immense difference in your care and in your ultimate health care spending and that’s why Medicare and some of the big insurance companies are so interested in it. They see the financial advantage and that’s their job… I see the advantage to your health and health care!
Your primary care physician is supposed to be the conductor of the orchestra . He’s the one that refers patients to other doctors and then follows up with the other appointments and tests that were ordered etc. This sounds simple and appropriate but in the real world this is very fragmented. Some patients know the medicine changes that their last specialist made and many don’t. Some patients remember all their appointments and some patients don’t. If You have multiple medical problems or see multiple specialists… good luck at keeping the communication open and up to date. This is extremely difficult in practice. One patient could have a cardiologist, a kidney doctor, an eye doctor, a vascular surgeon, etc. and each of them is trying to keep in communication with the others and is a very fragmented system. Currently the electronic medical records do not communicate well with each other. This will not be fixed anytime in the near future. It infuriates me when patients tell me… ”the doctor didn’t have the report”… perhaps you have had a similar experience?
Once a doctor recommends that the patient see a specialist he may have no way of knowing what day the visit was, what the findings were etc. until the doctor sends his report. Some offices are quick with their reports and some are not so quick. What if I don’t get a report. How can I review a report I didn’t get? What if the patient misses the appointment or a test or labs? What if another health care provider changes the patient’s medications? Sometimes important details are lost in a 3¬10 ¬page consultation note and it is a nightmare trying to keep the medical record true and correct let alone attend to the myriad details of the outside consultations, tests and appointments. This is very difficult and important work and finally the importance of this work has been recognized and codified.
So Medicare has offered physicians a monthly extra monthly incentive to really step up and stay on top of patient’s care. To actually “coordinate the care”. This means hiring someone in particular who will monitor the appointments, the results, coordinate communication between the medical offices etc. on an ongoing basis. I can either hire one person to manage between 200¬/250 patients or I can outsource it to professionals. Luckily, here in America, companies have risen to the occasion to offer this service to physicians and their patients. The internet, the fax machine and the phone enables the co¬ordinator to work from anywhere. Anywhere for me at least means anywhere in America. The person co¬ordinating your care will be calling you from somewhere in the USA. I understand the reasons to outsource to China but this is way too important to handle offshore.
This is a new program. These are new opportunities to improve patient care. This is actually the most proactive thing for patients I have ever seen Medicare do. EVER . I think this can really make a difference by decreasing errors and increasing communication. In terms of medical dollars this is dirt cheap and can have a big impact. It’s encouraged and covered by many insurance companies and each patient can sign up or drop out anytime for any reason. I always find that type of arrangement very reassuring. No special contracts. This is an opportunity for patients to get better co¬ordination of their care by a incentivized caregiver. This sounds like a win¬win to me.
Again, this is not some crazy program I have cooked up. This is a program that has been encouraged by the government and is part of current and future Medicare programming.
Usually the other major insurance companies follow suit. For people with complicated medical situations or any combination of serious chronic medical conditions this level of oversight can make a real difference in your health. Best of all is that this is not some limited time offer, this is not something available only to the first 100 callers… this is something your primary care practice can be doing. This, as I have said, is a new program and many practices just don’t know how to approach this program but it’s something that every office can do in one form or another. This program, like the cognition test Cognivue, passes my test. For me the test.. ”Is it in the best interest of the patient?” This could be a great thing for patients if it works out. It may turn out to be too good to be true but you must know by now that I am an Optimist. Check out this new program and how it can make a difference in your life or the life of someone you love! This is the shizzle my nizzle!
Original Published in Table Hopping Night Life Magazine, June 2016.
Chasing Longevity | May 5, 2016
Some pundits opine that with advances in medicine the average life span can be extended to 120 . After all ,wasn’t the average lifespan just 30 or 40 years of age something back in the 1800’s?….we are so far advanced from that time period it should be easy to extend life from 80 to 110 or 120?
Well, It turns out that the real life expectancy has not changed much in 2000 years. After all Socrates died at the age of 70…and it wasn’t from natural causes at that. It turns out that the claim that average life expectancy was 35-40 was very much skewed by infant mortality and that the usual span of life hasn’t really changed over time. Sure, we have made strides with public sanitation and infection control but that just means that the average person is living longer not that we have extended maximum life expectancy over time.
Sure there is evidence from manipulating the environment in nematodes , yeast, mice, etc you can increase longevity in these lower species but really..?? Really? Are you serious about comparing human beings to worms and yeast?? I would trust more the research from the primate world….that at least might have some real relevance to our species. Nature magazine published in 2012 a study of 25 years of primate research that involved caloric restriction as a means of living longer. Caloric restriction is one of THE leading concepts in life extension. Eat less and live longer has been shown to extend life in much lower life forms. The Nature article showed no benefit to caloric restriction in extending life duration.
Before we go organ by organ in our search for long life let’s quickly dispense with all the cloning and gene splicing come on’s. We are just as likely to unleash some alpha helix armageddon as we are to cure any real disease or extend life and neither is likely in the lifespan of anyone reading this article despite all the recent headlines so let’s move on to what’s currently plausible.
Alright ….let’s take this one organ at a time…..We can keep your heart going or use a replacement or artificial pump..we have this technology already. We can keep your lung function going indefinitely with the respirator. We already have the tech to replace your kidney function. We can’t replace your liver function yet but we will have artificial pancreas soon and we can control your gastric system very well. Sure your joints will suffer over time but we can design exoskeletons to support us in our dotage. We can replace your blood and most of your joints and there will be artificial skin aplenty. BUT the one thing we can’t seem to make any headway in life extension is mentation. The body functions we can maintain perhaps indefinitely but the brain seems to wear out at a certain point regardless of what we do.
Before I unload the truth as I know it on you let me share the thoughts of some of the leading experts in longevity. Thomas Perls is the Director of the New England Centenarian Study at the New England Medical Center. He believes that Iron is a cellular toxin and that we can extend life by decreasing our iron load. He therefore donates blood every 8 weeks to keep his iron level on the low side. Lower iron levels might be one reason women typically seem to live longer than men.
Perhaps you prefer the advice of Dr. Mark Mattson ,Chief , Laboratory of Neurosciences, National Institute of Aging,National Institute of Health…He advocates intermittent fasting and keeping daily calories to below 2000 calories a day.
Personally I rather like the advice of Felipe Sierra, Molecular Biologist, Director of Aging Biology, National Institute on Aging…”I laught a lot” …Reflecting his scepticism about the current state of life prolongation.
So the experts have weighed in but I would like to add my three cents as to why living longer is not really such a great thing for individuals or for society.
Penny One
Think what this would do to the divorce rate?….People have a hard time in this day and age to stay married for 10-20 years….If you get married at age 20 and are likely to live to120 what is the likelihood that you will still be with the same person? Living longer doesn’t necessarily mean living longer happily together.
Penny Two
Who is paying? You know most people don’t plan for retirement already…if they live twice as long someone is going to have to pay to take care of them …how can this be sustained? Where will these resources come from? The social security lockbox is already busted open…who can afford for you to live longer and almost certainly need more care as you get over the 100 year mark.
Penny Three
What’s the point of sustaining the body when the mind has faded. What do we do if the limiting factor is your mental function. Even those geriatric patients that have been able to avoid dementia at an earlier age eventually have more trouble with memory and cognition. There are a very few people living into their 90’s and beyond with remarkably preserved mental function. Most people hit the memory wall at or before the age of 85 plus or minus 5 years and it’s all downhill from there. Is there a point to living until 120 years of age if the last 10 years are in diapers?
On a more philosophical note I would suggest that most people have a much more limited existence after a certain age….Depending on the person this could be at age 50 or age 75 but sooner or later most people start to really “ turtle up”. They do less and less…don’t go out as much, don’t interact with family as much, don’t travel as much,, do less and less in their social groups, the church, etc ..in short….don’t live as much.. Is it too offensive to say they are slowly shutting down and I think their quality of life dwindles incrementally ?. My sister Marijo, tells me that I am too judgemental….If they are happy to go from bedroom to couch to kitchen with slippers and doing the tea and toast thing and slowly slip away who am I to judge? I just don’t think that’s the best way to spend your golden years. I’m just saying that most people don’t do more, try more, press onward as they reach the last chapters of their life and I am afraid that living to 120 is only going to prolong the most difficult chapters not the most desirable chapters.
I close by exhorting you to carpe diem! Living long is, I am sure, a desirable thing but Living well I think might be a better goal. Until next month….get well …stay well!
Original Published in Table Hopping Night Life Magazine, May 2016
Bring On the Death Panels | April 5, 2016
One of the things I hear patients talk about when they mention Obamacare is the “death panels”..as they sneer these words they look to me for some knowing and indignant nod of agreement at this latest oppressive government outrage.
Unfortunately, they are again disappointed in me because I stop them in their tracks when I intone…”We need the death panels…the death panels are a very good idea…I’m all about the death panels !”
The term “death panel” conjure up some white coated tribunal of indifferent doctors ..hired guns as it were …strangers who will chose who lives and who dies. Which grandma still has a little life in her yet. Whom to refuse fourth line chemotherapy. Which sick little baby will be tossed off the side of the mountain as the ancient Spartans used to do with children who did not seem whole and well. Cruel, Arbitrary and Indifferent ! Who could be comfortable with those decisions?!
Swap out the word “independent” for “ indifferent “ and I am actually down with the plan. You will be as well once I have explained things from my standpoint. When you really think about it, and I don’t blame you if you haven’t been preoccupied with this subject… who better than to decide on your medical fate than a professional medical team of independent experts. This isn’t about the death panel randomly picking out people at Destiny USA for harvesting like some grim reaper Halloween pageant. This whole issue is about what to do at the end of meaningful productive life. This is about not torturing Grandma during her final days despite the well meant desires of their family.This is not just about what makes economic sense. Frankly I think economics should not factor into the equation in any way shape or form at all but you can’t be ignorant of the financial issues. WNET news reports that “Medicare, the health insurance program for the elderly, spends nearly 30 percent of its budget on beneficiaries in their final year of life. Slightly more than half of Medicare dollars are spent on patients who die within two months.” That’s a staggering amount of money and sadly it’s usually poorly spent. Way too many grandmas spend their last few days on Earth in some oddly lit room full of strangers and stranger equipment…often tied up to the bed or some equipment , sedated lest they pull on their life support. One tube going in here and another tube coming out there Never well enough to have meaningful communication with their family. Dragging out the inevitable process from hours to days if you allow nature to take its course to weeks or even longer if “all measures are taken” to keep grammie going . I’m sorry but that’s just not right!
Although I am sure Obamacare’s underlying concerns are financial I view the Death Panels from a more moralistic standpoint. Sometimes enough is enough. Just because you can artificially prolong someone’s life doesn’t mean you should. My sister who is a doctor in Florida once approached my mother with consternation and although I wasn’t there I imagine a little indignation as well…”Mom” she decried .” Do you know that your health care proxy…your first born son ….Bud..(meaning me) ….has told us that if you were demented and in a nursing home and had pneumonia ….he would withhold antibiotics ..he would just let you die ! “ My mother responded ….”That’s precisely why HE is my proxy and YOU are not ! “ I know Momma wouldn’t want to be kept alive under those circumstances…and I have the conviction to honor HER wishes. Not impose my own.
That’s always one of my founding principles…do what the patient would want…not what I would do or what the family wants….What would the patient want had they still had the capacity to tell us? WWMW..What would Momma want ? That actually makes it easier for me. I feel better when I am honoring the known wishes of the patient. Having said that I also feel there is a place for an independent evaluation of the end of life situation.
There comes a time…and it’s almost always involving the hospital…when the question has to be raised ….Are we doing too much? Have we gone too far?.. I think there is a place for an independent panel to weigh in on this issue. If it’s obvious that we are dealing with a possible end of life issue I think we should call a “Code White” Although we can work out the details later it would be, I think, relatively easy to convene a panel of independent doctors who can evaluate the situation and the patient and weigh in on the appropriate use of advanced life support. Mind you these people would never have the last say in what happens to the patient but they would determine whether insurance of any kind should pay for the care.
So I could envision this scenario…..Your mother has advanced dementia and hasn’t been able to say the names of her kids in years or live independently. She gets pneumonia and is hospitalized. She does poorly despite usual hydration and antibiotics…and the questions become….should she go to the ICU for closer monitoring?…should she be fed by a tube since she is not eating well? ….How many tests and procedures to put her through ? CODE WHITE …is called an within a day a panel of doctors would have reviewed the chart and examined the patient and would be able to weigh in as to what’s the most appropriate thing to do. At that point they would not say what could or could not be done but would say what would be covered by insurance. It’s OK to say “Keep Momma alive at all costs !” But it’s also OK for a panel of experts to say …”We feel that aggressive care is not appropriate but It’s fine if you want to proceed but it’s not going to be covered by insurance and its 5,000 dollars a day for the ICU and can we have 3 days stay in advance.?!” . Of course there is the risk that these oversight doctors will be incentivized to cut short care to reign in finances but what we have now is just as bad….No cost control whatsoever and even worse …no routine evaluation of the appropriateness of care. You rightly fear a government that will devalue lives but I see every day where we , from an understandable combination of love and regret and fear , put our loved ones through procedures that rob them of their dignity and deny them a comfortable reflective peaceful passing. We can do better…we must do better and the Death Panel conversation is a good place to start.If this article does nothing else but get you to make sure Momma has a Health Care Proxy and someone both knows what Momma wants but has the strength to carry out HER wishes then I have been of service…
Until next month…get well …stay well….
Let’s Roll | March 7, 2016
Dr. Barry
I am wincing as I type this….no, not from my painful turn of prose…I took a beating in the dojo where I attempt to learn jujitsu. Well, the truth is I take a regular beating there but this one taught me a lesson. Hopefully only a temporary pain but a long remembered lesson. I love jiu jitsu… it’s like adult wrestling and chess mixed together.
…and the workouts where you spar / grapple / roll even for 3 minutes can leave me feeling exhausted. I love that feeling. If I am going to work out I want to feel beat afterwards. Jiu-Jitsu_Brasileño Now let me admit that I am terrible at jujitsu as my attendance has been less than stellar this last year. When you don’t practice often enough it’s hard to remember the right moves and counters. I know that if I go more often that has to help. Since in my profession I exhort my patients to work out more regularly I thought it would be wise to practice what I preach and make jujitsu attendance a bigger and more regular part of my routine. So,I set my schedule for twice a week. Between twice a week at the dojo and my biweekly sax lessons I am bound to improve myself somehow and someway. So there I was at class last friday. rolling with a guy less than half my age, twice my strength, and much higher belt level. I knew this guy doesn’t roll lightly. But I’m there for the challenge and besides when you are as old as I am, relative to the rest of the class…and as inexperienced as I am ..pretty much everyone is better than me and I am bound to get whooped each and every time. My ego can take it and it’s always great exercise and hopefully I am slowly getting better. I like it when my opponent has a serene look…this one guy wouldn’t recognize serene if he saw it in a magazine. Maybe it’s my innate paranoia but I get a subtle “ I’m not going to get much out of rolling with this guy..it’s a waste of my time “. That’s absolutely true…!! .I have watched him roll, he is very good and goes hard so I understand where he is coming from. During our roll he actually took it easy on me and I think that might have pissed him off even more because even when he went easy it was hard for me to sustain an attack or defend myself. During just one of the many times he was choking me or using an arm bar I might have resisted a bit too much for too long and got myself in a position where my opponent was locking my arm up to make me quit. Whenever you feel you have been bested and are ready to admit defeat and start again all you have to do is tap the other guy and they will let up. When people don’t tap they are telling you to use more pressure, better technique etc before they will admit defeat. So when I didn’t tap immediately the higher belt took it to a higher level and we could both feel when I hyperextended my elbow. It didn’t get dislocated just stretched a wee bit more than usual. It felt funny for a second then everything was back to normal and we continued the three minute session. I rolled with two more guys before I staggered off the mat. It was only later while driving home that it started to hurt. I knew nothing was broken …just painful. It was very tender today but there is still fullish range of motion and terrible swelling or bruising so let’s see how it goes before I go running off to the doctor. As long as it gets a little better each day I will just follow it. I had already learned long ago that active people will get injured. You can’t stop because of injury …you have to modify. This elbow thing will not allow me to use the rowing machine so I will spend more time on the bike and ski machine. No the lesson I learned this time was to TAP EARLY! Don’t be all macho on the mat…When you know you have been beaten… accept defeat and move on. Leave the dislocations to someone else…anyone else. I am not normally a guy that says “Know your limits.” How can you know your limits without testing them? Don’t sell yourself short. I try to remember this is a marathon not a sprint. If I resist too much and get hurt that affects my overall ability to train. Recurrent injuries have made many a person finally give up their sport. If I take it a little easier I can stay in the game longer. Let’s see if the other guy is still rolling when he is my age.! Jujitsu is one of the few sports you can do at any age…you don’t see a lot of guys playing baseball, basketball, soccer or football as they get past 40 years of age…but you can “roll” on the mats until an advanced age if you have the desire. I hope you have some physical activity you can keep interested in through all phases of your life. Until next month…get well …stay well…and when you get injured regroup and get back in the game !
MAKING A DIFFERENCE WITH A WORD CLOUD | Feb 7 2016
Dr. Barry
Well, It’s February and that means Valentine’s Day is around the corner. Hopefully you are not expecting “that column” The one where I say how important sex is to men and how easy it is to make us happy. Before the cat calls of chauvinism start I am only echoing the sentiment of Dr. Ruth, Dr. Laura, and the girl from friends.
RFH_WordCloud2No, love is an easy subject which you will be saturated with on the radio, TV, newspapers etc. Writing about love and sex ..two different but important topics …that’s the low hanging fruit…too easy for me. Been there done that. Well perhaps just one suggestion…use oil…use lube ..it works on the feet, it works on the neck and it works on the tender bits. It can really make a difference.
Speaking of making a difference I am writing this week to bring to your attention the idea of a WORD CLOUD for someone who is sick and or dying. OK, pay attention, this is important for a change. Most of you will turn from this. I don’t blame you… it’s a tough and touchy subject .Perhaps just one amongst you will follow the advice in this column and that would be worth it .That would make a difference. I know it’s not an easy subject but it’s an important one. elderly-hospital-patient-1437289
I write today about word clouds. Specifically, word clouds for people who are very ill. Let me explain…this is not an original idea on my part. This comes from an article printed in the Annals of Internal Medicine last year. Listen, serious illness, death and dying are tough to write, read and talk about but it’s important and can make a big difference. The full article involved transitioning the patient from the medication and procedure centric focus to focusing more on the wishes of the ill patient. Basically you have a frank conversation with the patient…The last chapter of your life is being written…you can tell us what’s important to you and what you want to accomplish before the last page is turned. “I want to see my nieces again” “I want to reconcile with my ex sister in law” “I want to get in the garden again and surround myself with the sights and smells of the flowers” “I want to have this music play at my funeral etc”. This is difficult stuff and many people shy from it…both health care professionals and patients and family alike.
words-639306A word cloud is basically a message board. It’s a framed collage of words as a keepsake for the patient AND family and friends. You bring a board you can write on…Put the patient’s name prominently in the middle and have staff, friends and family mark it up as they see fit. People can add special expressions or pet sayings or phrases…something that connected them to the patient. The word cloud prompts recollection and reflection. Family sees and contributes …Friends see and contribute. This connects everyone to everyone else. This gives people a focus point for conversation when they come in the room. It gives you something else to focus on other than the hospitalization and illness itself. Visiting patients in the hospital …especially seriously ill patients can be very uncomfortable for people. This is a way to focus the conversation away from illness and towards the patient and their shared memories. It doesn’t have to be just “how’s the food” and long awkward silences. Instead you can focus on the Cloud Board ..“I wonder who wrote that !” “I wonder what this means?” When the hospital staff see such a visual expression it acts to remind them that it’s not just another body in the bed…it’s a “touchstone to appreciate the footprint of the patient’s life and to learn what mattered most to the patient.”Doctor_consults_with_patient_(4)
Let’s say the patient improves and goes home…they have a great memento of the experience with real comments from real people about themselves. Not just an inexplicable hospital bill. Let’s say the patient succumbs from their illness…the family has a one of a kind memento of the patient which can be brought to any service they might have …and can serve as a visual remembrance for years to come. Flowers fade. Notes get put in some drawer. This word cloud will long serve as a reminder of the patient and who they touched in their lives. I sent an example along with this article that hopefully they can reproduce to give you a better idea of what I am talking about…a picture is worth a thousand words they say .
As a doctor I struggle with the idea of making a difference in someone’s life. I struggle too with making a difference in someone’s death or serious illness. With this word cloud idea I think I can make a real impact in how people deal with the process. You can too. This doesn’t have to come from the doctor. In fact I don’t ever see this coming from the doctor or staff so it’s up to you! You CAN make a contribution during this difficult time…a contribution that will stand the test of time. Go, make a real difference. I’ll be here when you get back.
Get Out! Is It Christmas Already? | Dec 2015
Dr. Barry
GET OUT! Is it Christmas time already? It’s a wonderful time of the year but it’s very stressful for a lot of people. The traveling. The shopping. The scheduling. What to get for who. It is a very busy time for most people. Busy busy busy but it’s important to stop and take stock for a moment.
Dare I say be mindful? When people are “busy” they are getting stuff done but they are usually not thinking much. Not thinking about their lifestyle. Not thinking about what’s really important during this Holiday season. I love the line from Dickens’ A Christmas Carol where Scrooge is confronted by the ghost of his long dead partner Jacob Marley … Scrooge complimented him on his business acumen when alive and the ghost remonstrates, “Mankind was my business. The common welfare was my business; charity, mercy, forbearance, benevolence, were all my business. The dealings of my trade were but a drop of water in the comprehensive ocean of my business!” His trade was not his business! Let me help. Let me give you a couple of ideas for the holidays. First…the gift of massage…Get someone you love a gift certificate to massage therapy.
It’s the antidote to busyness. There are a few people out there who don’t like massage and we are rounding them up for analysis but they can always re-gift the certificate. The nice thing about the gift certificate is that the person you give it to can arrange when they want the massage…It doesn’t add to the scheduling stress of the holiday. Also, consider the gift of a yoga class…nothing is more relaxing and revitalizing as a yoga class…you might not have thought of this as a gift idea but it’s a good one…for an interesting variation that even my wife liked…try Aerial Yoga! Even your friends that have everything or have tried everything will have been unlikely to have tried this yet. Lest I leave the wrong impression…my wife is super easy to please…she just doesn’t find regular yoga strenuous enough…not enough sweating for her hour of exercise…She was, however, very impressed by the aerial yoga.
Second…the gift of your company. Take your aunt out to one of the seasonal events…Maybe you have done Lights on the Lake one time too many…still plenty of other venues for you. Take them outdoor skating downtown. Not very expensive but it will be a memorable experience for everyone. Take them for a horse driven carriage or sleigh ride at Highland Forest…being on the sleigh covered with a blanket as you glide along the pathway with the twinkling of the stars competing with the jingling of the bells on the horses…memory magic! Let me recommend the Desantis Xmas at the Palace show. Hearing seasonal music done by live local talent in this great venue never gets old to me.
Often, they have talented kids from the local schools perform and that’s bonus time! This is a great show for the young and old and everyone in between. The popcorn made fresh in the lobby is another draw for me. My office is one of the sponsors for this show and we never miss it!
Also, the Winter Solstice Celebration is coming back to Syracuse. This show will be at St Paul’s Cathedral downtown and run for 3 4 nights. When the Solstice Celebration was last in town it was an eclectic mix of solemn, seasonal, and joyful music. You will leave the Cathedral uplifted and how many events can you say that about!! There is so much more to recommend…Spend an afternoon snowshoeing or X country skiing with family or a friend. Being outdoors in this weather is very very good for you…it increases your metabolism and helps you burn off some of those Christmas goodies. Bottom line is that this holiday should be about you growing your personal relationships not your relationship with Amazon Prime. Merry Christmas and Happy Holidays to one and all.
The Fast Track | November 3, 2015
Dr. Barry
I have studied diabetes for years…all primary care doctors have…but only recently have I been exposed to a concept that can really make a difference in the care of diabetics. One of my Signature MD patients sent me a link to Dr Jason Fung …a doctor with a “new” approach to treating type 2 diabetes. Immediately, I saw the rightness of the idea. There have been multiple new drugs in the past several years but they just increase our medication choices…they don’t have a meaningful impact on changing the lives of diabetics. When you become a diabetic you go on one med…after a bit you go on a second med…eventually many people go on an injectable agent…all the while monitoring their sugars, blood pressure and cholesterol levels routinely. We are treating the sugar number but not the underlying problem which is that your insulin levels are too high.
am talking now about the very common type 2 diabetes not the uncommon type 1 diabetes where they don’t make enough insulin. So, most diabetics have insulin resistance and high insulin levels. High insulin levels prevent you from burning fat, High insulin levels cause weight gain. High insulin levels keep your belly fat growing. High insulin causes salt retention and therefore raises blood pressure. So, high insulin levels bad. Now the current diabetic teaching is low carb, frequent small meals etc… Not bad advice but no where near the best advice for treating high insulin levels. To treat diabetes and prediabetes effectively you must get the insulin level lower. Turns out that this is possible and doesn’t require any strange new meds, treatments or therapies.
Ok, how much extra time in your day do you need for this new treatment? How much money will it cost? How many choices will you have to make each day? Special equipment? Extra doctor or professional visits? The short answers are that it frees you from too many choices. It will save you time. It will save you money. No special meetings or equipment needed. Do I have your interest piqued yet? Well, I am talking about intermittent fasting. Fasting lowers your insulin level back to normal. This allows you to start mobilizing the fat in your body. Fasting reverses all the metabolic processes that insulin resistance causes.
There are many many types of fasts…I have gently recommended the 5:2 diet for years….5 days a week you eat healthy…2 days a week you take in only 500 calories or less. This is simple, basic and reasonable. I recommend doing the two days in a row for best results but you can vary the schedule to suit you. The intermittent fast recommended by Dr Jason Fung involves skipping breakfast and lunch every day and only taking in calories from 6 10 pm at night. Yes, this flies in the face of all the recommendations that you should eat a big breakfast and or have 5 small meals a day. If you follow that advice, you will keep spiking your insulin and weight loss will be much harder. This advice certainly has not made a dent in our diabetic problem or obesity problem. With intermittent fasting you don’t have to make a decision as to what to eat for breakfast or how to manage eating lunch on the road etc.… You don’t have to spend extra time in the gym, buy special scales or tubs, or learn anything new about calories, fats, protein etc. The first few times are psychologically daunting but almost UNIVERSALLY people that do the intermittent fasting FEEL BETTER. More energy. More mental focus. Less stomach issues. As the doctor said on one of the many videos I reviewed for this issue, you can do the test of 1. That is , try it for yourself ..you be the judge. You don’t have to ask anyone else what happened to them or how they feel. You can try fasting for yourself and see for yourself and feel for yourself the benefits. “Oh I could never fast…it’s just too hard !” Really? A billion people fast for Ramadan, Hindus, Buddhists, and old fashioned Catholics all have experience with fasting.
I am not going to give you the play by play because it really is just that simple…black coffee and water only until 6 pm. Eat healthy or not for 4 hours then no food after 10 pm. There are many variations on the Internet. Start with Dr Fung on youtube and off you will go. By the way…this is not really some new fad or trend. Fasting has been around as long as we have. When people tell me that it’s impossible to do I refer them to the TV show…Naked and Afraid ..where strangers are put together in the wilderness for 21 days to survive. The vast majority of them never find anything to really eat and that has not prevented anyone from completing the challenge. They might get sick from drinking contaminated water but no one quit due to lack of calories.
You don’t have to need to lose weight, you don’t have to be a diabetic, you just have to want to feel better. If you are a diabetic on lots of meds it would be prudent to check with your doctor about which meds to cut back etc. Your doctor should be sympathetic to your efforts even if he is not familiar with fasting. If he can’t be bothered perhaps it’s time to upgrade your medical care. When I mentioned fasting to one of my colleagues he opined that he thought the idea made sense but that we couldn’t get people to go along with it. I have more faith in you than that.! Did I mention that people who do fast say they feel physically and mentally better!
Let me close with a few quotes about fasting so you know it’s not just me! “Humans live on one quarter of what they eat; on the other three quarters lives their doctor.” Egyptian pyramid inscription, 3800 B.C. “Fasting is the greatest remedy the physician within.” Philippus Paracelsus, one of the three fathers of Western medicine “Instead of using medicine, better fast today.” Plutarch, a Greek biographer and moralist “The best of all medicines is resting and fasting.” Benjamin Franklin Until next month…get well stay well…
Preach, Practice, Repeat | October 6, 2015
Dr Barry
I am trying to practice what I preach…I have always believed that good living will trump most medications. I am not saying you can treat all medical problems with diet and exercise but I am saying that lifestyle is more important than medications.
Look up the treatment recommendations for hypertension, heart disease, diabetes, arthritis, etc and the first line will say either diet and exercise or lifestyle modification which is really the same thing. Your doctor glosses over this because he or she has no control over what you eat or whether you work out…What we in the medical profession can control are the meds and you know we love our pills! We give out pills to help you sleep at night and then another pill to keep you awake during the day. One pill for your blood pressure and another to counteract the side effects. When you add in the supplements and the vitamins and aspirin many people find they are taking 10 pills a day or more. We can’t control you but we can control the pills we give you.
So, my mantra has been diet and exercise…exercise and diet…I read somewhere that to get the same benefit a person gets from statin drugs (the popular cholesterol lowering drugs like crestor, lipitor, zocor etc ) …the radical alternative that has the same benefit as the statins….eat more veggies ! Now I am talking about primary prevention here… If you have already had a heart attack, blocked arteries, stents, stroke, diabetes etc that’s secondary prevention and the statins are very important for those people.
The debate has raged however as to how important it is for the average Joe to take a statin. Some doctors think they are overprescribed while other doctors think practically everyone should be on a statin. The studies are reviewed all the time with different conclusions depending on who is doing the interpretation. The most recent recommendation regarding statin use involves using a risk calculation like https://cvdrisk.nhlbi.nih.gov/..If your 10-year risk is higher than 7.5% you should consider a statin. This number is calculated by putting in your sex, your age, your cholesterol number, smoking status , and blood pressure information.
So, I try to plug in my numbers and when I punch the calculation button I get an error message. It seems my cholesterol level is so high that the computer assumes that I mistyped the number. My cholesterol is so high that when I tried to get life insurance years ago the agent said…don’t bother to even apply. My response at the time was to show them my recent cardiac cath results which did not show any blockage. So even though my cholesterol was high…it was not sticking to my arteries. They didn’t care that I didn’t have blocked arteries …they only cared about the number on the paper…So I went on meds…got my number to where they wanted it and got my insurance. Of course I stopped the pills afterwards…I am not a pill guy if I can help it.
Fast forward to this month…From time to time I get chest symptoms. Could be anything…probably nothing but that’s not how I treat my patients. If you worry about some symptom and some test can give us information why not get the test? At least twice a year I will push myself past the limits of my endurance physically…usually hiking and skiing with the Clan Haswell. I would rather not keel over in the near future because life is great right now. My wife still seems interested in me and my professional work has never been more satisfying with Signature MD so I would like to stick around long enough to at least see how Iran, Greece and China all play out.
I told you that I took meds to get my cholesterol down…I didn’t stay on the meds…I don’t like meds and what I read says you can accomplish the same thing with the right diet and exercise program so that’s what I concentrate on. But am I being stupid not treating my high cholesterol? Are my arteries slowly and silently clogging up? In my favor is the fact that I am not a smoker or a diabetic ..that makes whatever cholesterol you have stickier. Also, my family history is good…neither parent having had an mi or stroke. So , do you go with a good family history and lifestyle or go with the population based scientific calculation. Well, you don’t have to be abstract about it…you can just measure the amount of blockage and act accordingly. So, last month, I went to St Joseph’s Hospital and had a heart catheterization. They snake a wire from your wrist or groin to your heart and inject dye to check the arteries. It’s an interesting sensation. Not pleasant but tolerable. Dr Simon and his team were very professional …not even giving me grief about my not wanting to take any sedating meds. I don’t like to alarm my wife and I figured if I skipped the sedating meds I could drive myself home. My wife is a working girl after all and no need to keep her from her job. Bottom line is that there were no real blockages. Maybe a little plaque here and there but no blockages that needed stents, balloon angioplasty etc. If that’s all the blockage I have after 57 years of genetically high cholesterol I am doing the right things!! Maybe the tequila has some role in keeping the arteries open but that’s another column altogether. Until we know for sure I am going to credit the exercise and diet. I feel a little vindicated with my diet and exercise mantra. I also think having a persistently optimistic attitude is also important but that may be more for my head than my heart. There is data to suggest that being happy…having a positive attitude ..is as important for your heart as it is for your head and I want to believe that as well.
The deal I made with the heart doctor was that if there was any plaque at all …any narrowing…I would go on the statins. I don’t like statins but a deals a deal. If they will only come up with a pill I could take Sundays only…that way I could be possibly compliant with doctors’ orders. Just because I think I am a good doctor doesn’t make me necessarily a good patient!
So, just like I preach and practice…if you worry about a possible problem and there is a test for it…why not find out for sure. You know I don’t like surprises or guessing. When it comes to your health you shouldn’t either. Never be afraid to be proactive with your health…It’s not wrong to say to your doctor… ”This is my symptom…this is what I read about it…this test seems to provide clarity…is there a reason I should not get the test?” Until next month… Get well… Stay well.