My Blog

IF YOU HAVE…….

For anyone watching television these days, they are hard to escape. You know, the “if you have” commercials. If you have erectile dysfunction, firbromyalgia, dry eyes, rheumatoid arthritis, osteoporosis, or over active bladder. It seems like pharmaceutical companies have been hawking us their products, via “direct to consumer marketing” on the tube forever. As a mostly free-market individual, I am usually blasé about such things, but I for one would like to see these advertisements banned.

When my patients come to me with medical problems, I try to prescribe the best solution for their problem. Often it is a generic medication, but sometimes when no generic is available, brand name drugs are necessary. However, to create a need in the mind of the patient, when there is minimal or no problem, that drug “X” will cure disease “Y”, is often disingenuous. Yes, many middle age men have trouble maintaining erections, and in this respect the ED drugs have been nothing less than a godsend. However, how many men over the age of 55 wouldn’t want to have a stronger erection, but don’t actually have a disease? I once had a 90 year old male patient who asked me for a prescription for Viagra as his wife of 60 years sat in the exam room rolling her eyes, non-verbally pleading, “Please doctor, no, don’t do it.”

Or the middle age woman whose various aches and pains have now been diagnosed as fibromyalgia, who is telling me about all of the side effects she is having from her new medication. Not surprisingly it turned out she asked her family doctor to prescribe it for her after watching a television commercial.

Commonsense should tell us that non-life threatening illnesses might not be worth the encyclopedic list of potential side effects. Even the commercials themselves disclose this as they spend almost as much time telling us about all the bad things that can happen if we take their medicine, as the good ones. So is the newest, and usually most expensive, osteoporosis drug worth taking if it can also cause heartburn, back pain, bronchitis, diarrhea, headache, abdominal pain, dizziness, or (rarely) disintegration of the jaw?

I for one say it is time to ban consumer-driven marketing from television. We can’t prevent patients from researching their medicines on the web. But let’s stop creating a demand for the latest drugs in between episodes of “Lost” or “Scrubs.” Until then just pass me the remote so I can find the mute button.

WHEN LESS IS MORE

After thirty years in medical practice, I often think there’s very little left which will shock or surprise me. Two recent hospital encounters caused me to reflect how too often we physicians are occupied with doing things “to”, rather than “for” patients.

Mrs. A was a fragile 83-year old nursing home resident with a bit of dementia. She was sent to the hospital emergency room because of a sudden change in her behavior and was found to be having a stroke. A medical brain specialist, or neurologist, was immediately consulted who after examining her and doing a CAT scan of brain, decided to administer an intravenous “clot-busting” drug. After initially improving, she took a turn for the worse later that night and was moved into the intensive care unit. That is when I was asked to see her for an abnormal EKG, or electrocardiogram. Glancing at the squiggly lines of her heartbeat, I instantly new she was having a heart attack. Since she was given the clot-busting drug the day before, she was not a candidate for more of this or any other blood thinners, as she might bleed into her brain. As interns and residents raced to place her on a breathing machine, I noted in her chart a living will and do not resuscitate order. I quickly called her guardian who confirmed the family did not want her on life supports. Rising quickly from my chair, I halted the training doctors just before they inserted a breathing tube in her throat. She died later that day.

In the rush to do as much as possible to save her life, not one of her doctors had called her family to ask about the patient’s wishes and advanced directive. At any age, a heart attack and a stroke within 24 hours has a very small chance of survival.

Mrs. B was recently placed on kidney dialysis. Although mentally sharp, she had many heart and medical problems. I was asked to see her for chest pain and an abnormal heart rhythm. Committing someone to dialysis is always a serious decision, but I was stunned to find out that she was 96 years old! Although we can argue the appropriateness in denying patients long-term kidney dialysis in the 60’s, as they do in England, this seemed to be clearly out of the range of common sense for me. I wondered if her kidney doctor, surgeon who made her kidney dialysis arm graft, or her family physician ever talked to her about the implications of doing this.

As reimbursements for procedures decline, physicians and surgeons become increasingly competitive. There is a common perception that if they don’t do what the family doctor wants, a competitor will.

I see these as cautionary tales. They remind me that although we have taken an oath to protect the patient and their lives, sometimes our actions prolong the natural process of dying, rather than just adding days or months to living.

Most of my patients perceive me as thin. Having gained about one pound a year since I was 40 years old, my self-image is a little different. (By the way, I just past my 61st birthday.) As I look at my expanding mid section, I too struggle with a carb addiction and love of sweets, and although I exercise three times a week, I am forever searching for ways to “practice what I preach” to my patients. So during mid morning and or afternoon blood sugar plunges and a case of the slugs, I have discovered a new ally: nuts. High in healthy fats, protein, and low in carbohydrates, although calorie dense, they help stave off my hunger for a few hours. I have gotten so enamored with these treats, that I keep a small can in my car, and a glass jar full of them on my desk at work. Both my office staff and I understand that they are free to plunge in anytime, and I am forever refilling it.

My favorites are almonds and walnuts, although hazelnuts and cashews are a close second. I shun peanuts, not because I am allergic, but because they remind me of baseball games and the circus, and they seem more boring then the others. I suppose I should worry about unclean hands diving into the jar, but I trust my co-workers to practice good hygiene. When I go on vacation and return to an almost empty container, I like to think they missed the seeds more than me.

Multiple studies have shown nuts to be an integral part of a heart healthy diet, and if I can wash them down with an iced tea, then I can steal a little caffeine with my protein and fat. Don’t get me wrong; the snack machine, with its enticing chips and pretzels, forever tempts me. But as long as my nut jar is full, I can make it through another afternoon more cheerfully. I like to think that it keeps my staff happier as well.

Occasionally, the nut karma pays off, as someone will anonymously drop off an unopened bag on my desk. My wife of course thinks I’m nuts, but that’s a story for a whole other day.

“I think the Coumadin is causing my hair to fall out,” Linda said to me at her last office visit. Over the years, I had heard about, and seen many, side effects of this powerful blood thinner. However, hair loss wasn’t one of them. So I quickly reassured her that this wasn’t the culprit. We then reviewed the indications for her taking this medicine, which were a possible mini-stroke several years ago. However, since then she had been fine, and was taking a lot of arthritis medicines that might interact with the Coumadin. So I said, “If your neurologist doesn’t object, then I don’t have a problem with you stopping it.”

I have been practicing medicine long enough to remember when we never gave patients copious amounts of literature about the potential side effects of medications. I would simply give them a drug sample, or write a prescription, stating the two or three most common reactions, and told them if they felt anything else, to just call me.

This seemed to work out fine, but with the mushrooming litigation climate, and the advent of the internet, patients are now bombarded with copious information about their care, and in particular their medications. If I give them samples, then my electronic medical record spits out one to three pages of possible side effects or reactions, which can seem scary enough to make many folks believe I just prescribed strychnine.

If they take the medicine as prescribed, and somehow survive the trial period unscathed, then they can get the prescription filled. Then the pharmacist will produce yet another set of worrisome pages to read. Finally, most will on their own go to the internet to check out the drug, perusing testimonials from patients who either swear the medication was a life-saver or caused them to go blind, deaf, or have intractable diarrhea.

Frequently, a patient will return with the medicine bottle and side effect information in hand, claiming it caused something like dizziness, and therefore they can’t take it. When I ask them how they know this, they look surprised and say, “It says it right here,” handing me the educational pages. I look at the sentence they have highlighted, and read it back to them.

“It says may cause, not will cause dizziness.” Then they look at me confounded as if to say, “So what’s the difference?” Usually I choose not to debate the nuances of the two verbs, but try to suggest that the power of suggestion can be quite robust.

Yet I had some lingering uncertainty about my visit with Linda. So after she left, I consulted my electronic medication directory, looking up Coumadin side effects. Under the long list, the last one said “ hair loss.” Whoops. I swallowed my pride and sent her a letter telling her that indeed she had been right and I had been wrong. Sometimes in medicine, humility is as important as knowledge.

STRESS

“I have a lot of stress in my life,” is one of the most common complaints I hear from my patients. I don’t even have to ask them about it because they offer it to me as an explanation for a variety of maladies. For example, “My blood pressure is up today because of stress,” or “I can’t stop smoking, (or eating) because of stress.” Curiously, most people do not seem to realize that everyone has stress in their lives. It is how we perceive, or deal with these adverse events, which can have detrimental effects on our health.

The “Type A” personality was recognized long ago to be a risk factor for heart disease and sudden death. The hallmarks of this personality trait are individuals that are impatient, time-conscious, concerned about their status, highly competitive, ambitious, business-like, aggressive, have difficulty relaxing, and always rushing. They are often high-achieving workaholics who multi-task, drive themselves with deadlines, and are unhappy about delays. The resulting release of adrenalin causes a rush or “high” and can be quite addictive. It is so common in our society today, that even comedians entertain us with anecdotes about the many things that annoy or anger us.

Yet, in thinking about it, these difficult or challenging incidents can be viewed from more than one perspective. The person driving slow in the left lane is not trying to frustrate you personally. Just take in a deep breath and move to another lane. Mother nature did not single you out for punishment by having it rain when you planned a picnic or fishing trip, and the car company hasn’t plotted to aggravate you when your car won’t start. You get the idea.

If we live and breathe, there will always be things that can stress or exasperate us. Indeed, that is just part of life. What is necessary is to stop hand wringing and taking these annoyances as a personal attack. It is easy to accept, but more difficult to incorporate into our beliefs.

So when you pick the slowest line in the movie theater, smile and talk with your spouse or date. If you can’t handle waiting two hours to see your doctor, then bring a novel, laptop computer, or choose another physician. The important thing is to stop using these episodes to ruin your day and damage your health. Now if only that person in front of me in the checkout just didn’t have so many coupons……….

The Problem with Anecdotes

Anecdote: (noun) –a short, entertaining account of some happening, usually personal or biographical, or little-known entertaining facts of history or biography

I think the popularity of anecdotes in our public discourse started in 1982, when then President Ronald Regan in his state of the union addresses to Congress told the heroic story of someone who dove into the icy water of the Potomac River to save people after a plane crash. He used more personal examples and stories to illustrate or enhance his political points of view. More than one occupant of the oval office since then has also used anecdotes to make a long, otherwise complex and boring, speech more enjoyable and personable.

Now I enjoy a good story or anecdote as much as the next person. However, I learned a long time ago that in medicine anecdotes should not be substitutes for objective clinical trials and research to determine what drugs, surgeries, or medical policies produced the best results. For example, decades ago I, and other cardiologists, were taught to use medication to suppress or eliminate early or premature heart beats, known as premature ventricular contractions, or PVCs. When strung together, these PVCs could lead to fatal heart arrhythmias and even sudden death. The problem was that a study in the 1990’s finally showed that most of these medications increased, not decreased, the incidence of cardiac death.

As the healthcare reform debate rages, we are bombarded with stories, chain emails, and television commercials, which give heartfelt anecdotes about some one who got either good or bad care here, Canada, or the UK. Having practiced medicine in Pinellas County for almost thirty years, I can recite my own list of horror stories from medical care both here and abroad. I am sure there are Canadians who have had good experiences as well as bad. It just depends upon who is telling the story, and what their individual experience has been.

One would therefore assume that objective data would be more useful in assessing the quality of a nation’s healthcare system. However, even the definition of quality is debated. Is quality medicine judged only by good results, or also by the way the patient was treated? Is the incidence of death from heart attack and stroke better or worse in the USA or England? It depends upon how the doctor lists the cause of death on a death certificate. How about rates of cancer and cancer survival? People rarely die of prostate cancer for example, but it might be diagnosed and treated more aggressively in this country.

One thing I am certain of however is that clinical trials and statistics, even though they are not immune from manipulation, are better than anecdotes. The latter serves only the point of view of the storyteller, and may or may not be applicable to large populations. They do however make long-winded political speeches seem more human and entertaining.

CONTROL

I have a friend who recently lost his wife of twenty years to cancer. She was only 49 years old. They had two children and were deeply in love. Our daughters had been very close growing up; however, grew apart when they attended different high schools. As I listened to his passionate and loving eulogy, I could not help but reflect upon how much these two individuals had loved each other and their children. They did everything in their power to protect themselves and their family. And therein lies the irony.

You see, when they had traveled, as they had often done, they had always taken separate planes in case one of them were to die in a crash and therefore not leave the children parentless. They were very intelligent people, and I believe fully understood that the likelihood of this happening was extremely remote. Nonetheless they wanted to take every possible precaution, no matter how small, to keep their family intact.

There were no plane crashes, but no one can predict or prevent the occurrence of cancer at any age. She developed breast cancer and had the most thorough and best treatments. Yet within a year a different cancer was discovered which could not be beaten.

In our growing technological society of instant answers via cell phones and computers, it is easy to succumb to the illusion that since we can so easily access and control information, it must follow that we can control future events as well. As my friend’s tragedy demonstrates, nothing could be further from the truth.

Again, I am reminded of “carpe diem,” or “seize the day.” For in truth, not only can’t we predict what tomorrow will bring, but it is folly to also think we can control it.

There was a twinkle in her eye as I walked into the exam room. “Are you surprised to see me?” Anna, (not her real name) was rapidly approaching her 105 Th. birthday, her mind still sharp and sense of humor intact. In truth, I wasn’t surprised.  Stunned would have been a more apt description, since by all objective medical evidence she should have died over ten years ago, having severe leakage of her mitral valve and significant blockages of all three arteries. Wisely, she had declined open-heart surgery when she was merely 92.

And then there was Harold, who just turned 95, responding philosophically when I asked him how he was doing. “You know doc, there are the usual aches and pains, but at my age, everyday is a bonus.”  Sage advice, I thought to myself, even if you’re not that old, and words I rarely hear from my other patients in their 70’s or 80’s.

Since no one of course knows how or when they will die, living one day at a time should not be reserved for the just the aged. Several years ago, two of my colleagues, both 50 years old, died in a horrific plane crash in North Carolina. In Buddhism, it is called living with “death as an advisor,” meaning to make the most of every single day since we do not know what tomorrow will bring.  So when my elderly patients ask me, “Will I see you next time?” what they really mean is “Will I live another six months?” To which I usually answer, “I don’t know if I will be here in another six months.” Many of them chuckle, which is my intent, and I like to believe it makes them more at ease with their mortality.

Another 92-year-old woman, Vera, went to visit some friends in Tennessee and drove back 12 hours non-stop to Florida. I told her I thought that was rather incredible, and she shook off my complement like it was “no big deal.” I don’t think I could have done that. And I’m not sure how many of my over 60-year-old peer group could have either.

These attitudes seem so common in my aged population of cardiology patients, that I recently asked my office to staff to pull the names and numbers of patients over the age of 90 who I had seen in the office within the past year. I had assumed it might be two- or three- dozen, and thus was startled to learn the number was actually 81, with two over 100.

The personality of these folks began to intrigue me as I started to discern a common thread during our often all too brief office visits. The nonagenarians are by and large non-complaining, and offer a victim-less worldview. I also wondered what, if anything, allowed them to survive ten decades or more of life. Was it clean living, great medical care, good genes, exercise, or faith? Certainly advances in medicine and surgery, as well as our willingness to treat and operate on ever-older patients, have played a role as well. However, in the end, I’ve concluded that it is mostly serendipity.

My 91 year-old mother just had surgery for a slow growing squamous cell cancer on her eyelid. She was torn by the decision whether to have surgery or not, appropriately surmising that the cancer might outlive her. Still spry and working out at her YMCA, she asked the dermatologist if she wasn’t too old for the procedure and he replied, “But you are a young 91.”

Some however do not seem to share this propensity of aging with grace. Rosina is a 95-year-old retired physician, no longer with any spouse or family, who asks me at every visit, “Why am I still here?”  I of course have no satisfactory answer to which she responds, “I am tired of living.”

“Do you want to intentionally hurt yourself?” I ask.

“No,” she replies. Her family doctor believes she is depressed, and has placed her on anti-depressants. I’m not convinced it has helped as she still asks me the same question at the beginning of the every office visit.

Yet for most of those lucky enough to reach 90, they do seem to appreciate life more than the rest of us “younger ones.” For the most part they approach each day and life with optimism, gratitude, and grace. Perhaps this is why they got to this age after all. It is a lesson that us more youthful folks could do well to learn.

ALONE

“Why am I still here?” she asks me at every office visit. Usually I respond with something like “I don’t know, “ or “it must be God’s will.” However, these answers do not really satisfy her.

Oksana, not her real name, is a retired Russian-American physician who in her mid-nineties, finds herself totally alone. Her husband of over sixty years, died a few years back, and since then she has felt isolated and depressed. Before his death they were inseparatable.

“Do you have any family or friends?” I ask.

“No. They are all dead, and we never had any children.” She sighs. “I have no one. I don’t know why I am still alive.”

As a physician, I have to ask the follow-up question, “do you want to harm yourself?”

“No,” she says quickly. If she says yes or wavers, I would have to recommend psychiatric hospitalization for suicidal ideation. She knows this.

I wonder why she doesn’t join an organization like “seniors without partners,” or socialize with folks in her condo. But with my limited time schedule for office visits, I defer this line of questioning. Or is it because I don’t feel comfortable with her situation, perhaps fearing that someday I too might be left all alone?

Her family doctor thinks she’s depressed and prescribes anti-depressants. The pills don’t help. At her next office visit she asks me the same question again with a dull and flattened affect. The magnitude of her heart disease is small, and she might live past 100, but I don’t tell her this.

Her plight reminds me that just because we are alone, it does not follow that we have to be lonely. She may never find peace with this, so for me to preach, “live one day at a time,” or “everyday is a gift, that’s why it is called the present,” may not lift her malaise.

These phrases remind me that life is fragile and uncertain. The “time to go” might occur at any moment, and our lives do not come with guarantees or warranties. I do my best therefore to encourage her just to be thankful and try to get out more often. I remain skeptical that her attitude will change or that my words will subdue her dark thoughts. Perhaps my responses are all that she really needs from me anyway. It might be my imagination, but she seems to leave the next visit a little less sad.