A Word Medwise

Mixed feelings on the end of Bin Laden

2011-05-04T18:37:00.001-07:00

My thoughts, like those of many in the U.S. and abroad, have touched repeatedly this week on the capture of Osama Bin Laden and his death. I was surprised at the emotions I felt, having sorrowed so deeply with so much of the world at the senseless terror and loss of thousands of lives on 9/11. I did not feel what I'd call joy...that emotion is a unilaterally positive feeling that I attach to personal milestones like the birth of a child, wedding anniversary or graduation; or a momentous achievement for a sports team or our nation, such as the elation I'd feel if the Cubs ever won a World Series, or if the U.S. ever paid off its debt.

I'm not sure that what I felt could be considered a sense of justice, satisfaction or evening up the score with terrorists. I'm not usually a vengeful or angry person, and "getting back at someone" isn't really in my armamentarium of wise actions. Avenging hurt by causing more hurt--an eye for an eye, tooth for a tooth--leaves us all blind and toothless before our time. :-)

Instead, I felt renewed sadness about the changed and frightening world in which we live. For instance, I don't think that publication of photos of a killed terrorist would even have been considered 10 years ago. It was felt to be nearly inevitable a few days ago. I don't think ANYONE, no matter how heinous, deserves to have his/her mutilated body displayed in public photos and videos. For our government to have elected to distribute Bin Laden's photos would have reduced us to the level of his extremist followers who routinely disseminated videos of beheadings to prove something. I am glad the "obvious" choice to censor these photos was made. The only consequence of their publication would have been to inflame Bin Laden's admirers and adherents, who already must be incensed at what they see as their leader's martyrdom at the hands of the evil American empire.

I also found myself reflective. I wonder what lessons our country and its allies learned, and still need to learn, from considering the views of Bin Laden's admirers. My faith teaches me to love my enemies and pray for those who hate me. I don't think I am mature enough in my faith to feel forgiveness for Bin Laden and his disciples, nor anything approximating love. However, I think there is much we can learn from knowing that not everyone loves America. We are often wasteful, selfish, aggressive, as individuals and as a nation. It's time to look in the mirror.

In the last decade or two I've seen a disconcerting trend toward self-centered behavior ("What's in it for me?" "Not in my backyard!"), angry polarizing rhetoric and short-sightedness (we pay attention to the news of the moment; not the years of rebuilding that Hurricane Katrina, the Alabama tornados, Haitian earthquake, Afghan and Iraqi wars require). Add to that some appalling laziness, profligate eating and energy use, and spending that don't take into account the debts we leave for future generations. I am as guilty of these faults as any of my neighbors!

We also have unparalleled opportunities: for literacy, intelligent communication and discourse, international sharing and cooperation, tolerance and mutual understanding. Technology is moving a bit too fast for me; I'm not ready to toss aside books or voice-to-voice telephone conversations anytime soon. Still, I have to acknowledge that the newest technologies and social networking have brought the world closer together (witness the revolutions ongoing in the Middle East, the ultimate outcomes still to be determined.) Dictators and terrorists can no longer hide behind censorship and iron fists. But to move beyond hate, we need as a nation, and indeed as a world, to move beyond age-old hatreds, stereotypes and misinterpretations and see the good AND bad in both ourselves and others...and try to build a future based on what's optimal for the majority of people instead of just the privileged few.

Survey says...

2010-07-24T07:24:00.001-07:00

I read a thought-provoking article this morning. http://blog.physicianspractice.com/content/article/1548468/1584203 summarizes a survey about consumer perceptions of health care quality, medical evidence, practice guidelines, and patient interactions with doctors.

The survey reflects a perennial truism. Over the years, people often report they distrust doctors in general, or the health care system--but rarely do they doubt "their" doctor. Patients never want to believe that a person charged with something as important as their health would ever be less than excellent. I am glad that the consumers in the survey rarely use public report cards on doctors, as I have found them to be quite flawed. I have been reported by some as having attended a medical school or residency program that I never set foot in. They get my address and hospital affiliations wrong. If publicly available information is so badly misrepresented, how trustworthy are the random ratings generated by one or two disgruntled or "gruntled" patients?

There is also a uniquely American tendency to suspect conspiracies where none exist. Clinical guidelines are based on medical evidence (which, so disappointingly, many people don't even know exists)! They are not constructed by evil insurance cabals whose sole purpose is to prevent access to the "best" treatment. New, more, and expensive isn't always best. I rejoice when someone's change in lifestyle enables me to stop a medicine, or cancel a surgical recommendation. I wish more people (and insurance companies!) placed value in prevention and a big-picture look at their health by a skilled primary-care physician. We save money for patients, and the health system...yet are not averse to spending it when it's truly needed to preserve or restore health.

My experience has been both similar to, and different from, what's reported in the article. More than 28% of my patients bring lists of questions or concerns with them. This is good, because it helps to organize the visit. However, trying to address too many concerns at one visit isn't good; invariably, important nuances are left out, and yes--doctors DO seem rushed because we ARE rushed! I've had 20-minute discussions with patients about just one topic: osteoporosis, high blood pressure, diabetes, or depression. Trying to cover all of these, plus a sore foot, a weak bladder, irritable bowel and memory problems during a "prevention" exam is too much. Separate wellness & illness visits, and bringing up the most important issue at the beginning instead of "oh, by the way, doctor, I get chest pain sometimes..." is prudent.

Here's hoping that, through the process of health reform in the next few years, we can reeducate patients and physicians alike to be partners and partakers of the best medical evidence and guidelines that modern information systems can provide!

Do we mellow or mold with age? Mind matters

2010-06-09T18:14:00.000-07:00

I've had intriguing discussions recently with mid-life patients (late 40s to early 60s) about how we are finding the aging process. Certainly, there's no denying that some of our body parts are getting creaky and cracky, stiff, sore or saggy. If I really thought about it, I'm sure I could list more than a dozen minor or major annoyances with most of my systems, head to toe. Hair is graying, vision's not as sharp...all the way down to some foot pains with walking.

My patients are amazing and inspiring. It's true that I've had "tired" and "old"-feeling 25- and 30-year-olds come in saying they're not as good as they used to be. But I also have patients in their late 40s and early 50s doing half-marathons, and a woman in her 60s who lost 107 pounds so far the old-fashioned way, with prudent small meals, exercise & support. Another lady went to Poland at 90...three years ago. She still lives in her own senior apartment, independently and happily.

I've taken a good look at my own assumptions and family models for aging and discovered a number of fallacies. My adoptive parents died young of debilitating illnesses; at 46 and 69, respectively. Because they died young, part of me doesn't expect to live to "old age." Maybe you have believed some silly things like I have: "I can never get my body back after having kids" or "I'm too busy/uncoordinated/important to exercise." Or "its all downhill from 30/40/50/60/80." I have a lot of examples that prove these myths wrong, if only I look around me. My birth parents in their 70s have their share of health issues but also positive outlooks. Patients or relatives in late years (80s, 90s) have bounced back from acute injury or illness, in some cases actually getting stronger and better than before. Skilled rehab can work wonders!

I'm having to attend more closely to my own health because of issues that popped up during a recent checkup. (Yes, doctors need doctors, and a physician who treats herself has a fool for a patient). I'm finding that the things I've told patients (and that they've told me) are actually true. You can feel 3 times more alert and energetic if you start exercising...the hardest thing is to get off the couch and "Just Do It," as Nike puts it so well. A good night's sleep does wonders. Small balanced meals & snacks throughout the day, low-fat, low-salt, and colorful with lots of fruits, veggies, and whole grains can taste good and make you feel SO much better! And some of the obvious, e.g. pills that stay in their bottles on the shelf don't do you any good. :-)

I have to conclude that many trite but true phrases endure because they ARE true! "Moderation in all things": food, drink, exercise, shopping, caffeine, computers, & moderation itself! "Like a fine wine, you mellow with age." "Mind over matter" matters. "You are what you eat." "Life begins at 40." Yogi Berra's immortal "Baseball is 90% mental, the other half is physical." "If at first you don't succeed, try, try again." "You're as good as you think you are." "The sky's the limit." Of course, there are practical limits a bit lower than the sky, but our potential to improve, to learn, to overcome, to cope is much stronger than we suspect. It's all in our hands (and legs, and backs, and abs, and minds)...there is power in positive thinking and I encourage you to aim high, find a few inspiring mentors & role models. Try something new--new foods, a new dance class, a new language, a new career or a new place to live. Believe me, it is NOT all downhill from here! :-)

Genetic Testing: A New Pandora's Box?

2010-05-12T05:44:00.001-07:00

As a family physician, I expect a number of requests to review genetic tests in the next few months, as curious patients receive results from Pathway or other companies that are marketing new tests for hereditary diseases to the general public.

I've read some early critiques from medical experts about the quality of the tests. Personally, I have some very basic concerns: should a person order such a test in the first place? Is the general public able to understand the complexities of genetic testing, which can be tough even for medically trained professionals to grasp?

I'll provide here some links to sites that can help the public--and doctors, too--understand the basics of whether to test, and how to test.

Genome. gov provides a simple guide to genetic testing. The National Society of Genetic Counselors has an excellent online pamphlet that explains different types of genetic counseling. For instance, a couple planning to have children can seek expert advice if one or both parents has a personal or family history of a serious genetic disease. Geneticists can also advise potential parents about testing for risks based on their racial background (keep in mind there are heightened risks of sickle cell disease in people of African descent, cystic fibrosis for white individuals, or Tay Sachs in people of Ashkenazi Jewish heritage). March of Dimes has a good overview of the types of situations in which expectant parents, or couples planning a pregnancy, might wish to undergo genetic testing.

A person whose family member has a serious condition such as Alzheimer-type dementia or Huntington disease might want to know about their risk of developing the same condition later in life, and may request a test from a genetics counselor. Finally, there are some counselors that specialize in interpreting genetic tests for cancer risk; breast cancer (the BrCa1 and BrCa2 genes) are the most common, but genetic factors can influence other cancers, too. The American Society of Clinical Oncology has a recent position statement (in fairly technical language) about the types of cancers for which genetic testing might be useful, at http://jco.ascopubs.org/cgi/reprint/JCO.2009.27.0660v1. Cancer.gov's helpful review of the many complex factors in the decision to undergo testing, consider direct-to-consumer testing, and interpret results, is at http://www.cancer.gov/cancertopics/pdq/genetics/risk-assessment-and-counseling/HealthProfessional/page6#Section_362.

Should you consider genetic testing? This is a very individual decision. Why do you want testing? Is there one specific disease you fear? Are you curious about your personal risks, or those for a family member? What decisions might the results affect for you: whether or not to marry or have children? Will results influence your career choice, if you might develop a serious disorder later in life? Are you looking for personalized information to help you adopt the healthiest possible lifestyle for your unique risks? The impact of testing must be considered before ever submitting a DNA swab or blood sample for analysis. These considerations are explored briefly by Mayo Clinic, and Intelihealth.com.

An excellent government site is "Genetics Home Reference." The home page is at http://ghr.nlm.nih.gov/. Helpful information about the direct-to-consumer tests such as Pathway's is at http://ghr.nlm.nih.gov/handbook/testing/directtoconsumer. In particular, an FTC advisory on these types of tests is worth reading: http://www.ftc.gov/bcp/edu/pubs/consumer/health/hea02.pdf. A caution about "nutrigenomics" is posted by the Minnesota Department of Health.

Considerations for any type of testing include one or more of the following:

1. Are you testing for the right mutation? It might be best to test a living, affected member of your family who has the disease that concerns you. Keep in mind there are many genetic abnormalities, and tests can't detect all of them.

2. Is the test reliable? So far, there is a broad and loud note for caution in ordering and interpreting direct-to-consumer test results.

3. Not everyone with a risky gene will get the disease, and the severity of the disease in affected people in the same family can vary. Some people are carriers of disease; they have one healthy gene and one abnormal gene, and the only people who could be affected are their children. Environmental factors may affect the likelihood of disease for some people; and just plain luck affects others. Read about reduced penetrance and variable expressivity.

4. Is there an action you can take that will reduce your risk, reduce the chance of passing a harmful mutation on to future generations, or prepare for birth of an affected child? Doctors often avoid testing that won't result in any meaningful change in health behavior or planning.

5. Should children be tested for a disorder that might affect them later in life, or might affect their reproductive decisions? (This is definitely controversial and should be discussed with a physician or genetic counselor.)

6. What if you find out that one or both of your parents is not genetically related to you? Or what if a man discovers that his son cannot be genetically related to him? This is uncommon, but can happen.

7. Could the results affect your ability to get health insurance? Legislation was passed to prevent this in 2008.

8. Are you emotionally prepared to deal with the results? How will the results affect your relationship with your family? For instance, if a 20-year-old woman gets a positive test result for BrCa1 due to breast and ovarian cancer on her mother's side, and her mother doesn't want to know her own genetic status, can the younger woman keep a secret? Do you have support, and knowledgeable professionals, to help you through the reactions and make wise decisions, regardless of whether you are positive or negative for a disease mutation?

Hopefully this introduction to the issues and facts surrounding genetic testing will prepare you to make your own decisions about genetic testing.

New Year...New Beginnings

2010-01-04T05:27:00.000-08:00

Even for the cynical, a new year represents a chance to consider improvements. This is built into some religious and cultural observations, e.g. Rosh Hashanah, Christian Advent & Lent, Chinese New Year. From a personal and practice standpoint, I like to start January by reviewing the previous year, tweak some things, and challenge myself to higher performance.

In 2009, I felt overwhelmed by commitments that I had undertaken without understanding their full responsibilities. They were not central to my current passions. So one of my earliest resolutions for 2010 is to drop what isn't high-priority. Although I'll miss people from these activities, I don't miss the work.

On the personal side, I was better at family involvement in 2009. We had some nice trips, communicated better within the family, and saw extended family & friends more than in many years. I haven't been as great at updating our Christmas card buddies, so I started the year with one of those dreaded family letters. Our kids didn't win any awards, my husband wasn't promoted to head honcho of a multi-billion dollar company, and I am not Queen of the Universe yet (although I like to think that's just around the corner...certainly I don't hold that position at home!) However, a roof is over our heads, food is on the table, there are enough love & hugs to go around, we are reasonably healthy, and my kids are progressing at an acceptable pace. Can't ask for more!

One thing I had missed, and took up again, is spare-time reading. Some of this is pure fun (Tony Hillerman books, the popular authors Gresham, Baldacci & Piccoult, rereading some Crichton, & a spy book.) Some is self-improvement and horizon-broadening. This included some reading about teamwork (The Five Dysfunctions of a Team, which should help my practice interactions as CEO & chief bottle-washer), intriguing topics (Nudge and Freakonomics were interesting views of Americans' economic behavior), personal improvement (finally got around to reading the 7 Habits of Highly Effective People--it actually makes a lot of sense and I plan to work through it in 2010 with a long-time friend from college).

In 2010, my most outrageous personal resolution is learning a new language--Chinese! After wanting to do this for several years, I figured that dropping other commitments would open up some time for this, and North Central College in our town has a conversational Chinese course that fits on my free Wednesday night. I have many Asian patients and want to be able to understand a little of their language, thought process, greetings, etc. I won't be giving any lectures in Beijing on Chinese liver problems, but I have always enjoyed learning about other languages and culture. I'm still fairly fluent in Spanish and I've learned (and forgotten) some German, Dutch, and American sign language. (and 3 months of 5th grade French, but that doesn't quite count...)

On the professional side, I usually make both business and clinical plans for improvement. Business-wise, I have a new manager, plan to expand to a new site in February part-time, and will revisit policies & procedures to make tasks smoother for patients and employees. More regular meetings among our clinical staff and support staff should greatly improve communication. If anything, we have too much new going on...new accounting software, new 401k, new employees, the new Plainfield site & learning to mine the potential of EClinicalWorks, the electronic medical record we bought in mid-2009. I trust my organized manager to keep me on task with all of this.

Clinically, I will post updates on the website for vaccine recommendations, health screening, etc. I also create an annual list of topics I want to learn more about. In family medicine, a major challenge is to stay current on a broad range of health conditions, anything from prevention to the latest treatments for H1N1 flu, prostate cancer or diabetes. The internet makes it easy to find & print resources for myself or patients...plus I have subscriptions to uptodate.com and two herbal/alternative medicine references (naturaldatabase.com, naturalstandard.com). I learn a lot from reading journals, but there is no substitute for lectures by experts, so I usually attend a major national conference at least every two years.

Finally, a commitment to both myself and those around me in all spheres of my life is to look after my own health, to listen fully, and focus on what's in front of me instead of the ten things racing in the back of my mind. I have actually used our treadmill once for its intended purpose (instead of as a clothes rack) since January 1. Hopefully I can keep this up and get some weight off and feel more energetic!

Transitions come in Twos

2009-11-24T18:44:00.000-08:00

A number of one-two punches have hit me in the last month, all dealing with the theme of family "transitions." Two employees leaving...two recent widows coming in for checkups...even two patients attempting suicide. We've also had a few long-term patients move out of state.

Change is hard. It's unfortunately a fact of life in medical practices, and often carries a sense of loss. To extend my thoughts on this a little further...

Whether an employee is with us for a few months or many years, a small practice becomes a second family. It can be rough when one or more of our work family moves on, even if it's to a well-deserved retirement or an energizing challenge with better benefits. I wish our departing employees a peaceful transition to whatever lies ahead for them. Welcoming new members to the clan is a privilege that helps offset the pain of goodbyes. I also console myself by knowing that few doors close forever. Some employees leave for a time, then return some years down the road.

Life & death transitions are the hardest. I cannot imagine losing a life partner after decades of togetherness--good times and bad times. The widows I met have good support, and they knew the end was near. They had months to make quality time to say goodbye to their spouses, although neither thought they had nearly enough time. In contrast, the people left in the wake of a sudden (and sometimes tragically "successful") act of self-harm--knowing that a person they care about felt intolerable pain in living, and could not bear another moment--may feel there is no safe place to vent profound hurt, anger, sorrow, guilt, and second-guessing.

With more routine transitions--patients leaving either permanently or temporarily for other climes--doctors often feel jumbled feelings. We are on the receiving end of patients' deepest secrets, their gratitude, their joys and sorrows. In over twenty years of practice, I've taken care of a few four-generation lineages. Couples who weren't even married when I first met them now have teenagers! Former toddlers are now grown, launching their own careers & families. There comes a time when a patient feels a call to move "back home," or to a chosen paradise to live their later years in leisure and comfort. I cherish memories of the times I've been there to help point someone to better health, whether it was through simple advice or through astute diagnosis. Closing out a record that will be copied for another doctor makes me wonder...can they read between the lines to see what I learned from this patient? Will they enjoy this family as much as I did?

In times of change, there are opportunities to reflect on what came before. This ideally won't come as endless self-recrimination--which is so especially tempting when someone attempts to cut short their life. "Why didn't we see it coming? What could I have done to prevent it?" Rather, we can seek lessons from the ups & downs of a relationship to help us interact more effectively with both known and new people.

In the end, transitions bring both separation and growth. Sometimes we can exchange hugs, gifts, silly cards, and best wishes for a new phase in life. Harder transitions are bumpy, jagged, angry, tragically incomplete. But they are part of life too. A sappy song from a few years ago has a line I often reflect on..."every new beginning comes from some other beginning's end."

Wishing people meaningful holidays, gratitude in their hearts, and every day (not just on New Year's Day), authentic relationships and a fresh start.

Reality is colored by your viewpoint...a gem of a lesson

2009-11-15T07:48:00.000-08:00

One of my hobbies is gem and rock collecting. I'm especially fascinated by stones that appear different colors in different light situations. A few examples...tanzanite looks a stunning blue in sunlight or overhead fluorescents, and violet in incandescent (indoor) light. Alexandrite (I just have the fake version, LOL!) looks green or gray in one light, red in another. More striking differences in "rock reality" occur under ultraviolet light. Some of the ugliest rocks take on a new beautiful personality under shortwave or longwave UV light, as you can see on my fluorescent minerals page, http://synspectrum.com/glowingrocks.html . Boring white, black or brown stones can transform into any color of the rainbow. I don't provide plain-light photos here, but another person with multiple interests (attorney-author-rock collector), Stuart Schneider, has some interesting examples of regular and fluorescent lighting at his site, http://www.wordcraft.net/fluorescent1.html.

Additionally, as anyone who's recently seen my office or home can confirm, I've been bit by an obsidian obsession since a trip to Glass Buttes, Oregon in early summer 2009. There are many gem-grade varieties of obsidian, including rainbow, midnight lace, gold/silver sheens, green, and mahogany as well as the typical black volcanic rock most people know. An article by geologist Jim Miller explains and shows some types of obsidian. More beautiful photos, and some great shots of Newberry Crater's lava flow (which we visited in 2008) are at a blog post at Original Beauty. Again, the right viewpoint and lighting are crucial for appreciating these stones. Midnight lace obsidian shows beautiful bands and swirls of darker material within transparent glass, when you look through it toward a light source. Regular light from behind or above you makes it appear to be a dense black and/or brown slab of rock. Similarly, in ordinary indoor light, an unpolished rainbow obsidian just looks like a boring black rock. When held at the right angle, after putting some water on it (or if you're lucky, after someone has polished it for you), beautiful bands of blue, green, or violet may appear. In sunlight, dull brown or gray rocks may acquire a gold or silver sheen at the right angle.

Rockhounds are also drawn by the allure of hidden beauty. Another fun adventure during our Oregon trip was a visit to Richardson's Ranch to dig thundereggs. Boring, globular clods of earth became beautiful agate-filled treasures when the store owner cut our finds in half. I wish I had the time, talent and equipment to polish all of them!

There are some obvious metaphors when you switch your focus from the world of rocks to the world of regular folks. The most important are these two:

1. Reality is very subjective. What you see depends on where you stand, what angle you're looking at, and what light you're viewing in.

2. Beauty can be hidden, and it may take some long, patient digging to unearth it.

I encourage you to approach people, life, and decisions with an open mind. After all, you can't judge a rock (or book) by its cover. Take time to get to know what's beneath the surface of people you meet. In politics and legislative decisions, including the current push to reform the health-care system, we are shown issues with a special polish that a candidate or officeholder wants us to see. Take time to look at complex issues from different viewpoints, (including perspectives you generally disagree with), before finalizing your opinion.

Welcome to A Word Medwise

2009-09-20T08:53:00.000-07:00

As a busy family physician, I find that each day brings new challenges and insights. The role of family doctors is now both more difficult and more important than ever. We serve as guides for patients to cost-effective prevention, diagnosis and treatment, and advocates for improved health in the community, country and world.

Doctors have always served multiple roles: healer, educator, coach, confidant. Recent trends within medicine have added new roles. The concept of a "patient-centered medical home" casts the doctor in the role of team leader for all those who are involved with a patient's care, from our office and in the community. With new technologies such as electronic medical records, we also find ourselves serving as, or needing, an information technology (IT) guru to trouble-shoot error messages from electrons that go "bump, boink, bzzzt" in the night. Finally, to survive economically when payments don't keep up with our overhead costs, we also must become politically active to seek changes that will benefit patients but not force doctors out of business.

I plan to share some of my own wisdom here, but more importantly, to present lessons I've learned from those around me. It is very easy for doctors to feel isolated and overwhelmed with the life-and-death issues we face daily. We learn a lot from patients, colleagues and mentors. I hope, in sharing their insights, to honor the folks who help keep me going in stressful times.

I try to keep my focus positive. One patient at a time, I work to help people maintain and improve their well-being, prevent illnesses that are preventable, and treat illness when it happens. I also support patients and their loved ones through serious setbacks, including planning and preparing for the end of life, which inevitably comes to all of us.

I look forward to sharing, and hearing readers' thoughts!