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High-tech Care with Old-Fashioned Values

Hospice

Today a patient of ours passed away after a long bout with colon cancer. As you may be aware unless we catch these early and surgery is curative the results are still very poor. Rural areas are prone to delay in seeking care when you have symptoms, long travel to get to specialists and travel issues if chemotherapy is needed. Families are very stressed and the challenges are great. For this patient, the family firmly desired that she remain independent once it was known that the initial surgery (which they had been told was curative) had not resulted in a cure. They were faithful in sitting with her, arranging appointments, dealing with chemotherapy and its complications and, finally, dealing with her unavoidable death.0

One of the changes in medicine that has been wonderful in the past 2 decades (most of you know my attitude about the lack of much real help for patients during that time of exploding medications and treatments for baby boomer diseases) has been the advent and spread of the hospice model. At its core hospice has several overarching goals.

First the dignity and autonomy of the patient is key. When you know you will die in a short time and when your loved ones are faced with that fact loss of control was (and still is) a fact of medical life. Patients and their families are often given false hope or forced down a path of more and more intervention with limited chance of success. Often families are coerced into treatment protocols because we as physicians just don't want to accept the "defeat" that death brings. The result is that patients lose control of decisions until they are too ill to make them any longer. Hospice changes that by bringing patient and family squarely into the decision tree. If a patient says "no more of that" or "I need to have ..." they are listened to and respected.

The second goal of hospice is to allow the transition from life to death to be as comfortable and natural as possible. This may mean that a patient stays at home in a familiar place to spend those last days. It could also mean that a patient chooses to be in a hospital like environment if that is what they feel would make them happiest. The hospice tries to deal with those decisions as best as they can. Certainly urban programs have more resources but rural groups have gotten quite good and addressing these transition issues.

Third, Hospice is about teams that support patient and family. In few other areas of medicine do the teams of nursing, pharmacy, medicine, social work and pastoral counseling work so closely (and well) together. The turf that sometimes exists in medicine is much less obvious in hospice and the result is care that flows smoother and is more rapidly responsive to the patient and their needs. All of medicine has been studying the hospice model and we have much to learn from it.

End of life issues by their nature force families to talk and force all of us to not only think of mortality but the immortal. Hospice has always been unafraid of the link between spiritual health and the comfortable death of a patient. Families often comment on how much the spiritual aspects of their hospice experience helped the survivors with their grief AND their own spirituality. I am grateful to the doctors, nurses, social workers, pastors and support personnel of our local hospices for the way in which they have helped my patients and their families through the past years. I am proud of the work they do and they should be too.
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In a flash

I have been thinking about Malcolm Gladwell's great book "Blink" (hard on the heels of "Tipping Point"). It is a book of stories and research that highlight the difference between the way in which our conscious mind makes deliberate decisions and the "rapid cognition" of our instinctive/uncounscious mind. In one of this blog's first entries I wrote about how experienced clinicians often correctly make a decision very rapidly based on limited information. These are not guesses, these are ways in which skilled clinicians will trust their instinct in a case.

In the book Gladwell shows how both conscious and the instinctive decisions can be right or prone to be wrong under certain circumstances. Under extreme physical and emotional distress, for instance, we process much less information that helps us read situations and people. We revert to stereotype for information and our processing becomes more like that of the autistic mind....unable to read facial or verbal cues which limits the accuracy of our decisions. At other times thinking through a decision may cause information overload and result in unneeded delay or inaccurate conclusions. In medicine both of these can happen.

When I was teaching actively in the medical school environment, I often told students and residents that if they "just didn't feel right" about a story or a pattern they were seeing they should listen to that feeling. I recall giving a lecture outlining this principle and THAT VERY AFTERNOON a student came to me in clinic with a gut feeling they were missing something. She had been interviewing a woman for about 30 minutes and the complaint was common as was the story but something was not right. I went in the room and introduced myself and recounted a bit of what I had heard from the student. Then I felt strongly compelled to ask the woman "How long has your husband been abusing you?". Never before and never since have I started an interview with that question asked that way. She broke down and related a story of fear and abuse and we started intervention to get her an her family safe. Was I smart? No....I just went with my instinct. But I could not explain why I had done so.

Gladwell's book points out research showing a myriad of facial expressions that may be flashed for a few milliseconds may have been what I "heard" from this patient. In other words it's likely her face flashed me a look of stress/fear that I instinctively recognized without even knowing I had seen it. Very interesting stuff. Often in medicine we order test after test and trust the tests not the patient or the story and then have too much information to sift though. The result is more specialist referrals and more tests NOT necessarily better or more accurate diagnoses.

In the Epilog he makes a case that major decisions (if not make under extreme emotional/physical distress) may be BETTER made by going with a gut feeling and lower level ones may be better with reasoned thought. Many of us know about a job, a decision that we thought through very carefully because it was so important AND WE MESSED IT UP! Similarly we may have made a decision under stress when reading facial or interpersonal cues was key meaning we could not tap into our rapid cognition or our reason....we just chose to stereotype. That decision also was wrong. I have been reflecting on major life choices in the past and facing me now and see how errors were made and wonder if I will do better in the future.
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Treating Ourselves to Death

This past week a patient of mine became quite ill and needed to be rushed to an emergency room. The situation looked dire and the symptoms were baffling. A sudden change in health for no good reason and what appeared to be a life threatening stroke or central nervous system disaster. I went over in my mind the last visit and wondered what I had missed. I assumed that I had not paid attention to some subtle symptom and now the result was disaster. Twenty-four hours later the picture is still murky but what emerged is this: medication given by a caregiver to ease a symptom that was mild likely resulted in severe sedation. The medication may or may not have been for this particular patient. This got me thinking about how many American households have stockpiles of old prescription and over-the-counter drugs that are "shared" by well meaning family members for symptoms similar to those for which the medication was initially given. I really don't blame families (although this is a very dangerous practice). I blame our medical/pharmaceutical complex that has convinced us that every symptom, every problems has a medicine (or two or three) that should be used to relieve the symptom. Now I am not saying that drugs do not help people ( I am after all not a herbalist or naturopath) but I am saying that sometimes symptoms tell us that our lives should be changed, should be lived differently. A century ago if you were tired, you slept. If you had muscle aches you rested. Now we pop a pill to eliminate the symptom that may be our body trying to tell us something. I see many patients (especially the elderly) who come in taking 10 or more medications. Not regularly for research shows that it is unusual for someone on 2 medications (that are given more than one time a day) to take them every day. The result is a mish-mash of daily drug therapies. "I felt my blood was up so I took an extra one of these and skipped that one all together." We have all become pharmaceutical experts and the ads in the magazines and on the TV just confirm the fact that we know what we need and how to take them. The problem is, we don't. More people die from medication errors than car accidents every year in this country....and those are the ones we know about. People overdose, they go to the ER and almost die, they are sick for a few days but get better all because they are taking mixes of many medications that ALL have potential for harm. The lesson this week is CLEAN OUT THE CUPBOARD and don't share your medications. And remember to always ask your doctor if you need to have a pill for that symptom you just mentioned.
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Purpose Driven or Other Driven?

I have been going through The Purpose Driven Life during my devotions for the past several weeks....I know, I'm behind the times. I am glad I found the book at last. Besides being well conceived, written and referenced, the book has nailed the issue of purpose for me right now. One of the exercises is to develop a life purpose statement. Although I will keep mine between me and God I would like profess some of the concepts here for patients to see.

1. Above all else my reason for being is to know and worship my Creator. All else is secondary.
2. The gifts He has given me and the personality with which I have been endowed must drive how I serve fellow Christians and reach out to the world. Not using them is a mockery.
3. Regardless of the stress and trials they are nothing if I keep eternity in view.
4. Recognition and success are not to be my drivers, the fruits of the Spirit are to be so.
5. I must not only worship with fellow Christians, I must study and pray with them in a small support group.
6. I am called to go and make disciples I cannot do that by hiding in one place.
7. Although I am not perfect He promises to make me so in eternity. I need to pray for a more and more holy life each day I have here.

These are great principles. They do not choose for me a practice, a place or a way of serving but they should help me solidify my purpose.
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Those Painful Diabetic Nerves and Pesky Bugs

Two common problems I face were addressed with some good studies in this past week's British Medical Journal (BMJ). The first involves the treatment of painful neuropathy caused by chronic (and often uncontrolled) diabetes. The longest nerves in the body are affected soonest so most patients complain of pain in the feet. The pain can be a severe burning and often does not respond to the usual over the counter pain relievers. Prevention with weight control and diet and later with tight glucose control is still the best way to deal with this problem but many of my patients still develop pain. Over the years my best treatment options have been topical (and occasionally oral) capsacin as well as low doses of tricyclic antidepressants or anticonvulsants. M. Wong, et al performed a systemic review of research documented in the literature. The results confirmed what clinicians have known: Capsacin works for many diabetics and when it doesn't use of tricyclic antidepressants and older anticovulsants worked quite well. In fact they outperformed the newer drugs with generally lower rates of withdrawl than some of the newer drugs. The good news is that many of the effective drugs are available as generics. If you have this problem please ask your doctor about capsacin and tricyclics before taking a sample of one of the newer heavily marketed drugs.

The second issue is diarrhea caused by antibiotics. Antibiotic use is widespread and the broad spectrum antibiotics kill gut bacteria along with the disease causing ones. This often results in diarrhea. In some cases a bacterium called Clostridium difficile may overgrow and it can produce a toxin that causes a severe diarrhea and colitis. These problems are especially worse in the geriatric patients who often overuse antibiotics anyway. For some time there has been evidence that the use of probiotics and even brewer's yeast could treat antibiotic induced diarrhea but that is like closing the barn door after the horse is out. M. Hikson et al did a quite nice double blind placebo controlled study looking at the use of probiotics to help PREVENT antibiotic associated diarrhea. Their results showed the they were able to prevent 1 case of diarrhea for every 5 persons treated with probiotics and more importantly for every 6 people treated they saw the prevention of 1 case of C. difficile colitis. Probiotics are inexpensive and readily available. They are well tolerated and this study confirms that early use of probiotics will prove helpful in preventing a common and potentially dangerous effect of antibiotic use.
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Childhood obesity

Childhood obesity was once considered humorous. Every TV show seemed to have one "fat kid" that added some type of spice or jokes to the script. Generally that was 1 kid out of 10 or less. We now are faced in East TN with rates as high as 33% of the children in grade school not just being overweight but clinically obese. Recently I saw a preteen who was over 100 pounds OVERWEIGHT. The scary thing is that as more children (and adults) become obese in this country it becomes harder to compare yourself with any reality. If we all are obese and we look at each other we think we are "normal weight'.

I cannot tell you how often I am faced with an obese child who comes into my office with a soda in one hand and a tongue stained by candy. At the same time the parents swear that the child is eating well. Most experts would say that obesity in children is largely preventable. Most children are not GENETICALLY obese. We make them that way. Us. The parents....we are the ones that develop food and exercise habits in our kids, model behaviors to our children and BUY THE FOOD WITH WHICH WE ARE KILLING THEM AS SURELY AS CIGARETTES WILL.

As America obsessed about fat and cholesterol (because of our fear of heart disease) we pushed more and more carbohydrates into our children's mouths. Companies in an effort to profit from our national sweet tooth developed high octane sweeteners like HIGH FRUCTOSE CORN SYRUP. As we cut the fat we also failed to utilize our satiety feedback system that allows our gut to tell our brain that we are full. This system relies primarily on fat intake for the feedback. When high carb/low fat diets are consumed it is not engaged as actively and our brain tells us to KEEP EATING. The high carb content of the foods our children eat also stimulate their insulin which, in the presence of high calorie intake causes the body to store calories as fat. So with high carb diets you are hungrier and you more readily store the extra calories you eat as fat....a bad combination. This high carb intake also causes a roller coaster effect of the blood sugar and people crave the carb/sugars that feed this cycle.

The result has been our children are sucking down sugar and doing it all day long. This in and of itself is worrisome but when coupled with our general lack of aerobic fitness in our parents and our children we see rapidly expanding waistlines.

SO what's the answer?

I would recommend you start with the whole family dramatically decreasing intake of carbohydrates. For kids this starts with sports drinks and soft drinks. Their primary drink should be water and WHOLE MILK. Studies have shown that diets with whole (as opposed to skim) milk result in fewer calories ingested and better weight control. Next eliminate the high amounts of potato products (fries, hash browns, tater tots etc) and limit the bread, rice, pasta and of course cookies/cakes/candies. Encourage vegetables, whole dairy and high quality meats. Mix in nuts and nut butters and moderate fruits. Push away from video games and TV which are the main source of entertainment for your kids and a large reason they have no time to do healthy activities. Finally, begin a simple exercise program. Pledge as a family to each walk for 30 minutes continuous daily. Use a pace that "makes you sweat". Do the walking together to model the behavior. Make it fun for your kids.
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July 4th

We had a parade in White Pine today to celebrate July 4th. It was fun to see people lining the streets to wave, get goodies and look at the floats. We passed out some water bottles and goody bags with our kids helping. (I'll post pictures soon). It started me thinking about research on community. People actively involved in community tend to live healthier and happier lives. We are not meant to be lone rangers. We need each other. At times that means we have to bear each other up emotionally, physically or spiritually. At times that means putting up with character flaws and habits that are destructive. People who know me well know that my "issues" often recur even though I say they won't. I am learning that God forgave those sins of yesterday, today AND tomorrow that He knows I will commit. He has no difficulty with me coming to Him repeatedly with my flaws as long as I am seeking to be more Christlike each day. Those around me may not see the attempt to repent and live more like Christ but I am convinced they will eventually. July 4th is about freedom. In America we are free to speak, to seek and to work. In Christ we are free to become the full human He designs us to be. I don't know what I will be in the end but it will be more like Him. I'm glad that I have friends and family who can understand that struggle, who put up with me in the midst of my growing pains and who know that the final outcome is sure. Thanks.
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Random Research Thoughts

I have been reviewing some recent British Medical Journal (BMJ) articles that deal with common questions in primary care. I will outline a few below.
1. What is the best method to encourage exercise in children or adults? This is interesting. A systemic review by Ogilivie et al of a total of 48 studies on the subject showed that almost all interventions resulted in change in exercise patterns in the most sedentary AND the most motivated patients. This is similar to research in the past that showed approximately 33% of smokers will make an effort to stop after their doctor merely suggesting that they need to do so. Obviously these initial changes fade with time but it is encouraging to know that by working with our sedentary patients we can have an impact.

2. Does low dose aspirin improve women's cognitive function? Again interesting results. J. Kang et al reviewed data from the Women's Health Study from 1998 to 2004 where nearly 6400 woment aged 65 or more were using placebo or low dose aspirin for a mean of 9.6 years. OVERALL the cognitive function in the study group was not improved by aspirin use. There have been some prior observational studies that have shown possible benefit and I believe we still do not know enough about certain subsets (smokers for instance). Future studies may tease these out.

3. Would a tonsillectomy be better than watchful waiting for recurrent strep throat in adults? This comes up every week. Some patients get strep again and again and the risk for more severe disease, although not as common in this day of easy access to meds, does exist. The study by ). Alho et al looked at 70 adults who had recurrent strep. Thirty-six had "instant" tonsilecltomy and 34 had watchful waiting. The intervention group was less likely to have further strep throat infection or throat infection or days with throat pain than those without the surgery. At 90 days strep had recurrent in 24 % of the patients without surgery and only 3% of those who had the surgery. Insurance companies take note. Waiting to do the surgery will result in more infections and more cost, more days of work and/or school lost.

4. What are the long term effects of restriction of sodium? N. Cook et al reviewed date from the TOHP (trials of hypertension prevention) study that was done in multiple sites on adults aged 30-54 years with pre-hypertension. They found that in addition to have a slight effect on blood pressure, there was a significant reduction in cardiovascular events during the followup. I am a fan of using sea salts as better mixes of mineral and salts. Using them generally causes a reduction in sodium salt reduction. This may not only help blood pressure but may result in fewer cardiovascular events such as heart attacks.
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