Sunday, July 30, 2006

A Weighty Issue

I cannot describe how pleased I am that so many of you are heeding my call to wedge yourselves into your running bras and get out on the pavement.

But I am dismayed to see how many of you immediately started talking about your weight—that you wanted to lose some, that you did lose some, that you weren't losing any.

If you go back to my original post, you will see that never once do I mention weight loss as a reason to run.

Whaaa--? I hear some of you thinking. Why would I do something so unpleasant if I'm not going to get skinny?

Sigh. OK. I will tell you why you should later. But first let me tackle the topic of getting fat.

You probably already know that the country is experiencing an obesity epidemic. The majority of adults in the U.S. are above a healthy body weight. This in turn has caused an epidemic of Type 2 diabetes. And diabetes is the number one cause of 1) blindness 2) amputations and 3) kidney failure requiring dialysis. How great would it be if we could avoid all that? So doctors are desperate to find a way to get people to lose weight. Fat people are also desperate to lose weight, because even as everyone has gotten fatter, discrimination against fat people has not decreased at all.

So if everyone's on the same side, what gives? Why is everyone getting so big?

It's tempting to say that it's the fault of the fast food chains. And they do play a role, but I would argue a small one. The problem is multifactorial. There are several important differences between the U.S. now and forty years ago (or the U.S. and some other countries where people have not yet started to expand). First, people no longer have to move. Most people can now do their jobs by lifting only their fingers; correspondence, chatting, ordering, everything can be done by computer. (Being a physician is one of the few professions where we must keep moving — from room to room, down the hospital hall, to the front desk.) Second, people and jobs have moved away from the city centers, so almost everyone commutes by sliding their padded butt into a carseat and driving to a parking lot next to their job. People don't even expend the energy to shift their own car gears anymore. Third, food is now available everywhere, at any time of day or night. Not just at fast-food joints; everyone has a vending machine no farther than an elevator ride away from their desk, a 24-hour convenience store (with a parking lot) on the corner down the street from their house, and a huge refrigerator stocked with goodies.

Humans are genetically programmed to eat when we can and rest when we can, because we evolved during a time when if you passed up a meal or a rest stop, you were that much closer to being the weak one who got left on the rock to distract the saber-tooth tiger. (This programming is not uniform; some of us are jittery and jumpy and more easily distracted and tend to stay naturally slim. It was probably an advantage to a tribe as a whole to have a few people like this, so as to be able to alert the calm ones to danger and to run really fast if need be.) It probably didn't happen often that anyone got fat back then, but even if a tribe were so lucky, the consequences of this—premature death—were not, evolutionarily speaking, undesirable; these folks had already had their offspring, who cares if they lived to be 90? It's not just humans who are like this, either. I used to feel really sorry for birds in cages, because flying seems like such a wonderful thing, and they're being prevented from doing it. Then I learned that when birds live in a place where there are no predators on the ground, they give up flying. They get fat and lazy and waddle around, just like humans.

So when you pass up running and instead pull your car into the 7-11 for a Slurpee, you are simply heeding your DNA. That's right, it's not your fault. So quit feeling guilty; it's unproductive. But do realize that you are not in the environment your DNA thinks you are, and it's now up to you to adapt yourself.

It's been shown over and over again that if you put people into a controlled environment, calories in minus calories out equals weight gained or lost. No one is immune from this law of physics. What can't (yet) be measured, though, is just how hungry a person gets when they take in less than they put out, or how unpleasant a person feels when expending calories. You may suffer more when trying to lose weight than I would, I can't deny that.

Which brings me to the running thing. Simply running will not cause you to get skinny. Running more and eating less will. The running part is simple; the eating less, harder. But I'll give you a rough idea of what has been shown to be helpful (and in fact, I follow most of the rules myself):
  1. Eat breakfast. People who put off eating until late in the day tend to be fatter.
  2. Avoid simple sugars. This includes, but is not limited to, soda, juice (yes, even 100% fruit juice), candy, cakes, pies, chips, and white starchy foods. Simple sugars go down easy, then shoot your blood glucose up, which shoots your insulin up, which makes your blood glucose plummet, which makes you hungry. Hello, vicious cycle!
  3. Make it a rule to stay away from the vending machines, the corner store, and the coworker offering donuts. Fast and easy snacks result in fast and easy pounds.
  4. Don't keep bad food you can't resist in your house. What's that? You need to keep stuff around for your kids? Why on earth would you want your kids eating crap either?
  5. Get enough sleep. Sleep-deprived people tend to get fatter; it's not known why.
  6. EXERCISE. Exercise alone doesn't guarantee weight loss, but it does seem to prevent weight gain. Over the years, I have watched everyone I know slowly, slowly expanding, with the exception of those who get regular exercise.
But please do not run for the weight. Run because a fat runner is much healthier than a skinny couch potato. Run because it makes you strong. Run because it makes you happy in your own body, whether it's lumpy or flat, tall or short, square or round. Run because you'll live longer (and no, you won't wish you were dead, ha ha). Run because when you're out there running (as slowly as you can stand to, remember), you will have the experience of being alive in the world with your body doing what it was designed to do.

Wednesday, July 26, 2006

Watching Golf?

I'm thinking I should compile some of the responses on my last post to give to my students and residents so they can get some perspective on what patients and other clinicians think about the topic.

A couple of things I wanted to to clarify:
  • Orange did not, in fact, spontaneously accuse me of having a stick up my ass. She simply agreed with me when I asked whether I did.
  • Although I address my patients in a formal way, I don't think my manner with them is formal. I welcome—no, encourage—their input, laugh and joke with them, pat their shoulders. A few of them routinely hug me, and a couple have kissed me. (One kissed me on the lips once. An experience I hope is never repeated.) And despite my byline, I have never actually uttered the words "That's Doctor Mama to you," except in jest.
I haven't been on the blogosphere much lately because things are fraying a bit around the edges here. One of my colleagues called me this weekend to report that she was having weakness in her hand and leg, and her rheumatologist thought she should be admitted to the hospital, but what did I think? When I told her to get her butt to the hospital stat, she said, "But who's going to take care of the baby?" "Er, where's your husband?" I asked. "Downstairs watching golf on TV."

I ended up meeting her at the hospital and staying with her the first few hours. She's doing okay, but she has a pretty scary condition, and a lot on her plate. Her husband is being a father finally (with the help of his mother), but I'm not sure it will last once she gets home. She's talking about changing jobs to decrease the stress in her life. I wish she'd change husbands instead. I've been filling in for her as much as I can at the office; one of my mothers-in-law is staying with us, so TrophyHusband has help at home ... and I'm terribly, terribly grateful that this is pretty much the extent of what I have to grumble about.

Wednesday, July 19, 2006

You Can Call Me Doctor If You Want

Orange recently asked me if I ever tell my patients to call me by my first name. The answer is no, never. I don't call them by their first names, either. I call everyone "Ms." or "Mr.," unless they really insist, in which case I avoid saying their name at all. This is the only area of life in which I'm like this; for instance, the only adults I didn't call by first name when I was a child were my teachers, and I find it weird and hilarious when kids call me Ms. DoctorMama (or worse, Mrs. TrophyHusband).

I just feel that if I'm going to be poking and prodding folks in their most intimate places, I better make sure that they know I respect them first. (I do let a couple of old men get away with calling me Miss Firstname, but I still call them Mr. Thrombosis and Mr. Bad-Hip.) I especially dislike it when high SES white people call me by my first name; I feel like saying, Listen, you really don't want me to be your friend, you want me to be your doctor, so let's not muddy the waters, all right? I don't much like it when doctors I don't know personally call me by first name either. It's especially obvious to me when this happens because there are two ways to pronounce my first name, and people who don't know me usually pick the wrong one. Makes me feel like I'm being examined by a telephone solicitor. (I run into trouble with our pediatrician because she's a nurse practitioner; it feels absurd to call her Nurse, but double-standard-ish to call her by her first name.)

Orange says I've got a stick up my ass, but she also calls it "quaintly elegant" and "traditional." What do you think? Are you on a first-name basis with your doctor? Do you think it affects your relationship either way?

Sunday, July 16, 2006

The Cat Came Back!

He waltzed in tonight, looking none the worse for wear, and in fact not even hungry. But he's not talking.

He would be in big trouble, but I'm too relieved to do anything but squeeze him and kiss him.

I hope this isn't a foreshadowing of what it will be like when HellBoy is a teenager and stays out past curfew. "You are in big trouble, young man ... oh, sweetie, I'm so happy to see you, can I fix you something to eat?"

I'm Not the Weepy Type, But

GoodCat is missing, and I've been on the verge of tears all day.

We let the cats go out on the back patio, and they climb around in the no-man's land behind the houses on either side of us, but they've never left the block. I knew when we decided to let them out that we were running the risk of losing one of them, but it made them so happy, and somehow when I imagined one of them going missing, I figured it would be BadCat, which would not be the worst thing in the world from my perspective (he's TrophyHusband's cat, and he has ... issues). But GoodCat is such a sweetheart.

Add to this the fact that a couple we really, really like just got job offers in another state, and that I'm on the rag, and I'm kind of a mess.

GoodCat is the one at the top of this picture:

If you've seen him, let me know.

Monday, July 10, 2006

Dropping Balls

Today I saw a patient I haven't seen in four months. The last time I saw him, I ordered some bloodwork because he has hypertension. And one of the things I discovered in that bloodwork was diabetes. Which is a good catch; hypertension plus diabetes is a deadly combination, and requires careful management.

Problem is, I didn't catch it. I signed off on the bloodwork and had it filed. So he's been walking around untreated for the last four months.

Another confession. Last month, I saw a patient I had been treating for chronic back pain. At his previous visit, I'd started him on a pain reliever we sometimes use when anti-inflammatories aren't cutting it but we're nervous about going to opioids. This medication worked very well for him; he was quite pleased, and wanted a refill.

Problem is, I had overlooked the fact that this patient had a contraindication to starting this medication: a seizure disorder. I don't know how I overlooked this; it's his ONLY OTHER PROBLEM BESIDES BACK PAIN. I nervously asked him, "Have you had any problems with seizures?"

"Funny you should ask," he replied. "I've had two seizures since I saw you last, after not having any for two years."

You might be thinking right now, wow, DoctorMama is one of those BAD doctors. Why should I listen to anything she says? And I sometimes feel that way too.

I can tell you that I graduated with honors from a good medical school and I trained in a top-notch residency program. I got excellent board scores, and I keep up to date. I teach (and learn from) medical students and residents.

None of these things guarantees that I'm a good doctor, of course.

I can tell you that patients like me, and recommend me to their friends and family. No one has ever sued me (yet). I've never killed anyone, or caused them irreparable harm that I know of. My patients' blood pressures and blood sugars are better than the national norm, even though their socioeconomic status is well below average.

None of these things guarantees that I'm a good doctor, either.

And none of these things kept me from making those errors.

I know I don't make a lot of mistakes, and I know that everyone makes some. But I'd rather make none. Yet I don't know how this can be achieved.

Looking at the first case, there is a system meant to keep me from making such errors: abnormal results are flagged with an asterisk on the lab sheet. Thing is, every abnormal result is flagged, even ones that clinically make no difference. I sign off "abnormal" results as normal all the time. The only system that differentiates the abnormals that matter from the ones that don't is my fallible brain.

In the second case—the guy with seizures—there are a couple of places that the contraindication might have been spotted. First is my PDA; I often look up medications on the electronic database, and under this medication it clearly says "caution if seizure history." Thing is, I look up only the medications I'm unsure about or unfamiliar with. Which category does not include this particular medication. I KNOW you have to use caution if there's a seizure history; I just didn't THINK about it at the time. And if I were to look up every single medication I prescribe, I couldn't possibly see the number of patients I do (which isn't all that high to begin with). The second place this mistake could have been caught is at the pharmacy; the computer there might have flagged this medication as a problem, given that the patient was also filling prescriptions for anticonvulsants. And perhaps it did, but you've seen the printouts from pharmacies—they're pages long, and include every possible contraindication and side effect. Who can take those seriously?

The patients themselves could have helped prevent these mistakes. The first patient never called to ask about his results; if he had, it would likely have prodded me to take extra care when signing off—though again, no guarantee—and the second patient could have asked if the new medication would interfere with his seizure medicine. But neither patient is the type to do that, and besides, that's not their job. It's my job.

Bottom line is, I dropped the ball, twice.

In neither instance did anything terrible happen. The first patient doesn't take his blood pressure medicines, and wasn't very interested when I told him that he has diabetes. (I did tell him that I had missed it on the last bloodwork; he wasn't very interested in that, either.) He may surprise me and do a better job controlling his diabetes than he has controlling his pressure, but a delay of a few months is not going to make a difference anyway. The second patient didn't hurt himself when he had his seizures, and he doesn't drive. (When I told him of my mistake, he was just upset that he couldn't keep taking the pain reliever. I prescribed him opiates.)

Some doctors are resentful of systems designed to keep them from making mistakes (and worse, of patients or family members who question them). I'm not. It's really scary to have someone's health or life depending on my imperfect mind, and I wish I didn't have to fly without a net so much of the time.