Saturday, August 30, 2008

What I Really Think

A couple of weeks ago during office hours, I saw a particular name on a chart, and my heart sank. This is a patient who sucks up an inordinate amount of my time every time she comes in, and to no discernible benefit to anyone. She has severe hypertension, for which she is on medication, and she obsesses about it. She takes her pressure three times a day, documents it each time, and brings the list in to convince me that she doesn’t really need blood pressure medication. Thing is, her numbers don’t even look very good. She doesn’t want to stop her medicine – I’ve told her that she is of course the boss of herself and doesn’t have to take my advice – no, she wants me to tell her to stop.

I sighed heavily to myself, then went into the room. And as I was sitting down to talk to her, she handed this article to me. Uh-oh, I thought, here we go.

My patient had circled one of the statements from the article:
I know that Reader’s Digest recommends bringing in a complete list of all your symptoms, but every time you do, it only reinforces my desire to quit this profession.
And I’m thinking, How am I going to get out of this one? Because I absolutely do feel that way. Then my patient says, “I read that, and I thought, That’s me! I bet that’s what DoctorMama thinks! So you know what? I didn’t bring any notes with me! And I stopped taking my blood pressure all the time – and you know what? I feel so much less stressed!”

And we had a really pleasant visit; she even hugged me on the way out.

Naturally I was curious to read the rest of the article, but I found that while I did agree with some of it, most of it didn’t resonate with me at all.

Here’s some of the things I have to admit I do agree with:
The most unsettling thing for a physician is when the patient doesn’t trust you or believe you.
“Unsettling” is the right word for this (though not necessarily “the most”). It doesn’t make me mad, it doesn’t make me insecure – I just don’t know where to go once I realize that a patient thinks that I’m full of it. Usually I just back off and say, “I can only tell you what I recommend; what you decide is up to you.”
It saddens me that my lifelong enjoyment and enthusiasm for medicine has all but died. I have watched reimbursement shrink, while overhead has more than doubled. I’ve been forced to take on more patients. I work 12- to 14-hour days and come in on weekends. It’s still the most amazing job in the world, but I am exhausted all the time.
At least a third of what doctors decide is fairly arbitrary.
Absolutely. But I usually let patients know this right up front.
Most of us haven’t been to see our own physicians in five years.
Quite true, but not just because we don’t practice what we preach. People mostly shouldn’t go to doctors as often as they do. I never lecture a patient who is essentially healthy about not coming in more often. Every visit is an opportunity for iatrogenesis, really. And most screening is overrated. Doctors screen folks a lot more often than the data say they should, partly to avoid having to argue about it and partly to avoid being sued for it.
In many ways, doctors are held to an unrealistic standard. We are never, ever allowed to make a mistake. I don’t know anybody who can live that way.
Sometimes it’s easier for a doctor to write a prescription for a medicine than to explain why the patient doesn’t need it.
Kind of true, but not stated correctly. What it should say is, Sometimes it’s easier for a doctor to write a prescription for a medicine that won’t work than to explain why it won’t.

Some of the statements seemed neither here nor there to me – such as:
Those so-called free medication samples of the newest and most expensive drugs may not be the best or safest.
Well, duh – I hope that most doctors are telling their patients this!
In many hospitals, the length of the white coat is related to the length of training. Medical students wear the shortest coats.
This is not a secret, is it? Medical students identify themselves as such, in my experience.

But most of the stuff in the article I could not relate to at all. For instance:
Not a day goes by when I don’t think about the potential for being sued. It makes me give patients a lot of unnecessary tests that are potentially harmful, just so I don’t miss an injury or problem that comes back to haunt me in the form of a lawsuit.
I would say the potential for being sued crosses my mind maybe twice a month, max. I long ago realized that the thing you get sued for is never the thing that you would have avoided had you been thinking about being sued.
It’s pretty common for doctors to talk about their patients and make judgments, particularly about their appearance.
No, not particularly about their appearance – about their personalities, yes.
In most branches of medicine, we deal more commonly with old people. So we become much more enthusiastic when a young person comes along. We have more in common with and are more attracted to him or her. Doctors have a limited amount of time, so the younger and more attractive you are, the more likely you are to get more of our time.
I feel almost the exact opposite. I am much more impatient with and bored by people who seem a lot like me. I love the crazy old coots – I could talk to them all day. (And “attracted to”? Um, eww.)
Doctors are only interested in whether they are inconvenienced—most don’t care if you have to wait for them.
What an awful view of the rest of the world this person must have. This is far, far from the truth in my experience.
When a doctor tells you to lose 15 to 20 pounds, what he really means is you need to lose 50.
Huh? Why would you do this? I don’t tend to talk in absolute numbers anyway, because a healthy weight for one person is different from that for another of the same height, but if a patient asks me how much they should lose to improve their health, I’ll give them an honest estimation.
Ninety-four percent of doctors take gifts from drug companies, even though research has shown that these gifts bias our clinical decision making.
Doctors often make patients wait while they listen to sales pitches from drug reps.
Long ago I took the No Free Lunch Pledge, and I’ve stuck to it. I don’t take stuff, and I don’t talk to drug reps. I made this decision when I realized that everyone thinks they’re the one who isn’t influenced by such things, and yet studies show everyone is. Why should I think I’m special?

Overall I think the article probably caused more harm than good. But maybe it will inspire a few more doctors to take the pledge. And I’m sure glad my patient read it.

P.S. Now that you know what I really think, you can go here for a (flattering) idea of what I’m really like.

Sunday, August 17, 2008

Maggot FAQs (& a Few InFAQs)

Department of Motivation/Inspiration

Q: Will I get better/faster? WHEN? I know you know the answer, don’t pretend you don’t!!! How not to get discouraged?
(Slowpoke) and How do you push past the three mile slump? (mrsssg)

A: One run out of the week (only one!), push yourself, either faster or farther—but NOT both, never both. You might try one run a week with someone else who’s a little bit faster than you are. You’ll feel like you’re dying, and it’ll be embarrassing, but the next run you do on your own will seem easier. You might “bonk” or “hit the wall,” and you must not feel defeated by this. A bad run is better than no run, and some days just don’t work out.

As for WHEN … if you are running slowly enough, you will be vastly better within six months. If you keep running too fast and doing each run like a wind sprint, you might never get better.

As for not getting discouraged, just keep reading the success stories here! (This just in: a picture of Victoria in the maggot shirt she won for most inspiring story. Doesn’t she look fantastic?)

Q: Any tips for treadmill running to make it, well, not suck? (Julie)

A: Aside from varying the speed/incline and watching TV, the one interesting tip I’ve heard is to try running some intervals BACKWARDS. I’ve never tried the latter, so do it at your own risk (and maybe take some video footage, please?). (Julie’s a little busy at the moment and probably not reading this, but perhaps in a couple months she’ll be back.)

Department of Pain

Q: Any thoughts on plantar fasciitis/heel spurs? (erika)

A: First, know that the heel spur is not the problem, but rather a symptom of the plantar fasciitis—it’s a little bit of extra bone that grows due to chronic inflammation. Special stretches and exercises help a lot, as does running later in the day rather than in the morning.

Q: I have an annoying little pain in the muscles next to my right shin bone. Any good stretches for this muscle? Can it do a lot of damage if I run through it? (mrsssg)

A: These are shin splints, and can be a lot more than an annoying little pain. The advice I got somewhere long ago when I started was that I should expect to get them at some point and to run through them. I did, and I did, and it worked out—BUT everything I read about them suggests not just running through them. Running on a softer surface, maybe better shoes, avoiding hills, and not increasing the amount you’re running all seem like good advice. (Since the standard advice for all pains in runners is “stop running,” and it’s patently ridiculous most of the time—and starting to be disproven—I’m automatically suspicious whenever I hear it.) (Thanks for the link, anonymous!)

Department of Gear

Q: Do you have any favorite online stores for running basics? (Slowpoke)

A: Some places I’ve ordered from more than once and liked every time are the REI Outlet, Campmor, and Running Warehouse; I’ve heard good things about Title Nine but haven’t tried them myself.

Q: What’s your opinion on spendy inserts? good, not necessary, imperative, couldn’t hurt? (blue)

A: Depends. I never used them until this year, when my shoes felt a little too uncushioned. First I tried cheap ones—not good. Then I tried spendy ones, and they do feel good. But good running shoes shouldn’t require extra inserts if your feet are pretty average-shaped (mine aren’t). I’ve heard warnings not to use inserts as a way to try to extend the life of your shoes, and that makes sense to me.

Department of Scatology

Q: I can make it 1 mile before I have to desperately find a bathroom to defile. I’m unsure how to add much distance through potentially bathroom-free territory and there have been times that I’ve had to cut off a run to walk, clenched and desperate, to somewhere that I’ll have trouble showing my face again. (Muddy)

A: I think long ago Denise had this question, and I was flummoxed. I still am, but I think this is what I’d do: run my first mile in a little loop back to my house, then continue my run from there. Also, try stripping all milk products from your diet, as lactose intolerance can present this way. Finally, relax about the showing your face thing. Everybody shits, and everybody’s shit stinks. Look at it this way: you’re making people feel less embarrassed about themselves!

Q: I find that I can’t poop unless I run, and I find that it takes longer and longer for running to work its magic. This is how I become literally addicted to running. And like a drug, it takes more and more to get the job done. I ran 4 miles last night and my intestines just laughed. (also Muddy)

A: Muddy, you do have some issues, don’t you? It sounds like you’re an IBS sufferer, and that’s a pretty tricky problem overall. The general advice I give my patients is to quit eating any simple carbohydrates (they plug you up), quit dairy as above, and find a daily dose of good old-fashioned Milk of Magnesia that works for you.

Q: When I run I get really itchy in areas it isn’t polite to scratch publicly. I’m assuming this is because of sweat, but whatever the reason I end up with a red butt from my attempts to ease the itchiness. Any ideas? (mdt)

A: Well, I just go ahead and scratch, but I know I’m less than couth sometimes, and I could see how this might get annoying if the itch kept up. Are you wearing underwear when you run? If so, take them off (but put your shorts back on, please). Next, try some toe-vagina-butt cream—maybe you’re a little yeasty. Third, try some powder—I love Lush’s Silky Underwear.

Q: My mother-in-law insists that running is bad for the PC muscle. Is there any validity to this claim? Please put this nagging fear to rest! (Allison)

A: No. No validity. You must already know that your mother-in-law is nuts anyway, right?

Q: Is it true that women who have had children have to pee more often, or does it just seem that way? I ran a half marathon and I swear I must have stopped at 6-8 port-a-potties. Also, I just got back from a week of camping and it seemed like no matter how many times I tried to empty the bladder before getting in the tent, I always had a 2 a.m. nature call. It was worse right after I had my daughter, when I finished a 5K by truly wetting my pants. What can be done, if anything?

A: Like this question, the answer is a three-parter.
  1. As women get older, they can have more trouble holding in their urine. This is only slightly more common with women who have borne children than those who have not (except for the unfortunate few with really nasty tears). But this is a basic muscle-strength issue, and no matter how old you are, you can get your muscles really strong if you work at it. Here’s a tip: Kegel while you run. Not the whole time (now that would be a challenge!) but every now and then.
  2. Having to get up to pee in the middle of the night is not a muscle problem, it’s a drinking too much problem. Just as with little kids who wet their beds, restricting liquid past a certain time can magically fix the problem. (A lot of people just naturally wake up in the night and then assume they have to pee, too.)
  3. Having to pee a lot while you’re running can be due to #1 or #2. Are you peeing a huge amount when you go? If so, you’re overhydrating—try drinking fluids until an hour before you run, then stop completely, then pee just before you go. Are you peeing a tiny amount? Then you may need more Kegeling.
Department of Postpartum Affairs

Q: Any post c-section running advice? (Jacq)

A: Just don’t be afraid. You won’t split open like an overripe watermelon, I promise. Follow the Slow Down rule, and you’ll be fine.

Q: Advice on a good running bra for a nursing mom? My chest is currently enormous so good support is a must but little one is still nursing enough that easy access is essential. (amy)

A: Anything with a front closure (zip or hook)—I’ll put another plug in for the Last Resort bra, because women with racks seem to adore it, and I adore the name.

Q: I’m afraid I have some kind of prolapse—I feel like something’s coming out “down there” when I run. (Rebecca)

A: This is a peculiar thing that happens postpartum, and it’s most likely due to the vaginal dryness when you’re in the non-ovulatory state. You can actually feel the rubbing together of the walls when you run, and it’s freaky. But it’s not prolapse, and it’s not dangerous.

Department of Weather

Q: Any advice on running in the heat? (Other than, “Wait until 7:30 when it’s only 85 degrees, dumbass.”) (anon)

A: Shaded paths (with company if it’s a sketchy area). Also, slow acclimation. Some of the best distance runners in the world come from the hottest parts of Africa, you know.

Tuesday, August 05, 2008

At Least I Floss Daily

My blogger meet-up the other week was terrific, which was no surprise to me, since every blogger I’ve ever liked on screen and had the chance to meet I’ve also liked in person. The only thing that has ever startled me is that many of them are much taller than I thought, since that’s one thing you can’t tell from pictures. For some reason I expect everyone to be kind of shrimpy like me.

For those of you who have had the opportunity to link up with a favorite blogger, have they been the same in person as they appeared to you on screen? (I don’t think you can count brief meetings at events like BlogHer, but I wouldn’t know for sure since I’ve never been.)

I will be testing my 100% record soon, because through happy chance, I have a quick trip that will take me near the lair of E of Oral Hygiene Queen, whom I have been wanting to meet for years. My only worry is that she will find my dentition lacking, and I think it’s too late to get my teeth capped. She can probably spot caps a mile away anyway.

Saturday, August 02, 2008

Feets, Don't Fail Me Now

I recently received this query from a friend:
My feet are trashed—ingrown toenails, blisters, corns, bunions. I fear they will end my running career. Any advice?
This made me realize: I forgot to tell you folks about feet! This is a gross oversight on my part.

This is what I told her:
Yes, running can trash the feet if you’re not careful. I can pretty much guarantee that your shoes suck and are too small, and you need new ones NOW. Your shoes should not be rubbing on your toenails or your corns.

Then, you have to become annoyingly fastidious about foot grooming. Meaning, getting a callous cutter (the scary ones with the razor blade insert) and using it aggressively a couple of times a week, and using corn remover pads for incipient corns. Then, get toe-vagina-butt cream (aka vaginal yeast cream, the cheapest way to get antifungal stuff over the counter, excellent for diaper rash too) and rub your feet with it daily to decrease fungus growth.

Finally, get these socks; they have 2 layers, which cuts way down on the blistering.
Less than 48 hours later came her reply:
I just got new shoes a half size bigger and about twice as expensive
and am IN HEAVEN.
So Maggots, watch out for your feets, please.

(There are new links to t-shirts on the sidebar, fyi.)