More Medical Myths

More medical myths I wish I could put down forever:

1. Drinking lots of water is good for you. NOT TRUE. (Yes, this is a repeat from my last medical myths post, but it seems to be the one people are most skeptical about, so I think it bears repeating. I'm not lying, y'all.) This myth probably started because of a misunderstood study long ago that the average amount of water a person uses for the business of existing for 24 hours is equal to about 8 eight-ounce glasses of water. The misunderstanding is that this is not EXTRA water; it's the water that already exists in all the foods and beverages (including caffeinated ones!) a person takes in during the day. Thirst is actually a wonderful mechanism for telling you how much water you need. Extra water does not benefit you. It doesn't help constipation, it doesn't help your skin, it doesn't benefit your kidneys (unless you have kidney stones), it doesn't help you exercise. Perhaps it helps some people avoid eating and drinking a lot of fattening junk, but this is questionable. What it DOES do is make you pee constantly, and in some instances can actually kill you. The water myth is reprinted in every issue of every health and beauty magazine published, so I have little hope of it dying.
   
   
2. Bedrest prevents preterm births. NOT TRUE. I know that it seems to make sense—it must help to "rest," right? And if you stand up, the baby might just fall out!—but studies have shown that it's useless. So why does nearly every OB in the country keep recommending it? Well, think about it. What if they didn't recommend it, and a baby is born prematurely? Yeah, they could be sued, but also, they'd feel awful. If they prescribe bedrest and the baby is born prematurely anyway, everybody says, "well, at least they did everything they could." And what you'll often hear is, "it may not help, but it can't hurt"—a saying that really lights my fuse. In fact, it can be harmful—scratch that: it almost always IS harmful. Maybe only slightly harmful, in that the mother becomes physically deconditioned and has a harder time with delivery and postpartum recovery, and in that the mother gets put out of work earlier than she may have wanted, but sometimes very harmful. I'll give you an illustrative anecdote: a woman who works in my institution as a secretary has preterm labor at twenty-some weeks, and was put on strict bedrest. Weeks and weeks. She nearly went crazy, but even worse, she developed a blood clot from inactivity. So she had to go on blood thinners to prevent her from dying from a blood clot to her lungs. And then had a terrible GI bleed from being on blood thinners and had to have a transfusion. So bedrest almost killed her TWICE. But did she even think about suing the doctors who prescribed bedrest? Of course not, because she believed that she had to do all of this for the baby's sake, and the baby was born healthy.
   
   I think the bedrest myth is also harmful in that it adds to the fear that women of childbearing age might be a liability in the workforce. There's a doctor in my institution who is on her third month of bedrest, and the burden on her department is substantial. I wouldn't be surprised if they hesitate to hire the next 30-year-old woman who applies for a position. But god forbid a pregnant woman has any problems and DOESN'T go on bedrest. Oh, the guilt! I had preterm contractions (rather than true preterm labor, in which there are cervical changes), which has not really been shown to predict early delivery, but there are plenty of women who are guilted into bedrest for even this condition, and people tried it on me—"Don't you realize that your baby is more important than your job?" (Part of the whole infuriating pregnant-woman-as-vessel thing.) I was fortunate to have a super-smart OB who is also my good friend, so I had someone backing me up in refusing to be put to pasture, but few women are this lucky.
   
   I think that the biggest obstacle to making people stop putting women on bedrest is that almost nothing has been shown to be effective in the long term to prevent threatened preterm delivery, and until there's something that CAN be done, it's very hard to get people to stop doing things that don't work. (There was a recent meta-analysis that old-fashioned progesterone might be helpful—keep your fingers crossed.)
   
   
3. Taking lots of vitamins is good for you. NOT TRUE. Taking a regular multivitamin probably isn't a bad idea, but in most studies, high doses of vitamins have been shown to be either useless or harmful. (The studies that show possible benefits get lots of press; the later ones debunking them, very little.) Fat-soluble vitamins (A, D, and E) can build up in your tissues, causing hypervitaminosis. Water-soluble vitamins (the B vitamins and C) are generally excreted by your body if they're not needed, though they'll turn your pee nearly fluorescent. Folate (vitamin B9) helps prevent neural tube defects in embryos, but it's added to all grain products these days, so deficiency is much more rare than it used to be.
   
   
4. Refined sugar is worse for you than honey. NOT TRUE. Sweet things in excess are bad for you, whether their sweetness comes from refined sugar, raw sugar, honey, fruit, high-fructose corn syrup, or whatever else is invented next. (I'm reserving judgment on artificial sweeteners for now, but kicking the sweet habit altogether is probably better than relying on these.) What do I mean by "in excess"? I can't describe it, but I know it when I see it. Or eat it.
   
   
5. If something is herbal/all natural, it's safe. NOT TRUE. For all its faults, the FDA does do a fairly good job of ensuring that drugs that enter the marketplace are reasonably safe and effective. But the FDA is powerless over "nutritional supplements" and herbal medications. It's not that herbal remedies are necessarily useless; several prescription medications have been developed from herbs, in fact. It's that they are almost entirely unregulated. There is no guarantee that what is printed on the side of a bottle of, say, milk thistle is a true representation of what lies within, and plenty of evidence that it is often a gross misrepresentation. There are some real rip-offs out there. And some herbs are powerful poisons.
   
   Somehow people started believing that doctors can't be trusted when we warn against natural remedies because we're biased against them. I'm not sure why we would be; we recommend plenty of things that don't require a prescription: a good diet, exercise, good sleep habits, quitting smoking. All of these things are all-natural and patient-initiated. And we'd love it if someone found a miracle cure for, well, anything, regardless of whether it required a prescription. I don't mind if a patient wants to try something herbal (in fact, I'll admit it, I'm happy if they get a placebo effect), as long as it's reasonably safe and not expensive. I just don't want my patients shelling out lots of money for anything that is useless and/or harmful.
   
   

(I know I'm coming off as anti-granola, and honestly, I'm not; I'm probably crunchier than most people think.) (Though granola can have a surprisingly high sugar and saturated fat content ...)

Any more myths you'd like to have debunked?

Running Q & A

Culled from the maggot files:

Q: I heard that you have to get expensive shoes fitted by a running professional or else you’ll end up with an injury.

A: This is only true if you are a fancy-schmancy, very high-mileage runner (in which case you don’t need this whole Q&A section, so why are you even here?). Most of you beginning to intermediate runners without significant orthopedic problems just need to make sure that your shoes:

1. fit you well (usually you’ll require a half-size larger than you wear in regular shoes)
2. are cushy
3. are intended for running
4. feel good when you run rather than when you walk (yes, you must run around when trying them on, preferably not on carpet. Yes, this feels idiotic)

It’s best to go to a real running store if you can, but you don’t need to break the bank. (Unless you’re the type of person who is more likely to actually do something if you’ve dropped a big chunk of change into it, in which case, go ahead, knock yourself out.)

Q: Do I really have to wear a sports bra?

A: Yes, unless you’re a man (and don’t have man-boobs). Yes yes yes. Please get those things under control. Even the Itty-Bitty Titty Committee members will bounce when running. As for the well-endowed, the bounteous thumbscre.ws provides this product plug: “Big-boobed runners: I got one word for y’all: Enell.”

Q: My knee/hip/foot hurts. Can I still run?

A: My rule of thumb is, if the running is either too painful to do OR seems to be making something WORSE, then no, and you might want to see an orthopedist. Otherwise, yes.

Q: My underwear scrunches up into my ass when I'm trying to run.

A: Gotta go commando. No panties for running. They either scrunch, wad, or give you VPL in your running tights.

Q: Why do my shins hurt?

A: Probably from shin splints, a poorly understood but usually temporary and nondangerous condition often seen when increasing mileage. If it’s not too bad, just stop increasing mileage for awhile, make sure your shoes are supportive, and ice your shins after running.

Q: Will running (especially on pavement) give me arthritis or otherwise damage my knees or hips in the long run?

A: No. This is a perennial favorite warning from smug couch potatoes – “you’re just going to ruin your knees!” There has been a lot of research in this area, and even among elite high-mileage runners, the opposite appears to be true. (The biggest risk factor for developing arthritis? Obesity.) It’s hard to link to studies since they’re mostly not open source, but here are a few choice quotes:

... [I]t appears that long-distance running does not increase the risk of osteoarthritis of the knees and hips for healthy people who have no other counterindications for this kind of physical activity. Long-distance running might even have a protective effect against joint degeneration.

The presence of radiographic hip [arthritis] and the progression of radiographic knee [arthritis] was similar for older runners and nonrunners. Lumbar spine bone mineral density remained higher in runners.

Older persons who engage in vigorous running and other aerobic activities have lower mortality and slower development of disability than do members of the general population.

… [O]ur observations suggest that a lifetime of long distance running at mileage levels comparable to those of recreational runners today is not associated with premature osteoarthrosis in the joints of the lower extremities.

498 long-distance runners aged 50 to 72 years were compared with 365 community control subjects to examine associations of repetitive, long-term physical impact (running) with musculoskeletal disability ... Runners had less physical disability than age-matched control subjects and maintained more functional capacity … Runners sought medical services less often, but one third of the visits that they did make were for running-related injuries. … Runners demonstrated better cardiovascular fitness and weighed less. … Musculoskeletal disability appeared to develop with age at a lower rate in runners … than in community control subjects ... These data suggest positive effects of systematic aerobic running activity upon functional aspects of musculoskeletal aging.

Q: Isn’t it bad to exercise where there are a lot of cars and air pollution?

A: If you have a choice, it’s best to run where you’re not taking bong hits from the tailpipe of a diesel bus. And if you have asthma, you may have more trouble on days when the ozone level is high. But overall, it’s still a lot healthier to run in a city than not to run at all. There’s not a lot of research in this area, however.

Q: When can I start running faster/farther than an arthritic sloth?

A: Patience, grasshopper. I mean, maggot. Running slowly is fantastic for your health; running faster adds very little to this. Almost everyone errs on the side of increasing too quickly, and then you're in trouble. If you must have numbers: once you're spending your whole 30 minutes running, wait a couple of weeks, and then you can start going EITHER 10% farther per week (not per run) or 3% faster per run (I can't do that math without hurting my brain, but if you're a numbers junkie, I suppose you won't mind).

Just Peeve

A weekend on call—64 straight hours of being at the mercy of any Nervous Nellie, Suspicious Sam, or Crotchety Carrie who insists on speaking to The Doctor—often leaves me feeling a bit … peevish.

So it was today that I got to musing on a few of my pet peeves.

I’m a live-and-let-live kind of person in general. Really. I notice when something is done wrong, but I don’t get worked up over it. Ok, sure, it bugs me when someone says “for you and I,” and I wish I could get people to believe that they don’t need to drink so much water. But as long as the only person who suffers the consequence of a mistake is the person who makes the mistake, I don’t much care.

It certainly distresses me when someone does something wrong that affects others. Littering, for example, or talking in a movie theater. But to really peeve me, a mistake has to not only mess things up for the rest of us, it has to require real energy on the part of the person making the error. Strenuous misguided labor that results in making things worse for others just chaps my ass. For instance:

Women standing up to pee. This is a silly practice. You really can’t catch anything from resting your thighs on a toilet seat. And it’s hard to do; it requires balance, strength, and concentration to avoid peeing on your own shoes. But why should I care if someone wants to get a mini quad workout in the restroom? Because it messes things up for the rest of us. Women can’t pee without splattering. Not necessarily a lot, but enough to baptize the toilet seat with a few stray droplets and cause an unpleasant splashing sensation for the next person who tries to sit down. This creates a moist domino effect: the next person is more likely to avoid sitting in the future, causing further splatter, and so on. Please, if it skeeves you out to rest your delicate thighs on a public toilet seat, either take some paper towels in with you to clean up after yourself when you’re finished (and remember, don’t flush them—just tuck them in the tampon box), or get one of these.

Using a car’s side mirrors as extra rear-view mirrors. The mirrors on the sides of the car are meant to reveal what’s in your blind spots. If you adjust them to show the back of your car, you are wasting your time, but worse, you are making it more likely that you will not be able to see the rest of us, and you may hit us. These are some good descriptions of how to properly position the side mirrors.

Installing Jacuzzi tubs in every frickin’ rehab and new construction in the country. Jacuzzis are stupid. I know of hardly anyone who actually uses theirs more than once a year. Jacuzzis are noisy, they take forever to fill, they use up all the hot water in the house, and they’re hard to clean. They take up a lot of space and cost a lot of money as well. But who do Jacuzzis really hurt? Well, anyone who wants to have a new bathroom with a real bathtub; it takes a lot of money to tear one out. But the Jacuzzi craze really hurts everyone, because they take twice the amount of hot water to fill one compared to a real bathtub, and they have motors. The amount of energy wasted on these dumb contraptions is outrageous.

What am I forgetting? Where have you noticed people striving mightily to do something completely idiotic and harmful? (Mentioning Hummers is too easy—that’s shooting ducks in a barrel. Dead ducks.)

A Fool for a Patient

This is a combination stupid patient story/stupid doctor story.

It’s a good thing I don’t believe in divine retribution for selfishness, because if I did, I’d never take a personal day again. Yesterday I woke up with, in addition to a lingering (though lower) fever and progressive rash, an unbelievably bad headache. TrophyHusband wrangled HellBoy while I lay in bed with a washcloth on my eyes and an icepack on my head. I finally somehow got myself up and into work, where I had to see patients in the morning. I got through each visit trying to move as little as possible (“You say you’ve got a gigantic wound on your foot with things crawling out of it? OK, I believe you — no need to take a look!”) Finally one of my partners noticed that my rash was creeping up my neck and down to my feet and that I looked like I was about to die. She took the rest of my patients for me and sent me home. I took my migraine med, but it didn't work, and I pondered whether to go to the ER just to get SOMETHING to make the pain stop. When I lay still, it felt like there were big shards of plate glass sticking into the top of my head; when I moved, it felt like someone was whacking the shards with a broomstick.

When TH got home and found me taking nap #4 on the living room floor, he said, "Um, you have meningitis, you dope." (He didn't really call me a dope, but it was in his tone.) And I was like, oh, right — fever, rash, blinding headache, and I CAN'T BEND MY NECK, duh.

It seemed pretty clear from the history that this was a viral meningitis, not bacterial, so I didn't want to go wait at the ER for a spinal tap to be told the same thing, but he did consult with an ID colleague to double-check that he didn’t need to hogtie me and drag me there. Then I doped myself up with every pain-reducing, nausea-relieving, and consciousness-altering (legal) medicine in the house and fell into a blessed sleep. Today the pain is MUCH better, and I can stand to look at a computer screen without shrieking "The light! The light! Make it stop!" But I still can’t look left without a stabbing pain in my eyeballs. Too bad I’m not a Republican.

The Verdict: Not Guilty

Wow, there are some mighty guilty folks out there. Reading the comments on my last post really helped, and I think I am developing a mantra collection:

• My first reaction: Good grief, you people should not be feeling so guilty! Which led me to: hmmm … maybe I shouldn’t either? So I like Ozma’s “compassion” mantra.
• Reading about all these ridiculous things others feel guilty about makes me realize that there are a lot of things I could feel guilty about, but don’t. Daycare, for instance. I know that this is the best choice for us, and I don’t sweat it … so maybe another mantra I can use when I’m feeling guilt-ridden is “It’s no different from daycare!”
• I realize I have a fear that if I’m not feeling guilty, then I’m being a bitch (as Orange brought up). New mantra: “Embrace your inner Bitch.” (Not that feeling guilty is the opposite of being a bitch. But it’s hard to imagine a guilty bitch.) (Though Orange, I think you should feel guilty about misspelling “wracked.”)
• A mantra that is a paraphrase of what Artemis said: “I’ve been wearing guilt like underwear, and it’s time to go commando!”
• Virginia’s mantra (“At least I'm not Bush, At least I'm not Bush”), while certainly true and quite funny, is almost too extreme for the circumstances. Perhaps “At least I’m not Britney”?
• NotMisery’s point that feeling guilty is a choice speaks to me. I’m all about making conscious choices to feel a certain way: I choose to be happy rather than sad (when I’m on the right meds, that is); I choose to be cheerful rather than bitter; I choose to be grateful rather than whiny (usually). I can certainly try choosing to not feel guilty. (I’m having trouble coming up with the opposite of guilty again, though. Innocent? No. Bitchy? Sort of. Well-meaning? Wishy-washy. Peaceful? Eh.)
  
• I like Ariella’s question, "What does this guilt really MEAN?" I think in some circumstances that could work as a mantra.
  
• Kungfukitten’s wand-waving and ass-shaking, though not a mantra, is a cheering mental image.

And so far, it’s working. I spent the first part of this past week visiting my parents. We got back Thursday, but I had scheduled Friday off from work as well. I had a brief thought that perhaps I should go in anyway, but armed with my new mantras, I resisted. Instead, I dropped HellBoy off at daycare, then went back home, ate ice cream for breakfast, gave myself a pedicure, read some blogs, ate peanut butter and ice cream for lunch, cleaned out my car, washed the shower curtain (I know those last two sound like chores, but they thrilled me), went out and had second lunch at a café, then bought myself new running shoes. Then I went to another café and read more blogs, while my in-laws picked HellBoy up from daycare. When I got home, I had them take him off to the park while I went out in the glorious weather and broke in my new shoes. All with nary a guilty twinge. Not bad, eh?

Today I came down with a virus that’s been going around — high fever and a weird rash — but I refuse to believe that this is punishment for my self-centered, guilt-free day. (I am deeply grateful that I was raised as a heathen rather than Catholic or Jewish or Southern Baptist.)

Guilty or Not Guilty?

I lived much of my life relatively guilt-free. I don't mean remorseless; I mean free of unproductive self-flagellation about choices I've made. I sort of assumed it was a combination of nurture and nature; my mother was never a guilt-tripper, and I was naturally fairly obedient to my super ego. I felt bad if I did something wrong, sure, but if I'd made the best of whatever situation I faced, I didn't beat myself up over things.

Then I gave birth. The instant HellBoy was laid across my stomach, looking bluish and stunned, a tidal wave of guilt crashed over my head. I wasn't good enough at giving birth; it had taken too long; I might have hurt my baby!

The guilty feelings continued sloshing around for weeks. I was starving him because I insisted on breastfeeding; I was going to roll over on him in my sleep because I selfishly wanted him in the bed with me; and on and on. Gradually, thank heavens, the tide receded a bit, and I was able to gain some perspective. But I never went back to my blessed pre-baby guilt-free state.

Lately I've been suffering from it a LOT. I feel guilty about going running when my son wants me to play with him. I feel guilty about NOT running when I've blogged about how frickin' important it is. I feel guilty about blogging instead of working. I feel guilty about not blogging. I feel guilty about snapping at my husband when I'm too tired to see straight. I feel guilty about driving to work and polluting the environment. I feel guilty about air conditioning. I feel guilty about not wanting to hear about the conflict in the Middle East. I feel guilty about saying it's not too hot to run and then watching the thermometer go into the triple digits.

It's as if all my years of not feeling guilty left me peculiarly impaired for handling it now.

I need some sort of method for dealing with this before it drives me crazy. A mantra or something.

What do you feel guilty about? And how do you handle it?

Query Awards

From today’s Keyword Analysis, brought to you by the Commission for Lazy Blogging:

Easiest query to answer:

5 things mates needed for a good marriage

Answer:
1. A good husband
2. A good husband
3. A good husband
4. A good husband
5. A good husband

Most masochistic query:

i just started running i am so sore is it ok to keep running

Answer: Heh heh heh. Yes. (But SLOWLY.)

Most rhetorical query:

toddler sleep problems

Answer: Ha ha ha.

Query displaying the most hopeless optimism:

typical routine three month baby

Answer: HA HA HA.

Query that most stumped me on initial viewing:

and one thing i chose to admit, is that your momma momma momma should let me babysit

Answer: A dumb Morningwood song. The correct wording is “and one thing I chose to admit, is that your momma momma momma SHOULDN’T let me babysit.”

Most jittery query:

running away from ritalin dr. knowitall

Answer: Are you SURE you don't need that Ritalin?

Slackingest query:

good doctors excuses

Answer: Go with back pain! They like totally can’t prove you don’t have it!

Best query:

killing maggots on goats

Answer: You have MAGGOTS on your GOATS?

Worst query:

maggots in bra

Answer: AAAGH! (On further research, there is apparently an internet “joke” going around with a disgusting photoshopped picture. Don’t go looking. It’s FAKE. What is the matter with people?)

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.

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.

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?

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.

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.

How's It Going, Maggots?

I got an email today that almost brought a tear to my jaundiced eye:

Subject: Thanks, Sarge!
This running thing, it is addictive. This is the first time in my Krimpet-fueled existence that I have exercised FOR FUN. And, after less than a month, I can already see my body contouring a little bit. It's a slow but very gratifying process; sort of like ordering a car in the mail and having a new piece arrive every few days.

It made me so goddamned proud. And it got me wondering how the rest of you have been doing. Are you remembering to take it S-L-O-W? Especially in this heat.

[Updated to add: and if you want to find out what happens if you don't follow the instructions, look here.]

A few other heat-related tips:

• Go with the wind the first half of the run, so that when you're coming home you have the breeze to help cool you off.
• Remember that drinking too much water isn't good for you. Eat a little something salty (unless you have high blood pressure) and drink a glass of water before you head out, and then have a glass of water when you're done. And sports drinks don't do much for you.
• Think it's too hot to run? Well, it's not. Get your butt out there.
  

I'm With the Band Now

I have to round in the hospital and take calls this weekend. The prospect is making me intensely crabby, so I'm laying low.

HellBoy, however, has been in a great mood ever since I broke down and bought him his one true heart's desire: a GIT-ar.























This thing makes him so happy, it's frightening. What's weird is, he's never seemed like a particularly musical kid. I think he must already know the secret: the guy with the guitar can always get girls, even if he sucks at playing it.