Sunday, October 29, 2006
OK, this little Jeremiad (call it what you will) shows more than a bit frustration and a measure of pique that some readers will find, well, unattractive. I wrote it years ago, and it has not received favorable local reviews, but I stand by the truths therein, and the truth sometimes hurts. So now you know how I really feel.
At least, most of my medical colleagues will likely agree.
Why Your Doctor Doesn't Spend More Time With You
Since the 1970's, when the image of doctors first began to decline, polls of patients have revealed a general perception that doctors cut short their time spent with their customers, to the detriment of patient health. Patients questioned after meeting with their doctors, whether in an office, a clinic, or a hospital room, almost uniformly feel that they were short-shrifted, that the doctor came in and left in a flash. The implication is that the doctor is uncaring, is missing vital information, is greedy.
But the truth is that doctors, like any other professionals, regard patients as jobs, as work to be done, as problems to be solved. Doctors assume, after all, that that is precisely what the patients want--someone to help them in a way they cannot help themselves. So, if the doctor spends enough time with their patients to do their job correctly, isn't that good enough?
Doctors who treat patients have to be able to do three tasks correctly: they have to listen and observe, retrieve and correlate information, and think (i.e.--put it all together logically, figure out the next step). Yes, they also have to perform (procedures), and, these days, to document (a process that often takes as long as all the others combined). And, of course, they have to communicate. It's this final task that is considered lacking in the modern medical doctor.
Why?
First of all, it is not entirely clear that the actual time and effort spent communicating with patients is lacking at all. In a clever study, patients questioned as they left the doctor's office thought the amount of time spent in the encounter with the doctor was much shorter than was actually measured. Other studies have repeatedly shown that patients immediately after leaving the doctors' office recalled less than half of what the doctors actually told them specifically to remember. So, who's to blame here when a patient walks out not knowing what medicine to take when, what the test results mean, where to go next?
I have resigned myself to the fact that many patients cannot grasp as simple a concept as a prescription to take a single pill once a day until they've been told this two or three times on different occasions. In educational psychology, the term is "blocking"; people can be mentally blocked from receiving information or instruction, and no amount of time, repetition, nor visual aids is always going to break through.
The irony, however, is that doctors receive (and often accept) the blame for this phenomenon; the patient never admits that he's simply oblivious. The clinical medical profession has spent enormous effort and money trying to solve this dilemma, so far to no avail. There are courses in how to communicate, training exercises, patient-education materials galore in every media, but nothing seems to help. It is a universal, cross-cultural phenomenon, not even restricted to the prima donna American patients. It's probably unsolvable.
When a doctor perceives that the patient just doesn't get it, the doctor is best advised to make sure the patient is made no worse by whichever course is taken, schedule another visit or punt the patient along to another doc, and move on to the next patient.
Furthermore, it is only important to do all this communicating, to empower the patient with information, if it makes a difference in the patient's health, isn't it? After all, (real) doctors are a poor choice for just entertainment. There has to be a reason for doctors to spend more time talking with their patients (and families), a provable difference in health outcome.
Certainly a doctor who spends less time visiting and more time studying the medical facts may be a better choice when it comes down to critical health problems.
Why do we long for the halcyon days when a doctor stayed at the bedside for hours and held the patients' hand?
Why do we value the alternative health professionals who are pleasantly chatty while providing scientifically worthless "treatment"?
Why do we regard a doctor who analyzes and decides quickly as callous, while a deliberate, unhurried doctor must be caring and compassionate?
What's really important here--the doctor's competence or compatability?
And, no, you can't always have both. Especially when you're very sick, your doctor does not want to spend all his time around you. The truth is no one does, since sickness is unpleasant, but at least your doctor has a vision of your returning to health or greater comfort and can stick with you until you achieve it. That's all you can or should expect. That's what you, through your insurance, pay your doctor for.
Get someone else to provide the comfort, to hold your hand and give you a hug and a "There, there . . ." (If you have no one else, you're really in sorry shape; call in a social worker.) Get your five minutes with the doctor and listen carefully!
If the doctor says, "Hmm!" and walks out without a word, don't worry--you'll be fine.
At least, most of my medical colleagues will likely agree.
Why Your Doctor Doesn't Spend More Time With You
Since the 1970's, when the image of doctors first began to decline, polls of patients have revealed a general perception that doctors cut short their time spent with their customers, to the detriment of patient health. Patients questioned after meeting with their doctors, whether in an office, a clinic, or a hospital room, almost uniformly feel that they were short-shrifted, that the doctor came in and left in a flash. The implication is that the doctor is uncaring, is missing vital information, is greedy.
But the truth is that doctors, like any other professionals, regard patients as jobs, as work to be done, as problems to be solved. Doctors assume, after all, that that is precisely what the patients want--someone to help them in a way they cannot help themselves. So, if the doctor spends enough time with their patients to do their job correctly, isn't that good enough?
Doctors who treat patients have to be able to do three tasks correctly: they have to listen and observe, retrieve and correlate information, and think (i.e.--put it all together logically, figure out the next step). Yes, they also have to perform (procedures), and, these days, to document (a process that often takes as long as all the others combined). And, of course, they have to communicate. It's this final task that is considered lacking in the modern medical doctor.
Why?
First of all, it is not entirely clear that the actual time and effort spent communicating with patients is lacking at all. In a clever study, patients questioned as they left the doctor's office thought the amount of time spent in the encounter with the doctor was much shorter than was actually measured. Other studies have repeatedly shown that patients immediately after leaving the doctors' office recalled less than half of what the doctors actually told them specifically to remember. So, who's to blame here when a patient walks out not knowing what medicine to take when, what the test results mean, where to go next?
I have resigned myself to the fact that many patients cannot grasp as simple a concept as a prescription to take a single pill once a day until they've been told this two or three times on different occasions. In educational psychology, the term is "blocking"; people can be mentally blocked from receiving information or instruction, and no amount of time, repetition, nor visual aids is always going to break through.
The irony, however, is that doctors receive (and often accept) the blame for this phenomenon; the patient never admits that he's simply oblivious. The clinical medical profession has spent enormous effort and money trying to solve this dilemma, so far to no avail. There are courses in how to communicate, training exercises, patient-education materials galore in every media, but nothing seems to help. It is a universal, cross-cultural phenomenon, not even restricted to the prima donna American patients. It's probably unsolvable.
When a doctor perceives that the patient just doesn't get it, the doctor is best advised to make sure the patient is made no worse by whichever course is taken, schedule another visit or punt the patient along to another doc, and move on to the next patient.
Furthermore, it is only important to do all this communicating, to empower the patient with information, if it makes a difference in the patient's health, isn't it? After all, (real) doctors are a poor choice for just entertainment. There has to be a reason for doctors to spend more time talking with their patients (and families), a provable difference in health outcome.
Certainly a doctor who spends less time visiting and more time studying the medical facts may be a better choice when it comes down to critical health problems.
Why do we long for the halcyon days when a doctor stayed at the bedside for hours and held the patients' hand?
Why do we value the alternative health professionals who are pleasantly chatty while providing scientifically worthless "treatment"?
Why do we regard a doctor who analyzes and decides quickly as callous, while a deliberate, unhurried doctor must be caring and compassionate?
What's really important here--the doctor's competence or compatability?
And, no, you can't always have both. Especially when you're very sick, your doctor does not want to spend all his time around you. The truth is no one does, since sickness is unpleasant, but at least your doctor has a vision of your returning to health or greater comfort and can stick with you until you achieve it. That's all you can or should expect. That's what you, through your insurance, pay your doctor for.
Get someone else to provide the comfort, to hold your hand and give you a hug and a "There, there . . ." (If you have no one else, you're really in sorry shape; call in a social worker.) Get your five minutes with the doctor and listen carefully!
If the doctor says, "Hmm!" and walks out without a word, don't worry--you'll be fine.
Monday, October 23, 2006
As the winter season gets into full gear, cold outside air and dry indoor heating make us start to scratch and scratch. This reminds me of an essay I wrote about 10 years ago for BUNK (the unpublished book).
Many, many Americans are walking around with dry itchy skin, for which they constantly seek medical attention.
Aside from those who work in sea water (like Polynesian divers or Hawaiian kayak paddlers you see on National Geographic TV shows), dry skin is entirely unnecessary, and may be the result of a strange advertising campaign aimed at the peculiar obsession with household cleanliness which Europeans imported to the U.S.
Remember that Twentieth Century culture was pervaded by efforts to sell detergent, a sulfhydryl compound of calcium carbonate (lime) which was popularized in the late 1800's as an alternative to soap (a sodium salt of organic fat). A lot of newspapers and electronic media were sold on the basis of advertising detergent, and, indeed, huge corporations developed on the backbone of clean clothes, clean floors, clean toilet bowls, and, ultimately, squeaky clean hair and skin. The cultural culmination of this obsession is the soap opera, a literary genre all its own (metaphorically with dirty intrigues by all sorts of clean-cut characters).
The detergentizing of the human body, however, is a physiologic nightmare for the skin, the largest organ of the body.
Skin is supposed to have a protective layer of sebum, an oily substance, which in turn covers layers of keratinized epithelium--dead superficial skin cells. It is a natural, virtually perfect covering that is flexible, water-proof, sun-screening, temperature-regulating, and attractively shaded. Without the oily covering, the dead cells rapidly deteriorate and flake off, exposing a live layer of quickly-reproducing epithelial cells and the supportive structures, such as blood vessels, fat, strands of muscle, pigmented cells, nerve endings, etc. These cell-layers, with nothing on top of them, will now work over-time to keep out the toxins of the external world, and will, therefore, overgrow with inflammatory cells and substances, taking on the red hue of blood, which looks bad and feels worse.
Once again a penchant for healthy cleanliness, taken too far, creates a health problem. But despite the evidence, advertising goes on and on, with bath soaps compared side by side to see which is more effective in cleaning glass.* Many of these soaps have trade names which conjure up images of nerves on end (Zest, Irish Spring), while others (Coast, Lifebuoy) recall the dried out skin of seafarers. The most ironic name in this class is Shield, which does all it can to destroy the shielding effect of the skin.
The skin of the scalp is oiler than that of the rest of the body, and the hair collects and retains this oil. Therefore, a little detergent in the form of shampoo is useful for the scalp, beard and genital areas (not under the arms, please), but "body shampoo" can be as harmful as detergent soaps. Live skin is not glass, and using a soap which leaves only squeak and no slick is a good way to end up at the doctor's.
* Indeed, the first use of Gamble's Soap was to clean up automobile windshields, a new invention of the late 1800's. A promoter named Proctor bought the patent and marketed the product as a body soap, naming it Ivory and emphasizing its purity as a sure sign that it is good for your health.
It's not.
Dry, Itchy Skin
Many, many Americans are walking around with dry itchy skin, for which they constantly seek medical attention.
Aside from those who work in sea water (like Polynesian divers or Hawaiian kayak paddlers you see on National Geographic TV shows), dry skin is entirely unnecessary, and may be the result of a strange advertising campaign aimed at the peculiar obsession with household cleanliness which Europeans imported to the U.S.
Remember that Twentieth Century culture was pervaded by efforts to sell detergent, a sulfhydryl compound of calcium carbonate (lime) which was popularized in the late 1800's as an alternative to soap (a sodium salt of organic fat). A lot of newspapers and electronic media were sold on the basis of advertising detergent, and, indeed, huge corporations developed on the backbone of clean clothes, clean floors, clean toilet bowls, and, ultimately, squeaky clean hair and skin. The cultural culmination of this obsession is the soap opera, a literary genre all its own (metaphorically with dirty intrigues by all sorts of clean-cut characters).
The detergentizing of the human body, however, is a physiologic nightmare for the skin, the largest organ of the body.
Skin is supposed to have a protective layer of sebum, an oily substance, which in turn covers layers of keratinized epithelium--dead superficial skin cells. It is a natural, virtually perfect covering that is flexible, water-proof, sun-screening, temperature-regulating, and attractively shaded. Without the oily covering, the dead cells rapidly deteriorate and flake off, exposing a live layer of quickly-reproducing epithelial cells and the supportive structures, such as blood vessels, fat, strands of muscle, pigmented cells, nerve endings, etc. These cell-layers, with nothing on top of them, will now work over-time to keep out the toxins of the external world, and will, therefore, overgrow with inflammatory cells and substances, taking on the red hue of blood, which looks bad and feels worse.
Once again a penchant for healthy cleanliness, taken too far, creates a health problem. But despite the evidence, advertising goes on and on, with bath soaps compared side by side to see which is more effective in cleaning glass.* Many of these soaps have trade names which conjure up images of nerves on end (Zest, Irish Spring), while others (Coast, Lifebuoy) recall the dried out skin of seafarers. The most ironic name in this class is Shield, which does all it can to destroy the shielding effect of the skin.
The skin of the scalp is oiler than that of the rest of the body, and the hair collects and retains this oil. Therefore, a little detergent in the form of shampoo is useful for the scalp, beard and genital areas (not under the arms, please), but "body shampoo" can be as harmful as detergent soaps. Live skin is not glass, and using a soap which leaves only squeak and no slick is a good way to end up at the doctor's.
* Indeed, the first use of Gamble's Soap was to clean up automobile windshields, a new invention of the late 1800's. A promoter named Proctor bought the patent and marketed the product as a body soap, naming it Ivory and emphasizing its purity as a sure sign that it is good for your health.
It's not.
Tuesday, October 17, 2006
Settling Your Stomach
Although unpleasant subjects, stomach and intestinal disorders are important to know about.
The sudden onset of cramps, diarrhea, nausea, and vomitting are among the most frequent afflictions in otherwise healthy people. For some reason, however, many people with these symptoms stop listening to their bodies and make the worst mistake possible--namely, they immediately try to put stuff, food and medicine, back into their stomachs.
The impetus for this behavior may well be the plethora of oral (and occasionally rectal) remedies for intestinal maladies, a situation as old as medicine itself. In some cases, it's a fear of dehydration or starvation. In every case it's wrong.
In developed countries, the cause of most acute diarrhea and vomitting is infection of the stomach and intestines by one of two common viruses (Rotavirus and Norwalk agent). Occasionally, it can be caused by bacteria (Salmonella, Shigella, and Campylobacter speces), by parasites (Giardia and others), by food tainted by bacterial growth (Staphylococcal food poisoning, so-called "ptomaine poisoning"), or by conditions of the intestinal tract itself (including chemical gastritis, gall stones, inflammatory bowel disease, appendicitis). In less-developed countries, infections with Typhus and even cholera still occur.
But regardless of the cause, when your body starts expelling the contents of the intestinal tract, it means that your body doesn't "want" what's in there. It's usually best to let your body do its thing--the vomitting and diarrhea slow down or stop as soon as you empty out. To let your mind overrule your body, just because you saw a recent PeptoBismol or Dramamine commercial, is not wise.
An irritable stomach will throw up anything you put in it, and the more you throw up, the more irritated it becomes. An infected or inflamed intestine loses its ability to reabsorb water, and the more you feed it, the less time it has to recover.
There is only one logical step in this situation: DON'T EAT!!
That's all--don't eat, don't even drink.
Ninety percent of patients can cure themselves if they take that first initial step, and the rest will make their condition much easier to manage. If you wonder how long a person can go without eating or drinking, it's likely to be much longer than you think. Certainly no one with a moderate level of activity gets into trouble by fasting for four or five hours, not even children, not even babies.
Most adults can safely avoid eating and drinking for up to twelve hours on a regular basis (remember that Hakeem Alajuwon, a seven-foot-two, three-hundred-pound star basketball player for the Houston Rockets played a championship series while fasting twelve hours daily for the month of Ramadan). Diabetics who check their blood sugar may be surprised to find that they do not get seriously hypoglycemic even with medication "on board." Most of us carry a calorie reserve that will sustain us for two to three days, and enough water in our blood stream for a whole day.
The second and perhaps more crucial step in aiding the recovery of your stomach and intestines is to replenish your water and food loss slowly and with the simplest and easiest-to-digest substances possible. The most readily available substances of this type are what we call clear liquids, i.e.--foods that are already in solution. This includes clear carbonated beverages (e.g.--ginger ale or 7-Up), clear soup broth, Italian ice or Popsicles, and gelatin, Gatorade, as well as a number of commercial products designed specifically to replace lost fluids (Pedialyte, Kao-Lectrolyte, and others).
These all provide water, sugar for energy, and salts which keep the cells functioning properly. They are clear because these simple chemicals are in solution.
If you cannot see through the liquid or food, it contains other substances such as fat (as in milk) or complex carbohyrates (as in oatmeal) or fiber (as in pulpy juice), which your stomach, in this situation, is not ready to tolerate. You start with clear liquids and continue until the nausea or diarrhea stops--usually for twelve to twenty-four hours. Though they are not particularly satisfying, clear liquids can sustain a person for days if necessary.
The next step is to try low-fiber complex carbohydrates--starchy foods such as rice, potatoes, bread, usually for a full day.
After that you can eat any fruits and vegetables, as well as low-fat meats, but no dairy products for another five days; it will take that long for your intestinal tract to tolerate lactose, the main sugar in most milk products. Even people who digest lactose can have a temporary lactose intolerance after a viral infection or some other assault on the intestinal tract, and drinking milk is the worse thing one can do in that situation.
If you respond to an episode of gastroenteritis by wolfing a ham-and-cheese sandwich and washing it down with a glass of milk, you're doomed to five more days of misery. Just rest your gut for a few hours, gently replace the water and salts with clear liquids, start foods gradually and stay away from milk--and you're better in no time.
Although unpleasant subjects, stomach and intestinal disorders are important to know about.
The sudden onset of cramps, diarrhea, nausea, and vomitting are among the most frequent afflictions in otherwise healthy people. For some reason, however, many people with these symptoms stop listening to their bodies and make the worst mistake possible--namely, they immediately try to put stuff, food and medicine, back into their stomachs.
The impetus for this behavior may well be the plethora of oral (and occasionally rectal) remedies for intestinal maladies, a situation as old as medicine itself. In some cases, it's a fear of dehydration or starvation. In every case it's wrong.
In developed countries, the cause of most acute diarrhea and vomitting is infection of the stomach and intestines by one of two common viruses (Rotavirus and Norwalk agent). Occasionally, it can be caused by bacteria (Salmonella, Shigella, and Campylobacter speces), by parasites (Giardia and others), by food tainted by bacterial growth (Staphylococcal food poisoning, so-called "ptomaine poisoning"), or by conditions of the intestinal tract itself (including chemical gastritis, gall stones, inflammatory bowel disease, appendicitis). In less-developed countries, infections with Typhus and even cholera still occur.
But regardless of the cause, when your body starts expelling the contents of the intestinal tract, it means that your body doesn't "want" what's in there. It's usually best to let your body do its thing--the vomitting and diarrhea slow down or stop as soon as you empty out. To let your mind overrule your body, just because you saw a recent PeptoBismol or Dramamine commercial, is not wise.
An irritable stomach will throw up anything you put in it, and the more you throw up, the more irritated it becomes. An infected or inflamed intestine loses its ability to reabsorb water, and the more you feed it, the less time it has to recover.
There is only one logical step in this situation: DON'T EAT!!
That's all--don't eat, don't even drink.
Ninety percent of patients can cure themselves if they take that first initial step, and the rest will make their condition much easier to manage. If you wonder how long a person can go without eating or drinking, it's likely to be much longer than you think. Certainly no one with a moderate level of activity gets into trouble by fasting for four or five hours, not even children, not even babies.
Most adults can safely avoid eating and drinking for up to twelve hours on a regular basis (remember that Hakeem Alajuwon, a seven-foot-two, three-hundred-pound star basketball player for the Houston Rockets played a championship series while fasting twelve hours daily for the month of Ramadan). Diabetics who check their blood sugar may be surprised to find that they do not get seriously hypoglycemic even with medication "on board." Most of us carry a calorie reserve that will sustain us for two to three days, and enough water in our blood stream for a whole day.
The second and perhaps more crucial step in aiding the recovery of your stomach and intestines is to replenish your water and food loss slowly and with the simplest and easiest-to-digest substances possible. The most readily available substances of this type are what we call clear liquids, i.e.--foods that are already in solution. This includes clear carbonated beverages (e.g.--ginger ale or 7-Up), clear soup broth, Italian ice or Popsicles, and gelatin, Gatorade, as well as a number of commercial products designed specifically to replace lost fluids (Pedialyte, Kao-Lectrolyte, and others).
These all provide water, sugar for energy, and salts which keep the cells functioning properly. They are clear because these simple chemicals are in solution.
If you cannot see through the liquid or food, it contains other substances such as fat (as in milk) or complex carbohyrates (as in oatmeal) or fiber (as in pulpy juice), which your stomach, in this situation, is not ready to tolerate. You start with clear liquids and continue until the nausea or diarrhea stops--usually for twelve to twenty-four hours. Though they are not particularly satisfying, clear liquids can sustain a person for days if necessary.
The next step is to try low-fiber complex carbohydrates--starchy foods such as rice, potatoes, bread, usually for a full day.
After that you can eat any fruits and vegetables, as well as low-fat meats, but no dairy products for another five days; it will take that long for your intestinal tract to tolerate lactose, the main sugar in most milk products. Even people who digest lactose can have a temporary lactose intolerance after a viral infection or some other assault on the intestinal tract, and drinking milk is the worse thing one can do in that situation.
If you respond to an episode of gastroenteritis by wolfing a ham-and-cheese sandwich and washing it down with a glass of milk, you're doomed to five more days of misery. Just rest your gut for a few hours, gently replace the water and salts with clear liquids, start foods gradually and stay away from milk--and you're better in no time.
Welcome to Bunk!
It's time to get this blog rolling.
My primary goal here is to inform readers (including, but not limited to, some of my own patients) about the perils of following many common practices and ideas about health care. These essays have been culled from innumerable in-office lectures I have given patients in over 25 years of practicing family medicine.
Forgive me if the style seems a little acerbic and supercilious, but, hey, that's how we doctors are when we are passionate about being right.
And I am right. You may disagree with what I say, but then you'll be wrong. (Go ahead -- dare you to comment!)
These subjects are not always about the glamorous leading-edge, high-tech areas of Modern Medicine. But they are about important aspects of living: the way we bathe, the clothes we wear, how we respond to the most common illnesses, the way we make love.
And how we interact with doctors and other HCP's (health care professionals). For that part, I am always in learning mode and invite stories, comments, and questions.
This is not an Owner's Manual. I'm not out to teach you everything about the body (especially since there is a lot we don't yet know), but more to stimulate your mind to question how and why your body suffers from what you think you're doing to help it. Hopefully, you'll learn something, explain it to another, and we'll all become a healthier society.
BUNK -- Myths, Mistakes, and Misinformation that can be harmful to your health -- will discuss specific health care topics.
A future blog (BALONEY -- Don't Believe All You Hear About Modern Medical Science) will tackle Big Pharmaceuticals, health care insurance, and self-promoting "research."
And hopefully, we'll sample from BULL -- The Hype about the "Best" Doctors and Hospitals, which will be something of a guide for medical service consumers.
It's time to get this blog rolling.
My primary goal here is to inform readers (including, but not limited to, some of my own patients) about the perils of following many common practices and ideas about health care. These essays have been culled from innumerable in-office lectures I have given patients in over 25 years of practicing family medicine.
Forgive me if the style seems a little acerbic and supercilious, but, hey, that's how we doctors are when we are passionate about being right.
And I am right. You may disagree with what I say, but then you'll be wrong. (Go ahead -- dare you to comment!)
These subjects are not always about the glamorous leading-edge, high-tech areas of Modern Medicine. But they are about important aspects of living: the way we bathe, the clothes we wear, how we respond to the most common illnesses, the way we make love.
And how we interact with doctors and other HCP's (health care professionals). For that part, I am always in learning mode and invite stories, comments, and questions.
This is not an Owner's Manual. I'm not out to teach you everything about the body (especially since there is a lot we don't yet know), but more to stimulate your mind to question how and why your body suffers from what you think you're doing to help it. Hopefully, you'll learn something, explain it to another, and we'll all become a healthier society.
BUNK -- Myths, Mistakes, and Misinformation that can be harmful to your health -- will discuss specific health care topics.
A future blog (BALONEY -- Don't Believe All You Hear About Modern Medical Science) will tackle Big Pharmaceuticals, health care insurance, and self-promoting "research."
And hopefully, we'll sample from BULL -- The Hype about the "Best" Doctors and Hospitals, which will be something of a guide for medical service consumers.
