Medicine and Fast Food

No, the practice of medicine is not like fast food.

We live in a society of fast cars, fast food, instant messages, and instant pictures.  We want it our way and we want it now.  This is evident by the fact that the average American household has $16,000.00 in credit card debt (2011 Household Statistics).  We want it now and well worry about payment or consequence later. This is also evident by the successes of instant messaging services, cell phones and fast food restaurants.

As a family practitioner, I feel pressured by both patients and insurance companies to serve up a diagnosis and a low cost generic pill with the same speed.  No, the practice of medicine is not like fast food. If it were, then I would install a drive up window next to my office desk, and place a large marquee with a clown wearing a stethoscope at my front door.

Medicine is an art.  A picture is painted of the patient by what is seen, heard, felt and understood through the eyes of the practitioner.  This can't be done over the phone or through a drive-through window. It requires a patient who is willing to place his or her history, symptoms, feelings, private concerns and trust upon the examination table It requires the astute observer to see all the reflections of light and shadows and all the highlights.  It requires the observer, the doctor, to recognized that many times this is difficult for the patient.  That trust is built through a relationship that occurs over a period of minutes and a period of years.  The beauty of the art occurs when the practitioner and the patient understand one another and application of healing can begin.

The art of medicine paints a different picture every time. That's why art isn't sold under the golden arches, or at the corner pharmacy.  No, the practice of medicine is not like fast food.

Vitamin D Effect on Weight

Vitamin D plays an interesting role in may aspects of human health. It plays a role in disease prevention including osteoporosis, some cancers, autoimmune disorders, hypertension, diabetes and has recently been found to effect weight loss.
What is Vitamin D?  It is an oil-soluble (fat-soluble) vitamin that helps in the absorption of calcium and phosphorus in the intestine and suppresses parathyroid hormone (PTH), the hormone that stimulates bone resorption (breakdown). Vitamin D also plays a role in muscle function and in the immune system, but our understanding in these roles are still limited. (1)
Vitamin D can be found in fatty fish, cod-liver oil and eggs. In the United States, cow's milk is supplemented with Vitamin D and this is often the source from which most people obtain it. Deficiency in Vitamin D often occurs from lack of sun exposure, inadequate intake, surgery to or damage of the intestines ability to absorb, or from kidney or liver damage resulting in problems processing Vitamin D. Recent studies reveal that obesity is a major factor in altering the way the body uses Vitamin D and stimulates PTH.

I find that about 30-40% of my patients are Vitamin D deficient.  Many researches claim this is due to poor sun exposure or the use of sun screens, however, I live in Arizona.  Sun over exposure is usually the problem here, yet I still find that 30-40% of my patients are deficient.  My patients should be able to get enough sunlight walking from their cars to the grocery store entrance.  I disagree that "lack of sun exposure is the cause."  Although our current labs claim vitamin D levels should be above 20 ng/dl, I find people do not get the needed effect until 25 Hydroxy-Vitamin D levels should are greater than 32 ng/dl.
Poor Vitamin D intake is usually the problem.  Our bodies convert 25 Hydroxy-Vitamin D into the active molecule 1,25 Dihydroxy-Vitamin D.  Recent studies reveal that higher Body Mass Index (BMI) leads to lower conversion of 25 Hydroxy-Vitamin D to 1,25 Dihydroxy-Vitamin D. (2,3)  Simply adding 25 Hydroxy-Vitamin D as a supplament frequently helps with weight management in many of my patients. Supplementation with 1000-2000 IU is often adequate.  Higher doses should be discussed with your doctor.

References:

1. C P Earthman, L M Beckman, K Masodkar and S D Sibley. The link between obesity and low circulating 25-hydroxyvitamin D concentrations: considerations and implications.International Journal of Obesity (2012) 36, 387–396; doi:10.1038/ijo.2011.119; published online 21 June 2011.

2. Frost M, Abrahamsen B, Nielsen TL, Hagen C, Andersen M, Brixen K. Vitamin D status and PTH in young men: a cross-sectional study on associations with bone mineral density, body composition and glucose metabolism. Clin Endocrinol (Oxf) 2010; 73: 573–580.

3. Konradsen S, Ag H, Lindberg F, Hexeberg S, Jorde R. Serum 1,25-dihydroxy vitamin D is inversely associated with body mass index. Eur J Nutr 2008;47: 87–91.

A Fat Attack Can Kill You

What is a "Fat Attack?"  A "Fat Attack" is defined as a gain of more than 5% of your total body weight.  A gain of this much weight can be notably detrimental to your health.  Gaining just 5% of your total body weight increases your risk for diabetes, heart disease, hypertension, stroke, osteoarthritis, polycysitic ovarian disease, allergies, and the list goes on . . .  Most importantly, your weight gain significantly affects your life and increases your risk of death by 20-40% according to recent study in the New England Journal of Medicine.
Between 300,000-400,000 deaths occur every year due to obesity.  435,000 deaths occurred due to smoking in 2008 according to the CDC.  Obesity is just as dangerous as smoking
"Overweight and obesity are now so common that they are replacing the more traditional public health concerns such as under-nutrition and infectious disease as some of the most significant contributors to ill health." (World Health Organization 1997 statement on obesity.)
So what should you do if you're having a "Fat Attack?" You should follow up with a your physician or a weight management specialist, a physician that is specialty trained in the treatment of obesity and its related disorders.
You can find a physician that has this special training through the American Society of Bariatric Physicians. These physicians have significant specialty training in identifying and successfully treating overweight and obesity conditions.
You can be successful in loosing weight and your "Fat Attack" shouldn't lead you to a heart attack. Look up your nearby bariatrician and start your treatment today.

Disconnect Between Private Medical Practice & Medical Education

It fascinates me that there is such a disconnect between the economic view of those in private medical practice and those in Medical Education or University Based Practices.  Recently read an interesting post by Bryan Vartabedian, MD, at 33 charts discussing the future and inevitable changes in medical practice.
It is my opinion that medicine is changing and the practice of medicine will probably be unrecognizable in the next 10-20 years.
Yes, technology is making the evidence of practice guidelines better and more effective, but that is part of the way medicine is changing.
Daily, I am barraged with "practice protocols and guidelines" from every specialty group and every expert committee (a full ream of paper is mailed to me daily from all these expert groups).  Insurance companies then accept these guidelines as the "gospel truth" and if I'm not following them to the letter, my paycheck is reduced.  The "art of medicine" is disappearing with the overlay of the flowchart and practice protocol or practice guideline.  But to earn my living, I have to either demonstrate I followed the protocol, or write an additional paragraph as to why the protocol is not appropriate for that patient.  It is impossible to do that 35 times per day even with the most efficient electronic medical record available (I know 'cause I have one).
But the educational system still appears to be teaching the students that the current evolution is the "best."  The student cry "foul" and question the experience of those who have been in the trenches and claim that the error is on the part of private industry.  This progressive view of medicine is killing the "art."  And it is in the "art of medicine" where the caring and compassion is found.
Medicine as we know it will change into an efficient, cold, assembly line of diagnosis and treatment dispensing, unless we collectively change it.  The enjoyment of medicine is found in its art.  Once that is gone, you will loose the great physicians.  You will have an industry of cookbook, cookie cutter practitioners dispensing the latest medial equivalent of the GM Volt. The government is driving this.  In my practice, 50% of my patients care is driven by Medicare in some capacity.  When you put the government in control of medicine your going to get more bureaucracy and less art.
What is the answer?  Time.  Only time will tell. Until then, we practice medicine the best we can with the tools we have and apply the art of that practice to each individual.

Health Care and Politics

I have been told by many that there are two things you never talk about: politics and religion.  I realize that I have broken these rules, but these seem to be the things that are most important in life and are at the forefront of the mind recently. 

It has been interesting to hear from my liberal friends and collegues about my last comments.  I find that the conversation and communication is important for two reasons.  First, truth is independant, and the only way to identify truth is to hear it, read about it, or find it through civil discussion with those around you. The truth about health care has been weighing upon my mind in the last year.

It has been upon my mind because it is what I do for 12-16 hours per day.  I am in the business of rendering care and attempting to provide the best care possible in few minutes I have with each patient.  But I am finding that political influences of both our state and nation have drastically affected the number of minutes I can spend, the type of care I can render and the choices I can offer to my beloved patients.  I have found that these political voices can no longer be silently ignored.  

As I have read, listened and discussed this with many around me (both conservative and liberal), I am finding there are really only two voices.  Those voices speak at various points along a spectrum of desired liberties, but there are really only two voices.  There are those voices that speak the language of the founders of this republic who understood that true freedom comes from liberty, and there are those that speak the voice of progressivism whos concepts of freedom are defined by various degrees of socialism. 

I have been accused of not understanding socialism and seeing all change in society as socialistic.  This is not the case.  Socialism, as it was defined in "school," is that society in which there is no private property. It is where the collective or governmental ownership oversees the distribution of goods and services. Socialism as defined by Marxist theory is a stage in society between capitalism and communism.  These political doctrines are founded in our understanding and acceptance of the concept of property ownership.  We see this in governments around the world in varying degrees in countries like France, Venisuala, Sweden, and Laos, etc.

Private property and liberty are insperable. We lose our liberty as the right to hold private property is removed. The difference in views between our country's founders and the progressives is their understanding of the conferrance of freedoms based on the liberties granted by ownership of private property.  Communism is defined as a society where ownership of private property does not exist.  In the words of Abraham Lincoln, "We all declare for liberty; but in using the same word we do not all mean the same thing.  With some the word liberty may mean for each man to do as he pleases with himself, and the product of his labor; while with others, the same word may mean for some men to do as they please with other men, and the product of other men's labor.  Here are two, not only different, but incompatible things, called by the same name liberty.  And it follows that each of the things is, by the respective parties, called by two different and incompatible names - liberty and tyranny."

How do these political ideologies relate to medicine?  Well, lets think about a three other concepts.  First, those things that make us different from every other country in the world are defined in our Declaration of Independance: 
   "We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness."
We believe that being created in equality, we each have the right to life, liberty and the pursuit of happiness.  This statement does not guarantee happiness, but states that we have a right to liberty and life.  We have a right to act in this life in those ways that will bring us liberty, the right do those things that allow us the ownership of personal property and seeking those things in our lives that bring us happiness.

Second, life is full of change.  Our society is different from what it was in 1776, the time when our founders wrote the words of the Declaration, and our society will be different 100 years from now.  Change is important; however, our assessment and acceptance of change must be done with prudence.  But, that which is lost in our society today is prudence.  Prudence is of the highest of virtues because its judgement is drawn from wisdom.  Prudence was exercised as a basis of society in 1776 because of man's view of himself before his maker.  Our Declaration states that these rights are "God given."  Today, many question even the existance of a maker, and prudence is lost. With prudence being lost in our society, our general ability to assess the way societal changes affect us now and in the future is greatly limited.

Third, it is important that we understand the definition of capitalism.  Capitalism is defined as an economic system characterized by private or corporate ownership of goods or services, by investments that are determined by private decision, and by prices, production, and the distribution of goods that are determined mainly by competition in a free market
So, how then does this relate you your medical care?  Your ability to obtain care relates you your understanding of what medical care actually is.  Medical care is essentially property.  You buy services. Medical care is a service or commodity, just as your home or car is a commodity with ownership. The progressive view goes beyond the statement that "men are created equal" and asserts that men should receive equally, a socialistic view.  They extrapolate that men should therefore recieve medical care equally as it paints medical care as a right.  Medical care is not a right.  Medical care is a commodity which is purchased.  Your body was designed to heal itself.  When disease, illness or injury occurs, assistance to those bodily functions of healing can and should be sought as the "pursuit of happiness."  Medical care is thereby a service that is rendered either through purchase or through a charitable act. 
 
So then the politics of medical care then also pertain to our liberties and our freedoms. Our government was designed as a republic for our protection and to ensure life, liberty and pursuit of happiness.  Our constitution provides an environment for us to seek our own happiness while not infringing upon the lives of those around us.  We are free then to seek happiness through our own inginuity, free to protect ourselves, and free to take individual risks.  When injury or illness arises, we are free to seek care and healing above and beyond what our body will do on its own. 
 
The progressive or socialistic view is that men have the right to recieve the same or equal care.  Seen as a right, the progressive government mandates this care.  The problem with this view is that our liberties are then taken away, because a politician decides what care is best and how often you can recieve it.  In a capitalistic society, the medical provider will attempt to provide the best most efficient care to be competative in that society.  In a socialistic society, the medical provider has no incetive to become better or to provide a better service, because the same service is mandated by the governmental politician.   Yes, the care is free, but your liberties of "pursuing happiness" through the type and quality of your care is now infringed upon, and your freedom is restricted. 
 
I am affraid that our so-called "liberals," as well as our progressive republicans in society, desire to recieve the benefits of socialism in a capitalistic society.  These two concepts are diametrically opposed to each other.  Capitalism, and the medical services created and rendered therein, cannot succeed in a socialistic society requiring limitation of liberty under the guise of "medical equality."
 
Our medical system is broken.  We have allowed our government to create programs like Medicare and Medicaid, socialistic programs, trying to create equality and limiting our liberty.  We are now dependant upon these medical insurance programs created and expanded 50 years ago under progressive presidencies and congress.  We, the children and grandchildren of these leaders, must now deal with the consequences of socialistic action.
 
May we recognize our real rights, and may we pick leadership to help us solve these problems and learn to more effectively pursue life, liberty and happiness.