Friday, November 30, 2007

The Doctor as a "Drug"

Michael Balint, MD was a physician who deeply probed the depths of the doctor patient relationship in his book The Doctor, the Patient, and His Illness. In this book, Balint also discusses two other important concepts that reveal much about the nature of the doctor-patient relationship. The first is the consideration of how the doctor functions as a primary therapeutic agent, much like a "drug", and the other is the concept of the "unformed illness". I'll discuss the "drug" doctor in this post and save the other term for later.

Patients visit doctors seeking relief from some problem, symptom or illness. Apart from surgery, the most common intervention used in the office is prescription of medication. Much like the use of medications, doctors also prescribe a "dose of themselves" when patients need relief. This comes, more than anything else, in the form of active, non-judgmental listening to their patients, encouraging them to talk about what "brought them to the doctor" by asking open-ended questions that put the patient at ease to express whatever is on their mind.

If this sounds more like a description of a psychiatric encounter, that's because Dr. Balint was both a general practitioner and a psychiatrist, and recognized that most illness was a highly complex mix of physical AND psychological factors. By serving as a safe, trusting professional who is genuinely engaged in the patient's problem, the solution starts to become the relationship itself. Patients obtain relief from many of their symptoms, particularly symptoms of "unformed illnesses" that may unknowingly have their roots in deep tensions, insecurities, or anxiety by having a good doctor-patient relationship and, thus, receiving a dose of the "drug doctor" in addition to their antihypertensive or diabetic or antidepressant medication.

Dr. Balint felt strongly that this "drug doctor" could not be effectively used without a highly developed degree of self-awareness on the part of the doctor that allowed them to simultaneously attend to the important medical issues while keeping a listening ear open to the life events and problems that contributed to virtually every patients illness.

Do you obtain a dose of your "drug doctor" when you make an office visit? Your comments are always appreciated...

Monday, November 26, 2007

Beware of Vitamin A

Most people think that all vitamins are good, and they are in normal recommended amounts. Sometimes health claims recommend high doses of vitamins. The B vitamins and vitamin C, which are easily excreted in the urine, are generally not dangerous even in higher doses. However, vitamins A, D and E are accumulated by the body and high doses can be dangerous. The most dangerous vitamin in high doses is vitamin A. The recommended daily allowance for vitamin A for men and women is 3000 IU for men and 2333 IU for women). Above 10,000 IU is considered dangerous, and may cause liver damage and birth defects in pregnant women.

A new analysis of the large Nurses' Health Study (over 70,000 women followed by Harvard researchers) has shown that women who consume more than 6600 IU of vitamin A had a higher risk of hip fractures after menopause. It appears that high doses of vitamin A contributes to osteoporosis of the bones.

If you take vitamins, especially multiple pills daily, check the labels carefully for the vitamin A intake. To be safe, do not take more than 5000 IU daily.

Winter colds, winter gastroenteritis, and winter flu

The leaves are almost all fallen. Holiday music comes from the elevator speakers. Winter is nigh and this also means that we face our toughest season for viral infections. Why in the winter? The experts think that this is because people are just jammed in together more than in spring, summer, and fall and people do easily exchange germs.

Certainly, germs can be spread by coughing and sneezing but the infectious disease subspecialists stress washing one's hands as the best defense and the best means of not infecting others. One expert suggests using soap and water for the length of time to sing two verses of "Happy Birthday", although, for the sanity of your family and co-workers, you might want to alternate with songs of roughly the same length or just sing mentally. Whenever washing up is not convenient, hand sanitizers are a good second option.

When one does cough or sneeze, the experts say to do so into one's elbow rather than into one's hands or by spraying the germs unimpeded throughout the room.

The Holiday Season is busy, stressful, and (I hope for all the eDoc clients) personally and spiritually fulfilling. Wash frequently to keep the germs at bay that would love nothing more than to set up shop inside you for several miserable days.

A Thanksgiving Wish List

On this eve of Thanksgiving, I'm glad that I live in a country where the best health care in the world is obtainable. I'm having a total knee replacement in two weeks and am glad that I'll be in a first rate institution with a great staff and great technology and am very fortunate that I have health insurance that will eliminate any financial burden from this process.
Although I am thankful for these things, I also have a Thanksgiving wish list:
--I wish that our health care system had not become such a financial juggernaut that primarily rewards hospitals and physicians who do expensive procedures.
--I wish that patients would learn how to take personal responsibility for their health care.
--I wish that every patient had access to the internet and could routinely interact with a physician online to get answers to health care questions.
--I wish everyone had a compassionate, caring primary care physician who would help them coordinate their health care.
Although I'm sure my wish list is lofty and unrealistic, each of you can make a decision to develop a relationship with a primary physician, hopefully one who encourages you to use the internet to obtain information and interact with him/her about health care. And you can use the information on the internet to help prevent disease rather than dealing later with treatment of conditions (such as diabetes) that may result from failure to address important issues, such as weight control and nutrition.

How do you start?:
1. Work on obtaining optimum weight (Body Mass Index of 25 or less)
2. Normalize your cholesterol (LDL of 100 or less)
3. Exercise (5 days a week of 30 to 40 minutes, combine weights and aerobics)
4. Get a physical (complete history, examination and basic lab tests)
If you have questions about how to do any of theses things, I'd love to hear from you.

Happy Thanksgiving...

An Exercise Tip from Satchel

"I use my single windup, my double windup, my triple windup, my hesitation windup, my no windup. I also use my step-n-pitch-it, my submariner, my sidearmer, and my bat dodger. Man's got to do what he's got to do." -----------Satchel Paige

“Man’s got to do what he’s got to do”. I love that concept. It can be applied to any number of life’s challenges or even to unpleasant, but necessary tasks. Acts of superhuman strength are said to have occurred when someone was required to do what they had to do----think of the woman who lifted a car off her trapped child. Or when the nerdy guy “rises to the occasion” to save the day. On a more mundane level, consider the single, working Mom who demonstrates tremendous ingenuity and multi-tasking skills in order to keep a roof over her family’s head and tend to the needs of her children.

The concept can also be applied to getting the recommended amount of exercise. Exercise for many fits in both the “life’s challenges” as well as the “unpleasant, but necessary task” categories. But taking a cue from Satchel, since you got to do it, you might as well figure out how. First of all, find out what you like to do. If running isn’t your thing, no big deal. There are many ways to get aerobic exercise. Walking, riding a bike, swimming, working out on an elliptical trainer will all allow you to reach a “moderate intensity” level of exercise. If gyms give you the creeps (I can relate to this), get outside. The weather is rarely too hot or too cold to keep you from getting in your 30 minutes a day. If you can’t exercise formally, see if you can walk or ride a bike to work. If you can’t exercise formally or walk or ride a bike to work, exercise in short bouts during the work day.

The point is, you can reach recommended exercise goals if you use some creativity and perhaps a little sacrifice. Very little I’d say, since we’re usually talking about missing a rerun of The Sopranos or missing half of the fourth college football game of the day. Listen to Satchel and mix it up-----walk to work on Monday, work out with weights on Tuesday, do calisthenics and yoga on Wednesday, ride your bike on Thursday, and so on-----“do what you got to do”.

A Sad Part of Holidays: Increased Domestic Violence

I enjoy the festive spirit this time of year. However, domestic violence is an ugly and secretive part of the holidays. Domestic violence significantly increases during major holidays. We can’t always control others, but we always can control the decisions and actions that we take.

During the holiday season, we can all stress about money. We can feel bombarded with unrealistic expectations. Guilt, depression, anger, fatigue, and alcohol are the real Grinch-factors of the holiday season. Triggers to domestic violence can be controlled with a few healthy strategies. Domestic violence never occurs in a vacuum. Few issues affect a family as much as domestic violence, and the negative effects of such violence are incalculable, especially among women and children. All of us have the responsibility to do all we can to prevent domestic violence.

Here are tips to help:

Avoid alcohol. Alcohol is the most significant contributor to domestic violence. If alcohol might be a contributing factor don’t risk consuming it or being around those who do.

Avoid people who contribute to negative interactions. Hang with those who support you and are positive in interactions with you.

Remind yourself that irascible family members will not have changed from the last time you have been with them. Limit your exposure to them. Consider a specific exit plan of how you might handle the provocative relative who gets your goat.

Keep control with your own emotions. Take an emotional-time-out when you feel stress build. Form and activate a specific exit strategy when you begin to feel tired, overly-stressed, and notice negative feelings and anger building.

Remind yourself that the stress of the holidays won’t last forever. Keep YOUR sanity alive and well, regardless of what seems to be going on around you.

Know that domestic violence has devastating effect on you, and those you love. Keep reminding yourself of the real reason behind the holiday season and family activities. Domestic violence is preventable.

Please share your helpful tips on this important topic.