Blog

A Healthy Immune System, and “Good” Nutrition

Good health isn’t just a matter of not getting sick, it is about maintaining a healthy immune system. A healthy immune system keeps us from getting sick, but we have to build it up. The building blocks of a healthy immune system are the food we put in our bodies and the healthy habits we use to maintain them.

Good nutrition is the foundation to maintaining a healthy immune system.

What is “good nutrition?” If we listen to advertisements, we should be eating Cheerios for breakfast, a Slim Fast shake for lunch and a Smart Choice frozen dinner every evening. I love what author Michael Pollan says in his book, In Defense of Food (and I paraphrase): if it has to be labelled “healthy,” it probably isn’t. Let’s dump all the “knowledge” we have from advertising and start thinking about how our food was originally provided to us.

What kind of food did our ancient ancestors eat? (Sure, they didn’t live half as long as we do. But that’s because they didn’t know about bacteria and viruses, and they had to worry about getting attacked by wolves and other beasts.) Fresh food is best. Pollan suggests only shopping on the outer perimeters of the grocery store (if we have to go to the grocery store at all, that is), and that’s good advice. Eliminate processed food from your diet; it has been processed so much that they have to fortify it with vitamins and minerals! Processed foods that have more than 2 or 3 ingredients should key you in to the fact that they are manufactured, not fresh.

“Fresh” means that the food should look as close to nature as possible, as if you harvested it yourself from your garden or orchard. If you choose to blend it or cook it in your kitchen, then that’s up to you. But I doubt you’ll need to add corn-derived chemical products to it, or throw in any preservatives. Another good tip Pollan provides in his book is don’t buy anything to eat that doesn’t rot. You could put a Twinkie in a time capsule and 100 years later when they open it up it should be just as “fresh” as the day it was manufactured. There is something scary about that.

It is good to know the source of your fresh food as well—to make sure it is not genetically modified (not to be confused with hybridization, which is different) and what chemicals have been used in the soil or on the plant. Just in case, always wash it, even if it claims to be washed. Remember too that the farther something had to travel, the less ripe it had to be before it got to the store. If you can get produce out of your own backyard, that is best of all. Learn how to preserve seasonal foods in such a way that you don’t deplete them of all their nutritional value.

And don’t forget water! Our bodies are composed primarily of water, so it is essential for your kidneys, your skin and your immune system to get plenty of clean water. If you are not sure about the supplements in your water, get it tested. Your county should be able to provide you with the ability to test your water source.

Exercise is important as well. Because your immune system requires an operating healthy heart, and your heart depends on a decent cardiac workout, try to get a minimum of 30 minutes of exercise daily, earlier in your day if able. Get the heart pumping, and the lungs breathing. It will help your metabolism, your immune system, and will also improve sleep quality, another important factor in maintaining a healthy immune system.

While it varies from individual to individual, many studies show that the closer you can get to 8 – 9 hours of restful sleep, the better it is for the immune system. And restful sleep means exactly that—restful. Learn good sleep hygiene and make sleep a priority as it is a critical part of good health.

Finally, avoid those chemicals and compounds that we KNOW can cause problems. Our bodies are constantly battling off cancer cells. When our systems are stressed, the immune system cannot keep up and cancer gets out of control. If we know that the chemicals found in cigarettes have the potential to cause cancer, it is best to avoid those chemicals. If we know that certain exposures can lead to cancer, it is best to protect ourselves from those exposures as much as possible. Don’t assume that the EPA or your employer or landlord will take that responsibility—it’s your body and your responsibility to make sure you treat it right, so don’t make assumptions about the quality of the air you breathe or the potential exposures. Take it upon yourself to have your environment checked when you’re able, and to avoid the things you know you should avoid.

Try to put at least one of these suggestions into effect this week. Add other changes gradually and it won’t FEEL like a lifestyle change, even though that’s exactly what it is. You owe it to yourself—and your immune system!

 

Change

“Change is the law of life. And those who look only to the past or present are certain to miss the future.” ~ John F. Kennedy

No one really likes change. Some may claim they want or welcome change, but there is something within them that wants to cling to the present, or the past. How many times have you thought to yourself, “But we’ve always done it this way!” Don’t worry; it’s natural to resist change. But understand this: change IS the law of life. Everything changes; hopefully it is in small, easily-digestible bite-size pieces, because we accommodate more change when it is slow and barely noticeable.

Think of the (usually) slow transition of the seasons, or the budding and then flowering of fruit trees. Eventually that bump at the base of the flower becomes a pear, or an apple. If one day there were bare branches and the next day full ripened fruit, how magical it would appear to us, though the same end is accomplished through the gradual process of growth.

I sense we are on the cusp of some big changes—in our neighborhoods, our state, our country, and in our world. I’ve told more than one of you “It’s going to be a long, hot summer,” and I mean more than just the weather. When so many different things are teetering on the edge, change is inevitable. Whether for better or for worse is anyone’s guess, and subject to their own perspective.

The Affordable Care Act started a wave of change in the medical world that continues to have an impact on patients and physicians and medical care workers daily. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2013 will change how physicians are paid, especially with the recently disclosed 952-page rules on payment. The very physician organizations that heralded that bill as the “Doc Fix” are now complaining that this will bankrupt the vast majority of independent physicians and are “demanding” the rules be changed. That will not happen any more than will Congress repeal or replace the ACA. These changes will impact American medicine for years, if not generations, to come. Locally, here at the Lake of the Ozarks, a major hospital chain has pulled out and left their clinic (and its patients) stranded. Sure, patients can travel 30 minutes or more to go to one of their other clinics, but they will NOT be able to “keep their doctor” as the hospital system has stranded him as well. He will now be an independent physician, but if he intends to bill Medicare, the rules of MACRA will actually punish him for being independent! How long can one tread water?

Meanwhile, we soldier along here at Direct Primary Care Clinics, serving our members regardless of their insurance coverage, or lack thereof. I anticipate a day that Medicare will not cover the medications I write for Medicare patients, and when that day comes I am sure we will find a way around that roadblock too. Because that is what change does—it forces one to either conform or to find creative alternatives.

Here’s to creative alternatives!

 

 

 

 

Propaganda?

Propaganda: noun: information, especially of a biased or misleading nature, used to promote or publicize a particular political cause or point of view.

The word “propaganda” did not initially have a negative connotation; the negative association with propaganda came about as the word was used extensively during World War II.

Today, propaganda is still widely used in business, politics and healthcare, and is something of which individuals need to be aware.

The true author of Propaganda was Edward Bernays (literally; the title of his book in 1928 was Propaganda.) By observing what was used during the First World War, Bernays outlined how to “regiment the public mind.”  This is the same man responsible for smoking among women. It wasn’t until Chesterfield applied his advertising techniques that women began smoking in numbers. Bernays was the master of using propaganda to sway entire populations to think a certain way, behave a certain way and—most assuredly—vote a certain way.

Just think of the today’s catch phrases used by media talking heads! While dining out with my sister, I actually got loud and argued with her, because she blurted out a summary of a political candidate that was sheer propaganda. I asked her why she thought that about this person; and honestly, she was so surprised at my outburst she couldn’t reply.  I accused her of being guilty of simple regurgitation of what she had heard others say. I made it clear that I was not a fan of this person myself, but I had become painfully aware of these subliminal messages that turn us all into thoughtless robots.

Advertisers use subtle propaganda all the time. Did you ever feel you just had to have a 50-cent corndog from Sonic? I even quoted the commercial when I took a bite and said, “There’s a hot dog in here!”

If you don’t drive a Lincoln you just aren’t as cool as Matthew McConaughey.  And what about my all-time favorite: “Ask your physician if (fill in the blank the name of medication) is right for you.”

We are manipulated at every turn—from the pulpit to the radio to television to newspaper. We are assaulted in the movies and television shows we watch.  I was watching a show the other day that is supposedly conservative. The family had just come home from attending church, and the matriarch was upset because the pastor confessed to having a problem with pornography addiction. It soon became obvious through subsequent conversation that everyone else in the household viewed pornography—every one but her. The subtle way they made this seem natural and all encompassing concerned me, because I realized that the writers of this episode were attempting to convince those who were watching that pornography is natural and all encompassing!

The little bit of time I watched (I turned it off once I realized the viewing audience, myself included, was being manipulated) I did not hear about how pornography contributes to human trafficking, or the impact on the lives of those in the industry.  The sex industry is rife with social concerns, but let’s promote it further by using a supposedly conservative sit-com to manipulate otherwise “sexually up-tight” Americans into thinking that “everyone does it”. Really?

That is misleading information to promote the idea that pornography is natural, everyone watches it and it’s no big deal. That is propaganda.

One would hope that the world of medicine would be immune to propaganda, but not so. Even the term “healthcare” is propaganda; it has molded people’s thinking more toward “health” than illness. However, physicians are trained to recognize and treat illness and disease.  We are also trained to treat individuals, not societies or populations.  But the concept of “healthcare” is more community based, more global, if you will.

The trend toward “health” as opposed to “illness” causes us to marginalize the diseased and concentrate on the healthy. If you want to create a society of only healthy individuals, to reduce the cost and burden of the few very unhealthy, you can use propaganda to change the opinion of an entire society.  For example, while recognizing that the concept of a “wounded warrior” will stir the empathy of most people, we marginalize these same veterans and they will die while waiting in line for their chance for treatment. Organizations like the Humane Society of the United States (HSUS) prey on the sympathy of people with these heart-wrenching advertisements, asking for money to help save the lives of dogs. But, they do not even believe in pet ownership, and actually destroyed animals that were orphaned from Hurricane Katrina instead of sending them on to be adopted!

These same subtle forms of propaganda are being used by our biggest organizations within the medical world and are working hard to manipulate physicians and patients alike into buying the concept of “healthcare” vs. medical care. Developing guidelines based on population statistics—and going beyond encouraging physicians to follow these same guidelines by actually tying physician compensation to the adherence of the guidelines—is one excellent way to lead physicians by the nose and get them to do things they ordinarily would not do.

How do you get people to give up their rights? By scaring them into feeling insecure. They will then clamor for more and more security. We will stand in line for hours to be pawed at and have intimate pictures taken of us in order to fly a couple of states away. We will get out of our cars and allow searches of our vehicles without a warrant, because we are afraid of being shot or incarcerated. We will continue to purchase online—in spite of having our identity stolen once or twice—because of convenience. We will allow our every move to be monitored, because we don’t want terrorists to blow up our schools and hospitals.

Do me a favor, get a copy of Enemy of the State and watch it.  I don’t care if you saw it when it came out in 1998. Watch it again. Watch V for Vendetta. See if you can find where propaganda was used against the people. Read Atlas Shrugged. Open your eyes to how we are being manipulated for most of our waking hours by all forms of media. Is there any subtle “nudging” in your television shows, your news programs, your book club books, your magazines, newspapers or in commercials? If you start looking for it, you will find it.

Start asking “why.” If someone tells you “Right to Work” is bad for Missouri, ask why. Then if someone else tells you it is good for Missouri, ask why. You may have to do some research.  Follow the money.  If the big money is being thrown into only one side of an issue, you should try to find out WHO and WHY.  Why did all the big insurance companies, big hospital systems and big physician groups enthusiastically support the Affordable Care Act? Follow the money, both going in AND going out. Why did Missouri lawmakers readily and easily agree to Anheuser Busch InBev’s supported legislation to allow them to put in coolers for package liquor sales? Follow the money, both going in AND going out.

I know; I’m conspiracy minded. I tell people this up front. I am used to name calling, since I am a Christian (originally a derision), a Methodist (again, originally a derision), a libertarian (“those people are plum crazy”) and a believer in the free market, EVEN IN MEDICINE!! The best way to get people to stop listening to those who buck the “status quo” is to marginalize them, call them names.  Please keep this in mind the next time someone says, “So-and-so? He’s (fill-in-the-blank).” Smile and recognize the propaganda machine is at work!

 

What Happened to The Country Doctor?

Paging Dr. Welby and More Doctors Like Him.

Many of us grew up watching (and still watch) old Westerns where every little town has at least one saloon, one hotel or boarding house, a jailhouse and a doctor. That town’s doctor does everything from surgically removing bullets to splinting a fractured leg and then rushing off in the night to deliver a baby at a farmhouse several miles outside of town.

These Hollywood ideals were based on more truth than fiction when it came to the small town physician. I grew up in a small town, so the “town doc” of the Westerns was not unusual to my family or me. Doctor Holtzman took care of all of us, and he did the best he could under the circumstances.

During my family medicine residency, I was fortunate to experience a four-week rotation at a small Navajo reservation’s medical clinic in New Mexico. I saw firsthand what a family physician could do with very limited resources, including treating patients who had no running water or electricity.  Later in my career, two Russian physicians wanting to study our “rural” clinic in central Illinois visited me. These doctors were overwhelmed by the resources we had in our clinic, knowing there was no financial ability for them to imitate our model in their rural areas of Russia.

With all our advances in technology and medical support resources, you would think our medical care system would be the best of all time. We can diagnose a heart attack in a matter of minutes, treat an evolving stroke as it is occurring, have radiologic images read by someone miles and miles away and surgically treat with robots. But for all our advancement in technology, has it improved our relationship skills or instead, has it lead to devolution of our communication abilities?

What price has the medical community paid to enjoy these technological advances? Most people can’t even see their physician face to face these days when having an office visit, much less experience home visits or calling their personal physician on the phone. How far we have come from the accessible and personable small town doc like my own Doctor Holtzman?

It is not only inter-personal skills that have waned, but also the diagnostic skills of many primary care physicians have suffered from years of being encouraged to refer to specialists. Unfortunately, this “trend” has led to the point that diagnosing some of the most common human conditions are passed off to other physicians and the treatment of these diseases are left to others as well.
At one time, there was a great push for the primary care physician to be nothing more than a gatekeeper—performing a type of triage and only treating the acute “Urgent Care” medical problems, while referring off all the others.  Fortunately, my residency programs did not buy into that concept.

Nothing against specialists—one never appreciates a surgeon quite as much as when a surgeon is desperately needed! When I have a particularly tough case—for example a patient with external signs of cortisol excess but all the laboratory readings of cortisol deficiency—I am grateful for the existence of knowledgeable specialists, such as endocrinologists, to help me sort it out.

However, I fully expect myself to be able to recognize cortisol excess in the first place. Solving the puzzle is one of the most rewarding aspects of my career choice, and I love being able to quote The A Team with, “I love it when a plan comes together!”

It is human nature to want to mechanize or standardize a process. It would not be very helpful if we got totally different results from laboratory to laboratory when processing blood work, or varying results from hospital to hospital when getting mammograms. Standardization helps to keep results similar regardless of where the testing is done. But, the interpretation of results cannot be truly standardized, nor can the treatment.  The interpretation and treatment need to be individualized to the person from whom the result was obtained—and dependent upon each individual situation and constellation of symptoms.

Attempts at standardization results in the construction of a wall or barrier. Each regulation placed on the standardization results in further structure to the wall; and the next thing we all know, we can’t even find the patient due to the thick barrier of “stuff”!

Robert Frost wrote in his poem Mending Wall, “Something there is that doesn’t love a wall, That wants it down.”

Something, indeed. When we find that our technology, that our regulatory bodies, that our very way of diagnosing and treating patients has come between us—the physicians and the very people we are attempting to help—it is our duty and struggle to break down that wall so we can be reunited with those we serve. It should be our attempt to reinvent ourselves in the likeness of Marcus Welby MD and Doc Adams, even if it should mean giving up some of those “advances” in medicine.

 

 

 

Recognizing the War on Pain Medication

Recognizing the War on Pain Medication

There is a war on physicians—and therefore on patients. However, there is another attack on the medical profession—the war being waged against pain treatment. Pain medications in particular are under the scrutiny of both the US Congress and in state legislatures.

For the last several years, there has been a push in Jefferson City, the state capital of Missouri, for the establishment of a Prescription Drug Monitoring Program, one that would track prescriptions for controlled substances in the state. One of the biggest arguments for this program is that Missouri remains the last holdout in the Union to not have one of these programs. But apparently, these programs are not sufficient: just look at the long list of bills introduced in this US Congress alone regarding pain medications:

HR 1725/S. 480 https://www.govtrack.us/congress/bills/114/hr1725/text / https://www.govtrack.us/congress/bills/114/s480/text

  1. 483 https://www.govtrack.us/congress/bills/114/s483/text

HR 953/S. 524 https://www.govtrack.us/congress/bills/114/hr953/text / https://www.govtrack.us/congress/bills/114/s524/text

  1. 636 https://www.govtrack.us/congress/bills/114/s636/text

HR 2805/S. 1134 https://www.govtrack.us/congress/bills/114/hr2805/text / https://www.govtrack.us/congress/bills/114/s1134/text

HR 2298 https://www.govtrack.us/congress/bills/114/hr2298/text

  1. 1392 https://www.govtrack.us/congress/bills/114/s1392/text
  2. 1431 https://www.govtrack.us/congress/bills/114/s1431/text

HR 3719 https://www.govtrack.us/congress/bills/114/hr3719/text

HR 3677 https://www.govtrack.us/congress/bills/114/hr3677/text

HR 3899 https://www.govtrack.us/congress/bills/114/hr3889/text

HR 4396 https://www.govtrack.us/congress/bills/114/hr4396/text

  1. 2479 https://www.govtrack.us/congress/bills/114/s2479/text

HR 4447 https://www.govtrack.us/congress/bills/114/hr4447/text

HR 4499 https://www.govtrack.us/congress/bills/114/hr4499/text

  1. 2543 https://www.govtrack.us/congress/bills/114/s2543/text

It is clear to see from this list that the United States Congress thinks it is the job of the federal legislature to “control” not only medications, but also who may write the prescriptions, mandate a protocol that must be utilized, create a master list of patients who take the prescriptions, enable access to a patient’s prescription record, and limit access to certain pain medications for Medicare beneficiaries.

I cringed to read the summary of HR 3719 that requires the department of Health and Human Services to coordinate with the DEA, the Department of Defense, the Department of Homeland Security and the US Attorney General to develop “best practices” guidelines. PLEASE NOTE THAT NONE OF THESE INVOLVE PHYSICIANS OR PHYSICIAN GROUPS.

HR 3677 would establish “peer review” process—this is equivalent to having physicians spy on other physicians regarding their prescription writing. From reading over the summaries of most of these proposed legislations, it is obvious that our congressmen and women feel it is their responsibility to “take on” the misuse of prescription pain medications. While that may seem a noble cause, you may rest assured that means more regulation, more loss of privacy, decreased access to these prescriptions and most likely decreased access even for physicians still willing to prescribe them.

When I was in medical school, there was a push to include a pain scale as another “vital sign.” That meant we should ask about EVERY patient’s pain, have the patient scale it one to ten, and record it in the beginning of all our notes along with other vital signs: blood pressure, heart rate, respiration rate and temperature.  We were chastised if every single note in a patient’s chart did not provide this scale, even if pain was not one of the complaints. By residency, I had learned enough to make Tylenol and/or Ibuprofen an order for every hospital patient, because I knew the likelihood of being called for “something for pain”, and generally at 2:00 in the morning. We were instructed on which narcotic pain medications tended to work best for different kinds of pain, which were safe in pregnancy and breastfeeding, what “schedule” each one had (whether they required a paper prescription, could be faxed, called in or could have refills) based on the regulations of the DEA.

Pain is strange. It is a totally subjective problem, meaning: there is really no outward sign, no testing that can be done to scale it and it is totally dependent on the patient reporting it. We always ask a patient to “describe the pain”: location, intensity, what does it feel like (burning, stabbing, aching), does it come and go, what makes it worse, what makes it better?  These questions help us understand from where the pain may be coming, what may be causing it and if there is something else going on that could be disastrous or fatal. It also helps us understand whether we as physicians need to treat it. Sometimes it is best to let the pain go untreated, as it can guide us. Some people do better with pain than others. Depression will make someone feel more pain, and pain can be depressing. Pain raises blood pressure. It causes the excretion of stress hormones, such as cortisol, which works against insulin; so, diabetics with pain will tend to have higher blood sugars. Pain can cause nausea and vomiting. It can alter a person’s thought processes and can cause anxiety. Pain is not necessarily a benign symptom.

However, because narcotic pain medication is easily misused, because people can claim to have pain when they do not, and because physicians have been trained to help alleviate pain and treat it as one of the main vital signs, there are a lot of prescriptions for pain medication.  Pain relief is often one of the main reasons people seek help from physicians in the first place. Pain is the body’s way of telling us something is amiss, and it comes in various shapes, sizes and styles. People have different tolerances for pain. In spite of all these variances, because of a handful of people who use their medications incorrectly, because of the thieves, the addicts and the greedy, it has become nearly impossible for physicians to adequately treat pain in today’s medical atmosphere. Further regulations, as well as both state and federal drug enforcement agencies want to be able to reach into medical records, physician prescription habits and patient privacy and consider anyone who either prescribes, fills prescriptions or accepts prescriptions from the pharmacy as suspects.

I fully believe there will be a day that I can no longer prescribe any pain medications for patients.  It may initially be patients on federal or state insurance programs; then it may extend to those privately insured. Eventually, it will hit the cash-paying uninsured patients. And at that time, I suspect that the only way to obtain pain medications will be on the black market.  Because, as we are all well aware, what is made illegal does not simply go away—it just goes underground.

 

 

 

 

 

 

 

 

Demise of the Individual in Medicine

“I worship individuals for their highest possibilities as individuals, and I loathe humanity, for its failure to live up to these possibilities.” – Ayn Rand, “Anthem”

One of the most concerning trends in medicine I see is the movement away from individualism and toward collectivism.

This trend manifests in multiple ways in our medical institutions, arising as such creatures as Evidence-Based Medicine and the notorious use of the Bell Curve (http://statistics.about.com/od/HelpandTutorials/a/An-Introduction-To-The-Bell-Curve.htm) to apply population-based statistics to the treatment of individual patients. While these statistics may be useful for adopting guidelines—i.e. MOST people will have this experience with this drug—attempting to apply guidelines as hard and fast RULES in the medical sciences is rather disturbing.

Many consider ancient Greek physician Hippocrates to be the Father of Medicine, as he lived in the 4th century BC.  A close look at the Hippocratic Oath, which many medical students take upon graduating from medical school, shows the importance of the individual patient above and beyond the concerns of the collective—the community, the society or the State. http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html

While the original oath first upholds sacred the community of medical practitioners as a family, it goes on to state that treatment for the sick will never be given to intentionally harm, that is, “according to my ability and judgment, I will keep them from harm and injustice.”

We have embraced this to mean, “First, do no harm.” But when there is a clash between individual concerns and the public concerns, to whom shall the “no harm” be directed? I would fully expect the physician who works for a public health organization (or one with a Master of Public Health degree) to take the stand that the concerns for the public health outweigh that of any one individual. However, it is my belief that for me—as a primary care physician —the medical concerns of the individual are, well, PRIMARY.  If not the family physician, then who will be the advocate for the individual patient?

The Hippocratic Oath goes on: “Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.” Personally, I interpret this to mean: I will not murder. I will keep private things private and to myself. I won’t take advantage of my position for personal gain.

These are the basic tenants of medical ethics. After the atrocities of the Second World War in the 20th century, it is no surprise that the oath I took with my classmates in 1999 includes refraining from unethical experimentation. If you read about the things that have been done to people in the name of “science,” you wonder how any physician could be encouraged to do such things. Then you find that it was all for the sake of “the good of the People.” The information gained could improve the lives of the Public; therefore, it was OKAY to subject others (particularly those considered to be sub-human) to all manners of experimentation, since it was for the Public Good.

As a modern example, let’s consider the “statin” debate. It is generally accepted in medical circles that statin drugs reduce cholesterol and therefore reduce the incidence of heart disease. Do we truly have a method of preventing heart disease by treating cholesterol levels, or have such a large number of studies (often sponsored by pharmaceutical companies that are developing statin drugs) been performed on certain populations that are sure to show improvement in cholesterol levels? Then, those same certain populations can be followed to see if heart disease develops, in order to create a logic that says “Using a statin reduces heart disease.”

I have trained myself to look directly at the study and see who was excluded rather than who was included as study subjects. This tells me who cannot be considered for a favorable result regardless of the results of the study! Think about it this way: if those individuals were excluded from the study, the designers of the study knew that portion of the population would skew the results away from what they want the study to show.

To further illustrate this, we can go to “Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis” http://www.nejm.org/doi/full/10.1056/NEJMoa0912321#t=articleMethods, the CREST study. Scroll down to “Selection of Study Patients” and look at who was excluded from the study. Then please note the last line of the section: “The full eligibility criteria have been published elsewhere.” Why? Would the eligibility criteria be so exclusive for the study that it may render the study of little use? But no, surely this is only going to be helpful for vascular surgeons to be able to decide whether they need to scrape off plaque surgically (endarterectomy) or place a stent, right? But, if I wanted to know if my patient with carotid artery stenosis (plaque build-up in the carotid artery) should be considered for a stent or an endarterectomy, I would go to the footnote (see that little number 10 at the end of that section?) and read the full eligibility criteria. I would do this specifically TO SEE IF THE STUDY RESULTS WOULD APPLY TO MY INDIVIDUAL PATIENT. I cannot apply population-based statistics to my individual patient because my individual patient may fall out of that Bell Curve!

So, I click on the footnote, and it gives me two choices of where to get the entire article (Design of the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST).

I can rent the article to read for $6 (good for 48 whole hours!) I can pay $15 to read it on the cloud or pay $38 to read, print and/or save a PDF file—just to see the full eligibility criteria for the study! So, I rely on what the article in the New England Journal of Medicine (which surprisingly allows access to the full article for free online) tells me about eligibility. Finding the complete facts can be an arduous and expensive endeavor, which is why some physicians rely on drug reps for their information regarding the efficacy of drugs for certain medical end points.

So here we are with physicians having sales representatives tell us why their drug is best at preventing heart disease. But, what if the whole cholesterol theory—stay with me here—is also a medical “certainty” built on the statistics of a few studies that excludes what could be a large part of the population that a physician will be seeing? In other words, what if an entire “disease” could be “created” for which only certain drugs can help prevent or treat? Before I ask you to slip on your tin foil hat with me, realize that it is not so outlandish to suggest this as a possibility.  I nearly threw a drug rep out of my office once for even using the term Chronic Obesity as if it were a disease and not a condition of storing too much reserve energy. But since their drug product was created to address obesity, they need a Disease (with a capital D) with which to associate their product. I asked her how long a patient needed to be on the product and she said, “Oh this is for Chronic Obesity. They have to be on it forever.”

I refrained from explaining to her how the human body naturally works, because I knew she was simply regurgitating what she had been taught to say by her company. By the way…I don’t prescribe their drug!

My argument for having multiple blood pressure medications, even those that work the exact same way in the body, is that what may work for one patient may not work for another, or may have undesirable side effects in one patient and not in another. I have seen this even in the same drug families. Humans are truly snowflakes—the basics are the same, but there are little variations all over our bodies, and that is what we can SEE. There are untold individual variances, chemically and microscopically, which we can only imagine. With that much diversity at the cellular (and sub-cellular) level, imagine the vast variability at all levels at once when it comes to disease process and drug or nutrition intake!

But, as physicians we are supposed to stick to absolute guidelines and certain measuring tools to satisfy some lofty powers that be, guidelines that were established based on the same kind of studies as the CREST study that we looked at above, which has excluded some patients from the study??!!

This kind of “logic”, once one really thinks about it, is not consistent with what we were taught in medical school. We were taught that life is NOT composed of absolutes, but a vast amount of variance that means we can only give it our best guess as to what we should do (if anything) in any given circumstance.

As a direct primary care physician—one paid by the number of members DPC has, NOT the number of patients I see in a day—I do not have any Meaningless Use mandates from the federal government forcing me to follow guidelines.  I can tell you what the recommendations are, whether it is for the care of those with Diabetes Mellitus or for breast cancer screening; but, my pay is not tied to meeting certain bullet points in a bureaucrat’s mandated guidelines. Therefore, I will tell you the guidelines, but if I don’t think those guidelines necessarily apply to YOU, we will discuss our options. I do believe I need to know the guidelines, and I need to know the options; however, it is your decision since your body still belongs to you and no one else.

And, you can trust I’ll roll my eyes or argue in anger whenever anyone suggests I need to consider the good of the community/society/public/world over the good of YOU, the individual. I don’t WORK for the community, society or the public—I work for you, my patient.