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Latest Posts

How Much Water Are You Supposed To Drink? Your Urine Will Tell You

Perhaps you’ve heard that increasing your water intake is part of a healthy lifestyle – and that you should drink at least 8 glasses of a day. This “rule of thumb” is actually not based on scientific evidence. Although for many people it’s not harmful advice, you may not need to work so hard at getting enough water every day.

The amount of water that your body needs depends on three main variables (yes, needs can vary with different illnesses and conditions, but let’s talk about the average American):

1. Your body’s size

2. Your activity level

3. Your environment (weather and humidity conditions)

The larger you are, the more water you lose from sweat (be it from physical activity or hot weather conditions), the more water you need to replace. The amount you need can vary a lot – and in most cases there are two tricks you can use to stay properly hydrated: Read more »

Seven Secrets To Successful, Long-Term Weight Loss

Most people who have lost weight understand how easy it is to gain it back. In fact, I often hear patients tell me that over the course of their lifetimes they’ve “tried every popular diet out there” and yet have failed to keep the weight off permanently. If that’s your situation, you’re not alone. It’s estimated that only 20% of overweight individuals are successful at long term weight loss. But there is hope for success, and we can learn the secrets of “successful losers” from the National Weight Control Registry.

In a flash of brilliance, sociologist Rina Wing and psychologist Jim Hill decided to create a database of weight loss success cases, and simply observe how they live their lives over decades of time. They called this research study the National Weight Control Registry, and it has been enrolling study subjects since 1994.  What they’ve found is that those who have been successful at losing at least 30 pounds and keeping that weight off for at least 1 year share many behaviors in common. I believe that the closer we follow in the footsteps of these successful people, the more likely we are to be fit for a lifetime. So here goes – this is what the study subjects report: Read more »

The Potential Risks And Benefits Of Vitamins: A Look At The Evidence

The discovery of various vitamins – essential micronutrients that cause disease when deficient – was one of the great advances of modern scientific medicine. This knowledge also led to several highly successful public health campaigns, such as vitamin-D supplementation to prevent rickets.

Today vitamins have a deserved reputation for being an important part of overall health. However, their reputation has gone beyond the science and taken on almost mythical proportions. Perhaps it is due to aggressive marketing from the supplement industry, perhaps recent generations have grown up being told by their parents thousands of times how important it is to take their vitamins, or eat vitamin-rich food. Culture also plays a role – Popeye eating spinach to make himself super strong is an example this pervasive message.

Regardless of the cause, the general feeling is that vitamins Read more »

*This blog post was originally published at Science-Based Medicine*

Healthy Eating: It All Boils Down To 3 Pieces Of Advice

I’m proud to have been selected as the national, nutrition (“mind”) coach for the Boys & Girls Clubs’ Triple Play Fit Family Challenge. This is a 6-week challenge – five families (you can meet the families on the Fit Family Challenge blog) will compete for a grand prize: an all-expenses-paid vacation!

My job is to support the families with evidence-based nutritional information that they can use to establish lifelong healthy eating patterns. Proper nutrition is one of the most critical components of preventive medicine, and can help to reduce the risk for America’s top 3 killer diseases: heart disease, cancer, and stroke (not to mention type 2 diabetes, osteoporosis, and high blood pressure). If these families help their kids to adopt healthy lifestyles now, they will have a lower lifetime risk of many major diseases. And I hope that the kids will also become evangelists for healthy eating to their peers!

I’ve been thinking a lot about what I’ve learned over the years as a nutrition journal editor, avid foodie, and rehab physician, and I think that (to begin) I can truly boil down all we know about American eating habits into these three pieces of advice (note that these are based on HHS’s Dietary Guidelines For Americans, 2010): Read more »

Should Med Students Be Taught How To Maintain A Healthy Lifestyle?

Last week I wrote a simple post on eating yogurt with fresh fruit for lunch. It wasn’t until later that I realized why it’s a medical lesson.

It happens that yesterday morning I was up and out early. I saw a former colleague walking along the street. He’d gained weight, and walked slowly. I thought about how hard he works, and what a good doctor I know him to be. And yet any citizen or patient might size him up as heavy, maybe even unhealthy.

The problem is not that he’s uneducated or can’t afford nutritious foods. He knows fully about the health benefits of losing weight and exercise. The problem is the stress and long hours of a busy, conscientious physician’s lifestyle.

When I worked as a practicing doctor and researcher at the hospital, I rarely ate a nutritious breakfast or lunch. My morning meal, too often, consisted of Read more »

*This blog post was originally published at Medical Lessons*

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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