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What To Expect If You Get The Flu

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One of my dear friends just came down with influenza, and she asked me for some advice. Top of mind questions included – When can I go back to work? And when will I get better? So in a nutshell, here’s what I told her (borrowing heavily from the CDC website):

  1. The most common flu symptoms are: Fever or feeling feverish/chills; Cough; Sore throat; Runny or stuffy nose; Muscle or body aches; Headaches; Fatigue (feeling very tired)
  2. Adults shed influenza virus from the day before symptoms begin through 5—10 days after illness onset. However, the amount of virus shed, and presumably infectivity, decreases rapidly by 3—5 days after onset.
  3. Most experts believe that flu viruses spread mainly by droplets made when people with flu cough, sneeze or talk. These droplets can land in the mouths or noses of people who are nearby. Less often, a person might also get flu by touching a surface or object that has flu virus on it and then touching their own mouth, eyes or possibly their nose.
  4. Uncomplicated influenza illness typically resolves after 3—7 days for the majority of persons, although cough and malaise can persist for >2 weeks.
  5. The 2011–12 U.S. seasonal influenza vaccine virus strains are identical to those contained in the 2010–11 vaccine. Annual vaccination is recommended even for those who received the vaccine for the previous season. Vaccination is the most effective prevention strategy available to reduce your risk of catching the flu.
My suggestions: Don’t go in to work (if you have the option) until 5 days after illness onset. If you go in earlier, you can wear a little face mask (and use Purell or other alcohol-based hand sanitizer) to prevent spread of the virus. Next year, get your flu shot early in the season.
As far as treatment is concerned, the Mayo Clinic recommends: LIQUIDS, REST, and TYLENOL or IBUPROFEN for pain. No vitamins or supplements have been shown to shorten the course of the flu.
P.S. My suggestions are relevant for “garden variety” flu sufferers. If you are immuno-compromised, elderly, or otherwise in a high risk category, please check out the CDC website for more information.

Motivation Is More Important Than Information At Reversing Obesity

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I recently found my way to an interesting NPR podcast via a link from Dr. Ranit Mishori (@ranitmd) on Twitter. The host of the show interviewed a physician (Dr. Mishori), an obesity researcher (Sara Bleich), and a family nurse practitioner (Eileen O’Grady) about how healthcare providers are trying (or not trying) to help patients manage their weight. Several patients and practitioners called in to participate.

First of all, I found it intriguing that research has shown that the BMI of the treating physician has a significant impact on whether he or she is willing to counsel a patient about weight loss. Normal weight physicians (those with a BMI under 25) were more likely to bring up the subject (and follow through with weight loss and exercise planning with their patients) than were physicians who were overweight or obese. Sara Bleich believes that this is because overweight and obese physicians either don’t recognize the problem in others who have similar body types, or that their personal shame about their weight makes them feel that they don’t have the right to give advice since they don’t practice what they preach. While 60% of Americans are either overweight or obese, 50% of physicians are also in those categories.

Although it’s not entirely surprising that overweight/obese physicians feel as they do, it made me wonder what other personal conditions could be influencing evidence-based patient care. Is a physician with high blood pressure less apt to encourage salt restriction or medication adherence? What about depression, smoking cessation, or erectile dysfunction? Are there certain personal diseases or conditions that impair proper care and treatment in others?

Several callers recounted negative experiences with physicians where they were “read the Riot Act” about their weight. One overweight woman said she handled this by simply avoiding going to the doctor at all, and another obese man said his doctor made him cry. However, the man went on to lose 175 pounds through diet and exercise modifications and said that the “tough love” was just what he needed to galvanize him into action.

Dr. Mishori felt that the “Riot Act” approach was rarely helpful and usually alienated patients. She advocated a more nuanced and sensitive approach that takes into account a patient’s social and financial situation. She explained that there’s no use advocating personal training sessions to a person on food stamps. Physicians need to be more sensitive to patients’ living conditions and physical abilities.

In the end, I felt that nurse practitioner Eileen O’Grady contributed some helpful observations – she argued that the rate-limiting factor in reversing obesity is not information, but motivation. Most patients know what they “should do” but just don’t have the motivation to start, and keep at it till they achieve a healthy weight. Ms. O’Grady devoted her practice to weight loss coaching by phone, and she believes that telephones have one big advantage over in-person visits: patients are more likely to be honest when there is no direct eye contact with their provider. Her secret to success, beyond a non-judgmental therapeutic environment, is setting small, attainable goals. She says that if she doesn’t believe the patient has at least a 70% chance of success, they should not set that particular goal.

Starting goals may be as simple as “finding a workout outfit that fits.” As the patient grows in confidence with their successes, larger, broader goals may be set. Weight loss coaching and intensive group therapy may be the most motivating strategy that we have to help Americans shed unwanted pounds. Apparently, the USPS Task Force agrees, as they recommend “intensive, multicomponent behavioral interventions”  for those who screen positive for obesity in their doctors’ offices.

I think it’s unfortunate that most doctors feel that they “simply don’t have time to counsel patients about obesity.” Diet and exercise are the two most powerful medical tools we have to combat many chronic diseases. What else is so important that it’s taking away our time focusing on the “elephant in the room?”  Pills are not the way forward in obesity treatment – and we should have the courage to admit it and do better with confronting this problem head-on in our offices, and also in our own lives.

How To Have A Healthy Old Age: Food For Thought On Labor Day

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I’ve spent the last couple of weeks making house calls to “at risk” seniors in rural South Carolina. At the rate of about 7 house calls per day, I was able to make some observations based on a respectable sample size. I was both surprised and intrigued by the living conditions I encountered, and I’m pleased to report that I have now performed my first physical exam under the careful scrutiny of a cat, rooster, and hen team (photo at left). On another house call I was offered a pygmy goat as a thank-you for my efforts, and countless good-natured folk offered me home made iced-tea and such edible delectables as fish patties and peach honey.

But what struck me the most was that certain seniors were in far better health than others their age, and that the healthier ones all had one thing in common: strict daily exercise regimens. I realize that this is not ground-breaking news (that exercise is good for us), but the stark contrast between those who exercised and those who didn’t could not have been clearer to me.

One particularly charming 85 year old man gave me a tour of his vegetable garden, and explained that he bicycled into town six days a week to give away okra (and other veggies) to church friends and town folk. Growing vegetables and giving them away was his current life’s work, and although he lived in extremely modest circumstances, what he owned was tidy and clean. He was joyful, bright, and had the physique of an athlete.

Contrast this man to another patient in his 80’s who didn’t exercise at all, and stayed inside smoking cigarettes most of the day. He was blind in one eye, nearly deaf, struggled to breathe, had sores on his skin. He was depressed, over-weight, and swollen from heart failure. I was so sad to see his condition, and the relative squalor in which he lived. Urine and smoke odor permeated the house, and I wondered how much longer he would survive.

When I arrived at another octogenarian’s home, I noted that the garage was filled with watermelons of various sizes. Upon further inquiry, the gentleman said that he had hand-picked the watermelons from a plot of land that he owns 2 miles from his house.  He brought them back to the house with a wheel barrow… and had made many trips back and forth over the past week. He was taking no medications and had a completely normal physical exam.

And so my days went – back-to-back visits with seniors who either were engaged in an active lifestyle, or who were wasting away, cooped up indoors with advancing dementia and chronic disease. I realized that no medical treatment has the power to overcome the relentless damage that inactivity, smoking, and deconditioning cause. The secret to a healthy old age lies in lifestyle choices, not pill bottles.

As we enjoy the last holiday weekend of the summer, let’s consider how important labor actually is to our mental and physical well being. You’re never too old to haul watermelons down the road, grow okra for your neighbors, or simply commit to smoking cessation and daily walks. If you do this regularly, your health will surely improve – and your quality of life will be enhanced immeasurably. In the end, adding life to years is what medicine is all about.

Are Women More Motivated By A Chubby Fitness Trainer?

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I was taken aback by a recent conversation I had with a gym owner. She is interested in encouraging middle-aged women to come to the gym for beginner-level fitness classes and was planning a strategy meeting for her staff and key clients. I asked if I could join and she said that I was expressly un-invited. Slightly miffed I asked why that was so – after all, I’m a rehab physician who has devoted my career to getting people moving.

“You’re too advanced.” She said. “Beginners wouldn’t relate to the way you work out, we’re really more focused on creating a less intimidating environment for women.”

“You mean, like the Planet Fitness ads? The ones where athletes are not welcome?” I asked, confusedly.

“I don’t like those ads but the idea is the same. Beginners feel deflated by working out with people who are in far better shape. They don’t even want their instructor to look too fit.”

“You’re kidding me. Women would actually prefer working out with a chubby trainer?”

“Yes. In fact, I’ve had some women come to the gym and actually request NOT to be paired up with some of our personal trainers specifically because they look too fit. They are afraid they will be asked to work too hard, beyond their comfort zone.”

“So why are they coming to the gym in the first place?” I asked. “What is motivating them if they don’t want to work out hard or change their bodies in the direction of athletic-looking trainers?”

“They’re just interested in staying the way they’ve always been. Maybe they’ve started putting on weight after they hit their 40’s and 50’s and just want to get back to where they were in their 30’s. They’re not interested in running marathons or lifting the heaviest weights in the gym. They don’t want to be pushed too hard, and they prefer trainers who look healthy but not extreme.”

Medically speaking, it doesn’t take extreme effort to be healthy. Many studies have shown that regular walking is adequate to stave off certain diseases, and weight loss success stories (chronicled at the National Weight Control Registry for example) usually result from adherence to a calorie-restricted diet and engagement in moderate exercise.

In a sense, these women who “don’t want to work that hard” are right – they don’t have to perform extreme feats to be healthy. However, I am still fascinated by the preference for “average looking” trainers and the apparent bias against athleticism. This must be a fairly common bias, though, because national gym chains (like Planet Fitness) have picked up on it and made it the cornerstone of their marketing strategy. “No judgments” – except if you’ve got buns of steel, I guess.

When I choose a trainer I am looking for someone who embodies the best of what exercise can offer. An athlete who has practiced their craft through years of sweat and effort… because that’s my North Star. Sure, I may never arrive at the North Star myself, but I like to reach. And that’s what motivates me.

But for others, having a professional athlete for a trainer may be a mindset misfit. If your aspiration is to be healthy but not athletic, then it makes sense to find inspiration in those who embody that attitude and lifestyle. The important thing is that we all meet the minimum exercise requirements for optimum health. According to the CDC, that means:

* 2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) every week

and

* muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest,  shoulders, and arms).

How you get there, and with whom you arrive, is up to you. Chubby or steely – when it comes to health and fitness the best mantra is, “whatever works!”

Should Patients Have Access To Lab Test Results Before Their Physician Reviews Them?

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Six weeks ago I had a skin lesion removed by a plastic surgeon. About 7 days after the biopsy, I received a letter from the pathology lab where the sample had been analyzed under a microscope. I eagerly opened the letter, assuming that it contained test results, but was disappointed to find a bill instead. As a physician, it felt strange to be in a position of having to wait for a colleague to give me results that I was trained to understand for myself. However, I knew that in this case I was wearing my “patient hat” and that I’d need to trust that I’d receive a call if there was an abnormality. I haven’t received a call yet, and I assume that no news is good news. But what if no news is an oversight? Maybe there was a communication breakdown between the path lab and the surgeon (or his office staff) and someone forgot to tell me about a melanoma? Unlikely but possible, right?

Patients experience similar anxiety in regards to lab tests on a constant basis. In a perfect world, they’d receive results at the same time as their doctors, along with a full explanation of what the tests mean. But most of the time there’s a long lag – an awkward period where patients have to wait for a call or make a nuisance of themselves to office staff. Shouldn’t there be a better way?

The New York Times delves into the issue of “the anxiety of waiting for test results,” with some helpful tips for patients in limbo:

As patients wait for test results, anxiety rises as time slips into slow motion. But experts say patients can regain a sense of control.

  • Start before the test itself.
  • Because fear can cloud memory during talks with doctors, take notes. If you can, bring a friend to catch details you may miss.

Some pretest questions:

  • What precisely can this test reveal? What are its limitations?
  • How long should results take, and why? Will the doctor call with results, or should I contact the office?
  • If it’s my responsibility to call, what is the best time, and whom should I ask for?
  • What is the doctor’s advice about getting results online?

Do I think that patients should have access to their results without their physician’s review? While my initial instinct is to say “yes,” I wonder if more anxiety may be caused by results provided without an interpreter. There are so many test results that may appear frightening at first (such as a mammogram with a “finding” – the term, “finding,” may mean that the entire breast was not visualized in the image, or that there was a shadow caused by a fatty layer, or -less commonly – it can also indicate that a suspicious lesion was observed). I’m not arguing that patients can’t understand test results on their own, but medicine has its own brand of jargon and nuances that require experience to interpret.

Consider the slight deviations from the mean on a series of blood tests. They can be perfectly normal within the patient’s personal context, but may simply be listed by the lab as high or low. This can cause unnecessary anxiety for the patient. And what about PAP smear results that are listed as “ASCUS” – atypical squamous cells of undetermined significance? These can occur if the patient merely had recent sexual intercourse, and are not necessarily indicative of cancer at all.

And what about the “ambulance chasing lawyers” out there? Will there be additional frivolous law suits created by lab test results reported direct-to-consumer as abnormal in some way (when they really aren’t, given the full clinical picture) and patients assuming that their physician was negligent by not reporting the abnormality to them sooner? It could happen.

In the end I think that physicians all need to make a concerted effort to forward (with an explanation when necessary) lab test results to patients as quickly as possible. But since doctors are the ones ordering the tests in the first place, they do have a right to see them (before the patient when appropriate) – and an obligation to pass on the information in a timely and fully explained manner. That’s the value of having a physician order a test – their expertise in interpreting the results are part of the package (and cost). When patients order their own tests (and in some cases they can) then they should be first to receive the results.

As for me, I’m going to have to resort to “office staff nuisance” to get my results confirmed… just like any other regular patient. Oh well. 😉

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