Good Doctor, Bad Doctor- Call Someone that Cares

As much as most of us complain, it is truly a privilege to be a physician in the United States. There have been tons of articles and posts about “what it’s like to be a doctor,” but this submission focuses on what it takes to be a good (or a bad) one. The truth is that though we’re talking about physicians here, this can be applied to ANY type of worker, from doctors to cashiers, to accountants, to flight attendants, etc…

After a while, as much we’re taught not to judge, anyone in any medical community develops a sense of who’s “good” and who’s “bad” at their job. It’s fascinating to see how this happens as invariably, it is entirely subjective. His good is her bad and vice versa. Increasingly people are reaching for more formal resources as guidance; however, the criteria that are being used to pass judgment are inconsistent at best. From hard facts like readmission rate, LOS, and hospital-acquired infections to several years in practice, the prestige of medical school/residency program, and social status to hours the office is open, reviews of office staff, and office address. A patient even once told me that he chose his doctor because of the electronic health record that was being used in their practice*!! None-the-less, I take issue with all of these quality “metrics”- I say that none of them are as important as would seem at face value…

In my primary role, I feel very fortunate to be looking at hard data all day long. Much of this data is about physician performance, and it often takes an experienced eye to look past all the noise, deep into the data set to uncover the sometimes hidden truth. It is very troubling for me to see someone that I KNOW is a great doctor be labeled as marginal by (complex) data. Our organization’s Physician Status Reports are carefully presented as “point-in-time” assessments of physician performance because they are! Anyone can get better (or worse) at any given metric tomorrow. It’s a continual process of growth and a part of every doctor’s commitment to lifelong learning. Do you think in 2018 doctors have a varying commitment to lifelong learning? But again, all of this is trivial…

So What’s the Answer?

Allow me to explain using a clinical vignette. A 32-year-old female with a fever, no chills, body aches, rhinorrhea (runny nose), anorexia (poor appetite).

What’s the diagnosis? Even my 9-year old would say, “Papa, this is a clear case of viral syndrome- antibiotics are not indicated here. Consider supportive therapy.” We should all be proud of his clinical acumen, for he is right! The point is that virtually anyone (or nowadays any connected device) can take a set of objective facts and perform a Bayesian analysis of the probability of any given diagnosis given signs and symptoms, but is that what a doctor is? I think we would all overwhelmingly agree- No. A “good” doctor is much more than the guts of a good AI-engine. But let’s be more specific about what we mean and maybe even come up with a single, overarching metric for determining quality… read on!!

Some say that a good doctor is a healer- one that heals the patient, i.e., makes them feel better. A good doctor evaluates much more than just the symptoms of the disease but is deeply concerned about the patient overall well-being. Fever and productive cough of rusty-colored sputum is likely pneumonia, but what about the mass in the lower abdomen that eventually suppressed the immune system enough to succumb to the streptococcus pneumonia (that we all have in our normal respiratory flora)? What about the distant history of STDs that exposed the patient to the virus that triggered cancer that led to the mass? Who would think that a patients sexual history would have anything to do with rusty-colored sputum? The answer is a doctor that CARES about her patient enough to spend more than the 30 seconds it would take to make the current diagnosis (and miss the real underlying root cause of the presenting illness). The rest of these findings would take even the most astute clinician a lot more time to elucidate from the average patient- time that they simply don’t have in today’s health care system (12 minutes on average).

Well, We’re All in the Business of Providing Care, Right?

Care is a word that is thrown around all the time, both in healthcare speak and in real life. Care in health care can mean any of the following (according to Google):

  1. Noun. The provision of what is necessary for the health, welfare, maintenance, and protection of someone or something.
  2. Noun. Serious attention or consideration applied to do something correctly or to avoid damage or risk.
  3. Verb. Feel concern or interest; attach importance to something.
  4. Verb. Look after and provide for the needs of.

We most often use the word Care as defined in #1. Apprehensively, I think we often assume that #2–4 are inherent in conversations, but I sometimes wonder if it really is- EVERY TIME. I mean, the majority of healthcare workers care most of the time, but I think there are only a few that care every. single. time. On every interaction, they #2-#4- for these physicians, #1 happens automatically… My friends, allow me to propose that it is these workers that are our BEST doctors, cashiers, accountants, and flight attendants. It’s the ones that #2-#4, every time. Conversely, those that only #1 and don’t actively assume #2-#4, are just having a bad day.

But is it anyone’s fault? Don’t we, as a nation, measure our desired outcomes? I have yet to come across the “CARE” measure in any of our most recent national policies or guidelines. Is Patient Satisfaction a surrogate of Care? Perhaps, but our current patient satisfaction metrics are only accurate for HOSPITALS, not individual doctors. Do we need evidence-based research to know that #2-#4 leads to better outcomes, less opioid-related death, increased patient satisfaction, better patient safety, and less physician suicide? Some would say we do. Do they really #2-#4? Wouldn’t it be great to measure how much they really care?

For most patients, modern medicine has made it easy to diagnose the medical condition, irrespective of the root cause. What modern medicine is increasingly failing to do is: heal the patient. It is my experience that irrespective of what type of #1 you provide, #2–#4 play a HUGE part in the healing process. By definition, Artificial Intelligence will NEVER be human and therefore incapable of providing #2-#4 for the masses, unless the masses change their definition of human first! This is more likely…

Let’s Ask the Right Questions

It turns out that we’re all just off on our frame of reference- it’s about every definition of the word care, #1-#4. The good news about what is being proposed here is that if you agree, you’ll realize that even the idea of “bad” doctors should be impossible… When ANY type of worker stops caring, isn’t that when they should seek something new? Sadly, no physician would disagree that the Care metric has been on a downward trend in the past decade. If it existed, the Care metric could help us all anticipate burnout and engagement waaayyyyy better, but what is really exciting is the potential effect it might have on our process improvement efforts!! How would our care environments look when every single worker #2-#4ed for every single task they performed?

If we all can agree on this proposal, the questions change for every one of our innumerable health care debates. The new question becomes: how can we enable doctors and health care workers to #1-#4 for their patients? Isn’t this what we all want from our health care system? I think we would all gladly pay for this type of care.

*Actually, the best determinant of health care quality is ACCESS to information, so this patient was actually smarter than the average bear.

The Harmful Effects of Smartphone Blue Light

Chances are, you’ve spent pretty much all day staring at screens like the one you’re looking at right now. This highly advanced, beautiful display is designed with very powerful electronic lights that allow developers to present images and videos of any quality for your viewing pleasure.

Several studies are underway to determine the effects of the blue light emitted from smartphones, on your health. From the preliminary results, most experts are anticipating serious repercussions on your health.

What is Blue Light?

Without getting too technical, natural light is composed of ultraviolet, infrared, and visible light rays. Blue light has the highest energy wavelength and is a part of the visible spectrum. In fact, blue light is everywhere, and the natural blue light that we are exposed to in the daytime is beneficial for us.

However, the artificial blue light emitted from digital devices such as smartphones, computers, etc. can be detrimental to health, particularly during nighttime exposure potentially causing damage to your vision, sleep, brain functions, and overall health. The adverse effects appear to be many and are slowly being sorted out in the medical literature.

Adverse Effects of Blue Light

Disturbed sleep schedule
Our bodies follow a natural cycle that allows us to stay awake and alert during the day and helps us sleep at night. However, when you stare at these screens too long and especially before you fall asleep, it affects this natural rhythm, known as the Circadian rhythm.

This leads to a disruption of melatonin production, a hormone that provides your body with the cues for when to sleep. This can make it hard to fall asleep and can completely ruin your sleeping patterns. In turn, prolonged sleep deprivation alone can lead to several serious health issues as described next.

Cognitive impairment

If your sleep is disturbed over a long period of time, it leads to the buildup of neurotoxins, which can result in a vicious cycle making your symptoms worse and worse. Inadequate sleep will eventually affect your cognitive abilities and can affect school/job performance and any situations that require focus.

Memory loss

Sleep rejuvenates and refurbishes brain functions, and a repeated disruption of your sleep cycle will lead to impaired memory function during the day. Disruption in the production of melatonin is the root cause of the disturbance of sleep hygiene.

Impaired immune system

Your immune system produces protective, infection-fighting substances like cytokines while sleeping. Sleep deprivation prevents your immune system from building up cytokines, thus leading to an impaired immune system, thereby making you more prone to contracting infections and falling ill.

Increased risk of diabetes

Diabetes is one of our countries most serious epidemics. One out of every three Americans will be diabetic by 2020. A Harvard study has potentially shown a novel connection between blue light exposure and diabetes. The disruption to the Circadian rhythm can result in a reduction of leptin levels that can cause an increase in blood sugar levels.

Obesity
Disruption in melatonin hormone production can also disrupt the functions of the hormones that control hunger. Coupled with poor dietary habits, consumption of highly-processed food with poor nutritional value will ultimately cause obesity.

Increased risk of cancer

Several studies have linked nighttime smartphones usage to some types of breast and prostate cancer. Again the reduced secretion of melatonin causes lower melatonin levels that have been linked to increased cancer risk.

Harms vision

Some studies have shown that constant staring into our smartphones can lead to damage in vision by harming the retina over time by contributing to age-related macular degeneration. Macular degeneration is a common and severe cause of permanent vision loss and blindness. Studies are also being conducted to evaluate the blue light effect on cataract progression. The thought is that staring too long at your smartphone can result in reduced blinking rates, which in turn causes digital eye strain. This kind of strain on the eyes can lead to irritation in the eyes, dry eyes, fuzzy vision, difficulty focusing, headaches, neck and back pain.

Can lead to depression

When your melatonin levels are disrupted or suppressed by blue light, the resultant disruption of your hypothalamo-pituitary axis has been linked to clinical depression.

Summary and Recommendations

Research on the effects of blue light on the human body is emerging and the results are unsettling. Disruption of your melatonin axis appears to be the mechanism of its detrimental effects, and poor sleep is the vehicle by which they manifest in your body.

Fortunately, there are several steps you can take to limit these effects. The most obvious is to abstain from looking at screens after sundown. This can be unrealistic for some in which case the use of blue light filtering glasses can significantly reduce its impact. If that’s not stylish enough for you, many smartphones come equipped with a “night-mode” which programmatically turns off the blue light after dark. Enabling this function is generally a pretty straightforward process and can be found online by a simple web search on the model of your phone with the search terms “blue light filter.” Finally, taking melatonin supplements may also be beneficial in tempering the potentially dangerous effects of blue light.

Don’t End Up as NASHty as I Was…

by
Baber Ghauri, MD

Don’t Tread on Me

American FlagI am an American.  I believe in democracy and freedom of speech and choice.  Like any American, I vote with my dollar and take advantage of all the liberties that having some dollars affords me.  I started medical school in 1997, giving me almost 20 years in the noble field of health care- at least 12+ as a board-certified attending physician.  I also feel privileged to have had the opportunity to be recognized for many other honors and appointments, both clinically and otherwise.  My strong Punjabi heritage makes me a Foodie- like Americans, Punjabi’s can eat!  With the strong exception of pork, the Pakistani diet is pretty much meat, meat, and meat- sound familiar?  If you’d rather, stop reading right here, my Pakistani-American heritage is the double whammy that forms the basis of what I’m about to tell you.

I write this blog post today because I know I have friends, patients, and family members that are in the same boat.  Those of you that know me know that, like so many other physicians, my wife (also a board-certified physician) and I recently underwent a bit of a transformation, I’m talking in excess of the clinical transformation that everyone in health care is going through.  The additional growth we’ve experienced is the underlying reason for the inefficiency and poor performance we are trying to correct in health care.  It is undermining our entire health system, and it’s my obligation and professional duty to share my experience.  Going through this has made me a better physician, a better father, a better friend, and a better member of our great society.  Maybe it’s a reverse mid-life crisis, either way; it started about seven years ago with the result of a routine blood test.

I Was Fine!

I had a very mild transaminitis, which means my liver chemistry was a little off- barely a smidgen above the upper limit of normal.  I felt fine.  I played basketball and tennis regularly and arguably in the best form of my athletic career.  I was 6′ 1″ and weighed about 170ish lbs.  This translates into a body mass index (BMI) of about 23, which is well within a normal, healthy range.  Throughout my life, I’ve always been the skinny, lanky guy that could use a few extra pounds.  Having never been one that likes to nap during the day, I noticed here and there that I would feel drained and would often fall asleep right before dinner time.  Thinking back, I recalled that my father also often fell asleep when he came home from work, so I figured this was “normal.”  I saw my outstanding primary care doctor- he was mildly concerned about my findings and appropriately wanted me to get a liver ultrasound to see what was going on.  But I never did.  I was fine!!  I decided I would recheck in 3 months- though not exactly supported by the evidence, and this was not entirely unreasonable for a patient that wanted to take a conservative approach, or at least that’s what I convinced myself.
ABIMThe diagnosis was already clear to me- lab error.  After all, I had nothing!  I was fine!!  No complaints!  I was wayyyyy too busy to worry about it.  Guess what else…  I never even got tested again- I was soooo sure.  Hey, I am certified by the American Board of Internal Medicine and licensed by the State of Pennsylvania to know what’s up!!  Who knows better than me- no one!!  Time went on, I changed nothing, and a couple of years later the drained feeling became more frequent (by this time my weight jumped up to near 190 lbs), but I was still performing at a high level and doing the things that I needed to do- I continued to sweep it under the rug.

Wake Up Call

It was my Integrative Medicine training that caused me to reflect on this experience, and after I sustained a moderate injury to my knee (in part due to the additional weight), I finally realized that I was in denial.  The results were suggestive of either NASH (non-alcoholic steatohepatitis) or NAFL (non-alcoholic fatty liver)*- both fancy words for liver inflammation.  It was mild, but I was genuinely astonished- it was tough for me to accept and maybe that’s why I never followed through with the definitive ultrasound that would have confirmed it in the first place.  The liver has a very high tolerance for insult, but once it’s mad, can cause serious misery.  Mine was JUST beginning to get annoyed with the drained feelings I was having.
Even after I finally came to grips with the diagnosis, it took me another 1-2 years to get to my current station- as of mid-2016, I’ve:
  1. Basically given up soda and sugary drinks, especially those with high-fructose corn syrup.
  2. Reduced my meat consumption to very little red meat
  3. Pretty much eliminated processed meat (the World Health Organization has classified all processed meats as class 1 carcinogens- yes this means they can cause cancer)

    Processed meat is a Class 1 carcinogen
  4. All but eliminated oxidized cholesterol consumption (fast food or foods cooked at high temperatures)
  5. Memorized the Bristol stool scale and try to keep track (the disgusting link, what do you want me to do?  I’m a doctor!  The funny thing is that my 8-year old knows it better than I do!)
  6. Increased fish and seafood intake (wild caught, not farm-raised)
  7. Essentially cut out dairy, but was never really a big dairy person in the first place
  8. Tremendously increased my fruit, nut, legume, and vegetable consumption (which I always loved anyway)
  9. Basically stopped using my microwave (microwaves can wreak havoc on the nutritional value of good food)
  10. Focused heavily on staying hydrated
  11. Perhaps most importantly, I tremendously reduced my intake of sugary foods (I actually read labels now)
Having just returned 12 lbs heavier from a 2-week long family road trip, I need to reiterate that I am FAR from perfect!!  This was an incredibly fun time eating primarily at restaurants but also making many trips to the markets to maintain that fruit and fiber intake.  If not for this, that 12 lbs could easily have been 18 or 20!  Even still, just one day afterward, I dropped 2 lbs and anticipate to shed at least another pound of water weight from all that salty restaurant food.  And I have no doubt that the remaining weight will also come off now that I’m back to my usual routine that is mostly based on whole foods and home cooking.  Even still, given the decreasing nutritional value of food, it is becoming even harder to consume the right amount of dietary nutrients, but I digress…
The best part of all this is that I really do like the way I eat now as compared with prior; therefore, I insist that I am NOT on a diet.  I still eat “bad” things like cookies, cakes, iced tea, hot dogs, and many, many others- BUT at least now I KNOW what these things are doing to me.  There’s a difference.  The brain is extremely powerful, and I believe that knowing allows the body to better combat the effects of these harmful foods.  For example, I recently noticed that I tend to crave more green leafy vegetables when I eat, let’s say a cheesesteak (see- I’m far from perfect).  This is probably because my BRAIN knows the fiber causes less absorption of the oxidized cholesterol and carbohydrates.  In other words, this was something I feel I did subconsciously and wasn’t “on purpose” per se- it was something I realized after the fact.  But now it is more purposeful.

Exercise? Not so much…

Now for the controversial topic- EXERCISE.  I don’t do it…  well, let me clarify, I exercise like crazy, but it’s not “going running” and “going to the gym” exercise, but more like playing with my kids, playing basketball, other cardiovascular activities, and doing my own home improvement projects type of exercise.  In other words, I don’t say I exercise, I say I’ve increased my activity- tomato/tomahto to some, but important for me- because I have never liked to “exercise”.  For those who DO like to exercise, they should exercise!!  They should just know there is increasing evidence that intense exercise more than 3-4 days a week (especially with no recovery days) increases MORTALITY!!  Yes, this means they die sooner than those who don’t!!  But I digress again…  It’s my opinion that exercise itself only has a mild effect on body fat and weight loss- I believe that when you’re spending 1-2 hours a day exercising, that Big Mac just doesn’t taste the same and you think twice about the next one.  It’s my opinion that every pound of fat lost or transitioned to muscle growth is 80% due to diet and only 20% due to exercise.  Here’s some evidence on diet vs exercise in weight loss.

Fast forward to 2016 (before my vacation), I was back to my 172 lbs, and although my weight has redistributed a bit, there is no question I have a bit more truncal obesity than I would like- I’m developing Metabolic Syndrome X which is a precursor to type 2 diabetes mellitus.  My Dad has been on years and years of drug therapy for type 2 DM, and until recently, I was taught that it’s primarily genetic and there was little to no chance that I would be able to avoid it- I thought it was inevitable for me…  But no longer!  Not only can type 2 DM be prevented, but type 2 DM can even be reversed if you do get it!!!  But why didn’t I know this before?  Why are we NOT teaching this to our medical students?  Ok, maybe I’m just out of touch- but why do almost none of my colleagues know what it is?  Why??  Could it be because frosted Lucky Charms are NOT “a part of a nutritious breakfast”?  They do magically create a delicious 40%+ profit margin- but I digress again.

Knowledge is Power

I DON’T HAVE TO BE DIABETIC- I have a choice!!  What a great country!  It is this hope that has driven me to do better for myself.  I share my story with you today because I thought everything was fine- it wasn’t.  I thought grocery stores were there to provide food, not make as much profit as they possibly could.  I thought the nutritional powers that be were keeping an eye on the American diet and magically working behind the scenes so that I could not possibly buy food that was bad for me!  I was wrong.
If I hadn’t come to these realizations, I would probably be diabetic by now or worse.  I would be at high risk for cryptogenic cirrhosis (liver failure) if I really had NASH*.  Those that know me well know that this experience has been profound for me- I think it has saved my life.  I know now that it is NOT EXPECTED to develop high blood pressure, coronary artery disease does not need to be a normal thing that happens to everyone, dementia is not a “normal part of aging”- all of these things have reasons- some we know already, but many we do not.  Most significantly, it is NOT NORMAL to be on prescription drugs to counteract the effects of these diseases for the rest of your life.  Like any of my colleagues, for at least one decade I have prescribed a countless number of these drugs and told countless patients and family members that they will need to be on them for the remainder of their life.  With the help of our growing medical community of integrative practitioners, we need to now work on safely getting people OFF their chronic medications and shifting them to a treatment plan that is rooted in non-prescription interventions- we can’t afford them!  IT IS POSSIBLE!!!  I didn’t know it was before, but I feel blessed to have learned many of these strategies.

Food is Medicine

Pharmaceuticals will always be necessary for patients that are the sickest of the sick as well as for infections, symptom control, and secondary disease prevention.  But do we need them to poop?  Do we really want to believe that we should eat whatever we want and have to rely on pills to eliminate it from our body?  Who do you think benefits from this idea?

Drugs will have a place for people that can’t or otherwise don’t want to recognize that FOOD IS MEDICINE and that you can’t exercise off the detrimental effects of Kentucky Fried Chicken, you have not to eat it in the first place…  These poor patients are doomed to a lifetime of prescription medications and doctor visits- just like many of my now deceased patients and family members- even though I continue to have bad eating habits, I feel fortunate and even empowered that I now have the choice to remove this from my personal destiny.  But I also feel concerned that it took me almost ten years to get to this point.  As a physician, shouldn’t it have been much faster?  In many ways, I feel my original training made it HARDER for me to accept these realizations.  Had it not been for my integrative medicine training, there’s a near 100% chance that you would not be reading this right now.

I’ve learned that my Pakistani-American approach to eating IS the root cause of my health issues.  There’s a reason that immigrants from China, Africa, and Sweden die from the same coronary artery disease that kills every other American in our country- my friends, I’m extremely sorry to tell you it is our food choices that are making us sick.  I wish it wasn’t, but it is…  I’m not talking about the hamburgers and hot dogs, and I’m talking about everything!!  Even the dairy, the GMO vegetables, the concentrated animal feeding operation (CAFO) meat, and the “healthy” fast food!  Please prove me wrong if you think otherwise!!  I beseech you to convince me, and I love KFC!!  But until then, I need to do my best to set an example for my children, family members, patients, and all others around me- it has not been easy, but it has at times been quite fun.  I’m on a mission, and the good news is that I’m not alone…

It is reassuring that some of the smartest people I know are choosing not to look the other way and are independently coming to the same realizations.  The challenge is bringing this knowledge into today’s practice, which is becoming increasingly standardized.  This means we doctors need to understand the data and stop following the status quo if it doesn’t make sense- even if it’s a protocol.  With the current fiduciary position of our health system, reform, and adoption of the BEST possible means to increase the quality and reduce the cost of healthcare is inevitable.  Can the care of our sickest patients be protocolized?  I happen to believe some of it can, but we need to THINK creatively about each patient’s care BEFORE we institute protocols.  It turns out the sickest patients often require an individualized care plan.  This is the basic philosophy of Integrative Medicine- consider all evidence-based interventions, not just the ones that are traded during business hours on Wall Street.  The stakes are so high for pharmaceuticals now that increasingly we see trusted authorities looking the other way when it comes to sound process and logical reasoning to get the desired outcome, aka fraud.  Forget the human element, just thinking as an economist might, our health system has declared that we can’t afford to make these mistakes anymore- we just don’t have the money to pay for them.  But I digress again again again.

Summary

I have been extremely naive about the food that I’ve been consuming throughout my life.  There is increasing evidence that food that is processed or high in animal fat can be deadly to the human body- duh?!?!  Even being in relatively great shape, I probably started to develop a potentially very serious condition of my liver that can eventually lead to diabetes and serious health issues.  It’s my opinion that not only my patients but also a large percentage of my friends and family are also at extremely high risk to have NAFLD.  I share this personal message with you today because I’m concerned.  I’m concerned about how this happened to me so insidiously.  I also feel it is my duty and responsibility as a physician and a member of our society to share the knowledge that can benefit others.  If you have a family history of diabetes, have transaminitis, or are starting to have truncal obesity- see your doctor NOW.  Most of us doctors are not well-trained to discuss how your nutrition can very often reverse your illness- that’s OK, MAKE THEM learn or seek assistance!!  Finally, we all need to rethink our food choices- vote with your dollar, stop buying foods that have ingredients that you cannot pronounce and buy organic whole foods that are locally sourced.

More to come, this is important stuff- thank you for reading my story, your comments (yay or nay) are welcome…

*NAFLD stands for non-alcoholic fatty liver disease which is subdivided into NASH and NAFL.  As much as I would LOVE to talk about the pathophysiology of all the diseases mentioned in this post, others have already done a much better job than I could, and I encourage you to reference your favorite medical knowledgebase for more information.