TLC - Exercise

Exercise is important for so many things! Research (see references below) indicates that it can:

• Increase your energy level
• Increase your sex drive
• Decrease your appetite
• Help you lose weight
• Make you happier
• Help you sleep better
• Make you live longer
• Be enjoyable
• Improve or eliminate chronic diseases (high blood pressure, diabetes)
• Make you feel better about yourself
• Help you make friends
• Prevents or delays onset of dementia
  
• Improves cognitive function

While almost everyone knows exercise is good for you, many people find it hard to get started or stick with exercise. Here are some tips for you if you find it hard to exercise:

1. Don't exercise, just be more active. You know this one already - take the stairs instead of the elevator, use your fingers to change the TV channel rather than the remote, take the parking spot that is farthest away from the store. This type of activity really does help!
2. Resurrect an old love. I recently started ballet classes and playing on a soccer team again - things I haven't done since college. It is great. Not only does it not feel like exercise (okay it feels like exercise when I am running down the soccer field) but it brings up a lot of great memories for me as well.
3. Find a partner. If you exercise with someone else (even if it is a paid personal trainer) you are more likely to stick with it. Since everyone should be exercising, it should be easy to find someone who needs to exercise too.
4. Rotate your activities. Exercise, like a lot of other things, can get boring if you do the same thing day in and day out. Sign up for a new class at your gym, do different activities in each season, try something new.
5. Do it for at least 6 weeks. Exercise feels good, but is a hard habit to keep and an easy habit to lose. Just commit to 6 weeks. I bet you will miss it if you don't do it after 6 weeks. That will make it easy to keep doing.
   
6. Beware of schedule changes. Starting a new job, changing gyms, a change in the seasons, a new school year are all things that can cause your schedule to change and make it easy to let exercise go. Whenever you are looking at a new schedule, make sure you schedule exercise too.
   

References:

Chakravarty EF, Hubert HB, Lingala VB, Fries JF. Reduced disability and mortality among aging runners: a 21 year longitudinal study. Arch Int Med 2008;168:1638-46.

Johansson M, Hassmen P. Acute pscyhological responses to Qigong exercise of varying duration. Am J Chin Med 2008;36:449-58.

Liu MR, So H. Effects of Tai Chi exercise program on physical fitness, fall related perception and health status in institutionalized elders. Taehan Kanho Hakhoe Chi 2008;38:620-8 [Abstract].
Martinsen EW. Physical activity in the prevention and treatment of anxiety and depression. Nord J Psychiatry 2008;62:25-9.

Plaisance EP et al. Postprandial triglyceride responses to aerobic exercise and extended-release niacin. Am J Clin Nut 2008;88:30-37.

Rolland Y. Physical activity and Alzheimer's disease: from prevention to therapeutic perspectives. J Am Med Dir Assoc 2008;9:390-405.

Family Doc: Family Doc: TLC - Sleep

Family Doc: Family Doc: TLC - Sleep

Family Doc: TLC - Sleep

Family Doc: TLC - Sleep
http://www.blogcatalog.com/directory/health/general-health

TLC - Sleep

Okay, sleep is not an "official" part of therapeutic lifestyle change, but I consider it the foundation of your ability to carry out the other components. It is nearly impossible to gather the motivation to exercise if you are exhausted getting out of bed in the morning. Reaching for sugary or caffeinated beverages is natural if your energy is lagging. And, carrying a sleep deficit sets you up to be stressed out - therefore making it more difficult to make positive changes like quitting smoking.

Research indicates that it is ideal to get between 7 and 9 hours of sleep, so the old adage to get 8 hours per night has some data to back it up. Both too little and too much sleep are associated with not only feeling poorly but a higher risk for death and disease.

Getting 8 hours of sleep each night is challenging for a lot of reasons:
1. You don't have 8 hours to spare.
2. You enjoy staying up late to spend time with your spouse, watch TV, or have some quiet time after the kids are in bed.
3. You have to wake up so early that you'd be in bed before the sun goes down if you got 8 hours of sleep.

Whatever the reason, rearranging your life, habits, and schedule around a reasonable sleep schedule is worth it!

A lot of my patients have problems with sleep. Most commonly this involves either difficulty falling asleep or waking up throughout the night. Sleep hygiene is what I most often recommend.
Sleep hygiene is just like personal hygiene - a series of behaviors or habits that help keep you healthy (and clean). Some general guidelines include:

1. Remove the TV from your bedroom. This is the hardest one for most people. Having a TV in your room makes it difficult to fall asleep and stay asleep. Your bedroom should be a quiet haven that promotes sleep - and TV does not fit into that.

2. Remove the TV from your bedroom. I'm serious about this. It is really important.

3. Make your room comfortable - good mattress, right temperature, quiet, and dark.

4. Try to keep on a regular schedule. Go to be at the same time and get up at the same time (even on the weekends). This helps tune your body into when it should be sleepy and when it should be awake.

5. Just like kids, adults need a calming bedtime routine. Sitting up in bed watching Law & Order with a bag of chips and a Diet Coke does not promote good sleep. Choose relaxing activities in the hour before bed - reading or doing a crossword puzzle under low light, taking a bath, talking with your spouse, meditating, etc.

6. If you can't fall asleep after 15 minutes, get out of bed and do a quiet (not TV) activity until you feel sleepy.

7. Your circadian rhythm is light dependent. You tend to wake up when exposed to bright light. This can happen at 11 pm or 6 am. TV and computer monitors emit a bright light that tells your body it is time to wake up. Avoid bright lights before bed and use bright light in the morning to help wake up.

8. Find a way to deal with persistent worry or anxiety that might interfere with your sleep. This could include meditation, journaling, prayer, etc.

9. Avoid naps if you have problems sleeping at night. Naps can be good but are not a substitute for a sustained night sleep.

10. Avoid caffeine before bed (probably anytime after dinner). Do not use alcohol to help you fall asleep.

Good night!

Health Information on the Web

A quick detour from TLC (Therapeutic Lifestyle Change)...

I've recently discovered a new google offering - the google knol (knol.google.com) - these are shared bits of wisdom on a variety of topics (including how to drive a long-distance truck). But, there are a number of high quality health topics written by physicians from around the country. Not every topic is mentioned, but it is a worthwhile site to check out.

Other great sites include:

mayo.com (general health info written at a 6th grade (I believe) level

http://www.nlm.nih.gov/medlineplus/tutorial.html (wonderful site with video of different health topics and procedures)

www.familydoctor.org

I strongly recommend that my patients investigate health concerns and treatments on reputable web sites for a number of reasons:
1. It will reinforce what you learned at the doctor's office
2. It often has written information, pictures and sometimes even videos
3. You may find out new information that even your doctor doesn't know (yet)
4. It will often give a more comprehensive view of the topic than can be covered in a normal doctor's visit

Happy surfing...

TLC - DIET

As I mentioned in my last post, TLC stands for therapeutic lifestyle change - things that you can change in your diet, exercise, emotional health, weight, and behaviors like smoking or drinking that are therapeutic (make you more healthy). If you asked a hundred different doctors what they thought was the most important change, you'd likely get a dozen different answers. However, since this is my blog, I get to decide! Actually, despite today's subject, I think the most important thing is to stop smoking. We'll talk about that a different time.

Today, I wanted to talk about diet - what you eat. We had an endocrinologist (a doctor who specializes in things like diabetes) come and talk to our medical practice yesterday. She spent over an hour talking about diabetes without mentioning any medication treatment. Just goes to show you that non-medicine treatments often are the most important part of any treatment plan. She had a great slide that looked something like this:

Treatment of Diabetes

1. Diet
2. Diet
3. Diet
4. Diet
5. Diet
6. Diet
7. Diet
8. Diet
9. Diet and exercise
10. medication


If you are having a difficult time reading that last line, it says "medications". So, whether you have diabetes or not, whether you are overweight or not, diet matters a great deal. If you go to the bookstore, you will see dozens of books on "diet". Many of them have a gimmick: "Eat only fat and protein", "Don't eat any sugar", "Only eat foods that begin with the first letter of your name".

These diets actually do work. Not because the authors have found the magic bullet to achieve weight loss, but because calorie restriction - any type of calorie restriction - will equal weight loss. That's just basic thermodynamics.

However, you don't need to spend any time or money researching the best fad diet. Just eat a healthy diet and practice moderation. What's part of a healthy diet? One great place to get a lot of information is: www.mypyramid.gov

Basic information includes:

1. Brown is good. Brown bread, brown rice, brown pasta. All the "brown" stuff is made from whole wheat or complex carbohydrates. Carbohydrates are just another name for sugar. Simple carbohydrates (like white bread, white rice, or a Twinkie) turn into sugar very quickly in your digestive system. This has a lot of different effects, but to keep it simple, simple carbohydrates can cause weight gain, a burst of energy followed by feeling really fatigued, insulin resistance and even diabetes. Complex carbohydrates break down into sugar more slowly. This is better for your body, a more natural way for your body to absorb sugar, and not associated with the quick up and down sugar levels that you see with simple carbohydrates.

2. Fruits and veggies rock. Do you ever see nutritional supplements or vitamins proclaiming their "anti-oxidant" benefits? Anti-oxidants abound in fruits and vegetables and, while we don't understand exactly how they benefit your health, they help repair damage inside your cells. Over time, this may reduce your risk for heart disease or cancer. Eat as many fruits and vegetables as you can. Every January, I try to eat 8 fruits and vegetables a day. It is hard and I don't have much room left for anything else. So, if you are not a huge fruit and veggie person, just try to gradually increase to a goal of about 5 servings per day.


3. Eat things in their most natural form. This just means to choose an orange instead of orange juice, a baked potato you cook at home rather than one that comes from the frozen food section, or "real" oatmeal instead of an over-flavored packet of instant oatmeal. Now, we all eat "processed" foods because we are no longer part of a society in which people raise their own chickens, grow their own corn, or bake their own bread (unless you are Amish, but then you probably wouldn't be reading a blog). So, just get closer to the food's natural state as much as possible.

4. Do not make anything forbidden. This is likely one of the biggest culprits in diet failure. You ate the forbidden piece of cheesecake, so the whole diet is ruined. Or, you just absolutely must have chocolate and that is not allowed on your "diet". Anything is okay in moderation. "Moderation" means different things for different people. Basically, you can eat whatever you want as long as it does not become a significant source of your daily calories (meaning you only ate 1000 calories today but all of them came from a lemon meringue pie), it is an occasional treat, and you eat a serving at a time (rather than half a cake, a box of twinkies, etc.).

5. No diet sodas. I know this is a touchy subject. And, I have to admit that this is not any organization's "official" recommendation. It is just my personal, albeit educated, opinion. The reason for this particular piece of advice is my belief that diet sodas can contribute to obesity. I'm not sure how this happens, but recent research in lab rats indicates a few possible mechanisms. It may be that when you drink a diet soda and your brain expects to get 250 kilocalories of energy but doesn't, that your ability to accurately detect the caloric content of food is altered. This might make you more prone to overeat. Or it may be that your body thinks it is getting 250 kilocalories of energy, but doesn't and tries to "make up for it" by giving you a craving for more calories in some other way. It also seems that your body processes drinks differently from foods. Whatever the reason, I strongly recommend eliminating diet sodas. This does not mean to substitute with regular sodas (especially if you are diabetic). Instead, choose non-sugary drink options - water, iced tea or coffee.

I hope this is a helpful overview of dietary lifestyle changes.

Therapeutic Lifestyle Change

I was all excited about my new invention - I was going to start the field of lifestyle medicine. This would be a specialty focus in diet, exercise, nutrition, stress reduction, etc. However, like many new inventors, I discovered that my invention was....already invented. Yes, lifestyle medicine is already a field of medical specialty. Yet, as a family physician, I still have rich opportunities to practice lifestyle medicine with my patients.

Often, as part of the documented treatment plan, I've noted - TLC discussed/advised. What does that mean? Well, it is my shorthand for Therapeutic Lifestyle Changes were discussed and advised for the patient.

TLC is just that - Tender Loving Care for your body. Eating the right foods, weighing a healthy amount, getting physical activity, avoiding stress, getting adequate rest, not smoking, not drinking a lot of alcohol or caffeine - all of these are great ways to not only feel better but are also important to healing diseases like high blood pressure, heart disease, depression, and diabetes.

Therapeutic Lifestyle Changes are also one of the hardest things to do. It is far easier to pop a pill for your high blood pressure than it is to cut out the salt in your diet, lose 20 lbs and start a walking program. However, guess which option is cheaper, more effective, healthier and has fewer side effects?

More to come on specific elements of TLC...

The $ behind the doctor's visit

My parents recently visited a new primary care physician. My father was shocked to see the bill (to the insurance company) was $283.00 for a simple office visit. I explained to him a little about how billing works and where the charges come from. Maybe it would be helpful to others to demystify the office visit charge.

Most office visit charges are based on 3 main factors - 1) the type of visit (office visit, physical exam, or consult visit); 2) whether you are a new patient or an "established" patient to that clinic; and 3) the "level of service" or how much the doctor does during the visit.

The first two are pretty self-explanatory but the third confuses even the most seasoned physician. Level of service is determined by how much history a doctor gathers (asking about why you are coming in, other symptoms you are having, your past medical history, medications you are taking, whether you smoke or drink, etc), how extensive of an exam the doctor performs (listens to heart and lungs only or does a head-to-toe exam); and finally how complex the medical issues are (simple cold versus a complex patient with multiple serious medical problems). Visits can be charged at anywhere from a level 1 to a level 5 (except for physicals which are a "flat" fee).

Level 1 - this is rarely billed by a physician, but may be billed by a nurse who checks a TB test result on a patient's arm, for example.
Level 2 - very straightforward type of visit, for example, checking a rash in an otherwise uncomplicated patient with no other concerns.
Level 3 - most common type of visit - fairly straightforward visit for a cold, sinus infection, sprained ankle, or a visit with a complex patient for a single issue that is stable and needs no change in medications.
Level 4 - most patients with uncontrolled diabetes, multiple medical problems, or presenting with a serious concern (like chest pain) will warrant a level 4 visit.
Level 5 - I rarely use this code because it involves a high level of care and a serious medical problem. One example of a level 5 visit would be a child with uncontrolled type 1 diabetes who presented having a hypoglycemic (low blood sugar) reaction requiring me to coordinate specialty level care on an urgent basis.

This is a very general overview. Visits can also be billed based on time. If a doctor spends more than half of the visit counseling a patient or coordinating care, the doctor can bill for the corresponding level visit (level 3 is 15 minutes, level 4 is 25 minutes, level 5 is 45 minutes). I typically use this type of billing when I am diagnosing someone with diabetes. I spend almost the whole visit counseling about diet, exercise, medications, tests, complications, etc. and very little time examining the patient or asking about other symptoms.

So, you can get a sense of why health care billing is so complicated and difficult to figure out. My next post will be on "RVUs", the basis for assigning a "value" to each and every service provided to patients.

What my patients mean to me

The best part about being a family doc is definitely my patients. I continue to be amazed when one of my patients returns to me for a visit after I have sent them off to the heart specialist, bone specialist, or blood specialist for a condition that I do not have the expertise to treat. Inevitably, after I ask them what the specialist recommended, they will tell me the prescribed treatment and say something like "But I told him, doc, that I wouldn't do anything until I talked to you." Flattering as this is, I remind the patient that I sent him or her to the specialist specifically for a recommendation that I wasn't able to make. However, it demonstrates the trust that my patients have in me and I hope that trust is a manifestation of the care they sense I have for them.

My patients are much more to me than a sore throat, diabetes, or a broken foot. Maybe it is because a family doctor has to focus on the whole person - there is no "part" we don't take care of - that I still look at my patients as whole people. This allows me to not get too upset when my patient with heart disease decides to stop taking his cholesterol medication. Yes, cholesterol lowering is important, but I can understand that the side effects from this medication make his quality of life so poor that it's just not worth it. This "holistic" approach satisfies the humanity of my profession, allowing me to become much more than a technician or an expert. I am a care provider in every sense.

Of course, that is not to say that I adore each of my patients. Many are challenging causing me to groan inwardly when I see them on my schedule. I never want to lose sight, though, of the individual person who has a completely unique make up, set of circumstances, and hopes and dreams for himself.

What is a family doctor?

I remember going to a "family doctor" growing up. He was actually a general practitioner with no formal training in family medicine. But, he embodied many of the characteristics I try to display in my family medicine practice.

He lived in the community where he practiced. I went to school with his kids. I worked in his office as a summer job. You would see him at the grocery store or church. He had immediate legitimacy because he knew where you came from.

He was available. If I stepped on a nail and needed a tetanus shot, my mom could just take me over right away. I wasn't turned away and sent to the urgent care clinic or the emergency room. He was my doctor and just provided what I needed.

He practiced a lot of "social medicine". Prescriptions were often given for social maladies - domestic violence, substance use, poverty, illiteracy. These are the true illnesses that patients bring to their doctors so often.

He was compassionate. He frequently "no-charged" patients who were facing financial difficulties. It drove his office manager wild to lose the income, but he was a true softie, and cared more for his patients than his checkbook.

He also displayed qualities I actively avoid.

He was always busy and always late. He routinely scheduled 4 patients every 15 minutes. I could not be happy doctoring that many patients that quickly. As much as possible, I try to schedule the actual time I will need with patients and stay on time with my appointments.

He cut some insurance corners. I remember one occasion when he charged a patient for a visit (she was insured through the state medicaid system) without actually having seen her. He did talk to her on the phone and provided a prescription, but did not see her face-to-face for a visit, which is usually required to charge for an office visit. I can now appreciate the temptation to do that since I sometimes can spend 1 or 2 hours in a day taking care of a patient without seeing that patient in the office. But, I play it straight with the insurance rules and regulations.

He was not home much. He worked long hours, burning the candle long after the clinic closed. I love my family and enjoy being with them. When my day is done, it is done. When I am on call, I perform my responsibilities but don't spend extra time doing non-essential things.

He did not pay attention to the business aspect of medicine. One summer when I was working in his office, I added up his outstanding bills. The total was in excess of $40,000.00. Wow. That is a lot of money. I try to attend to the balance between cost and income so that I am practicing in a fiscally responsible fashion. That said, the financial aspects of medicine in the U.S. are nonsensical and atrociously designed.

As a family doctor, I take care of the whole family. This both means that I frequently have entire families as my patients, but also that I "treat" the emotional and psychological aspects of a patient's illness in all of his or her family members.

I take care of patients from birth (sometimes even in utero) until death. That is really cool!

I take care of patients wherever they are - home, hospital, jail, nursing home, or my office.

I provide the majority of health care - labs, chronic disease management, procedures, acute care, form completion, patient education, counseling, and hand-holding.

Being a family doctor is the most fun kind of doctor you can be.