A Country Doctor Writes:

1) EXERCISE MORE

I talk to people almost every day who think they can lose weight by exercising. I tell them that is impossible. I explain that it takes almost an hour of brisk walking to burn 100 calories, which equals one apple or a ten second binge on junk food. To lose a pound a week, you need to reduce your calorie intake by about 500 per day – that would be the equivalent of five hours of moderate exercise every day. We’d have to quit our jobs to do that.

2) EAT MORE FRUITS AND VEGETABLES

The other fallacy I hear all the time is that, somehow, adding “healthy” fruits and vegetables can make a person lose weight. I tell them that adding anything to their daily calorie intake will have the opposite effect. I more or less patiently explain that our job is to figure out what to take away instead of what to add. Maybe substituting a fruit for a Whoopie pie is healthy in other ways, but it has almost nothing to do with weight loss.

3) EAT BREAKFAST

A third fallacy is that eating a healthy breakfast will ensure weight loss. To explore this one, I ask: “Are you often hungry?”

So many of my overweight patients deny ever feeling hungry – that gnawing feeling in the pit of your stomach and the low blood sugar onfusion and weakness I feel by 9 or 10 am after doing barn chores on an empty stomach (only coffee).

When I hear “I never feel hungry”, I don’t recommend starting a good breakfast habit because that would likely increase a person’s daily calorie intake. But when I hear that a breakfast skipper goes for the doughnuts mid morning due to hunger, I certainly recommend eating breakfast. When I do, I always point out that the typical American cereal and banana breakfast, along with soft drinks, is actually the major reason for our obesity and diabetes epidemics.

4) EAT 3-4 MEALS A DAY

The fourth myth is that you somehow have to eat a certain number of meals. That depends on how you feel. If you’re in the habit of eating, say breakfast and supper and have no symptoms if you were to skip lunch, then why eat it, unless you’re trying to put on weight? The problem, again, is when a meal-skipper gets the munchies. We need to avoid that trap.

5) DIABETICS NEED CARBS (AND SEVERAL MEALS PER DAY)

Number five is all the overweight diabetics who have been told by dieticians and diabetic educators that they must eat a certain amount of calories or carbs or number of meals just because they are diabetics. That is sometimes the case, because some diabetic medications can cause low blood sugar if you skip meals, but it is by no means a universal truth. If you want to lose weight and feel just fine not eating all the meals and snacks those people tell you to consume, why force yourself to do it? Why not listen to your body (instead of your desires or prior indoctrination)?

It is a sad state of affairs that almost everybody knows complicated things like operating their smartphone but are so lost when it comes to knowing what to eat. (We can thank the food/snack industry for that.)

April 28, 2008 I published my first post on A Country Doctor Writes. April 28, 2021 I published my video blog Why I Don’t Order Fasting Bloodwork Anymore. Today, A Country Doctor Writes broke all previous records for number of views. My first post back then and my first video blog (after the general introduction) touch on the same topic from different angles and I explain what has changed over the past 13 years.

All my videos in one place: https://acountrydoctortalks.com

Primary Care is now mandated to screen for depression, among a growing host of other conditions. That makes intuitive sense to a lot of people. But the actual outcomes data for this are sketchy.

“Don’t order a test if the results won’t change the outcome” was often drilled into my cohort of medical students. Even the US Public Health Service Taskforce on Prevention admits that depression screening needs to take into consideration whether there are available resources for treatment. They, in their recommendation, refer to local availability. I am thinking we need to consider the availability in general of safe and effective treatments.

If the only resource when a patient screens positive for depression is some Prozac (fluoxetine) at the local drugstore, it may not be such a good idea to go probing.

The common screening test most clinics use, PHQ-9, asks blunt questions about our emotional state for the past two weeks. This, in my opinion, fits right into the new American mass hysteria of sound bites, TikTok, Tweets, Facebook Stories, instant messages, same-day Amazon deliveries and our worsening pathological need for stimulation and instant gratification.

Two weeks??

Does anybody need to be labeled with a mental illness that will follow them for the rest of their life because of a fleeting emotional funk?

What is the likelihood that a person – particularly during a pandemic and a historic economical downturn – who feels down in the dumps for a couple of weeks is going to be better off if started on a dependency-causing, mind altering SSRI that many people can never eventually stop because of severe withdrawal symptoms? And, consider the very modest therapeutic benefit of antidepressants on chronic and severe (but not mild) depression.

If we look at the statistics, a recent JAMA study found that 8.5% of a study population had active, diagnosable depression before Covid and 27.8% after the pandemic took hold. Historically, the lifetime incidence of depression is over 20% according to another JAMA article from 2018.

In many ways, depression is a cultural, societal phenomenon, whether it is fleeting, like the modern American definition allows, or chronic. And I believe that the cure in many cases requires cultural, social, societal, spiritual and existential interventions.

The fact that rates of depression can vary depending on external circumstances brings me back to my previous exploration of the way modern psychiatric treatment has negatively altered the natural history of depression – a disheartening consequence of our well meaning professional interventions.

We Have Lost Track of the Natural History of Disease

Are we wrong in our short perspective of what constitutes clinical depression? I think the past year is telling us that. “This, too, shall pass” needs to be paired with “First, do no harm”. A state of feeling depressed is not necessarily the beginning of a lifelong disease, best treated with drugs.

This may come as a surprise for people with business degrees:

Doctors don’t really care when a test was ordered. We care about our patient’s chest X-ray or potassium level the very moment the test was performed. We also don’t care (unless we are doing a forensic review of treatment delays) when an outside piece of information was scanned into the chart. We want to know on which day the potassium was low: Before or after we started the potassium replacement, for example.

In a patient’s medical record, we have a fundamental need to know in what order things happened. We don’t prefer to see all office visits in one file, all prescriptions in another and all phone calls in a third. But that seems to be how people with a bookkeeping mindset prefer to view the world. In some instances we might need that type of information, but under normal clinical circumstances the order in which things happened is the way our brains approach diagnostic dilemmas.

Yes, I have said all this before, but it deserves to be said again. Besides, only 125 people read what I wrote about this six weeks ago, while almost 10,000 people read my post about doxepin.

Patients’ lives are at stake and, in order to do our job, we need the right information at the right time, in the order we need it, even if the bookkeepers prefer it a different way.

We are the clinicians. When non-clinicians design our “workflows”, things can work out just like the Boeing 737 MAXX. The engineers thought their new autopilot was brilliant, but it made no sense to pilots. Planes crashed and people died. Boeing at first tried to blame the pilots. Healthcare systems are still blaming providers when the systems we work with don’t work for us.

What percentage of medical errors occurs because we can’t quickly find the information we need – or, worse, because our systems are so clumsy that we don’t have time to enter it according to the prescribed workflows? The statistics may not reveal the true magnitude, just as the Boeing disaster was not immediately attributed to the autopilot. Many medical mishaps are probably blamed on human error instead of the EMR.

We deserve better and our patients deserve better. People around me think I don’t like technology. That’s not true. I just have no patience for technology that doesn’t work. If online banking worked like my EMR (Hi, Greenway!), the banking system would collapse. Facebook, TikTok, Amazon, Google, WordPress and my old iPhone SE seem to work just fine. Why can’t EMRs?