A Country Doctor Writes:

Norman Grant was a new patient. He had chronic back pain, not helped by surgery or a dozen injections after that. It all started with an industrial accident in 2001. He had settled his case and was on chronic OxyContin, which far from kept him functional. But as of January 1 his insurance was no longer covering that drug. He only had two weeks left of it.

He told me he hurt when he rolled over in bed, when he walked or if he sat or stood still too long. He didn’t have sciatica. His legs had normal strength and sensation. He could bend his back forward or back without too much pain.

I was puzzled.

“Show me exactly where your back hurts”, I asked him. He pointed low, to the right. I banged with my fist on his spine and palpated the muscles along his lumbar spine. No pain. Then I pressed over his left sacroiliac joint. No pain. But the right one was exquisitely tender.

I asked him to lie down on my exam table. I tested the range of motion in his hips and it was pretty normal. Then I checked for pain in his left S-I joint by flexing his hip and knee and pushing his left leg to the side and toward the exam table.

“It hurts on my right side”, he said.

I repeated the procedure on his right side.

“Ouch, I feel a click when you do that”, he exclaimed.

“Did anybody X-ray your S-I joints or your pelvis or talk about that area?” I asked.

“No, but I kept telling them it wasn’t my spine that hurt, it was down there.”

“We need some X-rays of that area, and there may be things we can do for you besides giving you more or stronger pain pills”, I explained.

He grinned and thanked me.

“I kept telling them I hurt down there, but they wouldn’t listen or check it out the way you did.”

“Well, we’ll see, maybe we’re on to something”, I said. I wondered to myself, could it really be that he had a disc herniation that really wasn’t causing any of his symptoms and his S-I joint problem had been overlooked for all these years?

We use the word health rather loosely in America today. Especially the expression health care, whether you spell that as one word or two, is almost an oxymoron.

Health is not simply the absence of disease, even less the pharmaceutical management of disease. The healthcare “industry” is not the major portion of our GNP that it is because there is a lot of health out there, but the opposite. What consumes so much money and generates so much profit is, of course, sick care. The sicker people are, the more money is spent and earned in this market segment. It is a spiral, and a vicious one.

Health is a naturally occurring phenomenon, a state of perfection. Modern life has corrupted many natural, self-healing biological mechanisms and upended the natural order of things in our bodies – just the way it has altered our environment.

Our bodies are pretty ingenious in their ability to heal. When I crushed my finger in my garage door a few years ago, my disfigured fingertip, bisected nail and contused nail bed slowly regained their original shape, almost like a lizard grows a new tail. Yet in an opposite scenario, a person with scleroderma can lose their fingertip to gangrene without physical injury because of what we call autoimmunity – instead of self healing, our bodies can engage in self destruction. My fingertip could heal perfectly but some people’s skin or stomach ulcers fail to do so.

We intuitively seem to have accepted that, most of the time, nature takes care of itself if we don’t mess with it. And when temperatures rise, forests burn or species go extinct, we are quick to assume our industrial or agricultural processes are the cause.

Yet, we have this head-in-the-sand view of disease that it is a random occurrence, the sudden manifestation of ancient and rare genetic glitches or I don’t know what. The real answer is that much of it is a consequence of what we eat and otherwise expose our bodies to – how we produce and refine food, how we alter its natural properties and how we over- or under-consume basic nutrients.

Functional Medicine asks and answers many of these questions and promises to be the future of medicine. I believe in this, but I also believe that the sick-care industrial complex is powerful enough to severely slow down this revolution. I also believe the food industry will double down its efforts to continue misleading the public.

Functional Medicine cannot charge MRI scale fees for telling people to simply follow an ancestral diet, so corporate medicine will never fully embrace it.

Functional Medicine, I believe, will grow slowly and steadily as a counterculture and somewhat of a cottage industry. But then, once it gains enough momentum, maybe the “industry” will want to pay some homage to it in order to stave off the revolution that could lead to its own demise.

I fully expect corporate medicine and the pharmaceutical industry to offer healthy sounding shortcuts, like healthy eating in pill form and fecal transplants for exorbitant fees when the natural ways seem too time consuming or boring. But I seriously doubt that we will see decreased sick care spending in the next 100 years.

But I do think a growing portion of Americans will lessen their faith in traditional “health care” and live more consciously, experience better health and alter some of the disease statistics that have seemed to worsen so much just during my 40 years in practice: diabetes, obesity, heart disease and many cancers.

Last week I became involved in two situations of pain between the eyes that seemed to potentially be presentations of very serious medical conditions.

Autumn took a call from her sister late on Friday afternoon. Her sister had been tested for Covid the day before and told Autumn she instantly felt a severe pain between her eyes and developed a nosebleed as soon as the nasal swabbing was completed. The nosebleed stopped, but the burning pain at the bridge of her nose had continued in spite of over the counter pain medications and the passage of 24 hours.

It was obvious that whoever did the nasal swab was under the impression that human nasal passages run upward at the same angle as the nasal bone and not horizontally. It was obvious that this had caused pain and a nosebleed. But the amount of pain seemed dramatic. I don’t know Autumn’s sister very well, but she never seemed melodramatic to me. I asked to talk to her myself.

“Do you have a nasal discharge from that nostril?” I asked.

“Yes”, she answered. “Constant.”

“Is it clear?”

“Yes.”

All I could think of was a cerebrospinal fluid leak. This can happen with nasal trauma, I knew, and a quick Internet search even turned up a case of this happening from a nasal swab for the coronavirus.

“You’ve got to go to the ER, and you need a CT scan”, I told her. Autumn told her she’d meet her there. I asked her to keep me posted. By 8 pm the scan was done and reported negative by the NightOwl radiologist, working in a different time zone. Autumn texted to me that the ER doctor called it a contusion. I wasn’t sure exactly what that was supposed to mean – a contusion of what, exactly. But I had done what I could and did not feel I overreacted by telling her to go to the ER.

The very next day I saw a young man with a pain between his eyes that got worse when he leaned forward. He also had decreased libido and mild erectile dysfunction, all for about two weeks. He had no nasal discharge, no visual disturbance and nothing abnormal on ENT or neurological exam.

My thoughts went to a pituitary tumor or a brain abscess from a sinus infection, but perhaps he was just feeling under the weather from an ordinary sinusitis. On a Saturday with no option for a same day CT except if I sent him to the ER, I prescribed a strong antibiotic and cautioned him to seek care if anything got worse or if all three symptoms didn’t clear after a few days of the antibiotic. After all, I told myself, his symptoms had been stable for some time and a few days would probably not alter the course of events.

Whether we take a phone call or see a patient in the office without any availability of diagnostic tests, sometimes all we do is triage and best guessing.

I slept soundly both Friday and Saturday night.

As the old adage goes: Medicine is a science of uncertainty and an art of probability.

Everybody knows how to operate smartphones and understands complex modern phenomena, but many Americans are frighteningly ignorant about basic human nutrition.

I am convinced this is the result of a powerful conspiracy, fueled by the (junk) food industry. Here are just a few examples:

Milk has been advertised as a healthy beverage. It is not. No other species consumes milk beyond infancy. Milk based products like ice cream and yogurt are on top of that often sweetened beyond their natural properties.

Fruit juices make it possible to consume the calories of half a dozen pieces of fruit faster than eating just one. Naturally tart juices, like cranberry, are sweetened the same way as soft drinks (high fructose corn syrup), and therefore no healthier than Coca Cola.

Things made from flour—like bread, crackers, boxed and instant cereal, pasta and snacks like pretzels or chips other than plain potato chips—raise blood glucose levels faster than eating table sugar: The breakdown of flour starts in our mouths because of enzymes in our saliva while sucrose doesn’t break down until it reaches our small intestine.

Sugary foods, even candy like Twizzlers, are advertised as “fat free”, which is a relic from the days when fat was believed to be bad for you. Many fats, like those in olive oil, salmon, tree nuts and avocado are extremely healthful.

Another example of tangential descriptions is when flour based snacks are promoted as “baked, not fried”. Flour is bad, no matter what you do with it and, in fact, the presence of fat slows down the blood glucose rise from highly processed carbohydrates.

Serving size is still used to deceive people. A small bag of chips may seem to have a modest amount of calories until you realize it is supposed to be two servings. Fortunately, some packaging now states how many calories are in the whole package. Serving size should be abandoned, since it has no basis in what people really eat.

Artificial sweeteners are still promoted as if they are a way to consume fewer calories. Unfortunately we now know that they often alter our intestinal flora which in turn can release hormones that make us hungrier and craving sugar even more.

Additives are often promoted as healthy, from probiotics to vitamins to extra protein. There is little evidence to support this.

Words like “all natural” are often used in food advertising, but mean nothing in terms of whether they are good for you or not. Poisonous plants, like hemlock, are natural but that doesn’t mean we should eat them.

So many people have trouble understanding the three types of calorie containing foods that exist: protein, fat and carbohydrates. That’s where I often have to start. And sometimes, when I ask people “walk me through your day, tell me what you eat”, I end up pointing out “it’s all carbs”.

This kind of basic information should be kindergarten stuff, not adult education.

Recently I solved a medical dilemma by changing the medication that seemed to have nothing to do with my patient’s problem.

Ethan Blake is a thin-boned, soft-spoken man with atrial fibrillation and a history of high blood pressure. He lives alone and prefers to shovel his own driveway. He also loves to walk his springer spaniel in the woods behind his house. He is in great physical shape.

At his routine followup early last month, he lamented how his fingers were always cold and painful when he goes outside in the winter.

He takes a blood thinner because of his atrial fibrillation and metoprolol to control his heart rate. He has also been on lisinopril for blood pressure since before he developed his arrhythmia.

We know that some people get cold extremities because of an underlying autoimmune condition. We then call his problem Raynaud’s syndrome. When it is an isolated phenomenon, we call it just that – Raynaud’s phenomenon.

His metoprolol could cause cold fingers all by itself, or it was at least likely to aggravate Ethan’s symptom because it constricts blood vessels. A different rate controlling medication, the calcium channel blocker diltiazem, does not constrict blood vessels but would not in itself do much to improve Raynaud’s phenomenon. The calcium channel blocker nifedipine is routinely used in Raynaud’s but does little for heart rate and could drop his blood pressure too much in combination with his other medications.

Switching from metoprolol to diltiazem could be tricky. Theoretically, during the transition, his heart could either start racing or slow down too much. You would have to do it gradually, because stopping metoprolol suddenly could cause a rebound surge in heart rate, like if you were to release the emergency brake on a moving car while flooring the gas pedal.

It seemed like a tricky situation.

I looked at Ethan’s historical vital signs. He has lost weight slowly over the last few years and his blood pressure lately has been on the low side, often 110/60.

A thought struck me: What if I had him back off on his lisinopril to get a blood pressure in the 130s? Would that increase the perfusion of blood to his long, thin fingers? Then I wouldn’t have to fuss with a switch from metoprolol to diltiazem or the addition of nifedipine.

I explained my theory. He was eager to try it.

Over the month of December, Ethan tapered his lisinopril from 40 to 10 mg while he kept track of his blood pressure. When I saw him the other day, his fingers were warm and he told me they felt quite all right outside most of the time. His blood pressure was 134/68.

We decided he could try stopping lisinopril completely and let me know what happened.

I wasn’t sure when we started out that my plan would work. It seemed a bit tangential to just let his blood pressure rise a bit when the seemingly obvious problem was constricted blood vessels. But as an amateur plumber I also knew that the main water pressure and the pipe size can conspire to cause poor flow in the faucet.