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There Are Few Shortcuts to Health

People aged 70-90 who follow a Mediterranean diet, are physically active, have moderate alcohol use, and are nonsmokers have less than half the heart attack, cancer and overall death rate of people who eat an average Western diet and have more average habits. This was the remarkable conclusion of the 2004 HALE study, involving people from eleven countries.

And the 2014 PREDIMED study demonstrated a 35-50% reduction in cardiovascular events by simply consuming extra virgin olive oil.

But there’s little money to be made for the pharmaceutical and health care establishment by promoting healthy eating habits.

In this week’s New England Journal of Medicine, there are two articles with opposite results from the use of different omega-3 fatty acids.

The first one, sponsored by the pharmaceutical industry, showed a 25% risk reduction from a supplement with Eicosapentaenoic acid (EPA), naturally found in fatty fish like salmon.

“Among patients with elevated triglyceride levels despite the use of statins, the risk of ischemic events, including cardiovascular death, was significantly [25%] lower among those who received 2 g of icosapent ethyl twice daily than among those who received placebo. (Funded by Amarin Pharma; REDUCE-IT ClinicalTrials.gov number, NCT01492361.)”

I remember reading about this substance way back in Barry Sears book, The Zone.

The second article showed no benefit from generic omega-3 fatty acids:

Supplementation with n−3 fatty acids did not result in a lower incidence of major cardiovascular events or cancer than placebo. (Funded by the National Institutes of Health and others; VITAL ClinicalTrials.gov number, NCT01169259.)

Conclusion: Good food and good clean living reduces risk by 50+%, branded supplements by 25% and generic supplements possibly not at all.

Is anybody surprised?

Physicians are Influencers

The comedy channels on my car satellite radio are handy for combating fatigue the last hour of my commute between Brooklin and Caribou. After dark on New Year’s Day I caught a comedian ranting about being told he was overweight by a doctor with the same predicament, and how the two sort of bonded and quickly dropped the subject after that. And I still remember the diabetes expert at Uppsala who couldn’t button his lab coat!

Like it or not, we doctors are under a certain amount of scrutiny. People check out our grocery carts, our cars, lawns, clothes and body sizes (mostly organic, 2010 German SUV with 256,000 miles, coastal scrappy and professionally maintained lush but with dandelions up North, always a tie, 165 lbs).

A certain amount of self disclosure and deprecation can be a good thing, but too much can get in the way of a therapeutic relationship.

I use myself as an example in some very calculated ways, some of which I have mentioned before in older blog posts:

I tell people “I was a strict lacto-ovo-vegetarian for fifteen years, but I gained too much weight.” After their jaws settle in their lowered positions, I go on and explain: “I lived on pasta, oatmeal and sandwiches – all carbohydrates.”

I also tell the story about how I at age 50, in a dance studio with wall to ceiling mirrors, figured out (when my wife said “Your belt is crooked”) why standing straight always gave me a backache: I have one leg that’s more than an inch shorter than the other. Now I just put my weight on my long leg and stand on tiptoes on my short leg and have zero pain and a better posture. (Know your body…)

Self disclosure is risky when it touches on subjects that could undermine our patients’ confidece in our ability to help them, because they ultimately care more about whether we can help them than what we’re like as people. That includes sharing our frustration with “the system”.

But when it comes to how fit we are, what’s in our grocery carts and whether we ever use a push mower, go for hikes, jogs or simply walk to the post office, we need to consider the public health messages we broadcast to our communities.

Here is where I wonder if younger physicians might believe these kinds of considerations belong to a bygone era. If so, I think they haven’t kept up with the Internet phenomenon of “influencers”. I stumbled onto it when I was looking for audiobooks on how to promote your ideas. I naively thought that’s what “influencers” did. After just a few minutes of listening I realized that “influencers” are people like most of us, who choose to publicize their lives, their tastes and their pursuits and become promoters of products.

Health care professionals are by default influencers, because people are naturally curious about our habits. After all, when I first came to this country, dentists recommended a certain sugar free gum and doctors had been known to prefer a certain brand of cigarettes.

Just like we have abdicated some of our power and leverage in dealing with health care organizations, I think we often underestimate the influence we can have on our patients lifestyle choices.

In fact, the woman I described in my previous post said, when I entered the exam room, “you look great, what are you doing?” I quickly ran through my daily diet (extremely low carb), my age (65), work hours (60, loving every minute), farm chores and so on.

We are being watched, and we have a chance to influence others with our own healthy examples.

Curiosity, Antidote to Burnout

A patient with chronic pain who had tried CBD oil brightened up my ten hour workday on New Year’s Eve.

The cannabis derived product, free from the classic mind altering THC, has a sketchy record as a treatment for pain. But this woman described something that made me think, and Google for answers.

“It took away all that stinging, burning pain I have had everywhere, but it made me notice my hip and knee pains more”, she explained.

I instantly formulated my question: Does CBD affect signaling in the slow nerve fibers associated with the diffuse pain of fibromyalgia and opiate induced hyperalgesia, thereby making her more aware of the rapid transmission pain messages from her arthritic hips and knees?

“It’s as if your body was like an old fashioned radio and you adjusted the tuning so that the static decreased and now you can hear the actual broadcast more clearly…”, I said.

“Yes, exactly!” Her eyes lit up.

I thought for a moment.

“I would think that is a good thing, empowering, in that your arthritis pain makes more sense and may be more predictable than your fibromyalgia pain. This new state may make you more able to gauge how much you can do before you overdo it in terms of the arthritis.”

She agreed, and promised to keep me posted.

New Year’s Day I read an article on the BBC website that made me think again of my patient’s observation and how it fired up my curiosity. Titled “The secrets of the ‘high-potential’ personality”, it described curiosity as an antidote to burnout and one of several predictors of professional success that the authors claim to be better predictors than the Myers-Briggs Personality Types.

“Compared to our other mental traits, curiosity has been somewhat neglected by psychologists. Yet recent research shows that an inherent interest in new ideas brings many advantages to the workplace: it may mean that you are more creative and flexible in the procedures you use, help you to learn more easily, increases your overall job satisfaction and protects you from burnout.”

The six traits are:

    Conscientiousness
    Adjustment (ability to reframe stressful situations)
    Ambiguity acceptance
    Curiosity
    Risk approach/Courage
    Competitiveness

At the beginning of my day, my mind had been wandering back to New Year’s Eves away from the office, trudging through the snow in the Swedish countryside or dancing at Chateau Frontenac in Quebec.

As my workday ended, I wished my Suboxone group Happy New Year and thought about the literature search I wanted to do on my day off.

May I never lose my curiosity…

Touching the Mezuzah – Revisited

Christmas always makes me think of my childhood in Sweden, but it also makes me think a lot about my place in time and in people’s lives. This year, as I alluded to in my post “Don’t Do Chronic Care in December”, I’m spending extra time with our opiate addiction recovery groups because of the obvious stress we have seen in those patients around the holidays.

My Swedish upbringing put me in more contact with the Old Testament than perhaps many American Protestants, and my High School exchange student year in this country placed me in the only Jewish Family in a small Massachusetts town (Hi, Bob!). My Swedish High School German prepared me well for speaking some Yiddish with my host mother.

I am of the Old World, and I find comfort in ancient traditions. The Mezuzah is one I learned about only in the last decade. This led to my 2012 Christmas reflection, quoted in its entirety below. This year I am not taking a mini vacation. I work half a day with my Suboxone groups Christmas Eve, and some time Christmas Day I’m heading 200+ miles north to our Caribou house in order to work at the Van Buren clinic December 26 and 27.

Merry Christmas, happy belated Hanukkah 2018 and thanks for reading…

Hans Duvefelt, MD

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TOUCHING THE MEZUZAH (12/24/2012)

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A mezuzah (Hebrew: מְזוּזָה‎ “doorpost“; plural: מְזוּזוֹת mezuzot) is a piece of parchment (often contained in a decorative case) inscribed with specified Hebrew verses from the Torah.

And thou shalt write them upon the door-posts of thy house, and upon thy gates. Deuteronomy 6:9

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It’s almost 4:30 and I have three more patients to see before my Christmas mini-vacation can begin. Snow and sleet are beginning to fall outside. Our lab tech, who leaves between 3 and 3:30, just called from home to warn the rest of us that she had seen nine moose on Route 1, probably attracted by the road salt.

“Three encounters in thirty minutes”, I think to myself, “and neither of them completely straightforward”. I used to shudder when healthcare administrators called medical office visits “encounters” , but the more I have thought about it, the truer the word rings to me. Two people meet briefly and try their best to communicate in spite of sometimes very different viewpoints and agendas. I remember the phrase “Marriage Encounter” from my first visit to this country in the early 1970’s – an event where couples learn to see each other with new eyes and communicate more effectively.

I have three fellow human beings to interact with and offer some sort of healing to in three very brief visits. Three times I pause at the doorway before entering my exam room, the space temporarily occupied by someone who has come for my assessment or advice. Three times I summarize to myself what I know before clearing my mind and opening myself up to what I may not know or understand with my intellect alone. Three times I quietly invoke the source of my calling.

4:35 – In Room 1 sits Bill Boland, the fellow who always sasses me for my habit of knocking on the exam room door before I enter. He had been in with pneumonia and his x-ray came back suspicious for a tumor. The purpose of today’s follow-up visit is to make sure he is feeling better and to tell Bill he will need more testing. I raise my hand in an automatic door knocking gesture, but catch myself and instead touch the doorframe briefly and take a slow breath before entering the exam room, ready to deliver the disturbing news.

4: 50 – In Room 2 sits Wally Parker, here to talk about his blood sugars. His wife is in the hospital with a lower GI bleed, and her colonoscopy showed an ulcerated tumor that is almost certainly malignant. “Why is he here tonight instead of at Mary’s bedside?” I ask myself as my hand reaches for the doorframe. At the same time I try to clear my mind of my own clutter and my guesses why he has chosen to keep this appointment under these circumstances.

5 o’clock – The child in Room 3 is an 11-month-old with a fever. He belongs to the pediatric group in town, but probably the slick roads and the late hour are the reasons he is here. A new patient, and a sick child at that, requires me to be unhurried and receptive. I must be aware of how well we connect, so neither this child’s young mother nor I miss something important in our encounter. In this case, the child has an ear infection and the mother is a registered nurse with an older child at home who has recurrent ear infections.

At 5:15 I wish Autumn and the new receptionist a Merry Christmas before I leave through the back door.

Route 1 is covered with snow and the large flakes coming right at me make it impossible to see with high beams. I drive slowly with only my low beams, and don’t see a single moose.

Our house is all lit up for Christmas. In one of the sunroom windows shines the metal star-shaped lamp that hung in my bedroom window when I was a child. I remember coming home from school in the dark, looking up at my star on the third floor of our Swedish apartment building, even closer to the Arctic Circle than where I live now.

I can see my wife in the kitchen window, but she can’t see me in the darkness outside. I quickly stomp the snow off my boots on the wooden steps outside the door. My hand touches the doorframe for balance, physical and spiritual, and as a brief gesture of love and blessing:

I am home. It is Christmas.

The Root Cause of Physician Burnout: Neither Professionals nor Skilled Workers

Too many specific theories about physician burnout can cloud the real issue and allow healthcare leaders to circle around the “elephant in the room”.

The cause of physician burnout isn’t just the EMRs, Meaningful Use, CMS regulations, the chronic disease epidemic or any other single item.

Instead, it is simply this: Healthcare today has no clear definition of what a physician is. We are more or less suddenly finding ourselves on a playing field, tackled and hollered at, without knowing what sport we are playing and what the rules are.

Historically, physicians have been viewed as professionals and also, more lately, as skilled workers. But we are more and more viewed and treated as neither. Therein lies the problem.

The way professionals are treated is this: You present them with a problem and they use their knowledge to solve that problem Since they know more than the requester, they aren’t micromanaged. They usually also set their fees and determine the time needed to realistically finish he job.

Skilled workers are asked to apply knowledge and workflows to relatively strictly defined tasks and it is the employer’s responsibility to make sure they have what they need to finish the job. If the tasks are unrealistic, the manager is held responsible: If the assembly line is moving too fast and the majority of workers end up passing on unfinished product or start pulling it off the line to finish later at home, the manager is likely to take the consequences. No one is likely to say that all workers, individually, are responsible for such chaos.

But in today’s healthcare, we have a rapidly moving assembly line. The foremen blame the workers for not attaching all the parts or not keeping up with the workload. Upper management doesn’t always take full responsibility, instead shrugging and saying: “it isn’t our problem, they’re professionals, they should be able to figure this out”.

Put simply: If anybody wants to define and manage our work for us instead of letting us do it, they become responsible for the outcomes if we aren’t given the time or the tools we, as the ones who went to school, know we need.

The cure for physician burnout is simple: Listen to us when we say what we need in order to do our best. We didn’t spend all this time and energy so we could collect our salaries and goof off.

Most of us still have a professional mindset. We want to do a good job and we know how to do it. Let us.

Don’t Do Chronic Care in December

I am beginning to think that we should not see chronic care patients between Thanksgiving and New Year’s Day. It just makes us look bad.

Our quality metrics make the last blood pressure and the last diabetic lab test of the year for each of our patients our final report card. We should quit while we’re ahead, in mid November.

So here we are: The office has Christmas decorations up. There are trays of Christmas treats on desks and in break rooms. Patient after patient now declares that diet and exercise are on hold until after the holidays. The phrase of the month is “Next Year, I’ll Eat Better”.

I thought of this when I saw Jerry Rigg the other day.

His chest pain was a bit atypical, the stress test slightly equivocal. His belly was quite a bit bigger than last year, but the indigestion medicine seemed to work and the cardiologist was quite reassuring. He had also spoken of diet and exercise, just as I had done many times before.

This man with all the risk factors didn’t take this episode as a warning, but as a green light for stalling a little bit longer before doing something to change his trajectory.

So, instead of beating on people who really don’t want to feast less during Thanksgiving and Christmas, what is a Country Doctor to do?

It didn’t take me long to know:

My Suboxone patients, who can’t have Tuesday group on Christmas Day or New Year’s Day, had fretted about Thanksgiving, which in many families can be emotionally charged or awkward. Major holidays also often expose them to relatives who are not in recovery, who may bring drugs to the periphery of the festivities. Every single one did okay, though. But after realizing their degree of concern, we are holding groups on Christmas and New Year’s Eves and halfway between.

I also have seen a couple of patients already in tears because they can’t afford presents for their children, because they miss loved ones that won’t be there this year or because they weren’t invited to something others in their family did.

I can’t really postpone or cancel my remaining hypertension and diabetes visits on such short notice, but maybe in the future, we need to be more focused on those patients who find the holidays hard.

If by doing that our quality metrics should happen to improve, is that so bad?

I Love Calling Patients – And I Don’t

That is, I don’t do it very much and I don’t love it with all my heart.

Talking to patients on the phone can be very efficient and quite rewarding, like when I called a worried patient today and told her that her chest CT showed an improving pneumonia and almost certainly no cancer, but a repeat scan some months down the road would still be a good idea. She told me she was feeling better, but still quite weak and that her sputum was still dark yellow. So, while still on the phone, I e-prescribed a different antibiotic, after going over her long list of allergies with her.

But as a primary care doctor with a productivity target of 24 patients per day, and absolutely no credit for phone calls, this is not something I am incentivized to do.

So instead, I am tempted to resort to the internal EMR messages:

“Mrs. Jones is looking for her CT results, please advise.”

I could have typed in what to tell he patient, but then when the medical assistant had her on the phone, she probably (hopefully) would have mentioned that she was still raising dark yellow sputum. The medical assistant would then tell her she’d check with me and get back to her.

Would I have remembered that the levofloxacin the ER gave her caused horrific nightmares if I hadn’t been engaged in conversation with her? Maybe I would have just tried to refill that?

How many back and forth messages would it take to handle something as simple as this, and how many times would the medical assistant need to call the patient back to get all the necessary information?

If all work we do was recognized as work, if Medicare and Medicaid paid our clinics for phone calls, doctors would have time in their schedules to personally return patient calls. (Medicare does, but so far only for people we sign up for chronic care management where they will incur monthly copays for this “added service”, mostly designed for nurse calls).

Some commercial insurers now do pay for phone calls, but in Federally Qualified Health Centers, where I work, private insurance is such a minor portion of our payer mix that their reimbursement policies are close to irrelevant for our bottom line.

The struggle in primary care is that right now, we get paid “per visit” with very little regard to “outcomes”, but very soon, our clinics will prosper or perish depending on how well our patients do and how much they cost “the system”. I talk with my bosses every week about how we can make this transition without losing our shirts.

Mrs. Jones, if I hadn’t called her myself, might have gone back to the emergency room several days later, in terrible shape, required admission to the hospital and incurred thousands of dollars of cost. My doxycycline prescription may have avoided that.

And, being able to personally get back to patients fosters loyalty and provides levels of reassurance that only come with the role of the physician.

Darn it, that’s what I am, and that is what I need to provide as much as I can of.


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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