A Country Doctor Writes:

A year ago this week, I made a stir with my post about five common weight loss myths. Today I had a patient conversation I have had so many times before: Someone was trying to eat healthier and lose weight at the same time. They are not necessarily the same thing.

This person was using flavored coffee creamers. I pointed out that they often have harmful fats, like palm and coconut oil, and chemicals that may not be good for humans to consume (corn syrup, trans-fats, milk protein [yet it’s called non-dairy], phosphoric acid [found in Coca-Cola, pesticides and fertilizer], mono- and diglycerides, sodium aluminosilicate [also known as feldspar, a ceramic glaze; it is explosive in powdered form] and proprietary artificial flavors). I even told her about Björn Gillberg, the Swedish chemist who in 1971 washed his shirt on TV with the powdered non-dairy creamer Coffee Mate.

“So what kind of creamer should I use?” She seemed flustered.

“Cream or half and half”, I answered. “They’re not all that good for you, but better than the alternatives.”

I pointed out that most of us want to do both things, eat healthy and achieve or maintain a healthy weight. But salmon, avocado, almonds and olive oil have calories, just like pizza, ice cream and Coca-Cola.

So it helps to prioritize a little. My recent patient, after some thought, wanted to attack the weight first. So my advice was about what to eliminate, rather than what to substitute it with. My point is that it makes little sense to skip the nightly ice cream and start eating yogurt instead if your number one objective is to lose weight. “Eat the real thing that you love, but only do it on the weekend”, I might say.

I scribbled down the math behind the lazy man’s guide to calorie counting, the theoretical 1 lb weekly loss if you eliminate 500 calories (kcal, to be correct) from your daily routine. I do it often enough I might save some time if I created a handout, but I believe in showing the math evolve on the paper as I talk – it’s more like telling a story.

Only after someone who wants to lose weight has eliminated some things do I discuss substitutions in earnest. People want to see results, and giving up ice cream, soda, donuts or beer brings results and makes people believe they can do it. Then, it makes more sense to talk about adding back something with fewer calories.

Like in so many other clinical scenarios, I like to “chunk it down” (see Leveraging Time by Doing Less in Each Chronic Care Visit) and to focus (see The Power of Focus): Reversing a disease process that has been going on for a long time is not usually something that happens quickly.

Five Weight Loss Myths I am Constantly Fighting

Just in the past few months I have had three patients with crippling chest pain brought on by exercise who were dismissed as having noncardiac chest pain. All three are now essentially symptom-free on isosorbide and metoprolol – common antianginals. I may not know exactly how this treatment works, but I am passionate about providing for my patients the common medications we know work. Even a simple country doctor can do that.

Once upon a time there was only one common kind of angina and only one kind of heart failure. Now we know there are two kinds of each. For some reason doctors are all excited about the new epidemic of heart failure with preserved ejection fraction, but skeptical and uninterested in angina with normal coronaries. Both of these more recently discovered diseases turned the old definitions upside down. Doctors of my generation (and younger) have had to unlearn what they taught us in medical school. Many are still bucking.

Angina pectoris is a syndrome, a group of clinical signs and symptoms with several possible causes. When I went to school we talked of blocked coronary arteries or a rare form of angina occurring during sleep and caused by spasm, Prinzmetal‘s angina. We now know that many people, perhaps half of all angina patients, have normal coronaries as far as we can see them on catheterization but poorly functioning smaller blood vessels rather than pure spasm. This type is triggered by exertion, just like angina caused by major blockages.

Heart failure is also a syndrome. For the longest time it was believed that the problem was that the heart didn’t push the blood out well enough with each beat. Only relatively recently did it become obvious that about half of all heart failure patients have poor relaxation of the heart. We have been measuring what percentage of the blood is pumped out with each heart beat. That number should be greater than 55%. But if there is less than the normal amount of blood in the heart and you pump out only half of that, you don’t get enough pumping done for things to work.

Neither angina nor heart failure are strictly disorders of a mechanical system of plumbing. These days the term neuroendocrine pops up everywhere in the literature. Our arteries, big and small, and our heart muscles are not static but constantly changing and adapting. And our understanding of how this all works is still in the early stages.

Maybe we should trust our clinical assessment more often and not look blindly at the results of imperfect tests like Lexiscans, crude angiographies and blurry echocardiographies: If it walks like a duck and talks like a duck, maybe it really is a duck?

Ruth grew up in Alabama and ended up in northern Maine last year. We still don’t have her medical records, but she says she was diagnosed with Crohn’s disease when she was a teenager. She has had six months of constant abdominal pain that gets worse when she eats. She seldom has diarrhea but sometimes feels constipated. She often has dry heaves and sometimes vomits.

Her bloodwork is normal and the CT scan that was done in our emergency room had only mild signs of thickened wall of her colon. Her upper and lower endoscopes had very modest abnormalities with nonspecific findings on biopsies.

She has seen a gastroenterologist downstate and is waiting to have an MRI of her small intestine.

Meanwhile, her constant abdominal pain is keeping her from holding down her new job. Hydrocodone has helped her, but that was a stopgap measure from one of her emergency room visits. Now the hospital doctors have labeled her a drug seeker.

As I listened to her story and watched her healthy appearance I began to wonder.

“Has your weight changed during all of this?” I asked.

“Not really.”

“And you have no blood or mucous in your stool?”

“No.”

“And you’re in pain every single day?”

“Just about.”

“And this started when you left Alabama? Was that a stressful move, a stressful time?”

“It was huge. And I’m still stressed out. I mean I can’t work and I’m not making any money. Does that matter?”

“I don’t know, I’m just looking for clues…”

I went over what lab tests had been done. Her inflammatory markers were only slightly elevated.

I had asked her to avoid milk and gluten containing foods when I first met her. She told me that made no difference.

The only symptom she has, really, is constant pain, I thought to myself. What if this is functional, an upregulation of pain signaling – the intestinal equivalent of fibromyalgia?

I have been vaguely aware of this condition, this scenario, but have no experience treating it. A quick search suggests the only treatment options are psychological and lifestyle interventions.

If this is neuropathic, would medications like amitriptyline or gabapentin or duloxetine work? Could they replace her hydrocodone?

She was willing to try.

A few days later she told me her nights are pain free on 10 mg of amitriptyline. But she’s too tired to take that medication during the day.

So, while the downstate gastroenterologists pursue their testing for where there might be physical disease pockets, I am looking in a different direction. They aren’t ready to do that yet and they may never be. Functional conditions receive little attention in medically underserved areas.

A Gut Feeling: Could This Case Really Be That Simple?

Ned is about my age. He came to see me about a year ago with swelling of one leg.

A few weeks after a steroid injection into his right hip, he noticed a gradual swelling of that leg. The hip felt fine. And Ned felt fine in general.

I examined him carefully and ordered what I think of as the usual tests when one leg is swollen and the other one isn’t.

Routine bloodwork and cardiac exam, venous Doppler of his leg, CT scan of his abdomen and pelvis were all normal. The orthopedic folks ordered an MRI of his swollen thigh. This showed the swelling of lymphedema but nothing else.

He got a compression stocking and carried on with his usual work and leisure activities.

Last month he got another steroid injection to the hip. A few weeks later, his lymphedema was almost gone.

I have not found anything like it in my search for answers. Has anyone else seen or heard about transient unilateral lymphedema, related to steroid injection or not?

One more instance of me confessing to my patient:

“I just don’t know.”

In some practices, patients with seemingly simple problems are scheduled to be seen by a nurse or medical assistant. Sometimes they can even just drop off a urine sample in case of a suspected urinary tract infection.

This is a dangerous trap. What if the patient rarely gets urinary infections, has back pain and assumes it is a UTI instead of a kidney stone or shingles on their back just where one kidney is located; what if they have lower abdominal pain from an ovarian cyst or an ectopic pregnancy?

Another dangerous type of “nurse visit” is when patients focus on one symptom or parameter, thinking for example that as long as their blood pressure is okay, their vague chest pressure with sweating and shortness of breath isn’t anything serious. It’s one thing if I want a couple of blood pressure checks by my nurse, but a whole different thing when it is the patient’s idea, assumption or self diagnosis.

In many cases, a telephone call with the provider or a triage nurse can be safer and more diagnostic than starting with a nurse visit. Because the symptom history is usually more important when making a diagnosis. And nurse visits tend to be skimpy when it comes to the clinical history, even though the provider assumes responsibility for the diagnosis and treatment of a patient they didn’t talk to or examine.

Seemingly simple things can sometimes be disasters waiting to happen. Nurse visits are not billable, only the dipstick urine test is in my first example. But the malpractice payout could be bigger than for a missed diagnosis made by a thorough clinician in good faith – if there was little clinical history and no physical exam done, not even eye contact between patient and treating physician.

Consider this analogy: How much less is a meal at the takeout window than inside the restaurant? The cost is usually the same and it certainly isn’t free.

A Happy Meal is a Happy Meal, no matter where or how you receive it. Diagnosis and treatment are not defined by their setting or visit charge.