A Country Doctor Writes:

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.

I sometimes tell patients “I work for the government”, but sometimes I say the opposite, “I work for you”.

Herein lies a dichotomy that is eating away at primary care in this country, like a slow growing cancer. I suspect everybody is aware of it, but it seems nobody has the inclination to deal with it.

2020 exposed how differently Americans view and prioritize things like personal freedom and public safety. We have also seen how vastly different perceptions of reality suddenly exist about what constitutes medical facts. Alternative facts and fake news are suddenly household concepts.

For years, American healthcare has paid lip service to ethnic and cultural sensitivity, as long as minority opinions or practices don’t clash too badly with the holy cows of western society. We tolerate circumcision in men, but not genital mutilation in women, for example. But we don’t even pay lip service to the majority’s right to direct their own healthcare.

Some people want to be screened for everything and some don’t. How heavy-handed should the healthcare system or individual providers be? If you buy a car and never bring it in for routine maintenance, isn’t that your personal choice, your personal freedom? Why should healthcare be completely different?

In bread and butter primary care, we are squeezed every day between patients’ requests for healthcare and the American quasi-religious medical quality dogma. The possibly well-meaning principles were set forth by CMS, the Center for Medicare and Medicaid Services, and turned into business opportunities for private health insurers and the many middlemen of the healthcare industry.

We disagree on whether mask wearing decreases the spread of the coronavirus and whether, even if it does, you can legally mandate it.

Yet medical providers have been routinely measured and financially rewarded for things like recommending aspirin use in middle aged people until it turned out that was faulty science. We have been mandated to do all kinds of things that have nothing to do with why people come to see us, because Uncle Sam (in the broadest sense of America’s paternalistic healthcare system) knows best what people need.

A patient smokes, feels depressed, has an elevated blood pressure and hasn’t had a screening colonoscopy. They also have this gnawing pain in the belly that six months later will turn out to be an inoperable pancreatic cancer. I can get 4 quality brownie points for clicking EMR boxes for smoking cessation counseling, scoring degree of depression and suggesting a behavioral health referral, advising salt and alcohol restriction and arranging for a blood pressure followup as well as referring my patient for a screening colonoscopy.

But there are no quality parameters or incentives for paying attention to this patient’s main concern, “Chief Complaint”, for making an early and correct diagnosis and saving the patient’s life.

Medical providers are disincentivized from listening to their patients because the screening opportunities have become the dominating purpose of primary care in the eyes of those in power.

People with new symptoms may have long waits to see their primary care providers, who are overburdened with screening and housekeeping duties. Doctors went to medical school, residencies and fellowships to learn how to diagnose and treat disease. We were never selected for or trained for the bookkeeping duties that are becoming the bulk of our work.

So much of what we do could be done by others, even digitally and remotely. It’s a new year in a shaken-up healthcare system in a shaken-up nation. It’s time to think about what we really need doctors to do.

I’ve always had a sentimental streak in me. To the extent I make resolutions this time of year, they have tended to be about being a better human being, and never about changing health or work habits or aiming for specific achievements. I had plenty of those thoughts, but they never came up at New Year’s.

This year in particular, I think a lot about gratitude and abundance: gratitude for the wonderful life I have lived and the good fortune I have had, and abundance as a frame of mind—focusing on what is instead of what isn’t.

If the past few years have taught me anything, it is that you never know what to expect. People change, careers change, death and illness happen around us, close by and far away.

My world is smaller than it was in my middle age. I have fewer distractions and I spend more time thinking at the same time as I have ended up doing more manual labor, for lack of a better word.

My promise to myself this year is to live richly in the moment, treasuring every day for what it is and do a little less thinking and a little more feeling. As I look back over my life, I know I am missing some details but I have powerful recollections of my feelings: I remember vividly the way I felt when I held my infant children for the first time or saw my mother for the last time. I remember how I felt the first and the last time I left Sweden.

I promise myself to feel grateful for the abundant peace and beauty in my immediate surroundings and the unconditional love from my animals. I promise myself to never expect others to behave or treat me in any certain way, but to always feel good will toward them. I treasure the affection of my children and grandchildren, but I don’t demand it or think I always deserve it.

After the Nor’easter

I promise myself to cultivate grace in my day, in my home and in my heart. I promise myself never to be greedy, not for material riches, not for love or attention, and not for more days or years in this life than my fair measure.

Yes, I fulfilled my dream of being a country doctor, and yes, I am a published writer. Yes, I raised two children, and yes, I have been able to embrace two cultures.

Now, I have no bucket list, as some people call it. I am happy exactly where I am, with exactly what I am doing. I wouldn’t trade it for anything.

I promise myself not to wish for what isn’t. Because what is suits me perfectly. I have arrived exactly where I am supposed to be: I read about Maine’s Swedish Colony in a Stockholm newspaper 40 years ago, just when I was starting out in medicine. And here I am today, after several twists and turns that eventually brought me here, then away and then back here again.

A little over 6 months ago, I declared I would post very little on this blog and focus my writing on books and other platforms where I would not be tied to a self imposed editorial calendar.

As my regular readers soon noticed, I kept writing and posting here at well over half my regular rate. I did write some articles for other platforms and I did compile two books, but I came to understand how much I enjoy the immediacy of posting my work as soon as it is finished—waiting for an editor to accept and publish my work was much harder than I had anticipated. I still work that way to a degree, but I missed being able to share my writing in real time.

So, know that I have not ended up putting A Country Doctor Writes to rest, just know that I post when I have something to share. I know that my regular readers are quick to read my work because they subscribe via email or WordPress or follow me on LinkedIn, Facebook or Twitter.

I do enjoy the freedom of not promising myself a set number or frequency of postings. I had developed an all-or-nothing view of my blogging that wasn’t at all necessary. It’s a little bit like my dietary habits. Let me explain:

As a child, I was a picky and squeamish eater. I could eat meat as long as it wasn’t recognizable as an animal part, such as a chicken drumstick or a piece of steak with its obvious muscle texture. Approaching my teens, I didn’t want to be viewed as a picky eater, so I decided to call myself a vegetarian, but I eventually decided to simply eat what I wanted and not worry about how to explain or justify my preferences.

So here we are. I write when I have something to say. But when there is snow to shovel, animals to take care of or family matters that occupy my mind, I go silent without worrying. Nobody will suffer from my periodic radio silences and nobody will set their alarm clock according to my writing habits.

I was being a little obsessive-compulsive about the whole thing. And now I have gradually given myself permission to go with the flow—of life, of waxing and waning inspiration and inconsistent degrees of ambition.

But I have come to realize that having my own “platform” is a very liberating feeling. I was just being a little hard on myself in my view of what that platform should look like.