ACP Internist Blog

Monday, March 18, 2019


There was a code blue on the ground floor. Weird considering no code blue is ever called there. I mean, not that they don't happen there. But it never reaches the overhead sirens since almost always it is happening in the emergency department where everyone is already there and ready.


I was on the tenth floor when I heard it. Typically those nearby run to get there. In case they are the first responders, the rule is to try. I wasn't near. But I did wonder what it was all about. Grady is busy, though. There's lots that I wonder about. And then I go on to thinking of something else.


I few hours passed and I was up in a patient's room. He was an elder and I'd come back to check on him one more time. The patient in the bed next to him was talking about what he thought had happened. “Somebody got shot in front of Grady,” the roommate said.

“Really?” I replied. “Oh my goodness. I didn't hear that.”

A nurse in the room turned away from what she was doing and chimed in. “No. That's not true. Some young brothers pulled up with somebody who'd been shot. Dumped him right on the curb in front of Grady like some luggage and pulled off.” She shook her head with hard disapproval. “That's a damn shame, right?”

“Wow.” That was all I could think to say. I wondered if my family and friends had heard this on the news and were worried. “So, no one was actually shot in front of Grady?”

“No, I don't think so, But isn't that awful? Just throwing somebody on the ground not caring if they live or die? And pulling off before you could see what happened?” She sucked her teeth. Hard.

“You said ‘brothers,’” my patient said. The nurse paused, balled up her espresso-colored fist on her hip and curled her lips at him in response. She didn't speak. Instead she just cocked her head for emphasis. My patient turned back toward the television and said nothing else.

“That's just TERRIBLE.” That's what the neighbor-patient said. Then he said it like five more times in case we didn't hear the first time.

“Wow,” I mumbled. Again, because I still couldn't think of what else to say.

After that it was silent for a few moments. That nurse wiped my patient's fingertip pad with an alcohol wipe and pricked it with a lancet. He winced. She rubbed it in this tender way that showed that she cared about his discomfort. I liked that.

“Man. I hope the guy who got shot did okay,” I finally said.

The nurse kept shaking her head angrily. Then she moved on to flushing my patient's IV line. “Me, too. Such a damn shame,” she said. “Who does that?” The roommate made a few more comments about “not knowing where this world is coming to” and “letting our ancestors down.”

No one disagreed.

Finally, my patient, a Grady elder, spoke:

“Look to me like them kids who dropped him off cared a whole bunch about whether he live or die. Bet you they somewhere distraught about they friend.”

“Friend?” the nurse said. Her face looked disgusted and her lip jutted out. “FRIEND? With friends like that, who needs enemies?”

The Grady elder turned his head in her direction and looked at her; his face impassive. “If you didn't give a damn about somebody, would you bring them someplace where you KNOW they'd do everythang to save they life if they got shot?”

He kept his eyes trained on the nurse. We all stayed quiet. He raised his eyebrows and went on.

“Look to me like that was they man. Somebody they really cared about and hoped would be okay if you ask me.” He shrugged and started fishing around in the sheets for his remote control.

I stared at him, taking in every word. I didn't want to miss a thing. The nurse was frozen in her tracks and the neighbor had (finally) stopped talking. All eyes were on the elder.

“The real question is this: Ask yourself WHY would some young brothers in a city like Atlanta feel scared to bring they friend into Grady after he got shot? WHY would they not be willing to stay long enough to make sure they friend don't bleed to death? You really thank it's ‘cause they don't care?”

When nobody had a reply, he let out a chuckle and shook his head. His expression suggested how naïve we sounded.

After that, he turned his television back up and settled into The Steve Harvey Show. And didn't say another word. But you know what? He didn't have to.

Damn, I love this job.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

Some health tips for doctors (or any busy professional) to be at their work peak

Practicing medicine at the front lines is hard. It's damn hard. Every minute you need to be alert, ready to respond to a potential life or death situation, and be called to another important problem. The current medical practice environment—with excessive bureaucracy, suboptimal information technology, and extreme time pressure with patients—adds exponentially to the mix, and can make for a very stressful job. Make no mistake, even without these added burdens, being a doctor is tough enough. It's certainly not a job for the faint hearted. At the same time, it's an incredibly rewarding career and there can be few better things than getting to form relationships with patients and their families, seeing them through their illness, recovering and walking out the door.

I wrote an article a couple of months ago about an experience I had when someone remarked to me about how impressed they were with physicians always needing to be on their “A-game” while at work. There's no time to sneak away while you're on duty, switch off, or relax in a dark room (unless you're a radiologist). Directly related to this, is another aspect of working in medicine—or for that matter, any busy profession—which is really not discussed enough. And that's how healthy (or conversely unhealthy) habits contribute to us not quite being at our best. If you look at other fields where there's talk about people being on their “A-Game”, it's invariably a performance-type situation, like a sportsperson or music artist. Ask anyone in these fields how important lifestyle habits such as diet, activity and underlying psychology, are to their overall level of performance—and they will tell you they are critical.

I liken being a doctor as being on a type of stage. Whether physicians always appreciate it or not—we are. Everybody around us, from the patient and nurse, to the housekeeping staff and cafeteria cashier—views you as a leader. How you interact with everyone is acutely remembered and your words carry enormous weight when you are walking around in that white coat. It's important to do everything possible to be at your peak, get to the correct diagnosis and treatment, and communicate well at the same time. Here are three health tips to focus on:

1. Diet
What we eat is the fundamental building block of how we are going to feel. In the interests of keeping things succinct, I will just give a few simple key tips. Generally, you want to avoid sudden sugar “highs and lows” during the day. Always eat a healthy breakfast prior to starting work (such as oatmeal with fruit). For lunch, ensure a well-balanced meal with a healthy protein (avoid red meat) and favor low-glycemic carbohydrates (brown rice, whole wheat or multigrain bread) over the higher glycemic index ones (potatoes, fries, white pasta and bread), which will produce rapid rises in blood sugar. Generally, most people find that eating too many carbs for lunch contributes to post-lunch lethargy. Something you should think about if you have a waiting room of patients to see or a couple of surgeries to perform.

In terms of snacking, you may need a mid-morning and mid-afternoon snack to give you a boost. Pick a healthy option like a fiber bar, fresh fruit, or handful of nuts (almonds or walnuts). Working in healthcare, you will often find yourself surrounded by treats like candies and chocolates. You don't need to avoid treats entirely (life is dull if you are too restrictive), but certainly not every day.

As for what you drink, it's really important to stay hydrated while at work (dehydration is a chronic problem among the general population). Pure water is ideal, but avoid sodas (especially the high sugar ones). Remember the classic rule of trying to drink at least 2 liters of water a day (eight 8-ounce glasses) doesn't apply to everyone—but can be used as a benchmark for a younger healthy person.

Tea and coffee are fine, but don't go over the top on the caffeine fix, and limit it to a maximum of two coffees per work day. I don't personally drink coffee, but I know most people around me in healthcare, appear to be addicts!

2. Activity
Depending on your specialty, you may or may not be particularly active during the day. Some fields, such as hospital medicine (my specialty, when I am working in the hospital), can lead to several thousand steps a day. Others in primary care, not so much. I personally work out in the gym before starting work, but that does require getting up very early, and may not be everyone's cup of tea. However, I still strive to be as active as possible while at work. If you are sitting down for most of the day, or standing still in the OR, get up and take a good brisk walk whenever you have some down time, and a longer one at lunchtime (leave the clinic or hospital and go outside if you can). Hopefully, you do other aerobic exercise outside of work too, but a brisk walk is at least categorized as moderate intensity. Also, try taking the stairs and ascending or descending as briskly as you can (safely, while holding onto the side!). This can burn significant calories during the day, but more importantly from the performance perspective—you receive an energy boost with a burst of cardiovascular activity, from both stair climbing and brisk walking.

3. Mindset and communication
Our internal mindset and how we communicate, is also a cornerstone of our performance. If you have a negative mindset, dislike your job, and have overwhelmingly negative interactions with those around you—there's no way you can be doing good work and performing at your best. If this is you, there's only 2 things you can do: (i) change yourself or (ii) change your circumstances.

To be working at your peak, you must show up at work with a positive mindset, determined to have meaningful interactions (obviously as a doctor, our most important interactions are with our patients).

A couple of things that may also help you: avoid hanging out with other negative colleagues (they will only bring you down ultimately) and practice gratitude. Remember how many good things there are about your work circumstances: you are in a field with lots of demand, you have free decision anytime to move to another institution or seek out alternative arrangements, and hey—you live in America, which alone puts you in the top percentile of the world in terms of opportunity and choice!

A final point is to strive for mental calmness, so that when the barrage of issues hits you as soon as you step into the hospital or clinic, you are ready. For many people, a small amount of meditation in the morning, or even a few deep breaths with mindfulness right before you step onto the stage, can help reset that adrenaline and cortisol.

If you want to be at your best during crazily busy work days, always keep in mind the above three areas of physical and mental wellness. And never underestimate the link between the two either.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.
Friday, March 15, 2019

Insurance company denies coverage for drug

A patient came to see me recently with a suspicion that his colitis was recurring. In general terms, colitis describes a condition when the large intestine is inflamed or irritated. Typical symptoms are diarrhea, abdominal cramping, and rectal bleeding. This patient was concerned as his last three bowel movements were diarrhea. He had been on a medicine called mesalamine, a safe and effective treatment for colitis, but he ran out of it 2 weeks ago. While he was taking the medicine, he felt perfectly well. So, his bowel change developed 2 weeks after he ran out of his medicine.

For readers who like to play doctor, choose among the following options:
• Schedule an urgent colonoscopy to verify that nothing has changed since his colonoscopy 6 months ago.
• Observe the patient without any treatment to give him time to heal himself.
• Recommend probiotics to restore his digestive health.
• Refill the mesalamine at his usual dosage.
• Request a second opinion because the case is mind-bogglingly complex.
• Prescribe an antibiotic because most cases of diarrhea are caused by an infection.

I thought that the most reasonable option was to reunite the patient with mesalamine, which had been extremely effective. Moreover, since the symptoms developed after a 2-week medication hiatus, this suggested that his colon was pleading for a medication refill. The patient, who is not a doctor, also thought this was the optimal choice, since he attempted to refill the mesalamine on his own prior to seeing me. However, he had new medical insurance and their response to the routine refill request was DENIED!

How it continued became a gerbilesque experience. We all felt like we were running on a wheel, expending lots of energy and effort, but with no traction. The patient had developed symptoms 2 weeks after he ran out of the medication. I surmise that 100% of gastroenterologists surveyed would have agreed that refilling the medication was the next step. So, even though the best medical option was to refill the medicine that we know has worked, the new insurance company won't cover it and the patient cannot afford to pay retail for the drug. (As a separate point, I challenge anyone including those with PhD's in economics to explain retail drug pricing.) The patient did his best to navigate the insurance company's website and found a colitis medicine that is covered, but it is medically inferior. Should we just cave and prescribe it to save money and a hassle? Is this an issue that we want on our sick patients' agendas? How would you like to face surgery and be told that the newer clamps and scalpels are out of network, but there are some rusty tools in the back that are fully covered?

I tried using our electronic medical record to ascertain if there were effective alternative colitis medications that would be covered, but neither I nor my staff could get a straight answer on this. If we were to call the pharmacist to ask which colitis medicines were covered, which we have tried in the past, we would be told that we would have to officially prescribe each drug individually in order to determine its coverage status. Doesn't that sound fun and efficient?

Does this vignette show medical care at its finest? How much time do physicians and our staffs burn up on tasks like these? Does this anecdote reinforce the notion that insurance companies' mi$$ions are to protect profits and not patients?

Do we want sick patients and physicians to have to fight just to get medicines approved? Shouldn't they be focused on health and healing? Keep in mind that my patient was not seeking exotic or experimental treatment. He only wanted the medicine that he and I knew could keep him well which is approved by the FDA for his condition.

If an avaricious shoe manufacturer decides to hike prices, no customer will be harmed. If the insurance industry, however, aims to maximize their profits, folks can get sick or worse. If this industry doesn't reform itself, then at some point others will do it for them. Wouldn't they be wiser to earn some good will with their customers and the public rather than create an army of enemies?

Who will be there to defend private insurance companies once the Medicare for All Express gains momentum? If insurance companies won't do the right thing for the right reasons, perhaps, self-preservation will motivate them to do better.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Thursday, March 14, 2019

Should you eat or skip breakfast?

Like so much else in a culture that perennially tests the lower limits of attention span, and like nearly everything we choose to ask about nutrition (e.g., is a calorie a calorie? Which is better, low-carb or low-fat? And so on …), the question we keep posing about breakfast is rather insipid and nearly useless. There are no valuable answers to vapid questions, and “should you eat breakfast?” is a pretty vapid question.

There are, however, related questions of real value- inevitably, the ones our culture rarely pauses to pose. Here is a smattering of those:
• What are some good reasons to eat breakfast?
• What are some good reasons to “skip” breakfast?
• Since all breakfast foods are obviously not created equal, what are some good choices and why?
• How much about breakfast is true for everyone, and how much of the valid lore should be personalized?

These, it seems to me, are good questions because the answers are apt to be of genuine utility. We'll get to those momentarily.

First, why chew particularly on breakfast this morning (it's morning as I write this- and no, I haven't had breakfast yet- perhaps explaining any typos)? The matter was in the scientific literature recently in the form of a meta-analysis in The BMJ. That, in turn, resulted in pop culture media attention, including my own participation in a recent NPR segment.

The singular question addressed in all of this probing and parsing was the value of breakfast for weight loss. That is rather different from the origins of breakfast lore, addressed below, but an unsurprising preoccupation in a culture intractably prone to hyperendemic obesity. The answers rendered by the meta-analysis were: no, eating breakfast does not help with weight control, and no, skipping breakfast does not make you fat. If anything, skipping breakfast might offer a slight weight-management advantage.

With your permission, and for the sake of efficiency, I will mingle the research findings with my own perspective to reach a quick conclusion about what this actually means. If people are hungry in the morning, and skip breakfast in a go-it-alone effort to control weight, they may well over-compensate later in the day; that's easy to do. I have seen this many times with patients over the years. So, yes, skipping breakfast CAN, indirectly, contribute to weight gain.

On the other hand, assign people to skip breakfast in the rather more disciplined context of a randomized trial, and you have punched a sizable hole in their daily calorie intake. Filling that hole with super-sized, out-of-control meals later in the day is understandably less likely while one is being periodically weighed, measured, punctured, and prodded for the sake of science. So, in such context, skipping breakfast might confer a weight control benefit.

As for observational studies, much devolves to definition. Many studies define a morning meal before 10 AM as breakfast, and no eating until after 11 AM as “skipping” breakfast. Accordingly, much of the fuss is about the difference an hour makes. The consistent answer is: not much. Anecdotally, I note that I have never considered myself a breakfast skipper, and my first meal every day is far more breakfast- than lunch-like (mixed berries, walnuts, steel-cut oats, or some similar assembly). However, I routinely eat my breakfast after 11AM, because I don't get hungry until then. The relevant research would catalogue me as someone who skips breakfast. I protest.

The lore of breakfast we all know so well. Breakfast is the most important meal of the day; it's important not to skip breakfast; eat breakfast like a king, dinner like a pauper- is not entirely wrong. Rather, the whole suite of messages has lost its native context the way a message loses its integrity in a game of telephone.

That context was mostly the classroom performance of kids who ate before leaving home, versus kids who went to school hungry. I trust no one is shocked to learn that studies have long suggested food insecurity and hunger are serious distractions when an 11-year-old is trying to learn algebra. Sadly, despite the overall surplus of food, and the prevalence of obesity, there has long been, and still is, hunger in the U.S. Food insecurity with or without overt hunger is even more widespread. These problems are of course even more pervasive elsewhere around the globe.

In the context of hunger, skipping breakfast is neither desirable, nor voluntary. So, sure, in that context breakfast is important, and all the lore pertains. But that context was lost in the retelling. Also lost was a focus on public health, replaced inevitably with good old American profiteering. As Julia Belluz rightly noted in Vox, cereal manufacturers coopted the gospel of breakfast to put a halo over the likes of multi-colored marshmallows and crunchberries. The lore, in essence, was corrupted into something like: breakfast is important; we make fortified, highly-processed, candy-like stuff you can put in a bowl and douse with milk; therefore, it's important you (or at least your kids) eat what we are selling!

OK, with the back story thus dispatched, here are my brief answers to those more useful questions.

Q: What are some good reasons to eat breakfast?

A: Since everyone sleeps, and few of us eat while sleeping, most of us will wind up with a sleep-related “fast” to break every day. Consequently, some form of “breakfast”- literally whatever is first eaten to end a fast- is inevitable. Have yours when first hungry in the morning, or whenever you find your energy or concentration will otherwise start to wane. Fill the tank, in other words, whenever it feels empty to you.

Q: What are some good reasons to “skip” breakfast?

A: The notion that your eyeballs will catch fire or your elbows implode if you don't eat something within some fixed number of seconds of your feet hitting the floor in the morning is…manufactured nonsense. If your energy level is high in the morning and you are not hungry, don't eat until you are. Skipping breakfast to control weight if you are, in fact, hungry is a dubious proposition; but there is no law of biology stipulating a need for three meals a day. Have more if you like to graze; or have just two. A late breakfast and dinner generally does it for me.

Q: Since all breakfast foods are obviously not created equal, what are some good choices- and why?

A: Most Americans, and increasingly people in developed countries around the world, eat less whole fruit than recommended for optimal health; less whole grain; and far less fiber. Breakfast fare offers an ideal opportunity to remedy such deficiencies with some combination of whole grain cereal (hot or cold), fresh fruit, and nuts.

Q: How much about breakfast is true for everyone, and how much of the valid lore should be personalized?

A: Wholesome foods, mostly plants, in balanced, sensible assemblies are universally good for Homo sapiens at breakfast, and every other meal. Exactly which variants on this theme you embrace, when, and how much, is entirely personalizable. You do you.

My conclusions on this topic remain much the same as the last time I opined. Dogma is a bad dish, at breakfast, or for that matter, at any time of day. Donuts are another bad breakfast choice, along with Danish, toaster pastries, and multi-colored marshmallows masquerading as “cereal,” to name only a few. Break your fast at a time that feels right to you, because of your daily routine, the ebb and flow of your energy, the patterns of your hunger, or whatever reasons matter most and work best for you. Whenever you do break your fast, what you eat matters. Choose well and wisely.

We have done to breakfast in America what we inevitably do in our culture to all matters of diet and health: turned it into a tale of sound and fury signifying next to nothing; a tale that wags at us a lot of dogma. Have breakfast by 10 AM, or after 11 AM, as the spirit moves you. Have wholesome foods. Avoid overcooked dogma. It's tough to chew, and sticks in the craw.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his Linked In page.