Category Archives: Health and Wellness

A Well-Balanced Breakfast

So.

I was frying up some eggs this morning for me and my youngest son. Three of the four were in the pan, and as I tapped the last egg against the side of the pan to crack it, I saw a Huge. Ass. Motherf#@ing. Spider. In the pan. Sizzling in the oil.

I did what any reasonable, smart, well-educated, outdoorsy, nature-loving, competent adult would do: I stood there with the cracked egg dripping into my hand, and screamed.

Andrew ran into the kitchen. “Mom! Are you ok? What’s wrong?”

All I could do was gesture, egg dripping down my arm, to the pan.

He looked. And he did what any reasonable, smart, well-educated, outdoorsy, nature-loving, competent adult would do: he screamed. Well, to be fair, it was less of a scream and more of a really loud “holy shit,” but I’ll count it as a scream for literary purposes.

At this point, the sizzling spider popped loudly. I screamed again. “Do something!”

So my resourceful college sophomore grabbed a couple of spoons and extricated the deep-fried arachnid from the frying pan.

As he dumped the spider in the trashcan, I plopped what was still contained in the open eggshell into the pan.

I tossed the shell into the garbage and washed my hands, as I contemplated the big question: Do we eat the eggs from the spider pan?

Medical analysis: as Andrew pointed out, the pan was full of boiling oil – no spider-trafficked microbes were likely to maintain their pathogenicity.

Human analysis: Ew.

Medical analysis: any potential toxin from semi-exploded spider unlikely to be potent enough in whatever traces might have reached egg to cause any noticeable clinical effect.

Human analysis: Ew.

Practical considerations: out of eggs upstairs, in a bit of a rush, and hungry.

Verdict: Meh.

We ate the eggs. I gave the ones furthest from the spider to Andrew, took the somewhat close one for myself, and tossed out the one that had gone directly onto the spot where the eight-legged creature had actually been. I viewed that as a reasonable approach. You know, from a clinical standpoint.

Anyway, the spider was much worse off for the whole experience than I and my son.

We discussed the situation over breakfast, noting that we all eat plenty of bugs and bug parts all the time, in blissful unawareness.

But seeing it is different.

Our minds are powerful. Our defense mechanisms are powerful. We have the capacity to contemplate our mortality, the vastness of the universe, the complexities of DNA, or the presence of bug parts in our food. But we also have the capacity to put those thoughts aside so that we can get things done and live our lives.

Sometimes something comes along that knocks us out of our blissful, practical-repression-of-stuff state and makes us face our mortality (or a spider). The mortality is always there. We ignore it. The spiders are always there. We ignore them.

Until one drops into our frying pan. At that point, we deal.

Sometimes it’s a little spider. Sometimes it’s a really big one. Sometimes it’s venomous. Sometimes it’s kinda cute. Sometimes we notice its magnificent web. Sometimes it scares the daylights out of us. Sometimes we just brush it away.

And, the vast majority of the time, the spider causes us no harm.

But worrying about the spiders, thinking about the spiders, can be paralyzing.

Some of us live where there are dangerous, potentially lethal spiders. In those areas, it’s wise to take precautions.

We should shake out boots that have been left outside or in the garage before we stick our feet into them.

But worrying about any potential spider in our house? Not practical. Not helpful. And if we’re too meticulous about removing every known spider, who’s going to eat the other bugs?

There’s always a balance. Always a weighing of the pros and cons, the risks and benefits.

The eggs were good. As was the coffee.

We didn’t look too closely in our cups.

No. No. Just No.

Words matter. Words have consequences. Lies matter. Lies have consequences. People have understood this for a very long time – note the biblical prohibition against bearing false witness against one’s neighbor (that one actually made it into the Top 10 list).

What our current president stated at his recent rally in Wisconsin is false witness, defamation, slander, against doctors. It goes beyond that to incitement. His words, his lying, defamatory, slanderous words, will cause death.

Doctors do not “execute infants.” Full stop.

They do not wrap a living, breathing baby in a blanket and “determine whether or not they will execute the baby.”

This particular outright lie of Donald Trump has painted bullseyes on doctors, nurses, and patients for violent anti-abortion extremists. Doctors may be killed because of his words. Nurses may be killed because of his words. Patients may be killed because of his words. His false words. His slander. His lies.

He has harmed doctor-patient relationships with his slander. His defamatory words drive a wedge between those who have spent lifetimes dedicated to helping others in their times of greatest need and those who need their help.

He has born false witness. He is quite possibly inciting murder. He has put my colleagues’ lives in danger. He has put my patients’ lives in danger – both from direct violence by those agitated by his lies attacking people seeking care, and by alienating patients from doctors who are there to help them.

The blood will be on your hands, Mr. Trump.

It Happens

Spent a big chunk of the afternoon cleaning up shit.

No, this is not a metaphor. We have a dog, and although most of the year we make it a point to clean up the yard daily, it’s been really cold and snowy and rainy and cold and snowy and muddy and cold and rainy and did I mention cold? and I just haven’t been in the mood to do it for a while. And today it’s in the 40’s and dry and actually (I think) supposed to stay warm for many days in a row, and so it was time to get out there and clean up the mess. And today is garbage pick-up day, and although the recycle truck comes early, the garbage truck comes late in the afternoon, so if I got out there and did the turd pick-up quickly enough, I could get it to the curb in time to be taken away from my house today.

So out I went.

The process involves significant risk of stepping on poop land mines, so, wisely, I wore Doug’s shoes (sorry, Dougie, but you weren’t home and your shoes were conveniently located at the back door and I love you!).

In my “reduce/reuse” effort to decrease our plastic impact on the planet, I save produce bags and newspaper delivery bags to pick up after our pooch, and I filled up quite a few.

So here come the metaphors (you knew they were coming):

Health? Life? Politics? Let’s throw in a little of all of the above.

We’ll start with the produce bags: onions, broccoli, and zucchini in, poop out. So the produce bags can be a metaphor for intestines. And we’re discussing chores we don’t necessarily want to do. Perfect segue for an update on the American Cancer Society’s colon cancer screening recommendations. They now recommend that people of average risk for colon cancer begin screening at age 45 (the old recommendation was 50). Gold standard for screening is colonoscopy (starting age 45 and then every 10 years for the average-risk folks). Those at higher-than-average risk likely need to start earlier and do it more frequently. The prep isn’t overly pleasant, but it’s way better than late-stage colon cancer. So talk to your doc about it. This public service announcement brought to you by a bunch of canine backyard bowel movements.

Moving on:

It’s fairly easy to be methodical in the collection endeavor, as our pup is quite consistent in his tendency to defecate along the periphery of our property – he’s an edge-pooper. For the most part, I knew where to look: within a foot of the fence. This is true for most of us. We learn when and where to expect crap. Yes, every once in a while, there’s a big steaming pile in the middle of the lawn where you don’t expect it, but by and large, in the day-to-day, it’s where it usually is. There’s a lot of traffic at rush hour. There are long lines at Trader Joe’s the day before the Super Bowl. You don’t get as much sleep as you’d like when you have exams or when you’re on call. Your spouse is snippy when he/she is under stress. You expect it. You plan for it. You deal with it. It might not be pleasant, but it’s not surprising.

Along the perimeter of our fence we have all sorts of perennials – day lilies, crocuses, hydrangeas, peonies, various other pretty green and/or flowery things that I don’t know the names of. And under the piles of fecal matter I found a plethora of green shoots. The icky and the good are right up next to each other. The fertilizer feeds the flowers.

Much of the excrement has been through multiple freeze-thaw-get-rained-on-and-snowed-on-and-frozen-again-and-thawed-again cycles, and although you can certainly tell that it’s shit, it’s not fresh shit – a lot of it is really dried out and actually somewhat easy to scoop up and most of it doesn’t really even have much of a smell. When life throws general crap at us is can seem pretty awful at first. The fresh stuff stinks – we should pick it up right then and get rid of it, because if you step in it, it embeds in every crevice of your shoe and you have to do the twist on the grass to get the big chunks off and then bring the shoe straight to the utility sink and scrub the rest out of the treads. But if you’ve just stayed away from the crap for a good part of the winter, it might not be so bad when you come back to deal with it later. Works for some things, not necessarily others. Breast lump? Deal with it now. But some things that seem like a big deal right now turn out not to be such a big deal through the lens of time.

Of course, we’d never leave our dog’s waste on the ground when out walking – you don’t leave that for someone else to step in or have to clean up. But we don’t always afford ourselves the same courtesies we give to others. Maybe we should.

I seem to recall I said I’d find a way to tie this to politics as well. I used a bunch of newspaper bags. Need I say more?

Truth be told, I only got around 40% or so of our property’s perimeter-o-poop (there was only so much I wanted to deal with at one time), so will head back out later today or maybe tomorrow. My shoes (well, Doug’s shoes) are clean for now.

It Could Have Been Worse

Well, I just had a relatively shitty morning. But it could have been a lot worse.

I have a lot in my head these days – plenty that’s good (like starting a new business venture with another doctor), but quite a bit that’s not so good (relatives with health concerns, multiple friends with significant health crises in their families, a friend who just lost a sibling), and I’m a little tired. My brain is doing a lot of multitasking.

Our dog’s annual checkup/vaccine visit was scheduled for 9 o’clock this morning, and he gets very stressed out at the vet’s office (read: “wont-even-step-on-the-scale-so-I-have-to-lift-and-hold-my-60-ish-pound-dog-while-I-weigh-us-both-together-and-then-weigh-myself-and-subtract-my-weight-and-then-heaven-forbid-the-vet-should-try-to-look-in-his-ears”). So I started to think about how much I hoped he wouldn’t stress too much, took him for a walk, and seat belted him into the car for the 20-minute drive. Perfect timing, since it was 8:35 when I left the house.

Except it wasn’t perfect timing, because the freeway is under construction and they closed the exit ramp that I needed to take to get there. Not a huge deal – I’d have to take a later exit and wiggle back to get there from another direction – GPS would get me there just fine. I called the vet’s office to explain what happened and tell them we’d be a few minutes late – they said “no problem.”

Thought about friends’ family members. A few miles later, there was an open exit ramp. I took it, and started using my internal sense of magnetic north to navigate until the GPS recalculated.

Again, no problem. Cell signal was strong. Map was on the screen. The little blue circle representing my car was on the blue preferred route. I glanced down occasionally at the navigation as we made our way to the vet’s office. Thought about the condolence call we’d be making this evening. Thought about the website copy I needed to complete today. Thought about the talk I’d be giving tomorrow to the Science National Honors Society at the high school my boys graduated from. I had a lot to do.

And then the map shrunk down to a tiny little box in the bottom corner of the screen. No clue why it did that. Glanced down and tapped the little box with my thumb. Eyes back on the road. Thought about my friend’s father.Glanced back at the phone – map still tiny. Crud. Eyes back on road. Tapped at the tiny map square again. Eyes back on the road. Thought about the new business bank account I needed to open. Glanced down – map still tiny.

Of course, what I should have done was pull into a parking lot and figure out what my phone map was doing, but what I did instead was continue to repeat my same action while expecting a different result. I didn’t have time.

Eyes on the road. Glance down. Tap. Eyes on the road. Glance down. Tap. Eyes on the road – oh SHIT. The pickup truck in front of me was stopping because there was a bus stopping in front of him.

Slammed on my brakes. Hit him anyway.

We pulled immediately into the driveway/parking lot of a bank. It took all my strength to turn the wheel – the power steering was dead. I jumped out of the car as he exited his and asked immediately, “Are you OK?” “Yes, are you?” “Yes. I’m so sorry.”

The front of my 14-year-old minivan was hemorrhaging red liquid onto the ground. I started to smell something burning and realized I hadn’t turned off the engine, so I immediately turned it off. Our dog was sitting calmly in his seat.

Called the police. Stared at my bleeding car. Looked at the hole that was punched in my front bumper by the trailer hitch (now slightly bent) on the back of the other guy’s pickup truck.

And now there were no other thoughts intruding on the issue at hand. Nice timing, brain.

Police officer showed up, took our info, and was just generally really nice, as was the guy whose truck I hit. Called my husband, told him what happened, and asked him to call the vet’s office for me.

Called our car guy (when your family’s “fleet” consists of vehicles that range in age from 6 to 22, you have a car guy), who told me where to have it towed. Called AAA, who told me a tow truck would be there within an hour.

The police officer stayed until I knew the tow truck was on its way. He offered to drive us up to the vet’s office (about a mile away), but I needed to stay with the car until the tow truck arrived. The officer gave me his card and told me to call if I needed any help with anything.

A woman pulled into the bank parking lot to use the ATM. She saw me and asked if I was OK. I said yes and thanked her.

I called the vet again, and they said they’d fit our dog in whenever we got there.

After just a couple minutes, someone from the towing company called and said he had a truck nearby that would arrive within five minutes. It arrived within three. The driver was also extremely nice – offered to drop us at the vet’s office, but my dog did not want anything to do with going up the steps into the truck (and I was NOT about to attempt to carry him, struggling, up them – picture, if you will, a 60-pound bucking bronco with nails that need to be trimmed). So I paid the tow truck driver for the miles-beyond-which-AAA-covers and started the walk to the vet’s office.

I may not have mentioned that it was about 25 degrees. My hands were frozen. I stopped at a store along the way, where the employee kindly allowed me to bring the pup inside for a moment to warm up.

I may also not have mentioned that one of our other cars (the 1997 model) is in the shop, so My husband didn’t have a car at work. One of his colleagues lent him his car so he could meet me at the vet’s office and bring me home. His colleagues also changed the location of their afternoon meeting to be near where we live so that Doug could get there easily.

I still had to pick my dog up and weigh the two of us together and then subtract me, but he is fully vaccinated and healthy.

The collision shop has managed to find used parts for the bumper replacement. The red liquid was not coolant – I had just squashed and punctured the power steering fluid line. I should have a functional car back by Monday.

It could have been a lot worse. I could have caused an injury. The repairs could have ended up costing a lot more. Any of the people mentioned in this story could have been unkind.

So it allows for perspective. Because of my line of work, and because I and people around me are all getting older, I am frequently exposed to people’s sadness, worry, pain, and frustration. It can really get stuck in my head, because my drive is to fix it. And when it can’t be “fixed,” I still want to make it better. So sometimes I think about it more than is helpful. Sometimes, like last night, I lose sleep. Sometimes I think about it when I should be getting other things done, so I end up thinking about getting those things done when I should be thinking about the smart thing to do when my GPS screen shrinks.

Perspective. Priorities. I can’t let thinking about the big things get in the way of thinking about the little things, because a little thing, like driving to the vet, has the potential to become a big thing. Perspective. Priorities. Even when you can’t change what’s happened, you can change the experience of those it’s happening to by being kind. I called the towing company to tell them how helpful their towing guy was. I called the police chief to tell him how helpful and kind his officer had been. Perspective. Priorities. Allowing the stress of being late and of having things to do cloud my judgement so much that I thought it was reasonable to try to fix a GPS issue while driving caused worse issues than just being a little behind schedule and could have caused much worse still.

I’ll consider this a wake up call. And I hope that, if you need it, my morning can serve as a wake up call to you as well, so that you don’t need your own.

Seeing a Person You Love in a Number

A friend posted an article on her Facebook page discussing a recent research study out of Sweden showing that people on the autism spectrum have a decreased life expectancy. This friend has a child with autism. Autism coupled with learning disability, according to this study, is associated with the largest decrease in life expectancy. This friend’s child has learning disabilities along with autism.

My friend is scared.

On top of her worries about social isolation of her child due to her conditions, on top of worrying about her child’s place in society as she becomes an adult, on top of the fears of every parent about their children’s health and wellbeing and risks in general, my friend has had dumped on her frightening data clearly relating specifically to her daughter.

Only it doesn’t relate specifically to her daughter.

It is an aggregation of data that compares medical and mortality statistics of a pool of 27 thousand people with autism with that of a comparison group of 2-and-a-half million people without diagnoses of autism. It is not specifically about my friend’s child.

But it is about my friend’s child, because it is about every person with autism.

That’s the thing about statistics. They are about everyone, yet they are about no one in particular. That’s an aspect of practicing medicine in a world full of data that is particularly challenging, fascinating, and maddening. And people not practicing medicine have a similarly challenging, fascinating, and maddening time navigating this world of information.

Problem is, humans are extraordinarily complex. First, there’s the biological complexity of any multicellular organism, the variability due to genetics, the effects of environment, the interplay of internal and external forces. Then there’s psychology – individual predilections, societal influences – and how much of each of those is due to inborn versus external influences of the individual or of the interacting individuals of society? Even seemingly simple questions can become metaphysical – why are x and y correlated? Does x cause y? Does y cause x? Does a third thing cause both x and y? Do the combination of a third, forth, and fifth thing cause x under some conditions and y under a different set of conditions, some of which overlap the conditions which predispose x to be affected? Is there something inherent in x or y or both that lead to their association? What, if anything about the properties of x or y or the conditions that combine to give rise to certain outcomes are modifiable?

If my patient or my child or my neighbor ostensibly fits into a category being described in a general news article reporting on a scientific study, how much weight and credence do I give to it? What about a medical or scientific journal article? Does that specific person truly fit that category? If so, in what ways? In what ways does he not exactly fit? How important is the closeness of the fit? Even if a seemingly perfect fit, what does that actually mean for a specific individual? What exactly did the researchers look at? What did they miss?

The autism mortality article wasn’t meant for my friend. It wasn’t meant for the parent of a specific child with autism. It wasn’t written to alarm her. It was meant for society. It was meant for those who would influence the allocation of funds for medical research and social policy development.

Which means that the article was meant for my friend – a parent of a specific child with autism, a person who advocates for funding of research and services and societal support. It was meant to alarm/alert all of us, and my friend is one of all of us.

My job as a doctor is to take data and apply it to real people. To dissect the data, to judge the quality of research, to integrate it with what makes scientific and physiologic sense, to humanize it. My job as a friend, a neighbor, a family member, a general citizen of Earth, is to comfort and support others. So here is my reaction to that particular article as it relates to the person who posted it and to her daughter:

The article refers to a correlational study looking at aggregate numbers. Although the numbers and conclusions are laid out as straightforward, the actual data and meaning are exceedingly complicated. The study is a start, a call to look more closely at an overall population and see where dangers are. It is a study of averages – it is not a study of individuals. It leaves ever so many more questions than answers. It does not know your daughter. It does not know you and your husband and your other children. It does not know your child’s teachers or doctors. It does not know your social supports. Although this study does not know all of the above, it can help you as it draws attention to necessary lines of inquiry regarding a population (of which your child is a member) that needs serious attention.

This study was done in Sweden. We do not know how the data extrapolate to other countries. Are there genetic or cultural characteristics in the overall Swedish population that could affect these data? The data showed different main causes of premature death in two different populations of those with autism – those with learning difficulties and those without. We do not know if these differences hold true globally, and we do not know what other differences or characteristics play a part.

There may be specific age-related spikes for the most common causes of mortality which could skew the data. Distribution of data points is extremely important to investigate, not just averages. At what else did the researchers look? At what did they not look?

There are people looking at important questions: How can we begin discerning the causes of the disparities? How can we ameliorate the causes?

So many questions. So few answers so far. So glad people are asking the questions that will lead us to information that will help individual people, and in turn will help a population at large. And sending strength to all who look at a headline with numbers and in those numbers can’t help but see the face of their child.

A link to the original abstract: Article in the British Journal of Psychiatry

A link to a discussion of the article by an autism research and advocacy charity in the UK: Autistica’s call to action piece

Pet Parallels in End-of-Life Matters

(Note to my children – do not read this. Other people who are close to me – you probably want to skip it, as well.)

It has taken me almost two years to be able to write this. We said goodbye to our beloved dog in early May of 2013. I grieved for well over a year.

About a month-and-a-half prior to his death, we had a big medical scare with him. I wrote at that time about how dealing with a veterinary emergency can provide us with some insights and practice parallels to dealing with human medical crises (Pet Practice). A veterinary crisis also has definite parallels to human end-of-life issues, and can highlight ethical concerns as well.

He was an older dog – old enough that my husband and I would occasionally mention animals’ life expectancies in front of our kids. The boys were well aware of what we were doing: “Mom, Dad, we know dogs don’t live as long as people, and you’re obviously trying to prepare us, but it’s totally going to suck when it happens, whether or not you remind us of how long dogs live.”

So he was older, slowing down in general, with a seizure disorder which had developed in his later years and was generally kept in check with medications (with one episode of multiple breakthroughs a month or two earlier), but reasonably active and happy overall.

The big scare I mentioned above came on pretty suddenly. He became progressively ill over the course of a day, and I brought him to the vet, who did a thorough exam and extensive lab work. It didn’t look good – obstructive biliary disease – and we were referred to a veterinary specialist for an ultrasound, expecting that it would show cancer.

I filled the family in on the details of what was happening, and I took him in for the imaging study. The ultrasound did not show cancer, but elucidated an issue that would be rapidly fatal if not addressed with emergent surgery.

I called my husband. Our dog was old. We didn’t have spare thousands of dollars lying around. We loved our dog. Our children loved our dog.

We happen to live about an hour-and-a-half away from one of the best veterinary schools in the country. I called them and told them what was happening. They said that we could bring our dog out there, and their estimate on the surgical cost was a bit lower than our local place.

I called my husband back. We talked again. Yes, our dog was on in years, but this was fixable. He could have a couple good years left in him. We would figure out a way to cover the cost. I brought him to the boys so they could give him a hug, and then I took him out to the veterinary school’s emergency clinic.

I brought the ultrasound disk and the lab results with me. They looked at everything, concurred with the diagnosis, and agreed that surgery was a reasonable option. “The other vet did tell you that the mortality rate for this surgery is about 30 to 35%, right?” Uh, no. No, he didn’t. How could I not have asked that?

I wasn’t going to change plans now. The odds were still in his favor, even if not what I had assumed. I gave him a kiss, signed the release forms, and gave the front desk my credit card.

And it worked. The surgery, though complicated, went well. He recovered. Within a few weeks, he was prancing and bounding and chasing rabbits like he did when he was much younger. We were so happy – we knew we had made the right decision. We played joyfully with him over the next few weeks.

And then he started seizing. Not just one breakthrough, but multiple. I brought him in. The vet upped his anti-seizure medications. He lost bladder control with the seizures, so I slept in the kitchen with him for the next two nights. He had more seizures. And his post-ictal (post-seizure) agitation kept increasing. It got worse through the next evening. His vet said there was nothing more he could do, and he sent us to the emergency clinic, which had a veterinary neurologist on staff.

The vet who was on duty that night in the emergency/specialty clinic was very kind. She said that it didn’t look good, but we were not without hope. She assured me they would do what they could overnight, she would keep me posted and I could come back in the morning to speak with the neurologist when he arrived.

So I headed back there the next morning. The neurologist said he recommended an MRI, since his seizure history sounded consistent with a brain tumor. The MRI would cost two thousand dollars. And then if it did show a tumor, and if it looked operable, we would have to decide whether to pay for and put him through brain surgery to remove it. He also said he had one other thing to try with medications.

I talked to our regular vet (a very smart man who had always given us sound guidance and advice), and he said that our dog had been through so much, that the prognosis was grim, and that if it were his dog he would not do surgery or the MRI (which would require anesthesia). I talked to my husband. We decided to give the neurologist’s pharmaceutical idea a try.

It didn’t work. The updates from the veterinary hospital throughout the day were very bad. We knew what had to happen. We told the boys, and we took them with us to the hospital so we could all say goodbye. It was a sad, tear-filled car ride.

They brought our doggie into a room with us. It was awful. He was horribly agitated, and he had lost his sight. He really didn’t show much, if any, sign of recognizing us. After hugging and petting him as much as and as best we could and saying what we needed to say, I told my husband and boys to wait in the waiting room. My husband wouldn’t leave me. The boys (12, 15 and 17 at the time) said they’d be ok and went out of the room together.

And then it was time. The vet gave me euthanasia consent papers to sign. I don’t remember exactly what they said, but I think I recall acknowledging the finality of the decision. And then it was really time. The vet asked if I wanted to stay. I said yes. I told my husband he didn’t have to stay, but he would not let me stay alone.

It was so very awful. So very, very awful. Our dog was clearly suffering. His agitation was severe – it had not been alleviated by any of the medications. I will skip the full play-by-play of the final actions, but I will describe a bit of what went through my mind.

“I have to be here. I have to stay here. Good pet owners stay until the end. I don’t want my husband to have to see this. I’m the doctor. I should be stronger than this. What am I doing? Why am I doing this? Am I doing the wrong thing? What if this is fixable? How much did money play into this decision? What kind of a monster am I? How can I do this to my family? Did I make this decision to stop him from suffering or did I make it to prevent me from suffering as I watch him? How can I do this? How can I not do this? Oh God, it’s done. What have I done?”

I stayed as long as I could, with my hand on his fur and my husband’s hand holding me. Then I had to get up. I had to go to the door. I kept talking to our sweet puppy dog. The vet still had her stethoscope on him. He had stopped breathing minutes prior but probably still had a few slow heartbeats left, but I just couldn’t stay any longer. I failed him in those last few seconds. He wasn’t alone, but it was someone else’s hand on him at the very end. The vet had no choice – she had to stay.

They handed us the bill at the front desk. We gave them our credit card.

We gathered our boys, held one another, and had a silent, tearful car ride home.

We grieved. And we recovered. But it took me a long time to recover.

This was a dog. Yes, he was our dog, our pet, a “member of our family,” but he was a dog, not a person. Yes, we all tend to anthropomorphize our pets, but I was not grieving his loss as I would grieve a person. We develop strong emotional attachments to our pets, and they symbolize responsibility, loyalty, and innocence. That wasn’t all of it. It was more complicated. It was much worse than when I had grieved dogs in the past as a child and teenager (and those previous times certainly hadn’t been easy).

I’m a doctor. I keep coming back to this. A big part of why I went into medicine was to prevent death. To promote life. To promote good health. To help give quality to life. And, when not possible to do the aforementioned, then to help support patients and their families through the loss of life. I have been with patients and their families numerous times at the very end of a life. It has been at times when my colleagues and I did everything we could to save a person but were not able. It has been at times when someone has chosen not to be resuscitated or to have “extraordinary measures” taken. It has been at times when the choice was to focus only on easing any pain at the end of life. It has been when removing life support. Some of those times were peaceful, and some of those times were frantic. But never, during any of those instances, did I myself do (nor write an order for someone else to do) something with the express purpose of stopping a heart. Even when removing  someone from ventilator support, we were removing a breath-sustaining machine (and therefore a life-sustaining machine), but the person’s respiratory system had already failed on its own – we were not purposefully making a person who was spontaneously breathing stop that breathing.

Almost two years ago, I signed papers authorizing a veterinarian to kill my dog. We use the word “euthanize” (“eu” meaning “good”, “than” meaning death, translating to a word that means “to kill painlessly,” generally to relieve suffering), which sounds much better than “kill,” but it doesn’t change what is done. Our vet told us we had chosen compassionately. In all reality, it probably would have been cruel to allow an animal to continue to suffer indefinitely with no understanding of what was happening, and it is not financially feasibly to put an animal on the comfort measures that we afford people at the end of life – our choice is a much harsher one with our pets. But still, I signed the papers to stop his breathing. What if I was wrong? I did not handle well the thought that I had chosen to end his life and that I could have made the incorrect choice. When I failed him in those final seconds, it was because I had failed myself. I second-guessed my thought process. I questioned my motives. I felt unworthy of him.

Those feelings hung with me heavily. There was an intense, deep feeling of guilt. Honestly, my really wrong decision probably was to have had him go through that surgery when he was so ill that month-and-a-half prior. It would have been a peaceful death if we had opted out of that surgery. There was nothing about the way he ended up dying that was peaceful. If only we had known then what was going to happen six weeks later.

People lament how much money we spend on medical care in people’s last few months of life. Policy experts and politicians look at the numbers and say we are wasting money and resources. People lament how so many people end up dying hooked up to machines in hospitals when they would much rather have died peacefully at home. But the vast majority of time I was working in a hospital, caring for people at the end of their lives, we had not known it would be the end. Surgeons did not usually advise surgery if they thought a patient was not going to live. We did not give people ventilator support with the expectation that they would not recover. And most of our patients did survive and return home, and get to celebrate another holiday or wedding with their families, and see more sunsets, and sing more songs – how many sunsets, how many songs are worth the cost of that care? More than once, even when an outlook was grim and we expected the worst, a person surprised us and recovered well beyond what we would have expected. And sometimes a person who we had expected to do well’s last moments were on a ventilator or with people pushing on her chest during CPR. We spend those resources and efforts at the end because we don’t know it’s the end.

We don’t know everything. And it’s really hard not to know everything. Especially when you’re the person who is supposed to have the answers.

Battling Buffoonery

My career is based on communication and empowerment within the medical world. I educate on the patient/family side and the medical professional side. It takes understanding and empathy from both sides of the stethoscope to optimize communication. It takes communication between both sides to bridge perceived power differentials. It takes work on both sides to change a culture of uneven power dynamics.

I read two Facebook posts within the past few days dealing with a culture issue that needs changing. This is a matter from the “general” as opposed to medical world, but that which is present in society-at-large certainly spills into medical or any other subset of society.

The first was written by a woman in her early forties, discussing the details of recent times (while in retail establishments) she’s received unwanted amorous advances from strangers (including a time when she had her young teenage son with her, and they included her son in the harassing conversation). The second post was by a friend whose 17-year-old daughter, who works weekends at a toy store, has been receiving come-ons from customers while their children play in the store. Both women experienced definite “ick” feelings as they were being harassed.

Thankfully, the majority of public interactions are not icky. These incidents referred to above are happily the exceptions to the general rule of civilized, respectful behavior. But although they are exceptions, they are not rare exceptions, and they are threatening.

I am close to the 17-year-old young woman. I feel perfectly comfortable offering her advice. And while I would like to tell her to respond to inappropriate comments with something to the effect of, “I cannot figure out why you would think it’s ok to say that to me,” I am hesitant to advise her to engage these people at all. I’m also hesitant to tell her to walk away. The first option places the power with her, while the second seems more like it leaves at least some power with the tasteless cad.

The problem is, it’s difficult to know whether the label “tasteless cad” is sufficient and accurate. If the issue is simply a lack of manners and a poor sense of humor, then perhaps pointing out the rudeness will help prevent the person from creeping out someone else. But what if the demonstrated disrespect reflects a fundamental disregard for the personhood of those harassed, and attests to a sense of entitlement? A challenge to that entitlement could theoretically provoke more of an assertion of power. Tough for a 17-year-old to gauge when it’s even difficult for a forty-something-year-old to do.

There are protections set up in schools and in workplaces (to prevent harassment from bosses or other employees), but there are no systematic protections regarding interactions with the general public. I would certainly report such matters to business management. A good manager will work to provide a safe environment for both employees and customers. Something as simple as placing a prominent sign reminding people to show respect to others can help establish expected conduct. Management can also ask someone to leave.

It’s more difficult when a store owner is the one engaging in the misconduct. If it’s the owner, I’d avoid that establishment and would warn others. A complaint to the Better Business Bureau or to the state Attorney General’s office may in some circumstances be warranted.

And for everyone’s well-being, we need to teach our kids by always modeling respectful speech and behavior – not reducing people to sexual objects, not describing relationships as conquests, and not indicating that it’s ever ok to make suggestive comments to strangers. If we witness inappropriate behavior, we need to show support to the person being hassled, and when possible we need to report the harassment (to management, to administration, etc., depending on where it is occurring). We need to hammer into our kids that it is never ok for others to harass them.

It’s better than it used to be, and we can all work together to keep improving our world. It will never be perfect, but the exceptions to civility should become increasingly rare.

Springing into the Pharmacy

Spring is here (although it may not yet feel like it). The days are getting longer. The temperature is slowly getting warmer. Green stuff will start poking through the ground and popping out on trees. We’ll see more of our neighbors, since they won’t be trying to get from their cars into their houses (and vice versa) as quickly as possible before they freeze.

Pollen allergies will start up again. And grass allergies.

So many people suffer from the watery, itchy eyes, itchy, runny nose, sneezy, general ickiness of seasonal allergies. And there are so many remedies in the aisle of the pharmacy – no prescription needed.

Several years ago, I spent the better part of an afternoon exasperated with our youngest son, who was maybe eight years old at the time. This was quite unusual. Unheard of, actually. Son number three tends not to piss us off. But he was acting really obnoxious. Not listening. Acting unruly. I was getting angrier at his behavior.

Then my husband (an engineer, mind you, not a doctor) said, “Didn’t you give him that anti-histamine a few hours ago?” Riiiiiiiight. He had had a reaction to some mosquito bites, so his pediatrician had told me to give him cetirizine to help quell the itchy welts.

Wonder-Doc over here hadn’t realized that her kid was reacting to a medication that affects the central nervous system.

As soon as my husband pointed out the obvious, my anger disappeared (replaced with a healthy dose of guilt), and I did a much better job of soothing my agitated son. And as soon as the drug was out of his system, he returned to his normal, sweet self.

The fact that something is available over-the-counter does not mean that it is completely safe/benign/without risk. This holds true for allergy meds, cold meds, or any medication for that matter.

Always read the bottle of a medication to see what potential side effects might be. Don’t drive when taking a medication unless you know how that medicine affects you and you are certain you can drive safely. Don’t take more than the recommended amount. Remember that any medication can interact with any other medication and that alcohol can interact with any medication.

Different people react differently to different things. Our middle son had taken that particular anti-histamine without any negative effects. Don’t assume that if a certain medication is fine for one person that it’s fine for another, or that if one person has difficulty with a particular medication that it’s bad for someone else. Talk to your doctor and your pharmacist with any concerns or questions.

A couple weeks ago, I was at the tail end of a cold. Our family was out in the car, and my eyes were itching and running non-stop. I had a post-nasal drip going and I was sneezing every two minutes. It was miserable. I needed an anti-histamine.

So we swung by a CVS and I picked up a small bottle of disolving-tablets-no-water-needed cetirizine. I took one. Within about an hour my eyes were significantly better and my sneezing frequency was cut in half. But for a short while I felt a little drowsy – almost as if I had had a glass of wine.

Available-without-a-prescription does not mean without-potential-consequences. Only take something if you really need it. Read labels. Ask questions. Watch for reactions. Listen to your body.

And enjoy getting back outside!

 

 

Vaccine Resistance – This is a long one….

Vaccines. Diseases. Measles. Big Pharma. Anti-vaxxers. Medical Industrial Complex. Individual rights. Herd immunity. Selfishness. Stupidity. Toxins. Chemicals. Autism. Encephalitis. Mercury. Thimerosal. Febrile seizures. Science. Anti-science. Pseudo-science. Alternative. Natural. Money-grubbing. Lying. Evil.

My Facebook feed has been blowing up with posts and memes related to vaccination. The topic cycles through the news and social media regularly and is prominent at the moment in the wake of the recent/current measles outbreak originating at Disneyland in California. People are angry. People are defensive. People are offensive.

I’m pensive.

Over the past several decades, vaccines have prevented millions of deaths. They are effective. There is no question about this. Current vaccines are exceedingly safe. There is no question about this.

Vaccines are not 100% effective. We need a high communal vaccination rate (generally 95% or more) to ensure “herd immunity,” which stops widespread epidemics and protects those who cannot, for medical reasons, be vaccinated, and those for whom the vaccine did not generate adequate immunity. Vaccines are not 100% risk-free, although the risk of a serious reaction is extremely small (for example, about a one-in-a-million chance of an anaphylactic allergic reaction to the Measles/Mumps/Rubella vaccine). Many vaccines have minor side effects, such as soreness at the injection site or a mild fever (the fever actually is a sign that your body is mounting an immune response to the immunization). The diseases the vaccines protect against have significant rates of severe complications (encephalitis – an inflammation of the brain which frequently leads to permanent damage, pneumonia (the most common measles-related cause of death), paralysis, sterility, blindness, deafness, death, etc., depending on the specific disease).

The scientific and medical establishment is in overwhelming agreement that everyone who can be immunized should receive all recommended vaccinations. The benefits far outweigh the risks. The vast majority of people in this country follow these recommendations.

And yet.

And yet we have pockets of people loudly protesting vaccines.

And some people listening to these loud protests and quietly forgoing immunizations for their children.

And this is a problem.

From the community health and welfare standpoint, this is a problem because there are enough people forgoing immunizations to impair our herd immunity. Those who are most vulnerable (people undergoing chemotherapy, people on immunosuppressive medications, babies too young to be immunized, people with immune deficiencies, people who are too frail or ill for their bodies’ immune responses to function properly, etc.) are at risk. And because the vaccines are not 100% effective, even those healthy folks who are fully immunized are at higher risk because of the decrease in herd immunity. So clumps of folks refusing to immunize will affect other people, not just their own families.

And because we are human, even if the herd immunity issue were not in play (although it most definitely is), many who understand the science and the importance of immunizing and the benefits versus the risks to the individual (putting aside, for the moment, the community as a whole) would still be frustrated by the failure of groups of people to vaccinate their children. Because even if (again, ignoring the public health risk for the sake of this argument) we could say to ourselves, “if they don’t want to immunize themselves that’s their problem – they can suffer from and potentially die from preventable diseases if they so choose,” (which I personally have a hard time saying), we still care about the welfare of their children.

And there’s the rub.

Because that is also what motivates the vociferousness of some of the people who loudly oppose vaccines. Not all of them, but some of them.

And understanding motivation is essential to understanding and communicating with people.

What doesn’t motivate people is calling them stupid.

At this time, I will not speak to the few people within the official medical establishment (M.D.s and D.O.s) who speak against, discourage, or otherwise buck the positions of the American Medical Association, American Osteopathic Association, Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), American Academy of Pediatrics, American College of Physicians, etc. My opinion and analysis of these people will be a topic for another day.

I will also not speak at this time to people who have not undergone the rigors of scientific medical training who hold themselves out to the public to be healthcare practitioners and give advice contrary to scientific medical consensus. This will also be a topic for another day.

What I will speak to right now is the vaccine resistance (and vigorous promotion of this resistance) that is found within small proportions of the general population.

The people I am speaking about certainly love their children. They are motivated to protect their children. They are motivated to protect other people’s children. They are motivated by fear. Deep fear.

I understand fear. And I understand fear of vaccines.

Most of our immunizations are done by injection. A needle is stuck into us (or our child) as the vaccine is injected into our muscle. It hurts.

We have evolved to resist being stuck and injected – we reflexively try to avoid bees and wasps. That resistance for most of us is easily overcome with our intellectual understanding of immunization, but we are definitely actively resisting a natural impulse when we allow ourselves to be injected. Sometimes fears can be too strong to overcome with our own intellectualizing and we need a little help.

Frequently, young children will cry when given injections. It’s awful to see your child in pain. Yes, that pain is to protect him from something that would cause much greater discomfort and could cause grave harm or even death, but the injection pain is right here, right now, and real, while that disease potential is not right in our face and we don’t frequently see the awful diseases that we once used to (due mainly to vaccination).

A child will frequently be fussy after vaccinations – her leg or arm hurts where she was poked. She may have a fever for a couple days. She may sleep poorly while she feels icky. And a parent feels awful, because the parent gave permission to someone to do this to her. This ickiness of vaccination is right in front of the parent, while the disease being inoculated against is not in front of the parent.

Although severe vaccine side effects are exceedingly rare, a parent may still worry about the potential.

We look for confirmation. We look for validation. We look for reassurance. We take it where we get it.

While most of us are able to intellectualize and rationalize the extreme benefit of vaccination, some of us have more difficulty overcoming the fears. When we’re having difficulty, the reactions of others can make all the difference in the world.

Who listens to our fears with empathy? Who rolls their eyes? Who sighs with exasperation? Who ridicules our fears? Who explains and educates? Who gives us time?

Although correlation does not imply causation, our tendency is to infer causation from correlation. We are suggestible. Although large scale data gives us significantly more information than a few anecdotes, we tend to remember and hang on to stories. When we are given some information we know to be correct, we are more inclined to believe accompanying information from the same source, whether or not that accompanying information is valid.

These tendencies, coupled with who is responding to a person’s fears (and how they are responding), will influence whether someone who is afraid will go in one direction or the other.

There was a recent study  that looked at information intervention to see how it affected parental attitudes on the MMR vaccine. For this study, parents were given a questionnaire which included questions on how likely they were to have their future children vaccinated with the MMR vaccine, whether they thought certain vaccines caused autism, and how likely they thought it was that someone would suffer serious side effects from the MMR vaccine. They were then randomly assigned to five groups. One group received information (from the CDC) explaining the lack of evidence that the MMR vaccine causes autism. The second group received text from the official Vaccine Information Sheets explaining the dangers of the diseases against which the MMR vaccine protects. The third group received pictures of children with measles, mumps, or rubella. The fourth group received a dramatic story (from the CDC) about an infant who almost died from measles. The fifth group was the control group – they received no vaccine information intervention materials, but were instead given reading on the costs and benefits of bird feeding. The parents were then given a second questionnaire which included the three specific questions mentioned above.

The results of this study showed that none of the interventions increased a parent’s likelihood of having a future child immunized with the MMR vaccine. The autism-vaccine corrective information did decrease the respondents’ beliefs that there was a link between vaccines and autism, but it also decreased the respondents’ future likelihood to vaccinate (mostly in the group of parents who originally held the least favorable view of vaccines). The dramatic story of the infant with measles increased the perception that the MMR vaccine has serious side effects. The pictures of ill children increased the parents’ likelihood of saying that some vaccines cause autism.

I don’t find the above results surprising, nor do I find them particularly discouraging, although headlines in response to its publication were generally along the lines of “You Can’t Change an Anti-vaxxer’s Mind” (that one was from the Mother Jones blog). The above study looked at four different “spot” information interventions. It did not look at comprehensive education, communication techniques, nor empathy of information providers – it simply provided limited, unifocal written materials. It is not fair to say, from the results of this study, that people scared of immunization cannot be reached.

If I had been a parent in this study given a story to read of a sick child, or had been given alarming pictures of children with measles, mumps, and rubella, I might then go to my computer and do a quick search on those diseases. While doing so, I would very likely come across websites promulgating false information about dangers of the MMR vaccine or quoting the (fully discredited) study linking the MMR vaccine to autism. I also might have thought, “Why are they trying to scare me about these diseases? Maybe they think they need to scare me because the vaccine is dangerous.” I wasn’t given information on the safety of the vaccines. I wasn’t told details about potential side effects. I wasn’t given an opportunity to ask questions.

Communication is critical. Comprehensive communication is critical. Empathy is critical.

The costs would likely be prohibitive, but it would be nice to set up a study (with the same questions looked at in the above study) where people with negative attitudes towards immunization were identified, where they were randomized to an intervention group where a doctor listened to their fears, addressed their concerns, quantified the risks and benefits of vaccination versus the diseases themselves, provided trustworthy further sources, and explained which sources were not scientifically trustworthy and why, all while maintaining an empathetic demeanor; a group where the above was done in an arrogant/ridiculing manner; and a control group where a doctor discussed the benefits of wearing a bicycle helmet. How might people respond then?

The anti-immunization community (both physical and internet) provides empathy. They tend to be comprehensive in their information (albeit false). They define the enemy (enemies). They pull people into their fold, making them feel a part of a valued and cared-for community.

Calling people names will not pull people back from a group that’s making them feel welcome and supported.

Again, the majority in this country understands the science behind immunizations, trusts the medical and science establishments, and immunizes their children against dangerous communicable diseases. People who are wary of immunizations are not trusting the overwhelming consensus of physicians. If they are already pulling away in some thoughts from the medical world, why would anyone think that insulting them would help pull them back?

A piecemeal approach of a written form here, a scary story there, or some random disease photo is also not likely to pull anyone back, nor is an internet meme with a snarky comment or comparison.

Memes make points or sum up arguments with a picture and just a few words, frequently with an element of humor. I frequently appreciate the humor and the analogies made when the memes are pro-vaccine. But when I look at those of the anti-vaccination type, it hammers home just how lacking a meme is. It may pack punch, but it lacks depth. It lacks nuance. It lacks explanation that addresses questions or concerns.

This is not to say that the memes are useless. They generally serve to support/confirm/validate what people on one side or the other already understand or believe. They also, by serving as an indicator of what someone posting the meme thinks, contribute to defining norms. So it is helpful for Facebook to have a preponderance of pro-vaccine posts, since it helps cement immunization as the acceptable/preferable thing to do, and it is possible to do this with humor, with analogies, and with respect. It is helpful for people to respond to/refute anti-vaccine posts in a respectful, empathetic, honest, respectful, non-condescending manner.

Here is my official, as-a-doctor stance on vaccination:

Vaccines save lives. Vaccines are not perfect, but the ones that we have now have been proven overall safe and effective. We’ve come a long way since the first documented attempts to immunize. Variolation for smallpox – rubbing material from smallpox sores into people’s skin to induce a cutaneous case of the disease which was milder than the normal variant and conferred immunity to the more severe infection – has evidence of being performed in China 1000 (yes, one thousand) years ago, and was practiced in Asia, Africa and Europe from the 1600s through the 1700s (see historyofvaccines.org). Our vaccines and their manufacturing process have been refined and improved remarkably over the past two centuries. All of our present-day science overwhelmingly indicates that the benefits of our current vaccines vastly outweigh the risks. This does not mean that the risks of vaccination are zero, but they are ever so much lower than the risks of not vaccinating.

Choosing not to vaccinate has risks not only to those who refuse to vaccinate but to others in the community as well. Doctors and medical researchers read studies, discuss findings, analyze quality of research, and continually ask questions to direct further lines of inquiry. As new information becomes available and as better methods evolve, we update recommendations and practices accordingly. All of our best available current information leads me to recommend immunization.

Immunize yourselves. Immunize your kids. And if you still have concerns or questions about vaccines, ask them of your physician. If you feel you are not being answered respectfully by your doctor, calmly and respectfully point this out, and ask again.

If you are a doctor and there seem to be multiple patients in your practice with similar vaccine concerns, hold a few group talks to openly address the concerns and share your knowledge with multiple people at once. Make a video addressing common concerns, make it comprehensive, include analogies, show appreciation for concerns as you discuss them, and put it on your website. No matter how exasperated you may be with the whole anti-vaccination issue, show empathy, kindness, and compassion to those with fears. Teach your patients, and don’t chase them away with outward manifestations of your frustrations.

Let’s live beyond the memes.

 

Following the Trails

Our family loves to hike. Traveling the trails is a deeply happy place for us. In fact, I don’t think there’s ever been a time when one of us suggested taking a hike and everyone didn’t unanimously and enthusiastically agree. A few weeks ago, my family took a lovely hike in a state park in Massachusetts. It was a gorgeous day – temperature in the upper 40s, blue skies, no wind. The hub of trails started at a large, beautiful pond. There were large hills in every direction (which we really miss in general since we live in a fairly flat region in the Midwest), and the trails were dry since we hadn’t had rain in a couple days.

We checked out the big map at the trail head and picked up a small folded guide to bring along with us, as there were so many choices and branchings of paths along the way. Both the large wooden and the small paper maps said, as pretty much all maps/guides in any hiking area say, to stay on designated trails both for personal safety and for protection of the land.

We started out along the perimeter of the pond, where most people were walking, and then headed away from the water on a path to see some cliffs. After a short while, we noticed that the path was not well-marked. It was easy enough to follow at the beginning as the cut through the trees was fairly obvious, but as the trees thinned it became more difficult to discern exactly where the trail was. A thick carpet of leaves was everywhere, and since it was early winter there were no ferns or other greenery growing where the trail wasn’t.

All five of us are good with maps and with judging relative distances. The guide we had showed various bodies of water as well as contour lines of changing elevation. With some work, we managed to figure out how to get to each subsequent destination along the trails on our afternoon’s journey in spite of the lack of trail markings. It was a lovely little adventure and a delight to be out in the woods.

But I couldn’t help but think about how disconcerting this could be to someone who wasn’t a seasoned hiker, who wasn’t familiar with topographical maps, and who was travelling alone or with young children. The signs said to say on the trails, but the sign-makers neglected to mark said trails. When you tell someone to stay on a trail, you can’t assume that someone will know where the trail is. You need to provide trail markers.

People frequently use the phrase “blaze a trail” metaphorically to indicate that someone is the first person to do something and that others will follow. However, the actual meaning of “blazing” a path is that someone is providing markers to be used by others to follow that path. It’s not just finding and knowing the way, but helping others find the way as well.

This is the case in medicine. Doctors can’t just tell their patients to do something without explaining in detail the hows, whys, whats, wheres, and whens. A doctor might know what a general piece of advice entails, but a patient could be figuratively lost in the woods without a mark in sight on any tree in any direction.

“Cut down on your sodium intake.” “Take this medication twice a day.” These concepts may be clear and precise to the doctor, but may be vague and unclear to the patient.

Doctors must describe the setting – the situation and what’s happening. They need to describe the different paths, landmarks along the way, and tips for getting through/over/around the difficult parts. They need to describe what to do if their patient wanders off the path – how they can find their way back if they can and how to reach help if they can’t do it themselves.

“Sodium is an element in salt that causes your body to hold onto more water than it needs, and because you have early heart failure it’s important for you to make sure that your body doesn’t have too much fluid. The medications you’re taking help, but your diet is important, too. For the next two weeks, try to prepare all your meals at home – I know you and your wife love to cook together! Don’t add salt to anything. Here’s an example of a nutrition label – see where it says “sodium”? Try to make sure that the total amount of sodium on anything packaged that you eat throughout an entire day doesn’t add up to more than 1500 mg. This is hard to do, and it will probably force you to avoid a lot of pre-packaged foods. If you have difficulty with this, I’ll help you set up an appointment with a medical nutritionist. Feel free to call me with any questions, and I’ll see you back here in two weeks.” Blaze the trail well.

Patients need to make sure they have detailed maps with them, an understanding of how to read those maps, knowledge of what the trail markers look like, hiking partners, and ways to reach help when needed. If their doctors have not been clear and comprehensive, they need to ask for clarity and comprehensiveness.

“When you say to take this medication two times each day, does that mean exactly 12 hours apart? If not, what is the rough window of time that’s ok? Should I take it with food or on an empty stomach? Are there any side effects I should watch for? Do I take the medication all the time, or only when I feel like I need it? Is there anything specific I should or should not do while taking this medication? Should I direct further questions to you or to my pharmacist?” When people point out that a trail is not well-marked, the park rangers will improve the trail blazing.

Maps. Markers. Trails. Skills. Partners. Guides. Communication. Enjoy your hiking!