Author Archives: drcharles

grilling aluminum foil safe

The Health Risks of Grilling on Aluminum Foil (Is It Safe?)

Is it safe to grill on aluminum foil? As the weather heats up, and the allure of grilling returns, it is important to consider some of the potential health risks. One of the great joys of my life is “manning” the grill – beer in hand, wafting smoke rising through the air, a delicious anticipation building. It seems worth the risk of consuming carcinogens present in the smoke and char. I’ve taken to grilling on aluminum foil as the iron griddle deteriorates, black gunk accumulates, and it generally becomes harder to clean – but is this practice actually dangerous?

Aluminum Foil is A Little Unhealthy

The answer seems to be a slight yes. Cooking with aluminum foil has been shown to create numerous tiny cracks and flakes in the surface of the aluminum foil as demonstrated with electron microscopy.  Moreover chemical leaching of aluminum into food occurs with greater ease when food contains acidic properties such as lemon juice or spices.

aluminum foil microscope
aluminum foil under microscope after ordinary oven cooking

Excessive aluminum in the body has been associated with health problems, but the evidence is patchy and not necessarily convincing.  According to the CDC, high levels of aluminum have been associated with Alzheimer’s in some clinical studies, though this remains controversial as the disease is thought to be multifactorial, and cause and effect has not been established.

Unhealthy Aluminum Dust?

Inhalation of aluminum dust in an occupational setting (i.e. not just grilling) has been implicated in the development of respiratory problems and even pulmonary fibrosis in some studies, but not in others, according to OSHA.

High levels of occupation aluminum exposure have been correlated with neurological declines in balance, coordination, and memory.

Oral aluminum exposure has been associated with reproductive toxicity.

It has not been classified a carcinogen.

In general it seems that aluminum exposure through typical sources (foods and water supply) is not harmful enough to cause great concern or regulatory action.

The mining, production, and disposal of aluminum, however, creates an undeniable environmental burden. Refining and smelting contribute to greenhouse gas emissions, including perfluorocarbons and sulfur dioxide, a precursor of acid rain.  Recycling of aluminum requires only 5% of the energy needed for primary extraction.

I’m Not Grilling With Aluminum Foil

And so I’m going to change this summer and choose not to grill on aluminum foil, less because of the hard scientific data, and more because of the knowledge that significant flaking and leaching occurs into my food. I’ve ordered a stainless steel griddle to put directly on the grill, which I’m sure will detract significantly from the joy of grilling, and add directly to the burden of scrubbing and cleaning afterwards.

Facebooktwitterpinterest
new car smell bad unhealthy

What Is “New Car Smell,” and Is It Unhealthy? (Yes!)

What is “new car smell” and is it bad for you? As I shopped for a new car last year, I realized that my priorities were considered odd by most car salesmen. The three most important characteristics I desired in a new car were good gas mileage, good crash safety, and relatively low concentrations of “new car smells.”

The often celebrated (but particularly noxious) “new car smell” is actually a synthetic blend of respiratory irritants and potential carcinogens off-gassing from the plastic, glues, and seating materials found inside the car.

One year later I am happy I chose my car from one of the top five lowest emitting models.

Testing of car interiors has revealed the presence of volatile organic compounds, (including formaldehyde, toluene, and benzene) polybrominated diphenyl ethers (PBDEs) which are used as flame retardants, and phthalic acid esters (phthalates).

These chemicals and substance are known to exacerbate respiratory illnesses, produce nose and throat irritation, cause headaches, and even irritate the skin. Exposure may even increase the risk of cancer, endocrine system disruption, and neurological problems.

The best cars of 2013-14 in terms of low levels of hazardous chemicals, according to The Ecology Center’s testing and report, include the Honda Civic, Toyota Prius, Honda CR-Z, Nissan Cube, Acura RDX/ZDX, Audi S5, and the Smart Coupe. The full list of car rankings is worth reviewing. Not listed but supremely admirable is the Amish horse-powered buggy.

As the summer approaches, and the heat goes up, off-gassing and the release of chemicals from car interiors greatly increases. It is wise to ventilate any car that has been sitting in the heat.

Some advise driving with the windows cracked to improve air quality. While this would certainly reduce the ambient concentration of chemicals released from the car interior, I worry that driving on busy multi-lane highways with the windows wide open trades poor quality interior air for poor quality exterior air.

The “outdoor” products of combustion and car operation include fine particulates and ultrafine particulates, the inhalation of which has been directly correlated with increased cardiovascular risk.

Ultrafine particulates in particular penetrate deep into our bodies via the lungs, create inflammation, and promote heart disease. Their emission has been estimated to result in an additional 4 million deaths per year across the world, according to the EPA.

In order to achieve the best air quality, perhaps some variation of this crazy yet deliberate plan might help. Purchase a car that scores well in terms of the safety of its materials. Ventilate the car well in the morning.

Then close the windows and run the AC with recirculated/filtered air while on the 4-6 lane highway, thereby decreasing particulates and combustion products inhaled from outdoors. Park and leave the car windows cracked open all day as the car bakes in increasingly hot weather.

On the way home repeat this sequence, being careful to disengage emotionally from the many provocations of aggressive drivers, who incidentally remind us of brain-starved, half-human zombies.

Good luck with your own paranoid routine, but do consider that new car smell when you purchase your next vehicle. It definitely gives me a headache.

Facebooktwitterpinterest
does nutrisystem work doctor

Does Nutrisystem Work? A Doctor’s Thoughts on the Diet (2020)

nutrisystem logo

I was recently asked by a patient: “Does Nutrisystem really work? And if so, how does Nutrisystem work?” I’ve never really examined the merits or nutritional underpinnings of Nutrisystem enough to provide a coherent answer, but in this post, I will review the positives and potential negatives that can be seen upon a brief review, so that next time someone asks if Nutrisystem really works I can give a thoughtful answer.

There are multiple ways to lose weight, but among the commercial weight loss programs, Nutrisystem, Weight Watchers, and Jenny Craig stand out. Note that meal delivery diets like Nutrisystem may appeal more to busy people, as the convenience of prepared meals saves you time and effort of meal preparation and proper portioning. (If you enjoy cooking and don’t mind counting points, you’ll probably want to skip meal delivery diets like Nutrisystem and try a DIY diet like WW or the Mayo Clinic Diet instead.)

Anyway, on the Nutrisystem homepage, I clicked on the link for “How Nutrisystem Works.” Four central ideas emerge easy, foods you love, safety, and effective. Hmmm, let’s look at each claim.

Is Nutrisystem an easy diet to follow?

For a weight loss program to be effective for a large number of people, with different lifestyles, work hours, and abilities in the kitchen, constructing a plan founded on simplicity makes sense. Nutrisystem controls the portions and ingredients with breakfasts, lunches, dinners, and snacks.

Rather than sitting down with a book or finding time to learn nutritional science, by eating the smaller portions and calories inherent in each portioned meal, they hope that you naturally recalibrate your expectations of what each meal should be. Gone are the laborious and joyless tasks of counting, measuring, and obsessive weigh-ins (which some data-driven personalities thrive upon, though).

Easy to follow? Meh, Nutrisystem is ranked #17 on U.S. News’ list of Easiest Diets to Follow.

Your favorite foods, made healthier?

nutrisystem meals
You can view the entire Nutrisystem menu here

Nutrisystem has crafted their foods with the input of nutrition experts. Upon a review of the actual foods, it seems like a fairly typical American food diet, which should be tasty for a majority of people. It does not rely upon drastic changes like Atkin’s meat and fat, Paleo’s obsessions with mythical hunter-gatherers, or the draconian cuts of a ketogenic diet.

The example Nutrisystem gives is a good one: compare their hamburger (240 calories, 8g of fat) with one eaten at Five Guys (700 calories, 43g of fat). Perhaps not as satisfying, but it’s still a hamburger, presumably food you like and are used to eating. They have also considered balancing nutrients, lean proteins, high fiber, low glycemic carbs, and not using artificial sweeteners or flavors.

Is Nutrisystem an effective and safe diet?

Nutrisystem is based on calorie restriction, providing about 1500 calories per day, which is in line with the daily recommendation for women on a weight loss diet. That means if you follow their program, the math implies that Nutrisystem should effectively result in weight loss of 1-2 pounds per week as your body burns fat instead of carbs for energy.

More frequent meals: There are several theories on how frequently to eat, with some newer trends advocating for intermittent fasting. This sort of eating may produce low blood sugars, low energy levels, and might not be conducive to everyone’s lifestyle or health conditions/medications such as for those with diabetes. Nutrisystem is built around the premise that eating smaller, balanced meals 5-6 times per day is safer and healthier, citing research from The New England Journal of Medicine.

In terms of the actual ingredients, most seem fairly good, even for processed foods like their bars and packaged foods. They also ask you to mix in fresh grocery items and healthy flex meals outside the Nutrisystem program. In general, I don’t like the idea of eating processed foods for the long term, even though Nutrisystem seems processed in a thoughtful manner to incorporate more fiber, lower carbs, and less sugar than other random processed foods on the shelves. It’s way better than a typical Entenmanns ingredient list!

So, does Nutrisystem really work?

In an ideal world, we could prepare delicious meals from scratch ingredients all day. We would follow food writer Michael Pollan’s advice, go to the local farmer’s market and eat real food, less of it, and mostly plants. This remains my overall advice to patients on how to eat healthfully.

But the reality is that we are increasingly overburdened with life, ordering stuff from Amazon at midnight because we can’t find time to even shop for essential items anymore. We’re consuming over 3400 grams of sodium per day, and more than a third of us are obese. So, the answer to whether or not Nutrisystem is healthy is a relative one. The program does stay within the FDA’s guidelines for levels of sodium, (under 2300 mg/day) saturated fat, and calories so for most people diet is probably a significant improvement over current bad eating habits.

Interestingly, credible review sites show mostly positive reviews with a seemingly high success rate. In fact, the overall satisfaction rating on ConsumerAffairs.com is over 4-stars, with most people inferring that yes, Nutrisystem did work for helping them achieve their weight loss goals.

In our overscheduled, overworked lives, Nutrisystem would provide a decent option, based on the principles above being non-controversial and nutritionally sound within the confines of having someone else prepare your food with the goal of losing weight safely.

Nutrisystem Cost: Per Day, Week, Month, Year?

Nutrisystem isn’t a cheap diet, but it’s relatively inexpensive compared to other meal delivery diets and services. Here’s the cost for Nutrisystem after applying their best coupon: (see below)

Cost of Nutrisystem for WOMEN:

  • Per Day: $10
  • Per Week: $75
  • Per Month: $287 (promotion)
  • One Year: $3550

Cost of Nutrisystem for MEN:

  • Per Day: $11.50
  • Per Week: $85
  • Per Month: $325 (promotion)
  • One Year: $3900

Note that you are expected to supplement their prepared meals with some fresh fruits and vegetables, as well as 3 meals on your own each week which will add to the total expense.

Note that these prices are based on the best new customer promotion available which locks in a lower monthly rate. Here’s the advert:

nutrisystem promotion banner
Well, apparently Nutrisystem worked for Marie!

*New: We found a coupon code for an extra $25 off here! 

*Tip: not all of their deals keep the price at the low signup rate, but the one above does. You should familiarize yourself with Nutrisystem’s cancellation policy, as signing up means committing to at least 2 months of the program.

Is this Diet Effective? Nutrisystem Studies:

*Disclaimer – This review of Nutrisystem does not constitute medical advice. Please consult your doctor before starting any diet, including Nutrisystem. some of the links to Nutrisystem on this page, when followed and resulting in purchases, may result in a small commission being generated.  We don’t expect this to do more than keep the lights on!

Facebooktwitterpinterest
constipation remedy

The Most Natural Treatment for Constipation

In the middle of an otherwise complicated visit, an older woman reminded me of a very basic treatment for constipation that she discovered 40 years prior.  It involves no medication, no special diet, and no unpleasant bowel regimen.  It does, however, require a certain maturity of character.  This technique demands assertiveness, social bravery, and a measure of self-assuredness that might be difficult to hone.  In Clint Eastwood’s movie The Good, The Bad, and The Ugly, there is an iconic line that goes: “When you have to shoot, shoot.  Don’t talk.”

So let it be with moving the bowels.

My patient told me that most of her life she was embarrassed to go to the bathroom in public places such as school, and then later work.  She would hold her bowel movements against the tide of peristalsis telling her to relieve the pressure.  She didn’t want the boys to know that she too defecated, or the popular girls to snicker at her as they seemingly excreted nothing but perfume and wavy hair.

By missing her body’s natural signals, by resisting the natural rhythm that wanted to move things along, she would back things up, creating the preconditions that would cause discomfort, immobility, and intestinal dysfunction later in the day as she struggled to make things happen on a socially convenient schedule.  And once the train stayed off the tracks for too long, a pattern of dysfunction became normal.

This may have done lasting, permanent damage to her system.

The bowels move materials using coordinated, progressive contractions, moving like waves through smooth muscle.  The assembly line moves in synchrony, and can be triggered to start going by the thought of food, ingestion of food, and circadian rhythms.  The gastro-colic reflex is a well-known example.  After receiving food in the stomach, the rest of the gastrointestinal system gets a cue to start moving things along.  It is best to ride the wave.

As my patient matured, and cared less about what people might think about her retreating to the bathroom on cue, she began riding the natural waves, at work, at home, wherever.  After completing an appropriate medical evaluation, colonoscopy, and gastrointestinal evaluation showing things were ok, she decided to get back to basics.  A typical morning might be eating breakfast, drinking some coffee, and then 1 hour later like clock work getting up and heading to the toilet when the feeling began.  Bosses, boyfriends, barbies be ignored.

*Related: Nutrisystem: 40% Off + $30 Off

After a while a certain understanding was reconnected between her behaviors and her parasympathetic nervous system.  A circadian rhythm also kicked in, and the whole show became a natural symphony.  OK, so maybe not that beautiful, but I digress.

In addition to drinking plenty of water, exercising, getting fiber from fruits and vegetables, perhaps constipation for some people can be thought of as a social timing problem.  Like brave actors who go out upon the stage under the bright lights and overcome their anxieties about being watched, scrutinized, and exposed, we should ourselves go with the natural flow, following our bodies’ rhythms and reflexes no matter how embarrassing.

I think this is particularly important for young girls, who are held to higher standards of propriety and appearance, encouraged to cloak themselves and their bodily realities more than boys.  For boys, by contrast, pooping and flatulence can even be celebrated as a sort of social currency.  But that is another topic for another post!

When you have to shoot, shoot.  Don’t talk.  Go to the bathroom.  It might help more than you think.Facebooktwitterpinterest

The Self-Defeating Logic of Gym Memberships

I belong to a local gym.  I’m supposed to go there to exercise.  I pay $40 a month for the privilege, but I would estimate that I actually get to the gym twice a month.  This failure to find the necessary time to work out is by itself a self-defeating, exercise-discouraging proposition.  By equating exercise with a third-party gymnasium, do we undermine our very notion of healthy activity?  Should not getting to the gym = not exercising?  Here are some ways to correct this fallacy of inherent defeat.

If you conflate healthy physical activity with a time and place that is not readily accessible, you unwittingly place a firewall around succeeding.  For example, I worked until dinnertime last night, had to run home (drive in a car, that is), and take care of domestic duties for the rest of the night.  By the time I might consider going to the gym it was already 11:00 PM.  Therefore yet another day of physical inactivity because there was simply no way to fit in the 1-1.5 hours needed to execute a trip to the local sweat house.

Are we exercising less because of this faulty logic?  Like other activities we outsource, ultimately there is a loss of efficiency and joy.  Look at cooking.  For some people making dinner is just too time consuming.  They rely instead upon take out, half assembled meals, or processed food.  The food infrastructure in the fridge collapses – no garlic, no basic ingredients, rotten milk… so that when a quick meal is desired, it actually takes more time to find an edible assortment of ingredients that could pass as a meal.  Better to cook your own food most of the time, and keep a healthy, steady supply chain coming from the grocery store.

Exercise does not have to entail purchasing a right to machinery, group psychology, and a physical location separate from the rest of your daily life.  As this Wall Street Journal article shows, some boutique gyms are charging upwards of $30 dollars for an individual class, with no coupons or discounts. Outrageous and expensive.

Here are some ways that you can get the cardiovascular benefits of exercise during the day, without settling in to an unhealthy lifestyle that can’t find the large chunk of time needed for the gym.  Several goods apps and websites exist that demonstrate home exercise routines using no equipment other than your own body.  My favorite is a free site called Darebee, which has countless exercise routines and videos to demonstrate proper techniques.  For a while I was doing these exercise almost once a day, sometimes scattered in between patients, or at night after the manic clock of efficiency can be turned off.  Some of these exercises like the burpees may have contributed to a groin pull I sustained, so remember your age and realistic fitness level!  Just go for a walk once a day, anytime, anyplace.

Taking the stairs, getting up and walking around the house/office at least 2-3 times per hour, and even fidgeting at your desk can help immensely.  One study found measurable benefits to circulation by tapping your toes and moving your feet up and down while marooned at a desk all day.

The gym is also covered in germs.  I heard a recent podcast, can’t recall the source, that described a recent study showing more harmful bacteria on the average free weight than on the average toilet seat!  Always wash your hands at the gym, and long pants seriously recommended.  But I digress…

So in summary, if you are in a busy, time-contrained phase of life, the old habit of equating “getting to the gym” with “getting exercise” is flawed.  It will actually make you unhealthier and more frustrated and defeated.  To maintain that gym membership as the only avenue for working out is a modern fallacy.  Instead, stay active as much as possible during the day, from fidgeting to stretching to walking to running.  If you can make it to the gym, that’s awesome and I must admit that I am jealous.  There are surely a lot of reinforcing psychological benefits to group exercise, as well as having access to better equipment.

On your mark, get set, stand up and move around a little!  Inspiring.

Related: Is Nutrisystem safe and effective? | WSJ coupons

Facebooktwitterpinterest

The Rise of Apps to Monitor Chronic Disease

The Wall Street Journal has an interesting article about the increasing sophistication of personal apps on your electronic device to help monitor and treat conditions such as diabetes, COPD, CHF, and hypertension.  Although not a new idea by any means, the concept of self-monitoring with apps is getting more sophisticated.  Instead of simply entering data and tracking numbers, many of these apps are fusing with body sensors, directing linking with health care systems and doctors, and applying algorithms to optimize compliance with medications, and to produce early warning alerts prompting interventions that might ultimately keep people out of the hospital.

The WSJ cites developments in several disease models:

Diabetes – this condition exists along a continuum.  Type 1 diabetes requiring extremely vigilant monitoring and anticipation of insulin needs multiple times a day; whereas a mild case of adult Type 2 diabetes may require attention to lifestyle and diet alone, with monitoring of HBA1c levels every three to six months.   Apps are similarly available along a continuum of lifestyle coaching, from vital signs and activity monitoring, to intensive blood sugar monitoring with feedback to help determine insulin requirements.

Although the Wall Street Journal reports on several studies showing improved patient outcomes, it would be interesting to see if such intense monitoring of activities and diet leads to a reduction in quality of life.  Some people thrive on having their fitbit measure their daily activity.  But others feel such monitoring is intrusive, a burden, and down right depressing.  Other studies have shown the opposite, namely that monitoring blood glucose levels may improve mood scores, and add a sense of control.

Heart Disease : The WSJ reviews some programs such as one for patients undergoing cardiac rehabilitation after suffering a heart attack.  Once again, the results of vital signs, activity, and lifestyle monitoring seem positive in terms of better outcomes and functional status after a typical period of rehab.  The cardiologist quoted does bring up a sensible goal, that such intensive monitoring be used during an initial, educational and highly structured period to get people on the right track.  But then as their health improves and the conditions are better understood and accepted, the patients graduate to less structured self care and self-monitoring.

All of this does bring up important questions:

At what point does all this monitoring and surveillance become intrusive?

In the social media era, we have had a serious erosion of privacy and personal boundaries.  How much self awareness and self measurement and reporting do we tolerate before wanting to rip everything off and run wildly through open fields?

The “pill for every problem” assumption that guides the medical/pharma complex of today’s healthcare system may soon be joined by the “app for every problem.”  Is this more empowering than burdensome?   Does is lead to uniform dependence on one size fits all treatment approaches, or does it liberate more patients from dependence on doctors, pills, and a vast amount of knowledge they simply have to trust their doctors are relying upon.

With the anticipated ubiquitousness of sensors, penetrating, riding, and floating around the human body in the coming decades, what will the integrity of the human body amount to?  Are we simply phenomena like the weather to be tracked, predicted, and engineered?  Will the increasing alarms and whistles signaling problems and suboptimal statuses soon fill our minds like a the beeping of an open refrigerator door?

Answers to such questions will be different for each person, and I suspect that generational lines will define much of the degree of acceptance of health care apps.  With the future of mankind fusing with inorganic technologies, it seems the infrastructure for monitoring the cyborg machines future humans may become is already developing with these support tools for the still-organic, early 21st century human.

The companies developing such apps, linking them with healthcare systems and populations, figure to rise in the ranks of prominent corporations featured in the Wall Street Journal as well, as the one segment of our future economic model that seems sure to generate productivity of some sort will be tending to human health.

Until its all just robots.Facebooktwitterpinterest

medical work horses

How To Be More Efficient As A Primary Care Doctor

As an overextended physician in my 40’s, with a family life and a daily sense of exhaustion, I have given up the quixotic dream of helping to change healthcare in this country. I’m just trying to survive each day, along with my patients, and to be an efficient and helpful primary care doctor.

If you too have accepted that our healthcare system is a bloated, unfixable, disappointing mess, and that you are just a squirrel trying to get a nut each day, then read on for small tips on how to survive, nay thrive, within the sad drama that has become the modern office visit.

Resolve that someday, when perhaps you are better rested, better informed, and the industrial-capitalist-insurance-forprofit model has eaten itself alive, perhaps then you will return to your passionate dreams about how to be a better doctor and craft a better medical world. In the meantime, here’s an atomic bomb shelter model to survive.

1. See patients in one room
I used to carry a laptop from room to room, fumbling around and drifting from place to place to see patients. Stop that. Set up shop in one room, and plan on being there for most of the day. Get a comfortable chair. A green plant. A mug of coffee and a water bottle. One room facilitates the rest of this list as you will see. Patients can be brought back and their visits begun in an adjacent room. When you are ready for them, leave your room and ask them to kindly join you next door where you’ve been preparing for their visit. Unless they are extremely old or frail, they will get used to the shtick, and come to expect it.

2. Take 1-5 minutes to review each chart before starting the visit
I used to feel so bad about running late that after finishing with one patient, I would burst into the next room, as if punching a time card, and apologize to the patient, barely knowing whom I was seeing next. Forget that. It doesn’t serve you or the patient to be unprepared for the visit. You will make mistakes, be unfocused, and look like you don’t remember them.

Instead, sit in your little home base with the door closed. Review the last visit or two. Jot down some quick reminders on an actual piece of paper. Among the 15 complaints from last visit, which ones still need attention? I write down chief complaints and quick to do lists. (Last visit – Chest pain, ?stress test done. Elevated alk phos. Bone scan ok. ?paget’s. See rheum. DM2. HTN. Colonoscopy scheduled? Dysphagia, needs EGD. Etc)

Review imaging tests. Jot down loose ends. Review specialist letters’ conclusions. Review recent labs.

Scan vital signs. Did they lose 20 pounds since last visit, unintentionally? Is the BP 180/100? Bad to miss that.

3. Set up the assessment and plan
Yes, do this before the visit. I know you haven’t even seen the patient yet, but unless she is here for a quick same day visit, she’s going to have her own agenda and priorities as soon as you open the door. If you don’t crystalize your own agenda before you are juggling hers, the visit is going to be even more of a struggle.

List 5-15 chronic or recent problems on the chart’s assessment and plan before even seeing the patient. If there are major tasks you know the patient needs, or has failed to complete, order them before seeing the patient. Chest pain, didn’t get stress test, you’ve already ordered it. You can always delete it.

Once the visit has begun, you can add new complaints and diagnoses. Sometimes the visit can become unruly, and finishing with a problem list 10-20 issues deep is exhausting. But 99214’s and 99215’s result, diligent care is achieved, and everyone is happy-ish.

4. Small talk is good, for a small time
This hurts the most. I love knowing my patients as human beings, appreciating their stories, legends, quirks, bravery, and fears. But this is survival mode, and if you are in a saturated situation with kids to pick up by 6 PM at school after-care, then you must stay on point after a brief detour into humanism.

This really sucks.

5. Let the patient’s agenda come first
You may or may not see the patient holding a tangible list of problems in hand, but what you don’t want to do is take over from the beginning, force your way through your pre-planned list of 5-15 items, and then find out they have 6 more. “I know you are here for a check up today, and I have a lot of questions to review with you from recent visits, but I want to give you the floor first. How are you? What can we help with today?” It sounds like family medicine softness. Kind of deadly. But it is actually eastern Zen philosophy combined with German engineering – letting the visit pass through you without resisting its true motivations, yet holding onto an invisible scaffolding beneath.

Once you’ve handled the patient’s biggest concerns, your preplanned list may already overlap with theirs, making the additional dump of your diligent reminders easier. Don’t drag this part out. You’ve already done the work from prior visits. Lung nodule, due for CT Chest, reminder and script given.

6. Demand enough time
Modern primary care visits cannot be reasonably accomplished in less than 20 minutes. Demand 20 minute visits for chronic care, and 30-40 for the most complex patients, hospital follow ups, new patients, and most “preventative physicals” which end up being chronic disease management with USPTF essentials added in. 15 minutes is disrespecting you and the patient, and making money for someone else anyway. Plus, with better care 99213’s are rare, so it evens out or you come ahead in terms of RVU’s and that stuff.

7. Smile, breathe, laugh if you can
It really helps. But don’t force it. A smiling or laughing doctor at the wrong time is creepy and unnerving.

When rechecking a blood pressure, walk the nervous patient through some calming, deep breaths, and while telling them to relax their muscles, you do the same. No laughing at this time.

8. At the end of the visit, give a narrative outline
Sometimes patients won’t let you talk as much as you need to. They are excited, nervous, or just talkative. You have to wrap this up in a tidy manner for you and them. “So I understand what you’re telling me. I’m going to tell you my impressions about what is going on, then review some diagnostic tests we may or may not want to do to figure this out, and then we’ll talk about treatment options.” That way they know to give you some space to help them. “After that, please ask any questions you have, and then we’ll run through a quick summary of your old issues with some reminders.”

Bring more structure to the visit as it progresses. Hopefully, it is satisfying for you and the patient. Making order out of chaos is what humans do, even if the laws of thermodynamics still prove everything we do ultimately creates more disorder. Alas…

9. Get up and escort patient out at the end of the visit
This is good manners. It is also a ceremonial display that this dramatic interaction has reached its natural conclusion. It stretches your legs, helps your back, and alleviates pressure on your hemorrhoids. Just kidding. Maybe not.

10. Return to your room, close the door
With peace and quiet, finish your note, organize your thoughts into coherent, thoughtful, narrative documentation. I insist on speech-to-text dictation (Dragon medical dictation software). I refuse to click on boxes or try to cram the patient’s complex story, overlapping ideas, and fluid assessment and plan into templates provided by most electronic medical records. It’s not human, and it’s bad. Enough said.

If I’m running more than 30 minutes late, I will stop finishing each note. Instead I will then move on to the next patient’s chart and start the whole pre-gaming process all over again. Leaving the full documentation of the visit for the end of the day, or “lunchbreak” whatever that is, is a total bummer. But it happens.

In between patients, take a deep breath or 5. Close and rub your eyes. Do some tai chi poses, or practice a minute of mindfulness stuff. It really helps, and maybe your first heart attack will delayed.

11. Noble sacrifices will be made
This part is optional, depending on how badly you need to get out on time and pick up your kids, or walk your dog. Consider sacrificing small talk with colleagues. Eat your lunch in that bunker of a room while reviewing the 25 phone calls that have come in for you while you were seeing patients. Put on some music. Stretch. This is a sad departure from those you work with. Optional.

12. Delegate
You can’t do it all. Don’t feel bad. Your mission is to be the doctor. Medical assistants and front desk personnel should be there to support the whole enterprise.

Good luck. Hopefully this will make you a more efficient, more diligent, better doctor within the horrible confines of a typical, busy primary care practice. There is no one-size-fits all. But this approach works for me. I bring significantly less work home, and achieve greater productivity than my colleagues.

I’m soldiering on, muddling through, being a workhorse. These are not visionary pointers, and there is little inspiration in them. But until the larger struggle is won against our broken healthcare system, some of us choose to survive within the system, while others set up systems of care that are off the grid with concierge practices, ideal micro practices, or some other funky model for cash.

It also helps to have a photo depicting a rustic, mossy cabin in the woods posted somewhere.Facebooktwitterpinterest