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How Medicine is Practiced Today

How Medicine is Practiced Today

November 7, 2021 (2,413 words)

The actor Stanley Tucci has appeared in over 70 films, and he always manages to be an authentic, relatable presence, even as a villain. The other night he was interviewed on NPR about a new book he has out, which describes a deep and abiding love of freshly prepared food inherited from his parents, and how his sense of taste was adversely affected for a time by his recent bout with oral cancer.

Mr. Tucci praised the medical care he received during his initial diagnosis and extensive treatment, and told the listening audience how one of his cancer doctors has actually gone on to become a close family friend.

Many older folks share his sentiments. They enjoy a close bond with their primary care physician, and with other medical specialists their deteriorating condition prompts them to consult.

I, however, am not one of those people. Without ever having held any sort of grudge against the medical profession, mind you, I’ve managed to live a doctor-free existence for most of my life.

That all changed a few years ago when a series of nagging ailments began to visit themselves upon me. After being fit as a fiddle for so long I found myself in various and sundry waiting rooms, filling out the same form over and over again. Being seen for a few minutes by two and sometimes three assistants, who often ask the very same questions you just answered on that multi-page form you are forced to complete upon arrival.

Then the doctor (my primary care guy, an internist, a couple of different urologists, an optometrist) pops in for a few moments, usually with his/her nose firmly planted in his/her laptop, where all my vitals are conveniently stored.

Just for the record, I’ve also found my way to the emergency room of my local hospital a few times during this stretch, and had occasion to visit the neighborhood Urgent Care walk-in-with-no-appointment place more than once. I’ve also had a series of blood tests taken, and more CAT scans and MRIs than I can keep track of.

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Most of my little afflictions have turned out to be false alarms. Nothing to get overly excited about, just a natural part of the aging process. Unpleasant, but unavoidable. Except for the Type II diabetes I have been diagnosed with. After fainting and falling to the floor in a restaurant, the EMTs who came to my rescue pricked me and said my A1c level was 12% (instead of 7%), and told me I needed to get this checked out.

I went to see my primary care doc – a relatively young man appearing to be in his early-forties – who assured me this condition did not require the services of a specialist. He told me straight away to change my diet and avoid starchy carbs, and stressed the need for regular exercise. He also proscribed a common diabetes medication called Metformin, a pill I was to take twice daily.

I left his office determined to turn over a new leaf. I immediately gave up what used to be my favorite foods: potatoes, pasta, pizza, and bread. I started swimming laps at the Y. I lost a few pounds along the way, and had to buy some new clothes to fit the now leaner version of me.

And I took my Metformin religiously, twice a day as proscribed. When I went back for a follow-up visit, new blood test in hand showing my A1c was now at 7.1%, I expected a round of applause. Instead, the young physician’s assistant peered at her laptop, only to announce my current A1c was higher than it should be. Completely oblivious to the dramatic progress I had made. Same thing with my primary care doc, once the assistant left and he appeared in the little exam room.

My next few check-ups came and went, during which I kept giving these two the benefit of the doubt, so to speak. They were the experts and I should follow their advice. Even if their bedside manner left a little to be desired.

Then I had a casual encounter with someone who told me that of course Metformin is not really good for you. Like all medications, this civilian explained, it was intended to curb one problem, but it usually interfered with another bodily function in the process. The details were admittedly sketchy, but the overall theme struck a chord, and reminded me why I had steered clear of doctors and prescription medicine over the course of the last five decades.

Once I stopped eating starchy carbs and started swimming laps 3-4-5 times a week, I began to regain my equilibrium. The dizzy spells were a thing of the past, and I was feeling pretty good once again. After a year or so I decided on my own, without consulting a physician, to stop taking the Metformin.

In advance of a regularly scheduled doctor’s visit this past June I had another blood test done, and it revealed my current A1c level was now at 7.4%. Still manageable, in my opinion. No need to go back on Metformin, as far as I was concerned. When I shared what I thought was the good news, my primary care doc had a fit. How dare I stop taking medication he had proscribed. There was no discussion, no interest in how I was feeling or what diet and exercise regime I was following. From behind my mandatory COVID-19 face mask I calmly suggested another blood test in a few months, to make sure things aren’t trending in the wrong direction. “Not unless you are prepared to go back on the Metformin,” he said with undisguised anger, before getting up and kind of storming out of the exam room.

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One could chalk up this doctor’s brusque attitude to any number of things. It was the end of a long day, and perhaps his patience was frayed. Long day or not, over the course of my previous visits a petulant streak seemed to be lurking just below the surface with this guy. Then again, I could be reading things all wrong. He could very well be a perfectly competent physician who just happens to be a little lacking in the empathy department.

And let’s not forget the frustration factor. Doctors keep telling us we need to change our diet and start to exercise, but hardly anybody ever does. Most of us go right on eating the foods we love, though they are demonstrably bad for us, and we almost never get any exercise. This has got to frustrate the living daylights out of any conscientious physician. Almost by default, they have no choice but to push a menu of prescription medications to treat what ails us.

Another mitigating circumstance contributing to what can be an occasional bout of brusqueness on the part of our medical professionals is the way every practice has decided to “scale.” This business model involves seeing as many patients as possible. More patients seen means fewer time spent with each patient. This is an unfortunate trend that puts an unreasonable demand on the individual doctor, and results in a less satisfying experience for the patient.

One can only learn so much from a cursory glance at a series of standard medical history questions that often don’t lend themselves to straightforward yes-or-no answers. It’s hard to know your patient when you only spend a few minutes with them. And when a good part of that time is spent looking at your laptop.

This is one of my gripes with how medicine is practiced today, minor malady division. The data our doctors have loaded onto their laptops is fine, as far as it goes. But it can’t tell the whole story. In order to truly “do no harm” you need to pay some attention to the actual human being sitting in front of you.

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As a follow-up to that contentious doctor’s visit of last June, I just had another blood test taken the other day, and my A1c level is holding steady at 7.4%. That’s with me being off the Metformin for over nine months. When it comes to treating my version of Type II diabetes, it would appear the ever-popular “diet and exercise” thing is a winning formula.

This is not meant as a grand indictment of Metformin, per se, or of the physician who proscribed it. The medication is there if you need it. But if you don’t need it, why take it? I only wish my primary care doctor noticed how seriously I heeded his advice on the diet and exercise portion of his initial proscription. Apparently in his eyes I was going to be on Metformin for the rest of my life. Regardless of what I choose to eat, and regardless of what exercise regime I may adopt.

That doctors seem to automatically and reflexively proscribe medication is another gripe I have with how medicine is practiced today. Though I admit they may be spurred in that direction by demanding patients who come in looking for a magic pill that will make everything better.

This medication-first approach stems from what strikes me as a denial of the obvious on the part of doctors and patients alike. It’s as if we have all forgotten the human body is not built to last. Sure, it’s good to try and keep things running as smoothly as possible, for as long as one can. But we are all falling apart, some more slowly than others, and we’re all going to die at some point in the not-too-distant future.

Granted my sample size is limited, and my evidence is purely anecdotal. But I am walking into these doctors’ offices as a relatively old man now. My best days are behind me. There are going to be aches and pains. My eyesight is failing and I don’t hear so good. I get up in the middle of the night to use the bathroom. I have a slight tremor in my right hand, the one I write with, that appears then disappears then reappears. There are just certain things that come with the territory, you know what I mean?

It feels like these youngish doctors are approaching me as if anything less than triathlon-level physical condition is cause for alarm, and requires “treatment.” Instead of a simple annual check-up, they insist on seeing me three times a year to monitor my condition, as if I’m on the verge of imminent collapse.

But again, this may not be all their fault. Too many of us are showing up at our doctors’ offices with symptoms that are either a natural part of the aging process, or the direct result of our own negligence, and saying “fix me.” In a world where we have been instructed over and over again to demand the best and have it our way, we are unwilling to accept the inevitable ravages of time. And simultaneously with that unrealistic expectation, we aren’t taking very good care of ourselves these days, either.

As has been duly noted in any number of venues, the conveniences that have become commonplace since, let’s say the 1950s, have resulted in a more sedentary lifestyle for most of us. And have inclined many of us to consume a much higher percentage of fast, processed food. These foods taste great but often lack any nutritional value. We end up eating more of them than we should, because our bodies are left craving a basic level of nutrition.

Lousy eating habits combined with little-to-no physical activity results in negative health outcomes, as they say. This forces doctors to deal with the by-product of our poor choices. I don’t envy them.

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The written report from my latest blood test states: “For someone with known diabetes, a value of 7% indicates that their diabetes is well controlled and a value greater than or equal to 7% indicates suboptimal control. A1c targets should be individualized based on duration of diabetes, age, comorbid conditions, and other considerations.”

I would like to find a primary care doctor who is willing to “individualize” my A1c “target” by discussing my circumstances in some detail, rather than relying on a chart that reads “A1c should be 7% or lower.” I’m not opposed to going back on Metformin if my condition worsens. But in my case an A1c reading of 7.4% may be okay, considering how I am feeling otherwise. The bottom line is I don’t want to be on a prescription medication if I don’t really need to be. Is that so wrong?

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A lack of personalized attention has infected many of the service industries we come into contact with – not just medicine. As a general rule, the bigness of an enterprise enhances its profit potential, but usually undercuts the quality of service being provided.

Then again, in the interest of giving doctors their due, our medical system does a pretty good job with the big stuff: trauma, transplants, cancer, etc. Just think of all those in-depth heart-to-heart consultations you see doctors and patients engage in on your favorite dramatic series.

The annoying tests we are routinely sent out to have done are often the only way to screen for these bigger problems. I’m prepared to submit to my fair share of MRIs and CAT scans every so often. But why not make getting those tests approved and paid for less of a bureaucratic labyrinth?

The way things are now feels like a giant game of bait-and-switch. No doctor or physician’s assistant or front desk personnel ever tells you what anything will cost, because they’re trying to wrangle as much money as possible out of the insurance company. And you’ll never get a straight answer on costs out of the insurance company in advance of a procedure. The patient is a pawn in a complicated chess match being played far above their head.

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I’m not one to sit back and pine for the good old days. But neither do I accept the premise that everything we are doing today represents a step forward from the way it used to be done. It’d nice to hear the actor Stanley Tucci is smitten with his cancer doctors. I’d settle for a primary care doc who would notice what a bang-up job I’m doing of dealing with my Type II diabetes through diet and exercise, without having to resort to prescription medication.

Robert J. Cavanaugh, Jr
November 7, 2021

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Science Trumps Religion

Science Trumps Religion

October 31, 2021 (373 words)

In the ongoing debate over whether or not to vaccinate for the COVID-19 virus, I recently heard an interesting take on the subject from the BBC World Service in London, courtesy of my local NPR affiliate that broadcasts this programming in what for us is the middle of the night.

The host was talking with two commentators who each fleshed out a different side of the argument. In Europe, where healthcare is provided by the state, it’s easier to mandate everyone be vaccinated in order to participate in public life. Here in the U.S, of course, we are live-free-or-die enthusiasts who pride ourselves on not being told what to do by any governmental agency.

Then one of the experts mentioned how some people are refusing the vaccine on religious grounds, without going into specifics. This exacerbated the other expert, who said: “we are now 200 years out from the Enlightenment, and you would think everyone knows science trumps religion.”

Hearing this piece of conventional wisdom repeated for the millionth time brought a smile to my face, as it always does. The idea that religion stands in opposition to science is patently false. No matter how a feisty partisan may misconstrue the facts in reaching this errant conclusion.

There is no denying the Enlightenment successfully put “religion” on the intellectual back burner. The hardcore materialist approach was adopted as the preferred societal construct by all who fancied themselves in the know. It’s easy to forget before atheism came into vogue, all the best scientists were devoutly religious. That is to say, they were Catholic.

Skepticism and outright disbelief in objective truth now rules the roost. From egg heads in the ivory tower to common folks on the street. Strange how we’ve all lost sight of a simple fact: The don’t-take-anything-for-granted approach known as the scientific method does a commendable job improving our level of understanding with each passing day, but it can never alter the fundamentals that undergird the material world.

Even if certain earnest souls who carry the banner of “religion” in today’s culture wars do a less-than-stellar job expressing the fullness and beauty of what are essentially immutable, metaphysical truths. Science never trumps religion. Science is religion’s best friend, its staunchest ally.

Robert J. Cavanaugh, Jr
October 31, 2021

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Lonely Hearts Club

Lonely Hearts Club

October 18, 2021 (802 words)

In the dating world of ‘mature singles’ there is something known as the “90-day syndrome.” That’s how long it takes for a new infatuation to run its course, and for the two adults involved to realize that maybe they don’t have that much in common, after all.

After recently experiencing this syndrome first hand, I’ve been forced to regroup a bit, reconnect with the familiar things that feed my soul, and reconsider just how difficult it will be to actually find a new significant other this late in life.

Part of the problem is being a little crotchety and set in my ways, as any older man or woman is prone to be. But the situation is further complicated by how so many of the things I most enjoy are essentially solitary pursuits.

My spare time is best spent out in the yard planting things, and weeding the beds that have already been planted. I also like to putter around the house, mainly organizing and re-arranging, with a little re-decorating thrown in from time to time. I do much the same thing at work, seeing to it the warehouse never gets too cluttered. As a general rule I like to create order and make things look nice. Symmetry facilitates my thought process, which in turn fuels my favorite pastime: writing. And isn’t that the most solitary pursuit of all?

As for other diversions, I have never really found anyone who shares my taste in music or movies, so I have grown accustomed to pursing those interests on my own, and have discovered a deeper connection to whatever I am listening to or watching as a result.

This runs counter to what people always say: “Everything is better with someone to share it with.” I have not necessarily found that to be the case.

But don’t go getting the wrong idea. It’s not as if I am devoid of social graces. I am always solicitous toward children and strangers, and can muster a requisite display of bonhomie around my peers when it’s called for – at least in short bursts. My charming public façade is sincere, but it is on a strict timer. Behind my smile I always end up looking for a polite way to take my leave. Retiring to my own company gives my mind a little breathing room, and lets me mentally wander and explore uncharted territory.

And there is no accounting for that nervous tick I sometimes display around others. I’m prone to giving long drawn-out answers to even simple questions of a personal nature, the ones most people quickly deflect with a pleasant-sounding cliché. When falling victim to this affliction I can inadvertently come across as a bit of a bore in what is otherwise a casual social setting.

For the record, I never set out to be this way, with such a pronounced solitary streak. It’s just sort of hard-wired into my DNA. Even when I was in my prime, which is a few decades ago now, I felt like a Benedictine monk who just happened to be happily married with four wonderful children. That may not speak well of my performance in the role of husband and father, but looking back I think I did okay on both counts.

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So how exactly do I now intend to identify someone who might want to find themselves a place in this picture? And who might care to include me in theirs?

They say opposites attract, but I’m thinking next time a little less opposite might not be a bad thing. Finding someone with an affinity for the arts and the creative process might be a good idea. As long as that person is not annoyingly artsy-fartsy about it.

And finding someone with an affinity for the entrepreneurial spirit might also help. As long as they see business as a calling, as a form of creative expression – much more than merely a means of making money. Entrepreneurs have the unique opportunity to transform the mundane task of earning a living into a vehicle for inner development – their own and that of those around them.

Just as important will be to meet someone who is already ‘not lonely,’ and doesn’t need to be carried away by the infatuation stage, with its constant texting and talking on the phone and trying to get together. Sure, all that stuff is fun, but it’s hard to maintain such a frantic pace.

One would hope a little infatuation will always be part of the process, and by all means should be enjoyed by both parties. But maybe it should not be allowed to take over our lives, and distract us from the things we have come to enjoy the most as individuals. Some of which may very well be solitary pursuits.

Robert J. Cavanaugh, Jr
October 18, 2021

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Denouement

Denouement

October 10, 2021 (34 words)

The physical intimacy we shared led me to believe you were more into me than it turns out you really are. And made me think we had more in common than we actually do.

Robert J. Cavanaugh, Jr
October 10, 2021

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Powerless to Effect Change

Powerless to Effect Change

October 5, 2021 (174 words)

There are many forms of physical and emotional distress that can befall us in the course of our lives. Some folks have to cope with more of these challenges than others, often for no apparent reason.

It’s the emotional form of distress I wish to comment on this morning. What makes any difficult emotional circumstance even harder to bear is when it’s accompanied by a sense of hopelessness, when one feels powerless to effect a change in the situation.

Professionally and personally, my life has been far from smooth sailing from an emotional perspective. But looking back I guess I always felt I could make things better, even if it eventually took longer than I wanted it to. I can’t imagine what it must be like to feel trapped, and forced to put up with a relationship that was just not working out, be it in a professional or a personal setting.

My sympathies are with anyone – friend or foe – who feels powerless to effect a positive change in their emotional life.

Robert J. Cavanaugh, Jr
October 5, 2021

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Seven New Laws

Seven New Laws

September 28, 2021 (87 words)

The headline read: “California Governor Gavin Newsome proposes seven new laws to address homeless.” This is no doubt a well-meaning gesture on the Governor’s part. However, in trying to resolve lingering and/or worsening social problems, it’s unfortunate our elected officials have no other trick up their sleeve beyond adding even more complicated and minutely-detailed laws to the books.

Without knowing the specifics of any of Governor Newsome’s latest ideas, something tells me additional legislation is not really going to solve the lingering and worsening problem of homelessness.

Robert J. Cavanaugh, Jr
September 28, 2021

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