Archive for October, 2011

I’m Your Doc, Not Your Provider!

October 29, 2011

New terminology has cropped up over the past few years, seemingly coined by the insurance industry. I am no longer a doctor or a physician, but am now regarded as a health care provider. Patients are no longer patients—but are now called consumers. These are cold, generic, and impersonal terms that I loathe.

I am a medical doctor whose job is to take care of patients. As a physician, I am not a wizard, a miracle worker, or a deity. I cannot magically fix all the aches and the pains, traumas and tribulations, and conditions—both benign and malignant—that plague mankind. I am simply a human being, imperfect and fallible, who gives my best effort to promote good health and manage illness.

One of the most enjoyable aspects of my medical practice is the meaningful relationship that I have developed over the years with many of my patients. Engaging their trust and respect through our interactions—central to our relationship—is one of the most satisfying aspects of being a physician. They have shared much personal information with me and have given me a wealth of knowledge that is not to be found in any medical textbook, journal or hospital grand rounds.

The term provider brings to mind Star Trek characters—the three non-humanoid beings who controlled the planet Triskelion, appearing as disembodied brains contained in a device giving them life support and communication abilities. Captain Kirk and his crewmates were brought to this planet to fight as gladiators to entertain these Providers, who gambled on the fights.

I am NOT a provider to consumers, but a doctor to my patients! What is the problem with the terms doctor and patient anyway?  Doctor is a very meaningful word—derived from docere, meaning “to teach”—insofar as patient education is so fundamental to the health care process.  Patient is derived from patiens, meaning “bearing an affliction.” Terms like provider and consumer ignore the humanistic, emotional and psychological aspects of the doctor-patient relationship and diminish the professionalism that is the foundation of this relationship. The term provider seems to suggest that medical doctors are interchangeable cogs in a wheel.

Clearly, the “industrialization,” “corporatization,” and “commoditization” of medicine has engendered this new terminology.  Medicine has become a business, and insurance companies now view relationships between doctors and patients as commercial transactions.  Unquestionably, there has to be a financial aspect to medicine, but the practice of medicine goes way beyond economics.  Over the course of day-to-day interactions with patients—whether in the office or operating room—the last thing on my mind is the “business” aspect of medicine.  I am focused on the basics of primum non nocere (first doing no harm) and the act of doing “good” for my patients.

Consumer and provider are demeaning terms for both patient and doctor.  They disregard the essence of medical practice—the warm, meaningful, humanistic and caring relationship between doctors and patients that transcends both the science and business of medicine.

Andrew Siegel, M.D.

http://www.PromiscuousEating.com

October 29, 2011

Reference:

“The New Language of Medicine,” written by Pamela Hartzband, M.D. and Jerome Groopman, M.D.

N ENGL J MED 365;15    October 13, 2011

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Prelude to Excess—Strategies To Deal With Eating “Orgies”

October 21, 2011

By eating orgies, I mean any circumstances in which we will be exposed to a great deal of food—a situation that can thwart our best efforts to be disciplined eaters.  The event may be a destination wedding, a vacation in Hawaii, a cruise, a weekend college reunion, a holiday dinner, etc.  Many eating forces are in collusion here—hunger eating; social eating; temptation eating; recreational/entertainment eating; opportunistic eating; etc.

For example, I will soon be confronted with a potential eating bender as I head down to New Orleans to attend a function at Tulane University.  New Orleans—aside from magnificent architecture, wonderful jazz and a rich culture and history—has some of the best and most unique food of any city in the United States.  Beignets, jambalaya, crawfish etouffee, gumbo, po-boys, red beans and rice, muffulettas, and on and on.  The NOLA chefs tend to have rather heavy hands when it comes to rich, creamy, calorie-laden sauces. It seems that a load of butter or cream is added to more-or-less all foods.  So how does your self-disciplined, daily-exercising, fitness/wellness-promoting blogger on promiscuous eating issues deal with this potentially promiscuous-eating situation?

I recommend the “bank and burn” tactic in anticipation of being in a situation that exposes us to a potential eating spree. Very simply, for a number of days prior to the event, we show caloric restraint (“bank” calories) by consuming fewer calories than we normally do.  This might mean strictly limiting portion size, skipping desserts, not eating anything after dinner except perhaps a piece of fruit, etc.—any device that will function to reduce our caloric intake. Then, when it comes time to the eating binge, we can use our “banked” caloric savings to balance out the over-indulgence that we know is likely to occur.  The “burn” component is to ramp up our exercise (“burn”) for a number of days prior to the event in order to further prepare for the onslaught of calories that will be likely be coming our way. The “bank and burn” tactic allows us to over-indulge (moderately, hopefully) and feel no remorse about it.

When at the food orgy, portion control is one of the greatest assets that we can bring to the table.  It is a sensible idea to split entrees or even order an appetizer for an entrée, particularly if the event is a weekend or week long one with many opportunities for over-indulgence. When it comes time for dessert, sharing is a very reasonable strategy.  Certainly a taste will do, won’t it?  We have already probably consumed a substantial meal, likely grander and higher in calories than we would have at home, and we are simply in search of a novel taste to serve as the finale for the meal. The intent of dessert is not to fill us up, but simply to provide a concluding arousal of our taste buds to serve as a sweet end to a hopefully memorable dining experience.

During the time spent at the event, it is important to stay active and continue the physical activities that we enjoy and that help keep us in good physical shape. Exercising will balance out the inevitable over-eating associated with the event.  When away, options are jogging, visiting the fitness center at the hotel, or doing lots of walking.  I like to bring my P90X workouts with me—they are loaded on a flash drive that I plug into my laptop and can work out virtually anywhere. One of my favorites is the 90-minute yoga workout—it is a great combo of aerobics, resistance, core, flexibility and balance—quite challenging and not for the faint-of-heart.

If we completely implode and totally, indulgently, excessively blow our normally well-controlled and disciplined eating manner, is it the end of the world?  The answer is a definitive no!  The key is to stop before it gets out-of-control. If our healthy eating regimen and our best eating behavior goes south, it is not a disaster. It’s okay to lose the battle as long as we win the war.  We are humans, subject to all the imperfections, weaknesses and foibles that are characteristic of our species. If we fall off the wagon, we can get back on without losing much ground. When we think with a long-term perspective, we understand that a little deviation or detour off the pathway need not affect the ultimate outcome of our journey. To quote comedian Jeff Garlin: “Slip ups are speed bumps on the road to recovery.” We need to be aware and attentive, focused and mindful, and if we break our regimen, not to despair but simply stop and desist before the matter becomes beyond our control.  So, we can go ahead and enjoy…but with an effort to make the lapse into promiscuous eating a moderate one.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food.

 

www.PromiscuousEating.com.

Website provides information, a trailer, excerpts, ordering instructions, as well as links to a wealth of excellent resources on wellness and healthy living.  The book can be ordered directly off the website or on Amazon in paperback format or e-book format for Kindle.

Boredom Eating

October 15, 2011

Life is not always thrilling and exhilarating—at times it can be mundane, and sometimes dull and monotonous…such is life.  Some of us try to fill these voids in excitement by placing food in our mouths.  This boredom eating is one of the more subtle types of emotional eating that often occurs without awareness and is capable of loading us with unnecessary calories that can lead to needless weight gain.  Anytime we eat for a reason other than genuine hunger it is generally not a good thing. Boredom is the devil when it comes to eating.

The act of eating is an activity—something to do to keep us busy.  We enjoy staying occupied and productive and find that when we have nothing on our “to do” list, eating can serve the purpose of keeping our hands occupied and our time utilized. Eating piques us with a barrage of sensory stimulation: creamy, crispy, grainy, hot, cold, crunchy, tingly, sweet, spicy, bitter, salty, aromatic, etc., which for a moment can relieve us of our ennui.

The truth of the matter is that had we been engaged and absorbed in another matter, the thought of eating would never have entered our minds. Human beings have an incredible need to productively pass time, and boredom-driven eating does not qualify for constructive time usage and should always be considered a self-destructive pastime.  Many persons who I interviewed for my book reported that they do not even think about eating if busy and not bored.  One 28- year-old stated the following: “I eat on weekends when I am home, when I am bored, inactive and have nothing to do, primarily to keep myself occupied during downtimes.”  Another 27-year-old reported:  “Boredom prompts me to eat. I was unemployed for 8 months and gained 10 lbs. When I have nothing to do, I eat—now that I am employed, it is less of an issue.”

Activity swapping is a constructive maneuver in which eating behavior that is driven by boredom is exchanged for an alternative behavior that will keep us away from unwanted calories. This substitute activity might be sleep, exercise, reading, phoning a friend, getting out of our home, taking a walk, taking a bath or shower, doing household work or errands, having sex—anything to relieve the boredom. Substitute endeavors may include participating in a hobby or interest that will be a less caloric activity than eating—gardening, woodworking, painting, knitting, whatever.  A 54-year-old related: I conquer boredom grazing with a substitute activity such as crocheting.”  A 49-year-old told the following story: “I used to eat because of boredom. I would get home from work at 3PM, but my husband would not come home until 6PM, so I would have a cocktail with chips, nachos, cheese, and some cookies. I joined a gym, so now I exercise instead of drinking cocktails and eating food.”

Staying busy and productive is important on so many levels—aside from giving us a sense of value and worth, it also helps us maintain a trim figure by reducing our caloric intake and increasing our caloric expenditure. So many of us, when engaged and occupied, do not think about eating; in fact, when we are truly absorbed and immersed in the matter at hand, may forget to eat completely! Many of those I interviewed reported that their situation was well controlled during the day when busy and occupied at work, despite ample opportunity for temptation, but poorly controlled in the evening when home.

Mindful eating—being conscious and aware of precisely why we are eating—goes a long way forward in recognizing and arresting boredom eating.

Bottom line: The hollow in our lives cannot be filled with food.  In behavioral terms, the best antidote to boredom eating is avoiding boredom by engaging in activities that keep us happy, occupied and productive, particularly those that occupy our hands and preclude eating.  In cognitive terms, the best solution is to eat mindfully, always aware of the underlying reason as to why we are putting food in our mouths.

Andrew Siegel, M.D.

This is a taste of what you will find in Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food. The book website is: www.promiscuouseating.com.

It provides information, a trailer, excerpts, ordering instructions, as well as links to a wealth of excellent resources on healthy living.  It is also available on Amazon as a paperback or e-book for Amazon Kindle.

Until Apple Invents The iFinger, PSA Is The Next Best Thing

October 8, 2011

‘”Don’t let the noise of others’ opinions drown out

your own inner voice.  Have the courage to

follow your heart and intuition.”

Steve Jobs

My blog last week was on prostate cancer vis-à-vis diet and lifestyle.  The lead article on the front page of yesterday’s New York Times reported on new United States Preventive Services Task Force (USPSTF) recommendations with respect to PSA testing (Prostate Specific Antigen).  The bottom line is that this organization is counseling against the use of PSA testing in healthy men.  They posit that the test does not save lives and leads to more tests and treatments that needlessly cause pain, incontinence and erectile dysfunction.

Two years ago, the same organization advised that women in their 40’s should no longer undergo routine mammography, setting off a blaze of controversy.  Their proposals were met with great resistance by many cancer organizations, women, and their physicians, many of whom continue to ignore them.

It should be well noted that the chairwoman of the USPSTF is a pediatrician!  It is obvious that prostate cancer is not a pediatric issue and should not be evaluated and managed by pediatricians.  I, along with other members of the American Urological Association, ardently disagree with the assertions of the task force that prostate cancer testing with the PSA test provides no clear benefits.  Urologists, radiation oncologists, and medical oncologists (those physicians in the know who are in the “trenches” and take care of prostate cancer on an everyday basis) understand how devastating prostate cancer can be, and the quintessential importance of early detection.

Confidently and unequivocally, I can state that when interpreted appropriately, the PSA test provides important information in the diagnosis, pre-treatment staging, risk assessment and monitoring of prostate cancer patients. Marginalizing this important test does a great disservice to those who may benefit from early prostate cancer detection; the recommendations of the task force will ultimately do more harm than good to the many men at risk for prostate cancer.

I have practiced urology for 23 years, in addition to 7 years of residency and fellowship training before entering practice.  I am old enough to have served as a physician in both the pre-PSA era and the post-PSA era.  In my early years of training at the University of Pennsylvania School of Medicine, it was not uncommon to treat men in the emergency room who could not urinate and on exam were found to have a rock-hard prostate and diffuse spread of prostate cancer to their bones…metastatic prostate cancer with a grim prognosis.  In the post-PSA era, that scenario—fortunately—occurs on an extremely infrequent basis thanks to PSA screening.  Essentially, annual screening with PSA and rectal exams has resulted in downward stage migration—picking up cases of prostate cancer in an early, curable stage before they spread and become incurable.  I have little doubt that PSA testing saved my own father’s life, who underwent prostate surgery for cancer 15 years ago and is now a healthy, thriving and active 80-year-old…in ALL respects!

Importantly, prostate cancer is a remarkably heterogeneous disease with every single case being unique—literally as different as snowflakes—thus, the management of prostate cancer must be individualized. The major challenge for those of us who treat prostate cancer is to distinguish between clinically significant and clinically insignificant disease and to decide the best means of eradicating clinically significant disease to maintain both quantity and quality of life.  Not all prostate cancers require active treatment and not all prostate cancers are life threatening. The decision to proceed to active treatment is one that men should discuss in detail with their urologists to determine whether active treatment is necessary, or whether surveillance may be an option for their prostate cancer.

What exactly is the PSA test?  It’s just a simple blood test that is sent out to a laboratory with results available in a few days.  Prostate-specific antigen (PSA) is a protein produced by the cells of the prostate gland. More specifically, it is an enzyme known as a protease that functions to liquefy semen following ejaculation. The PSA test measures the level of PSA in the blood and is the best tool currently available for detecting prostate cancer in its earliest— and most curable—stages. Although PSA is widely accepted as a tumor marker, it is prostate organ-specific but not cancer-specific. In other words, PSA can be elevated due to the presence of prostate cancer; however, not all elevated PSA tests mean that prostate cancer is present—benign prostate conditions can elevate it as well; the most common of these are prostatitis (inflammation of the prostate) and benign prostatic hyperplasia (BPH, an enlargement of the prostate gland).

Prostate cancer cells do not make more PSA, but rather less PSA than normal prostate cells. The elevated PSA that is detected in the blood associated with prostate cancer occurs because of a disruption of the cellular architecture of the prostate cells, the loss of this barrier of which permits the leakage of PSA into the circulation.

The PSA test is extremely helpful to monitor patients with a history of prostate cancer to check the status of the cancer. If the PSA level begins to rise, it may be the first sign of recurrence. Such a biochemical relapse typically precedes clinical relapse by months or years. Refinements in PSA testing include the following:

PSA velocity: It is very useful to compare the PSA values from year to year. Generally, the PSA will increase by only a small increment, reflecting benign prostate growth. If the PSA accelerates at a greater rate than anticipated—a condition known as accelerated PSA velocity—an ultrasound/biopsy is indicated.

PSA density: PSA density (level of PSA divided by the volume of the prostate) considers the relationship of the PSA level to the size of the prostate. In other words, an elevated PSA might not arouse suspicion if you have a very enlarged prostate.

Age-adjusted PSA: Age is an important factor with respect to PSA levels. It is now recognized that PSA will increase with the aging process in accordance with the increasing size of the prostate gland that occurs with growing older. For this reason, age-adjusted PSA levels can be useful to determine when further diagnostic tests are needed.

Free/Total PSA: Essentially, PSA circulates in the blood in two forms: a “free” form in which the PSA is unbound to any other structures, and a “complex” PSA in which the PSA is bound to a protein. The free PSA/total PSA ratio can offer a predictive value, in similar fashion to the way the HDL cholesterol/total cholesterol can be helpful in a man with an elevated cholesterol level.

In 2009, there were two studies published in the New England Journal of Medicine with respect to screening for prostate cancer. The results were summarized on the front pages of many newspapers, resulting in confusion for many patients. Dr. Andriole, in the United States, reported no mortality benefit from combined digital rectal exam and PSA screening after 7-10 years. Schroeder et al in Europe reported that PSA screening alone (without rectal exams) resulted in a 20% decrease in the death rate at a median follow up of 9 years. It is the consensus of many urologists that these studies were published prematurely, with ambiguous results.

The hard facts:

• 95% of male urologists and 80% of primary care physicians older than 50 have PSA screening—clearly those in the know feel that screening is beneficial.

• USA death rates from prostate cancer have fallen 4% annually since 1992, five years after introduction of PSA testing.

• Generally, urologists do not screen or treat men who have a life expectancy less than 10 years for the very reason that prostate cancer rarely causes mortality in the first decade after diagnosis and that other competing medical issues will cause death before the prostate cancer has a chance to.

• Prostate cancer is a slow-growing process and early detection and treatment is directed at extending life well beyond the decade following diagnosis!

• The aforementioned studies will not prove meaningful until carried out for 15, 20, 25 years and beyond—the time reference in which we expect treatment to make a meaningful difference.

Another controversial subject is at what age to stop screening for prostate cancer. According to the United States Preventative Services Task Force update, the “harms of screening outweigh the benefits in men 75 years old or older.” Studies have shown that at age 75 if you have a PSA less than 3, the chances of later developing high-risk prostate cancer are minimal. My opinion is that all 75-year-olds are not the same, functional age trumps chronological age, and that an individual’s preference regarding screening is of great importance.

I end with an important quote from Dr. Willet Whitmore, M.D., from way back in 1973, but still so relevant (Dr. Whitmore served as chief of urology at what is now Memorial Sloan-Kettering Cancer Center and died in 1995 of prostate cancer.)

Appropriate treatment implies that therapy be applied neither to those patients for whom it is unnecessary nor to those for whom it will prove ineffective. Furthermore, the therapy should be that which would most assuredly permit the individual a qualitatively and quantitatively normal life. It need not necessarily involve an effort at cancer cure. Human nature in physicians, be they surgeons, radiotherapists, or medical oncologists, is apt to attribute good results following treatment to such treatment and bad results to the cancer, ignoring what is sometimes the equally plausible possibility that the good results are as much a consequence of the natural history of the tumor as are the bad results.”

For more information:

www.BergenUrological.com

click on “patient education” and then on “Prostate Cancer: Second Opinion” to read my monograph.

To watch my video on PSA screening:

http://www.youtube.com/incontinencedoc#p/u/5/v3vHbh9gLnw

Andrew Siegel, M.D.

http://www.PromiscuousEating.com