NOT IN OUR STARS

I think we need to take responsibility for our actions. Somewhere along the way, blaming others for our mistakes or even for our bad luck has become the norm. Anytime something bad happens, it seems that someone else must be blamed.

A good part of this societal attitude change has to do with our legal system. One gets rewarded financially if personal responsibility can be minimized and victimization maximized.

We were all outraged by the story of the lawsuit by the lady at McDonalds who won millions by claiming the coffee was too hot that she spilled on herself. We all shake our heads in disbelief when we read about the burglar who hurts himself breaking into a residence and then sues the property owner.

Locally the students from Knightstown High School received a large settlement ordered by the court which ruled that the children's freedom of speech was being violated by their expulsion for the creation of a DVD that demeaned and threatened a teacher. Since the students were reinstated, wouldn't it have sent a wonderful message about responsibility if those families had donated their lawsuit proceeds back to the school or community?

You cannot watch television or read a newspaper without seeing an ad by a lawyer who wants you to sue someone just because you used a product even if you never suffered any ill effects. The only people who make any significant amount of money from class-action lawsuits are the lawyers but we all sign on in an attempt to get money for nothing.

Lawsuits are justified if a company knowingly allows an unsafe product to be available to consumers without informing people of the risks. If the risks are obvious then no financial recourse should be available if harm occurs.

You should not be allowed to sue a fast-food restaurant just because you became obese by eating their product. Your family should not be allowed to sue the hair dryer manufacturer if you get electrocuted using it while in the bathtub regardless of whether or not there is a warning sticker on the product.

There are many examples of lawyers and patients becoming millionaires from lawsuits which are based on bad luck, bad science, and bad lifestyle choices of patients.

John Edwards, one of the democratic presidential candidates, made his fortune as a lawyer by suing doctors over cases in which babies were born with cerebral palsy or other birth defects. From studies on placentas, science clearly shows us that the vast majority of infants afflicted had the damage occur during the earlier trimesters and that the bad outcome was predetermined before the onset of labor and delivery. That didn't stop the blaming of the delivery room doctors in many cases.

The Dow chemical company went bankrupt defending lawsuits over claims of illness arising over the use of silicon breast implants. Despite multiple studies without a single one showing any link between the implants and any disease in the women receiving them, lawyers and patients got rich. The medical and scientific facts didn't seem to enter into the jury decisions. Science eventually won out over the hysteria and the products are again available.

A generation or two of underground coal miners in Kentucky and West Virginia, and of course their lawyers, profited from the black-lung myth. While black-lung disease can show changes on x-rays, it only rarely causes any type of disability. The symptoms these patients had been almost exclusively from smoking. Studies found that the more time a miner spent underground, the less respiratory problems they had despite worse looking x-rays. The reason was they weren't allowed to smoke while in the mines and therefore had less tobacco exposure than those who worked above ground.

This brings to mind the case of the cigarette companies. It is abundantly documented that the adverse health effects of cigarettes were well known to the manufacturers many years before they were known to the health care community. Since this information was hidden from consumers, patients did not have all the facts needed to make fully informed choices on the use of tobacco products. The recent multi-state attorney generals' lawsuit was appropriate in this case.

In medicine, not all bad outcomes are someone's fault. It clearly can be, such as the incident with the wrong dose of heparin given to the babies at Methodist. But just as sometimes a bad outcome occurs despite good care, so too sometimes good outcomes occur despite suboptimal care. As long as physicians are human, mistakes will be made. The majority of which fortunately do not harm anyone.

If you are obese and smoke with poorly controlled diabetes and hypertension, don't blame the doctor or the drug company if you have a heart attack or stroke. If you exercise regularly and have a healthy diet and lifestyle, you have more of a right to look for other factors that may have led to a heart attack or stroke. Responsibility must always lie first with the individual.

To automatically assume that a poor outcome was the fault of someone else is naive and pompous. God heals and God calls people home. In our society, the tendency to place blame on someone every time a patient is stricken by or doesn't fully recover from a disease or illness, is as harmful as it is popular.

WAFER THIN MINT

I think that weight loss is simple. Note that I did not say it was easy. There's a big difference. It is important because of the increased incidence of arthritis, certain cancers, heart disease, gallbladder disease, diabetes, hypertension, and elevated cholesterol in obese individuals.

At the most basic level, ones change in weight is based on the amount of calories coming in and the amount of calories being burned off. With the exception of fluid retention, you will only gain weight if your caloric intake exceeds the number of calories you are burning off. Conversely, you will only lose weight if you burn off more calories than you take in.

There are 3500 calories per pound. Therefore to lose a pound you must burn off 3500 more calories than you are consuming. To achieve a one pound per week weight loss will require an average of eating 500 fewer calories per day, burning off an average of 500 more calories per day, or some combination of the two.

To lose 2 pounds of fat per week by diet alone would require a decrease of 1000 calories per day. This would be very difficult for most people and any faster rate of weight loss is unrealistic. More profound rapid weight loss claims usually are the result of temporary fluid loss and dehydration.

Looking at this long term is not as discouraging. Up to a 50 pound weight loss over the course of year can be targeted. It took a good while to get overweight and a year or more is not an unrealistic time frame to meet a target weight depending on the degree of obesity present.

Patients often complain that they can't lose weight even though they have a very low caloric intake. They need to learn that it is very difficult to lose weight with calorie restrictions alone. It seems that the body tries to conserve energy and if a significant decrease in calories is detected, the natural tendency is for the body to try and conserve energy by expending fewer calories.

Patients also complain that they are gaining weight year to year despite no change in diet and exercise habits. Unfortunately, as we age our metabolism slows down and we will gain weight unless an active effort is made to eat less and/or exercise more.

It is abundantly clear that genetics plays a large factor in determining one's weight. Not all of it is learned behavior creating poor eating habits. Everyone knows people that are couch potatoes and who eat an incredible amount of calories and are rail thin. We also know people who can seemingly gain weight just by looking at food. This is as unfair as it is undeniable.

A successful long-term weight loss plan involves lifestyle modification. Do not buy unhealthy food to tempt you in a moment of weakness. Nobody ever got fat eating carrots and celery sticks. Do not eat when bored or stressed. Ideally, eat only when hungry and not to the point of being full. Do not eat out of multi-serving cartons or bags.

Exercise aerobically daily. It is very enlightening to see how much walking or running is required to burn off the calories from one candy bar. Eat what you like, but eat less of it. Fad diets are by definition unlikely to be sustainable over the long run.

Weigh yourself weekly when trying to lose weight. A daily weight just leads to frustrations from the normal variations in hydration status.

Weigh yourself daily when trying to maintain your weight. Too much weight can be put on over the course of a bad week to not try and identify this earlier. If the weight is up 1-2 pounds over a day or two, be extra careful on the caloric intake until the weight has returned to baseline.

Of the two ways to lose weight, all medicines work by decreasing caloric intake. There is no medication that will increase your metabolism and allow you to lose weight without a change in your diet or exercise pattern.

In our society, it is harder than ever not to be overweight. A sedentary lifestyle is encouraged by the seemingly infinite channels on television as well as DVDs, computers and video games. Unhealthy fast food is heavily advertised, cheap, and tasty. Time constraints make it difficult to exercise and to shop and prepare healthy meals on a regular basis.

Progressive communities and lawmakers have recently attempted to tackle this issue in a variety of ways. Methods have included outlawing the use of unhealthy cooking fats, requiring caloric counts to be printed on restaurant menus, and banning the sale of soft drinks in public schools. I applaud all of these measures and wish that our locally elected officials had the intestinal fortitude to adopt these ideas.

Other more heavy handed measures that have been proposed include having a junk food tax and banning certain commercials. I am less comfortable with these options for a variety of reasons having more to do with my philosophy on the roll of government than on the desired results. I think I would be in favor of a mandatory showing of "Super Size Me" in high school health classes though.

But, as is typical of the American way of thinking, easy solutions are sought out. These often involve wishful thinking that the latest over the counter diet pill or weight loss diet will be the answer. For those with the means, surgery with liposuction or gastric banding is a tempting answer, but long term efficacy and safety issues remain.

Ultimately, the long term solution still involves eating less and exercising more. Weight loss can be simple as sugar and easy as (turning down a slice of) pie.

NOBODY GETS OUT ALIVE

I think that life is like Bob Dylan sang "he not busy being born is busy dying". When patients complain that they are getting old I remind them that the only alternative is not so great.

Hospice care can provide spiritual and physical comfort to the dying. It is for patients who have a terminal condition and are believed to have 6 months or less of life left. Enrollment requires that the patient not be seeking curative therapy for their condition. A large focus is on pain control.

Some doctors are hesitant to enroll a patient because of not wanting to guarantee that the patient will expire within the six month period. There is no penalty to the patient or the physician if the patient lives longer.

The hospice company employs social workers, chaplains, nurses, nurse aids, and a medical director to facilitate the transition of the patient to the afterlife. They can provide assistance to the patient as well as the family in their own home or in an extended care facility.

Elisabeth Kubler-Ross, in her seminal book "On Death and Dying", taught us the five stages of dying. They are denial, anger, bargaining, depression, and acceptance.

Clearly, a patient in the fifth stage is ready for and can benefit from hospice care. The problem sometimes occurs in the other stages and that is where it is critical to know the policies and philosophies of the individual hospice company and its medical director.

Most patients in hospice choose to have their personal physician remain in charge of their overall care. Some doctors choose to relinquish complete care over to the hospice's medical director. Some request that the medical director take care of pain and comfort issues only while other doctors use the hospice physician for consultations only if difficulties arise.

Some medical directors take a more aggressive, hands-on approach and will overrule the patient's doctor treatment decisions if a disagreement exists on how to best treat a specific problem. This is only appropriate when a patient is not receiving adequate symptom relief and the personal physician is unwilling to modify the current treatment.

While the patient has the right to withdraw from hospice at any time for any reason, the hospice has the right to withdraw from the patient's care for certain reasons. Some reasons are required by regulations and others are company specific.

All hospices will revoke a patient's care if curative care for the terminal condition is sought. Services can be restored should the patient later on abandon these efforts.

Some hospices will revoke a patient's care if the patient chooses to go the hospital for any reason. I strongly disagree with this position. There is no reason not to aggressively treat an unrelated condition if it will improve or prolong the quality of someone's life.

For example, if a patient has terminal brain cancer and is having a good quality of life, there is no reason not to consider hospitalization to manage unrelated conditions such as pneumonias or heart problems. Even surgery might be appropriate in certain circumstances.

Some hospices require a patient sign a statement that they do not want to be intubated, on a ventilator or have CPR performed on them. I strongly disagree with this position as well. Part of the service of hospice is to assist the patient in the dying process.

Not all patients are in the stage of acceptance when hospice services are appropriate. Hopefully, with counseling and time a patient can be moved through all the stages before death occurs. But to deny hospice care to someone because they are not ready to formerly sign a "Do Not Resuscitate" order seems almost cold-hearted.

Patients in the earlier stages of dying often need the spiritual and physical help that hospice can provide more than those in the later stages. A hospice should assist patients in the process of accepting a DNR order. This process may take weeks or months and in some patients it may never occur.

If you or a loved one is a potential hospice candidate, consult with the patient's doctor. If hospice is deemed appropriate, consult with several hospice providers to find the one that best meets your needs and is in sync with your philosophy on caring for the terminally ill.

WALK ON

I think that companies that advertise motorized scooters for Medicare recipients are intrusive and detrimental to the doctor/patient relationship. All marketing at its most basic level is about creating a need and then filling it. These companies try to create a need which doesn't necessarily already exist.

Now I understand that in America a company has the right to advertise its product in an attempt to create consumer demand. The situation is different however when the product being promoted requires the authorization of a third party, a physician.

This is similar to the direct consumer ads from pharmaceutical companies. They fall into two broad categories. The first is aimed at making the consumer aware of disease and that treatment exist while the second is aimed at getting the patient to pester his doctor for a specific brand of medicine.

When these ads educate the public about treatments that are available for embarrassing or seldom discussed health problems like overactive bladder, peripheral arterial disease, or restless leg syndrome, the chance for dialog is created. The patient might not have been aware of treatments available for certain conditions and has an opportunity brought up symptoms that a busy physician might not have the time to inquire about without prompting.

What I don't care for are the pharmaceutical ads that merely promote products for well recognized conditions like allergies and erectile dysfunction in an attempt to have a patient badger their doctor into prescribing a particular brand for a condition in which multiple medication options are available. The scooter ads fall into this category as everyone that's been to any grocery store or Wal-Mart knows that these devices exist.

The scooters are promised to be available at no out-of-pocket expense to patients, suggesting that only a cold-hearted physician would deny this marvelous device to his kind, frail patients. This creates ill will should the physician not acquiesce to the demands of the patient and the scooter company.

The companies hawking these devices are preying on patients' sense of entitlement. After all, the viewer who has Medicare has paid into the system his whole life. He deserves whatever products are available at no charge to Medicare patients whether or not it's needed be it scooters, diabetic shoes, hospital beds or a host of other medical products promoted to the elderly.

Most patients, even those that frail and elderly, need to be as active as possible. Use it or lose it certainly applies to ones mobility. Walk if you can, use crutches or a walker to assist if needed, and even a wheelchair that you self-propel as a healthier alternative than a motorized scooter. Some patients who have suffered catastrophic injuries or strokes are not ever going to ambulate again and are clearly going to benefit from the latter.

Most patients want one because it is difficult or painful for them to walk. While physicians strive to alleviate pain and suffering when it is associated with illness or injury, life is inherently painful. From birth onwards, pain is inevitable. Doctors should not attempt to completely eliminate pain from life. Limit it to manageable levels absolutely, but not at the expense of the patients' autonomy and overall health.

Patients should report their difficulties with walking to their doctors. Their doctors should evaluate them and cure what can be cured and treat to alleviate symptoms of those problems that cannot be cured. It is better to walk with some pain than to never walk without pain. The motorized scooter should be an option of last resort for those patients who would not otherwise be physically able to get around in any other way because the less you walk; the less you're going to walk.