family practice issues and general life events

Archive for May, 2013

Stopping smoking

Let me start this by saying, I have never smoked, so I personally never had to deal with that addiction and the cravings.  However, I do treat many smokers as patients and try to help them conquer that addiction.  The first thing I do know, is that everyone who is having problem stopping smoking has that one friend that just decided one day to stop and laid the pack down.  No problems, no cravings, just pure will power.  And to those friends, I say, stop it.  You are not helping your friend by saying,

“it’s easy, I just decided to quit and did it.”

Because for every one smoker who decides to quit like that, I have seen about 20 of the other kind.  Twenty who suffer from the cravings and the desires to smoke.  Those who have dealt with the stress in their lives by smoking.  Those who now struggle what to do with their emotions and how to deal with stress.  

Recent studies indicate that the average smoker tries 7 times before stopping smoking.  That is six times they were not successful.  Six attempts that frustrate and make them feel like a failure.  Looking at it as a failure is part of the problem.  Some studies indicate that tobacco is more addictive than heroin.   And heroin is the drug that everyone fears being addicted to.  In fact, when in an inpatient setting to deal with other addictions, the one addiction that is never dealt with, tobacco.  Rationale, if you take away the tobacco addiction, chances for relapse for other drugs increase significantly.

There are multiple choices of products that help with cessation, many replace the nicotine through patches, inhalers, gum, etc.  The goal is that by stepping down, you can beat the habit.  Then there is Chantix, which makes tobacco taste bad, and makes people nauseated.  Or Zyban/Wellbutrin which is an anti-depressant thought to help with the urges to smoke.  And the latest, the electronic cigarette.  This also is a tobacco replacement system, that removes most of the other products in a cigarette, but initially has nicotine.  Also with the goal of stepping down.  Also includes vapor to inhale.  I am a little skeptical to the claim that it is 100% safe and that you can do it forever without consequences, but as a means to get off of tobacco products, absolutely the lesser of two evils.

Now I live in a state with one of the highest levels of tobacco use.  While there has been legislation preventing smoking in restaurants and state buildings, we also have drive through smoke shops on tribal lands.  The one just outside my town, has three windows.  No need for waiting or getting out of your car.

The reasons for stopping smoking have been endlessly documented for both the individual and everyone they live with, especially their children.  The cost is also well documented.  But if it were easy, all of these products wouldn’t be needed.  Increasing taxes on cigarettes would stop those who couldn’t afford to stop.  

Maybe we should treat it like an addiction.  And maybe we should look to understand the science of addiction, and look at it as a real medical problem and not just weakness of the individual.  


Day 1- again Rebooting and starting anew

Today I am starting anew.  After working hard for 6 months and feeling good about myself, I spent the last 9, basically ignoring and backsliding.  Except I am currently in worse shape than I have ever been in my life.  What used to be a guaranteed starting point for getting back in shape (often too slow) was actually challenging to me.  This was disappointing.

Mentally, I am not there either.  I feel stress and anxious all the time.  I need to get back to where I was.  Where I don’t snap at people, even though they deserve to be corrected.  I am struggling because sometimes people don’t live up to the standards that you set for yourself.  And for them that is ok.  I need to be ok with that, when it is not my name on the line or my reputation, but sometimes I can’t accept it.  

Additionally, maybe I should stop trying to avoid conflict for so long, maybe then things wouldn’t erupt and they could be taken care of in a better way.  

I need to stop dwelling on things that I cannot control.  That is a big problem, I am a dweller.  And it doesn’t help.  If anything, it makes things worse.

I need to worry about me.  That is what I continuously tell my 9 almost 10 year old.  And sadly, I know where his worrying tendency comes from.

I need to put one foot in front of the other, and focus on the future, and stop looking back.

And I need to look at who I allow to influence my children.  Sometimes remarks that are said, maybe mean more than I have given them credit for.  And maybe, they should have been addressed earlier.  Sometimes when things spin widely out of control, the end result is good, but maybe there should have been a different turn along the journey to get there.  I want my children to be loving and accepting of people.  It is ok if you don’t believe in their lifestyle, if it doesn’t affect your life, why should it matter.

I want my children to be able to stand up for what is right and good.  I want them to be able to ask and demand an answer if necessary.  I want them to be better than I am.


Looking forward

Today, I am going to attempt to look at the positive and to focus on the future.  IT doesn’t matter what happened yesterday, there is nothing that I can do to change it.  (I am writing this, because I am needing to remember that).  Yesterday morning was awesome, my youngest got his red-black belt, the afternoon, not so much.  And since I already put a diatribe out on Facebook repeating it here, will only increase my blood pressure.  Which I am sure it has been running high for a while.  And yesterday, I finally snapped.  Probably had I not been running under increased stress for the past month, maybe I could have kept from it, had I not already had to walk away, I would have done better, had it not been done to my son, well I would have just let it go.  But to be honest, with the blood pumping in my ears, I dared to question why?  And apparently that was wrong.  And apparently all of the other parents agree.  And we should have kept not going, even though when the published time change occurred, and we were now able to attend, we should have stayed away, or at least have notified someone.  Even though we had said, we couldn’t go because it was at 10.  We had a belt test that MORNING.  And the change was made either Thursday or Friday.  But none of that matters, because we didn’t respond to an email, or maybe 4, that never arrived.  Asking why a phone call could not have happened or text?  She ONLY EMAILS!!!!!  

So now that I have expressed my upsets.  So now I have to get over it.  I need to.  For my health.  We are going to make a change, and move dens.  There is no other choice now.  Though my hubby has felt that they have been trying to push us out all year.  So my contact with them will be minimal.

It is easy, deep breath in, deep breath out.  Breath in, breath out.  Go get on the treadmill and walk out the anger, maybe push it as fast and hard as my body can take (which won’t be that fast or hard)  But I will do it.  

I will accept the Serenity Prayer as my mantra:

God, grant me the serenity to accept the things I cannot change,
The courage to change the things I can,
And wisdom to know the difference.

And I will look forward, because today is a new day.  And I can’t change the past, and for the most part I don’t want to.  Thank you for listening to my rant, and now I will walk away with my head held high, and push forward.

Why your Doctor shouldn’t just write you that antibiotic.

It happens almost everyday- a patient will call and say

“I have a (insert malady here) can you please just call me in something?  I don’t have (Time, copay, a ride) to come in and see you”

And my answer is 90% of the time, “No, you need an appointment to be evaluated”

The reason?  We for lack of a better one is we are running out of antibiotics and my giving you one without checking to make sure that your “infection” is bacterial, well is causes more harm than good.  Besides if you just have a cold (which is viral) you probably won’t finish the antibiotic anyway, and stash it over your sink for the next time that you get the sniffles, leaving behind what was once a harmless bacteria, a stronger resistant one. 

Misuse of antibiotics leaves behind the stronger bacteria which makes it more difficult to fight next time that there is an infection.  Sadly there has not been a new antibiotic class discovered since the 1980s.  But how can that be?

Figure 18: The Antibiotic Discovery Void


Source: World Economic Forum, adapted from Silver, L.L. Challenges of Antibacterial Discovery. 
In Clinical Microbiology Reviews, 2011, 24:71-109.


Is is a matter that drug companies can’t make enough money at it?  IF only.  Sadly, it isn’t. They continue to look for ways to fight infection, however today we encounter the ever increasing resistant bugs.  Currently, 100,000 Americans die each year from resistant bugs, while small compared to the numbers who die from heart disease and cancer, this number is only going to grow.

One reason, is the way we treat patients at the nursing home.  I routinely get calls to have a urine done on a patient.  Often what returns is a contaminated mess that the nurse is just sure needs to be treated.  This is an endless repetition of calls saying either, “No wait for the culture” or “No get a cath or a clean catch sample, that is full of contamination” or in the most extreme nurse going to tell family “Your doctor just doesn’t care about the infection, so they won’t treat it.”  prompting the family to immediately change to a doctor who will treat said contaminated sample or a trip to the ER so that they can be “properly” treated.  Or in the case of a patient with a chronic infection, endless arguments and sending 5 copies of the consultation from the urologist saying “don’t treat that mess, you are just causing increased resistance.”  And that is just for urines, coughs at nursing homes are often treated with a z-pack thrown at them, because it is easier than having them carted to the office for an evaluation.  Is it any wonder that c.difficile at the nursing home is almost considered normal.

The other reason for this resistance?  Patients out in public- All of you who decided you were filling better on day 5 of a 10 day course of amoxicillin.  So you kept the rest in your medicine cabinet above the sink (probably the worst place to store pills by the way) and then the next time you are feeling bad, well you started to take them.  Sadly after 5 days of old pills, you still are not feeling better, so you go into your doctor.  Unfortunately you have now confused the picture.  What might have been a cold, and needed only decongestants can’t be differentiated from a half treated bacterial infection.  And now, I am stuck with given possibly unnecessary antibiotics or not giving antibiotics and now that you have half treated yourselves you have caused resistant organisms only to survive.

Another scenario, patient goes to Doctor number 1 and they tell patient, it is viral after doing the appropriate exams and tests, and that no antibiotics are needed.  Patient then says “If I go to Dr #2 he will give me an antibiotic.”  Dr #1 has two choices, to practice good medicine in a day of decreasing reimbursement and risk losing patient, or the give into patient and practice “good business”

Add to that the routine use of antibiotics in livestock feed, and we are about to face a drug resistance epidemic that we never thought possible.  Resistant bacteria can be transferred from livestock to humans, and resistant bacteria has contaminated our water supply so much that they have found resistant strains as far away as Antarctica.

Some even wonder if our obsession in this country on controlled substances is misdirected and that maybe we need to worry less about the improper prescribing of hydrocodone and more about the improper prescribing of antibiotics.  While both could potentially have horrible consequences, the antibiotic misuse is more dire for the population as a whole.

Patients often ask me what do I do when either I or my children get sick.  Funny enough, the last time I was sick before this past December was 3 years ago.  Mine did happen to be bacterial and I finished my antibiotics.  My oldest son, hasn’t taken an antibiotic since he was in second grade 2 years ago when he had strep.  My youngest, its hard to remember, its been longer than that.  We spend considerable time washing hands, and less worrying about a little dirt in the house.  So yes, I practice what I preach.  

Antibiotics have a role in healthcare, but we need to attempt to make sure that they are used appropriately, because despite one or two recent antibiotics that came to market in the last few years, new drugs are few and far between on the drug pipeline.  It is an expensive process, and despite my remark that if only it were solely because antibiotics would have a hard time to be profitable once released, it takes on average $1 billion to get a drug to market from start to finish in this country.  There does need to be some means to get back the cost of that research.

So next time you start cussing because your doctor didn’t just call you in that z-pack maybe there is a good reason and maybe you should be thankful in the future.

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