I think that to be a better doctor, it helps to have been a patient. Or maybe it just helps to have experienced life with its ups and downs and twists and turns. Helping people feel better depends, in many instances, on understanding who they are, what they’re feeling and how they view their situation. Nothing happens in a vacuum. The better I understand the owner of the problem, the better I am at helping solve the problem.
Today was a good example of this. I was talking with a woman who was sent to me for abnormal liver enzymes. It turns out that she has a type of fatty liver known as steatohepatitis. She’s a nondrinker and has no other explanation for her liver condition. The biggest risk factors for fatty liver disease are obesity, Type II diabetes, high cholesterol and gastric bypass surgery. We used to think that fatty liver was nothing to worry about, but that’s not really the case. Fatty liver can progress to cirrhosis and liver failure. It’s a risk factor for Type II diabetes and heart disease. It puts you at higher risk for liver cancer. It’s not a blow-off diagnosis.
She is obese. She has Type II diabetes. She has high blood pressure. She has high cholesterol. She is on a list of medications as long as your arm. She also has rheumatoid arthritis. And that’s a problem. The treatment of choice for fatty liver disease is to lose weight, which would also help her diabetes and her cholesterol and her high blood pressure.
Sustained weight loss for most people is the result of a lifestyle change. Nobody loses weight for any period of time by dieting alone and there’s a lot of evidence to support that. It’s the result of a combination of dietary change (not just eating less but eating better) and increased activity to raise your metabolic rate. You live differently. And you should because how you’re living now is what got you into this mess in the first place. And changing you not only helps with these medical problems that are life-threatening and morbid conditions, it saves you money. “How much do you pay for all these medicines,” I asked her. “A lot! Way more than I should.” Do you think all this is helping?” “Some,” was the reply. “Well, how do you feel overall? I mean, what’s your overall sense of how you are?” “Not good,” was the response. “I’m tired and sore and don’t have a lot of energy.” “So, for about $400 per month, you get ‘works okay and I feel ‘meh’?” “Yup.”
“But here’s the thing, doc. Every doctor tells me I need to lose weight and exercise, but NO doctor ever tells me how. And my knees are not good so what am I supposed to do? Every time I try to do something, they hurt.” And that’s the crux of the problem: mechanism and ownership. We let her down on the first part, but she’s letting herself down on the second. She’s not owning her own health. If she owned this, she’d collar us and and say, “How do I make this work? What does it look like? What does exercise and increased activity look like for me with arthritis?” And maybe she’d get some answers but I’ve also been around long enough to know that our healthcare system likes to sell pills and foster dependence and talking to people is not well reimbursed. So there you have it. You’ll likely get a handy little generic print out that lists things to do for your fatty liver like “lose weight and exercise.” We love to hand out goofy little often completely meaningless “patient education” handouts. The ER is the worst for these. My favorite was the guy who showed up in my office with acute appendicitis after being discharged from the ER with a piece of paper that said, “You have been diagnosed with ABDOMINAL PAIN. ABDOMINAL PAIN has may causes…” Thanks. That was really helpful.
Anyway, the point is she’s letting herself down and we’re letting her down. She needs someone to work with her who understands what her strengths and limitations are. Someone who can develop a plan with her that’s doable, palatable and enforceable. She needs a personal trainer or integrative life coach (both of which The Well Being has, by the way).
And this is where the theme for the day emerges. I’m recovering from a significant foot injury. I’m a pretty active guy and I don’t like sitting still. But this thing kept me sitting for 6 weeks. And I’ve had a lot of injuries and surgeries related to sports and accidents over the years. And I’m 57. So the combination of doing nothing and letting a beat up old chassis sit for 6 weeks has made for a rather saddening and painful return. Not to belabor the point, but I’ve had a shoulder replaced, another that’s separated, two spinal compression fractures and degenerative meniscal tears in both knees. Things hurt. But the more I sit and the less I do, the more it hurts. So sitting is not an option, but I’ve got to pick my spots. When this lady talks to me about her knees hurting and how hard it is, I get it. No, I don’t know her world, but I’ve spent enough time in the world of injury rehab and chronic injury to know where she’s coming from. So she gets a bit of a pass from me on that part. But she doesn’t get a pass on the “I’m just doing nothing because it hurts and nobody told me anything differently” part. I started running a bit last week. My knees hurt, my back hurt, my shoulders hurt, I was horribly slow and in terrible shape. And I absolutely loved every minute of it. Was I frustrated? Sure! Do I feel good doing it? Not yet. It’s a process. It’s a journey. And the point is not to look at the final goals because, really, the only goals are “better” and “try.” If you persist, if you make continued small efforts, you will improve. And you will see (and feel!) your progress. And over time, things hurt less and you’re taking fewer meds and you’re spending less money on medications and doctor visits. You are on your journey to wellness and you will follow your own path.
I’ve put my patient in touch with a personal trainer and an integrative life coach that I work with. There’s also tons of information on line for folks and she could bounce it off her doc or us. We had a nice talk about how important I felt this was. And that I understood we needed to be smart and careful, but that also after years of being sedentary, that motor was going to sputter and smoke and knock for a bit as we were starting it up. Nobody’s getting any younger. We need to be careful how we handle ourselves. I’m hoping that with some guidance and accountability and support, she might start to turn things around. We all make comebacks. Comebacks are the cool part of finding out who you really are. I think she’s going to be pleased with who she finds.