Iliff Family Practice
Dr. Iliff's Practice Newsletter/Rant - 2021
2020, R.I.P:
There. It’s over. Nevertheless, it should not surprise you that this year’s newsletter can’t escape examining the impact of The Disease Which Shall Not Be Named (TDWSNBN). So here goes.
The Year of the Dog:
“A dog is the only thing on earth that loves you more than it loves itself” said the Seinfeld of the 1800s, Josh Billings. He’s the same guy who said “a good reliable set of bowels is worth more than any amount of brains,” which many of you have heard quoted from me when your bowels were not performing up to expectations. But in this miserable year, dog adoptions are up 30%, and that is very good news. “It’s an ill wind that blows no good,” my grandmother often said, and “every cloud has a silver lining.” The silver lining of 2020 is that more people have Man’s Best Friend sharing their home. Along with that comes an average of 2500 extra steps per day, according to one study, and a persistent rise in oxytocin— the pleasure hormone— even in the absence of sex. I regret that Jim Ramberg, who for many years ran a Dog of the Year contest in the Topeka Capital-Journal(which, against all odds, his dog won every year) is not still around, because the contest would now be dominated by Gabby and Loki, my dogs, who are simply the best ever, with the exception of Double, my canine of adolescence, who would follow me onto the campus of KU and wait faithfully outside an old limestone building until I emerged, having ignored thousands of passing students until the time when I would enjoy her enthusiastic greeting. ‘Nuff said. If you don’t have a dog, get one, and then...
Come On Out to the Iliff Commons, which has been swamped with new visitors under siege from TDWSNBN. I have a video showing no less than 14 dogs playing in or around the pond, most of them strangers to one another. None of them were wearing leashes or masks, either. It is a spontaneously joyous celebration.
The Commons, according to Google Maps, is now the highest rated recreational destination in Kansas. Of 137 ratings, only 8 are less than a perfect “5”, and the chief objection seems to be that there are no restrooms. The explanation for that involves its original purpose 20 years ago, which was to encourage my patients to come our for a walk after sitting in front of a computer or television all day. We thought that they could hold it for 45 minutes or so, especially if they follow my advice about daily psyllium. And, of course, the woods provide plenty of shelter for relief in an emergency. Human exercise didn’t really catch on, but the Commons was discovered by dog ownership, and the dogs never registered so much as a Yelp about the lack of bathroom facilities. The rest is history. Only problem is that at least one regular visitor bags her dog’s poop and then leaves the otherwise biodegradable contents for the Park Ranger (my wife) to pick up and carry home to our trash. I kid you not. Only two other visitors in 2020 rivaled that one for the Darwin Award. One, as Dorothy was crossing the dam on our ATV, protested that she was not wearing a mask. The other protested that the trail leading up to Papa Bison from the cabin provided a straight-on view of his testicles, which was disturbing for her children. They need to get a puppy, preferably a male.
Regarding TDWSNBN, I’ll leave my original comments, and a couple of supplements, on the website (doctoriliff.com) for the rest of the year. My predictions, like my predictions about the Jayhawks or the stock market, were less than perfect. I’ve had a lot of company in the humility department, including Anthony Fauci and everyone who was bold enough to stick out a neck in print. I was wrong that herd immunity would emerge quickly. I was right that schools should never have closed— the pandemic was safer for children than the flu, but more dangerous for old people. Yes, wearing a mask and social distancing was a good idea. No, shutting down small businesses was not. Should you get the vaccine when available? Yes, you should. I did, along with my staff. Beyond that, there are statistics and experiences in other countries to support almost any opinion. Give it a couple of years to sort out. Here’s some perspective:
Death Rates in Other Upheavals: As of the start of the year, TDWSNBN has killed about 390,000 Americans— so far, only one of them my patient. How does that compare? Well, adjusted for population at the time, the 1918-19 Spanish flu killed 7,155,000, the Civil War 6,570,000, World War 2 955,000, World War 1 372,000, Vietnam 93,000, and Korea 80,000. Statistics, of course, are meaningless if one of the victims was your friend or relative. I had a son who spent the better part of a year as a lieutenant on a road-clearing operation in Afghanistan, and I am well aware that if he had not come back, it would have been no solace that only a few thousand Americans died in that God-forsaken country. Nevertheless, we have to step back from our emotions and consider the trade-offs. A whole lot of Americans, most of them among the most vulnerable, have experienced extraordinary stress from shutting down the economy. Children, especially poor children, may never recover from the displacement of their education. Furthermore,
How Do Physicians Look at Medical Interventions?
We measure the cost of a test, procedure, or treatment on the basis of Quality Adjusted Life Years (QALYs). That is, a mammogram which saves the life of a 43 year old mother with a life expectancy of 88 years is worth 45 QALYs. A third round of chemotherapy which prolongs the life of a 72 year old grandfather for 6 months is only worth 0.5 QALYs. Then you multiply the cost of the intervention times the QALYs saved to determine the cost per QALY. No one publicizes this, because bleeding-heart politicians and journalists would immediately jump to “Death Panels” (Republicans) or “pushing Granny off the cliff in her wheelchair” (Democrats). A life may be infinitely valuable to God, but to a society, there has to be a limit. That limit is $200,000 per QALY, give or take a hundred thousand or so.
What’s the Cost to our Grandchildren for TDWSNBN?
When the economists finally add up the cost to America by the response of our epidemiologists— including the immediate effects in terms of jobs and education lost, and the generations-long repayment of the national debt, I predict the cost will be staggering and flagrantly unjustifiable by any standard of morality. This is because TDWSNBN kills mainly old people, while wars and the Spanish flu killed the young, so the cost per QALY is going to be shocking. I say this as one of the old people (71) who continued seeing patients in person throughout the pandemic, so its not a matter of “he jests at scars who never felt a wound.” I think my generation, in cahoots with economic elites who never missed a day of work, are going to go down in history as the most selfish and self-absorbed group in American history. We won’t be around long enough to apologize to our great-grandchildren.
One Lesson from this fiasco is that epidemiologists should not be the only voice in the conversation, although the press has given them the megaphone. Their perspective is essential, and must be considered. They have a difficult, and sometimes thankless job, especially when our country is sharply divided and conspiracy theories abound. They should not be subjected to harassment or death threats. However, the other voice should be that of politicians at all levels of government. It is their job to balance costs and benefits to society. That’s what we elected them to do. When I read the letters from the public which assume that medical experts have all the answers— the inevitable result of unbalanced journalism— it is the local politicians who have my sympathy.
NOW, BACK TO MEDICINE
Vitamin D to Prevent TDWSNBN:
By now all of us have been exhausted by the rumors of medicines which will ward off the disease of the year. Hydroxycholoroquine seems to be helpful, but only before symptoms appear, which means you’d have to take it all the time, and that would be impossible. Good news is that vitamin D really seems to help, and almost everyone is deficient due to sunscreens, indoor work, and the fact that adults don’t drink much D-fortified milk. The official recommendation is 2000 International Units (IU) per day. I get 1000 IU in my multiple vitamin, but I picked up little capsules with 5000 IU at the drugstore, and that’s what my wife and I take every day. Vitamin D is fat-soluble, unlike B and C, so you store it and potentially could overdose. That’s not a problem at the recommended level, but don’t go crazy. More is not always better.
Medicine and Technology:
In 1978, when I was in training, a psychiatry resident writing under the pseudonym Samuel Shem wrote a hilariously satirical novel, House of God. Now, as an old man like me, he has written a sequel, Man’s 4th Best Hospital. It’s a riff on a subject which is deadly serious: the way technology drives up medical costs, increasingly comes between patient and physician, and contributes to “burnout” in the profession. I was writing about this in my blog for the American Academy of Family Physicians ten years ago, without noticeable impact. We can’t change the world, but we can refuse to allow technology to ruin our practice of medicine. So: you’ll always get a live person, not a phone tree, during office hours. The answering service can always get me on my cell phone after hours. We will never promote “telemedicine,” and we’ll never use electronic medical records, with all their inaccurate data obtained by macros and cut-and-paste descriptions of exams which never happened.
My Yearly Denial:
No, I have no intentions of retiring. Work is my hobby, and I love it. At 71, I’m not in denial; I could have a medical catastrophe, but a life of diet and exercise has left me with a much younger body than my peers. My wife will tell me if I’m losing my mind. Therefore, foolish as it might seem, we continue to take new patients who are 55 or younger, with Blue Cross insurance, to limit our administrative burden.
Cheap Trick for Colds, Sinusitis, Allergic Rhinitis, and Snoring:
Twice each day, squirt each nostril with a nasal steroid (fluticasone, sold as Flonase over the counter, or others by prescription) and a nasal decongestant (oxymetazolone, sold as Afrin and many other trade names). Oxymetazolone will say not to use it more than 3 days because of addiction, but that doesn’t apply with a steroid spray at the same time. You can also use the same combination at bedtime if you snore because of nasal stuffiness. I’ve done it for years.
Pain Relief Without Narcotics:
Start with extended-release acetaminophen 650 mg (Tylenol Arthritis), 2 pills every 8 hours. Then, as long as you aren't diabetic or suffering kidney disease, add ibuprofen 200 mg (Advil), 3 pills every 8 hours, or naproxen 220 mg2 pills every 8 hours.. You can take both drugs at the same time. That will handle almost all acute and chronic pain. Next stop: tramadol 50 mg (prescription) every 8 hours. Yes, that is 5 or 6 pills 3 times a day. But it’s better than narcotics! If you have muscle spasms, I might throw in carisoprodol 350 mg every 8 hours. Don’t worry-- all these medicines play well together, and are cheap and effective. And better than narcotics!
Sorry About the Limited Medical Advice, but all my past newsletters back to 2004 are still authoritative. Talk again in 2022.