Iliff Family Practice
Dr. Iliff's Practice Newsletter/Rant - 2022
The pandemic, year two: It's time to hit the "reset" button. As I write this in mid-January (a previous draft depressed even me, so I'm starting over) almost half of Americans are depressed or anxious, up from around 15% two years ago. That's around the same percentage of physicians who are burned out, but that's been going on for ten years, and for a different reason- badly designed electronic medical records and working for large corporate hospital systems, with the attendant loss of autonomy. I don't have either problem (solo family physicians are rarely afflicted), and I'm having as much fun as ever. This rant is mainly going to address the "Good Life," which has been the subject of discussion since Socrates.
First, let's get the pandemic out of the way. Unless I miss my guess, the Omicron variant which is causing so much hysteria in the press is performing the same function as "chickenpox parties" when I had young children. It's highly transmissible, it rarely causes severe disease (and that almost exclusively among the unvaccinated), and it should contribute to the rapid arrival of "herd immunity" as it becomes endemic, like the other unnamed coronaviruses and rhinoviruses which circulate every winter in an annoying fashion as upper respiratory diseases.
Was I wrong when I wrote about "herd immunity" in the Capital-Journal in early 2020? Yes. That puts me in good company with everyone else who put their opinions in print, about one issue or another. The disease has been a nasty little bugger. I still think that the Great Barrington Declaration, of which I was a next-day signatory, was correct: we should have aggressively protected the vulnerable, allowed the economy to remain open (with masking and social distancing), and let the children remain in school. However-- the people who have to make decisions in government, schools, and businesses make a lot of people unhappy no matter what they decide. They deserve our respect and kindness even if we disagree.
Do I believe vaccines were a miracle? Yes, I do. Could I be wrong about that? Yes, but the chance grows smaller with every billion doses. Maybe vaccines will turn out to cause a problem in the future, but it's looking less likely all the time. We'll see. Physicians are crapshooters, and we change our minds as the evidence presents. Maybe, by the time you read this, I will have been proven wrong. It wouldn't be the first time.
Do I believe the "vaccine hesitant" were crazy? No, I don't. The vaccines were a new process. I believe in maximum liberty, and minimal coercion (like mandates) in a free society. I think everyone should be free to make up their own mind. My only problem is that my friends in the hospital system have been swamped by the unvaccinated. Therefore I believe that vaccination, besides being effective at protecting yourself, is also an act of charity and kindness to others, especially the hospital workers who are exhausted. But I understand the confusion which surrounds this issue.
So let's talk about the "good life." For a change, I'm going to try to be practical, and recognize that the "pursuit of happiness" enshrined in the Declaration of Independence mainly means- being practical, and honest here- "pursuit of pleasure." Therefore, for all of you who have gained ten pounds in the last six months on a diet consisting almost exclusively of broccoli and cauliflower, I'm going to pass on the diet diary. Cheeseburgers and Black Forest cake are really pleasurable. I understand.
When Dorothy and I established the Iliff Commons almost two decades ago, I was partly motivated by pleasure. We owned nine acres of virgin Kansas forest and a log cabin in the middle, invisible from the street, but when I got a small inheritance from the death of my parents and the 70 acres behind us came up for auction, we bought it. I thought maybe we could create walking trails and motivate my patients to exercise. It didn't turn out to be wildly popular with patients for that purpose, but it did with the general public-especially if they owned dogs. I suppose my elevator speech today would describe it as an "off-leash dog park which welcomes their humans." And that has turned out to be very pleasurable, indeed.
"Re-Wilding Our Minds" was a fascinating cover story in the Summer 2021 edition of The American Scholar. If you can find it online without a paywall, it's worth 15 minutes of your time. The author summarizes research about the value of spending time in natural settings. I was aware of a Danish study demonstrating the striking increase in depression and anxiety among people raised or living in an urban environment. It turns out that research is discovering the physiologic basis for that finding. We are biochemically wired to be happy in the woods, creeks, and prairies. Hunters and fishers- I'm not one of them- know that already. For the rest of us, it should be the learned (or re-learned) pleasure of a walk on a tree-lined streets- or Lake Shawnee, or the Governor's Mansion, or the Commons. And let your kids play in the dirt.
I'm going to add something which is, for me, unusual. It's not something I talk about in professional settings, but it's more important than anything I do- because 100% of my patients are going to die. It's only a matter of time. Me, too. The apostle Paul wrote that "God did not give us a spirit of fear, but of power, and love, and self-discipline." The apostle Peter advised us that we should "humble ourselves under God's strong hand, and in his own good time he will lift you up. You can throw the whole weight of your anxieties upon him, for you are his personal concern." Because I have faith in the faithfulness of Jesus, who died so that I might live forever, I do not fear death. As such, I am free to be reasonable about the life I live on earth, which is now much closer to the end than the beginning. My job, and your job, is to be faithful, sensible, responsible, and loving to the end of our days.
Which brings me to the perennial question: am I going to retire? Of course. When? Who knows? I'm 72 years old, and in excellent physical and mental shape. I love my work, and seeing old friends every day is a delight. But I could have a stroke, or start to lose my mind, or get pancreatic cancer. Until then, I intend to be faithful to my calling. And by the way- I just passed my family medicine board exam, again. That makes me good to age 80.
Assuming I have a choice in the matter, I will give you at least a year's notice before I retire from my normal practice. That will give you time to consider your options. I won't be able to refer you to someone outside the Joseph Warren Building for two reasons: first, I don't know anyone any more, because we never have family medicine department meetings and my old colleagues have all retired; and second, with all the youngsters selling out to the security (and often misery) of corporate medicine, all you can do is fight your way through a phone tree and get assigned to whomever is next up for a new patient. There may be another option. I'll do my best to find a couple of newly minted family physicians to do what Dr. Laccheo and I did in 1986: start a practice independently, where they work for you, not a hospital system. You know, where a live person answers the phone, and you know their voice.
Dr. Chris Stubbs has taken over for our excellent physician's assistant, Scott Ford, who has retired. Chris won't be working for Minor Med forever, but he is considering his options, including starting his own practice on the north side of the office. He is an experienced family physician, and who knows? He might be yours someday. Meanwhile, I'll see you at your next scheduled visit.
Back to the Future: 35 years ago I started this practice believing in the lifesaving and life-enhancing (that is, both quantity and quality) value of exercise. In that time, the "exercise prescription" has been proven by research studies over, and over, and over…. It's the only medical recommendation which has not once been contradicted or altered. Exercise is the only Fountain of Youth. It comes in a variety of forms, all of which are good- but only some are pleasurable without years of practice.
My wife and I are polar opposites on the same spectrum. Dorothy hates exercise for the sake of exercise, but she works her tail off maintains the Commons and walking the dogs. She probably never gets her heart rate over 90; for her, it's quantity over quality. Because of my work schedule, I opt for efficiency. Unless I'm helping her on weekends, I rarely exercise for over 25 minutes a day, but I more than double my resting heart rate during that time. We both get to the same place, as research would show; and for our age, we are unusually vigorous and healthy.
As your physician, I'm going to get back to preaching what I practice. There has been one new development in exercise research in the past few years: high intensity interval training, or HIIT. When I ran cross country at Shawnee Mission East, we did a weekly "interval" practice of 12 quarter miles. When I was training for a 3-hour marathon, I would do 12 one-mile intervals on the Shunga Trail. An "interval" is a limited period of exercise too difficult to maintain over long periods, with rest in between. We've known the value of that for a long time. The shocking recent research finding is that much of the value for health can be obtained through much shorter intervals than we have traditionally advised: you might run 25 steps, and then walk 50, repeated a number of times. The value seems to come from stressing your heart, over and over, maybe for 10 minutes or less. It's hard for me to believe, but the research seems sound.
Here's the problem: to stress your heart like this, you need to do a treadmill test if you are not already in good shape. HIIT is valuable, and a very efficient use of time, but it could be dangerous. If you want to stick to brisk walking for 150 minutes a week, you should be OK. But if you want to get the same benefit from 30 minutes of HIIT, let me stress you first under controlled conditions. I'm also going to start pushing the yearly "one mile walk" test as part of your physical exams. I pioneered that when I was on the Governor's Fitness Council, and it's the official "fitness vital sign" of the Kansas Medical Society and Kansas Academy of Family Physicians. My time: 12:30. For peak medical benefits, it's 14 minutes for males, and 15 for females, but don't let that discourage you; the important thing is to challenge yourself, and improve every year.
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 mg 2 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!