Iliff Family Practice
Dr. Iliff's Practice Newsletter/Rant - 2023
Dr. Chris Stubbs opened his private practice in Dr. Laccheo's old rooms on January 1. Since spring he's been seeing patients as a Minor Med employee, but as of 2023 he's on his own. I'm being restrictive in accepting new patients (under 55 with Blue Cross insurance) so I don't get too busy, but if you know or hear of people who want to escape the corporate culture of medicine- where the person you get on the phone has no idea who you are, and your care is likely to be farmed out to an "extender"- give his office a call at (785) 748-1641. Family physicians are most valuable for young families with kids; you get a lot of "by the way" free advice while the "identified patient" is being treated.
Covid: Here we go again! Yes, it's still hanging around, and at the end of December 2022 it's on about the same problem level as influenza and respiratory syncytial virus. RSV is just a cold for everyone except infants, where it may cause life-threatening lung problems. Influenza threatens everyone, some years more than others. Covid has been becoming less serious with evolution of newer variants. Many people get no symptoms at all. As of 1/1/23, it is mostly a threat to older folks with health problems. The latest version of the vaccine may be useful for them. My wife and I haven't gotten it as of Christmas, and probably won't. It's not a good idea, in my opinion, for anyone under 40 who is healthy, because the very small risk of myocarditis is probably greater than the even smaller risk of disease complications. But everyone by now has made their own risk evaluation, including the fear factor. Do what you think best.
Exercise testing: Looking back over a career of almost half a century, it's remarkable to me that I've consistently got one thing right - physical fitness is the most important factor, by far, for health and happiness. The research is astounding, and boring. It's a wonder to me that researchers keep turning out papers that show the same thing, over and over, for any age, health status, or physical condition. Just do it! 150 minutes a week of moderate exercise, or 75 minutes a week of vigorous exercise, is more important than anything I can prescribe. Heart disease is still the number one cause of death in America. After years of being too busy to offer the treadmill testing I do to myself every two years, I'm making it available to anyone with four or more risk factors. Those risk factors are on the back of the exam room doors. Just let Jamie know you want one, and she'll set it up.
Practice what I preach: Once in awhile I tell patients what my personal plan happens to be, but I'll go public here for the first time. I have an Apple Watch. It tells me that in the month of December I did 35 workouts averaging 36 minutes each, and burned 6,563 calories over what I expend just staying alive. Some of those "workouts" were just strolls with my wife and dogs on the Commons which burned, on average, 4 extra calories per minute. Others were fast walks, which burned 7 calories per minute. And then there were more intense workouts on the rowing machine, elliptical, or run-walks on the Commons, averaging 10 extra calories per minute. From mid-May to mid-October, I'll substitute swims for more intense exercise that takes it easy on my aging joints.
Take-home lessons: First, doing something every day should become a habit. I've been doing this from age 30 to 73, through starting a school, raising kids, and delivering babies, so don't be thinking you're too busy. A habit is a habit. It gets easier with repetition, but in the beginning it takes conviction. Second, those 6563 extra calories I burned in December are less than 2 pounds of fat. Habitual exercise is not a weight-loss program. It's a cardiovascular, anti-diabetes, and energy program. You lose weight by consuming less food. You gain energy, and years of productive, enjoyable life, by regular exercise. Afraid of Alzheimer's, cancer, heart attack, stroke, or Covid, like everyone else? Take a hike.
Alternative: work like my wife. Dorothy doesn't "workout." She works, out, by maintaining the Commons. Regular visitors know her, and our dogs, who follow her around as she works. Now get this, all of you guys who drive a ZTR or riding mower on your lawns: she walks behind her grass and brush mowers from spring through fall. Why are you building buns of steel when you could be exercising your hearts?
"Remember, being healthy is just dying as slowly as possible," quipped a wise guy. That is partially true, but it's not the take-home lesson. The goal is to die behind the plow, like our great-grandparents did, being useful and productive to the end not losing functionality step by step after multiple degenerative diseases and organ or joint replacements. Look, as Solomon said, time and chance happen to all of us. I could be growing a pancreatic tumor or widowmaker heart blockage as I write. Stuff happens. All we can do is the best we can. But we're living in a country where the Armed Forces can't find enough candidates who can pass a physical, and over one-third of the population has fatty liver disease and may not know it. Could this be a year to get real? There's a new medical crisis barreling down the tracks: nonalcoholic fatty liver disease, which may affect one-third of Americans, and most all diabetics. It can progress to liver fibrosis, cirrhosis, and liver failure. There is no proven treatment so far, although pioglitazone and vitamin E might help. The best treatment is (drum roll)…. weight loss and exercise.
Medical miracles? Well, not so much. We have good, cheap, generic drugs for the diseases which plague Americans, including the many self-inflicted ones. This has been the miracle of my career. Even heart disease is treated more effectively by high-dose statins than bypass surgery or stenting, except in emergent cases. What you are reading about these days are new drugs which nibble away at uncommon problems at an exceedingly high price. I'm looking at a picture of a nurse holding a syringe with a $2.1 million dose of Zolgensma, a one-time treatment for children with spinal muscular atrophy. But it isn't a cure. It just prolongs the time until death.
That's the problem all over the map. It's $165,000 for an extra two months of life here and there. Insurance, including Medicare, isn't structured to burn money like that. We'll see if we can grow a money tree to feed the flames. I'm skeptical.
Update on therapy for weight loss which doesn't involve self-discipline: there isn't any. The most effective therapy, at maybe a 50% success rate, is surgery. You can still eat your way through a gastric sleeve, but at least you can get it done safely in Tijuana for about $4,000, including the hospital stay. As many of you know, I won't prescribe drugs for weight loss which don't result in longterm success. There are clinics around town which will happily take your money. The one drug I will use is, but only for diabetics, is semaglutide, a GLP-1 inhibitor. It can result in average weight loss of 15%, partly due to suppressing appetite often with some degree of nausea. I hate nausea seasickness is torture for me but I don't mind prescribing it and putting Jackie through the torturous pre-approval process to see if your insurance will pay for it.
How would you like to reduce the incidence of anxiety, depression, suicide, eating disorders, and substance abuse among children and adolescence? It's not difficult. Just start having family meals together. That means around the dinner table at home, and with cell phones and television banished. Well, maybe it is difficult, because modern life has become a completely insane merry-go-round of sports, social activities, and work. And swimming upstream against the flow of modern culture is a really heavy lift. The problem is that those extracurricular activities stealing family time were accepted on the premise that- hold for it- they were making the kids happy and well-adjusted. It was a mistake. A big mistake. If society took the wrong fork in the road, the quickest way forward is to turn around and go back.
Speaking of anxiety: The incidence of functional mental illness, of which anxiety is a major component, rose from 1 in 350 a century ago to 2 in 5 today. Now, let's get serious. Is life really that much worse since the invention of the automobile? Yeah, I know- climate change is going to eliminate the species, God doesn't exist, everyone on Facebook has a more exciting life than you do, and you'd better watch your pronouns and questions when talking to a stranger. But really! Life will survive higher temperatures, God does exist, your Facebook friends only post their peak experiences, and the cancel culture will burn itself out for sheer lack of rationality within a decade. So pick up a good book (the Bible is a good start), sit by the fire or pool, depending on the season, and turn off those noisy voices that are driving you crazy.
May I blow your mind? The "conservation of matter" is one of the laws of physics. Every atom in your body has existed for 13.78 billion years, according to the physicists. In fact, every atom in the universe began as an almost infinitely concentrated speck before the Big Bang, which lasted for one second divided by 10 followed by 43 zeros, a period known as the "Planck Epoch." The universe has been expanding ever since, with hydrogen and helium atoms concentrating into stars, planets, and many other things made up of many other elements. Including me, and you. Some day all of our atoms will return to dust, and be reused. Do you think the part of you which is thinking right now is made up of atoms? That is, as St. Thomas asked, "Is the soul a body?" He didn't think so. I don't, either. If you would like to explore this meditation further, read a famous sermon by C.S. Lewis entitled "The Weight of Glory." Google will find it online, or read it here: https://www.wheelersburg.net/Downloads/Lewis Glory.pdf
Inflammatory disease: Ironically, the modern world's discovery of the importance of hygiene may have contributed to the rise of inflammatory disease. We wouldn't exchange much sanitation and sewers had far more affect on infectious disease death than the development of antibiotics. But exposure to a wide variety of germs in the first few days and years of life is essential to cultivating a diverse, anti-inflammatory microbiome. Studies show that when children are exposed to greater numbers of microbes during infancy, their risk of hidden, chronic inflammation in adulthood may decrease. Without these timely exposures, they may go on to develop immune systems that overreact to benign germs, foods, and other matter such as peanuts, gluten, pollen or household dust. They have a higher risk of becoming silently inflamed and succumbing to chronic inflammatory illnesses, including overt autoimmune diseases. You may be thinking of asthma, psoriasis, and rheumatoid arthritis, and you would be right. Therefore, unless you are already at risk from age and disease, quit being a germaphobe! Hypochondriacs are not the healthiest members of our species. Let the kids and grandkids play in the dirt. Invest in a dog. Drop the mask. You look better that way, anyway.
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, including the tramadol 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.