On Aging

Once again I find myself on the Inpatient service.  When patients are hospitalized for something, it's becoming more and more rare that their Primary Care doctor will follow them in there and take care of them.  That's where we step in.  It's always a busy month for me (70+ hours per week), but it's also given me an interesting view on people.

One lady I met was a 92 year old who was in for some leg pain following a lumbar spine fusion.  That's a pretty decent surgery for anyone, so it tells you something about her function prior to the surgery that they were even willing to do it.  She was just as pleasant as can be, and as sharp as a tack.  Funny, engaging, interesting, and very much with it.

I've also met some people on the other end of the spectrum.  There is a 42 year old with a heart that is only pumping about 1/3 as well as it should, who's had a couple of heart attacks, diabetes, smokes, requiring oxygen...you get the point.  It's amazing to see how people can age so differently.  

By far the saddest part for me isn't how they look, it's how they live their lives.  There is something about the "graceless agers" that is just slow all over.  They don't process as well, they don't understand as well, and when you ask them what they do, they have a hard time coming up with anything other than sitting around and doing nothing.  They often don't have many hobbies other than following something (football, Nascar, etc).  Their minds and bodies have simply gone with the status quo their whole lives. 

The people who are "graceful agers" have something that draws you in.  There is a light and intelligence behind their eyes.  They are engaged in the world around them.  They often volunteer or are plugged into the community somehow.  They often have a hobby or two, and have done interesting things in their lives.  This generation often stayed home with their kids and didn't have a career outside the home, but they found interesting things to keep their minds active.  Overall it's a pleasure to talk with them. 

With these experiences, and more like them, I've been giving a lot of thought to what makes people age well or poorly. Here's my list of what helps people age gracefully

1. Keep your mind active - This means more than doing the daily crossword, a word search, or reading a light novel .  It means doing something that challenges you mentally.  Learning a new language, learning a new skill, learning about a new subject in an in-depth manner, etc.
From a neurological and medical standpoint, if you don't use it you lose it.  Many people are actively learning when they are in college and start a new job, but after a while they get on cruise control with less and less requiring them to be mentally active.  Dust off that old noggin and do something different.

2. Keep physically active - The same lesson applies to muscles as it does to brains; use it or lose it.  Too many people don't push themselves physically.   Any exercise is better than none, and even a little makes a difference, but you should see the people who challenge themselves physically.  They hardly seem to age at all.  If you're going to work out, go for intensity and get your heart rate up to near your max (220 - age = Max heart rate), and lift some weights.  It's very hard to bulk up, so don't worry about that, but doing some dead lifts, squats, presses, and big lifts like these can keep you young for much longer than people have given credit to.

3. Be involved - For most of us that will often be church, but can be a lot more than that as well.  I've found that people are more well-rounded if they have some sort of community involvement and get outside themselves.  Helping others makes us realize what a great big world we live in and how great other people are.  This one is harder to measure in people, but they are just so much nicer if they are involved. 

That's it.  It sounds pretty simple, but humans are lazy.  If we have a chance to sit on the couch and not do something...that's exactly what we'll do.  We need to consciously develop these skills while we are young (or slightly older) and cultivate them throughout our lives. If you don't do this, one by one your current hobbies will drop off and you will do less and less each year.  This is the vision I try to show people.  It's not just that these people die earlier, it's that they lose out on so much in their lives that they could otherwise enjoy.  It sneaks up on them so slowly that they hardly feel it, until one day they realize they can't do thing they enjoy anymore.  I see it every single day in the hospital.

Tough Mudder

A couple months ago one of the surgical assistants tried to convince me to do a Tough Mudder.  For those of you who are not familiar with that, here is a link to the website with a video of what it entails.  It's probably a good idea to pause and watch it first before reading the rest of this post. 

http://toughmudder.com/

So it sounded crazy at the time, but the more I thought about it, the funner it sounded.  I looked up the dates and there was one in Wisconsin, so I convinced 4 other guys to sign up and we were good to go.  3 of the guys were from the ward, and one was from the residency.  The one from the residency was in really good shape (he did 2 triathlons this summer) but has never done any distance running, while the ones of us from the ward are pretty average athletes.

Honestly we didn't prepare as much as we would have liked, because we're all busy with work and such, but we'd already plunked down our money, so we were committed.

Here is a map of the course

  

The course is 3.5 hours away from our house, so it was a decent trip out there.  One of the guys had a conference out that direction, so he took another day and made a mini-vacation out of it.  The other 4 of us met up after work on Friday and drove out to our dive of a hotel.  It was a warm bed for the night, but not much more.  

We woke up in the morning and were a little anxious about it.  The weather was only 55 degree and it was pretty overcast.  With the prospect of an ice-bath for one of the obstacles, we were wondering if we wanted to go first (which most of us were scheduled for) or start at 10:40 where the other two were scheduled.  We decided that we'd do the 8:00AM start and just get it over with.  To give you a scope of the event, we got a rough estimate of how many people were running the event, and it looked like 15,000 were running on day 1 and probably 10,000 on day 2.  Yikes.  That is an absolute ton of people.  As you can imagine, the type of people who sign up for this are a combination of crazy and fit.  It was a fun group to be involved in.  The best part of the day was how everyone was helping each other out with all the obstacles.  It wasn't timed, so people were just interested in finishing in a decent time and helping each other out. 

Here's a basic rundown of the obstacles

1- Crawling under barbed wire in mud

2- Jumping over plywood that was belly-button height (10 all together)

3- 4 4-foot hills of mud with water pits in between

4- Climbing over 10'walls (2 of them)

5- Swimming under 3 sets of barrels in a water pond

6- A container of ice water with a barrier in the middle that you have to swim under.

7- Jumping over huge bales of hay probably 10' high in total

8- Crawling in mud through trenches dug in the ground

9- Jumping over a set of logs, then crawling under another, repeated 3 times

10- Running through some smoldering bales of hay with tons of smoke

11- Climbing up then jumping off a 20' high platform into cold (but not icy) water.

12-Swinging on 5 rings over a water hazard

13-Climing up a huge pile of steep mud

14- Climbing down a large plastic tube into water, then up another plastic tube out of it

15- Spider Webs (out of commission for us)

16- Repeat of #1

17- Repeat of #4

18- Crawl on plastic sheet full of water/mud with electric shock wires hanging down

19- Monkey Bars (not enough water underneath, so it was closed as well)

20- 15' high 1/4 pipe that you need to run up, grab the top, and haul yourself up on top

21- Three rows of hay bales with water in between and electric shock wired hanging down.

Most of the obstacles weren't that bad.  Even the ice-water bath wasn't that bad because you were only in it for a couple of seconds and you have enough internal heat from the 2 miles you just ran.  It definitely takes your breath away, but 30 seconds later you were fine again.  Oh, and it froze my eyeballs for a second or two.  

The most memorable were the electric eel, quarter-pipe, and electroshock.  I was in front for the electric eel so I get down on my hands and knees to get under the wires when BZZZT, I got shocked so quickly that I didn't even remember it.  It was very disorienting because I didn't remember getting hit, but I was face down in the plastic and water.  My first (confused) instinct was to stand up and back up.  Bad idea.  BZZZT.  It drops me to the plastic again.  BZZZT.  I need to get out of here!!  So I shot forward and got shocked about 3 more times for a total of six before I got finished.  Yikes.  It was actually more frustrating than anything because there wasn't anything I could do to avoid it.  It didn't matter how strong, smart, craft, or whatever you were...you were going to get shocked.  The quarter pipe was pretty high, and after running 11.5 miles, it seemed like a lot higher.  Thankfully I had enough gas left in the tank to sprint up to the top without any assistance.  Two of the other guys didn't have quite as much, so we had to essentially lift 170lbs of dead weight up over the top of it.  The last obstacle was the electroshock.  Having experienced the shock previously, one guy on our team decided to grab some reeds from a stream and try to part the wires and get through that way.  Mind you, this is 20 feet from the end and there are a ton of spectators and an emcee cheering people on or making fun of them.  For an event that prides itself on toughness, seeing a guy trying to part the wires put him in the "making fun of" camp.  He successfully made it over the first set of hay bales, and got into the first pit of water when BZZZZZZT.  He got dropped by the wires.  He was still conscious and got up quickly and ran through, but when he got hit, the crowd erupted into cheers.  I only got hit twice on that obstacle and as I was on the run, it didn't slow me down too much.  

Overall it was a tremendously fun event.  I loved doing it with a team, I loved having breaks in between running stretches, and I loved the obstacles.  I'd totally do it again.  If we all lived closer, I would love to get a family event going, though I admit that the electricity would turn many people off to it.  

Here are a couple of pictures from the event. 

Interview Wrap Up

We had an interview trip over August 11^th to the 25^th.  It was quite a trip.  The good news about being a family medicine doctor interested in practicing rural medicine is that I could move anywhere in the country for work.   After looking for more than 2 years at different places (calling CEOs, making lists, calling government offices) I realized that there were simply too many to look at all of them.  We happened to get a postcard in the mail from a recruiter (I get tons of these and throw them all away).  Melinda happens to look at it and it’s a lady who specialized in rural recruitment.  We talked on the phone and talked about what type of places I want and don’t want and started sifting through the choices from there.  We got about 10 quality options, 6 of which didn’t really work, and we were down to four. 

• 1.     Bandon, OR
•  Coquille, OR (We also got a interview a week prior to our visit for a town 15 miles away because a doctor was looking to retire.)
• 2.     Prineville, OR
• 3.     Orofino, ID
• 4.     Anaconda, MT

I’ll give you the brief highlights tour of each location. 

Bandon, OR – This is a town of about 3000 right on the ocean (sometimes called Bandon by the sea).  It’s a tourist and retirement community, so it has a lot of old people around, but a quaint downtown.  It’s cool (average high in summer is 70, but average high in winter is 60).  It rains a lot and is very green.  Overall it’s very pretty.  The doctors that I would work with are very nice people, but don’t really have the same goals in life or medicine as me.  They do a lot of cosmetic stuff (for wrinkles, etc).  they are also interested in hCG-mediated weight loss.  My approach is more lifestyle intervention stuff (changing diets, exercise, weight loss, etc).  I think it would be isolating medically to be the only one there who thinks like that.  It would also be a clinic-only practice (no ER, no call, no hospital work, no OB).  This would be very difficult to get my skills back after only being in clinic for a couple of years. 

Coquille, OR – (this one came up about a week before we left on our visit) It’s also a very pretty location.  It’s about 10 miles inland from the ocean but that makes a huge difference in temperature (about a 10 degree difference).  Beautiful valley ringed with mountains and pine trees with a river running through it.  It does have a surgeon who is big into prevention through diet/exercise/etc., which is exciting for me, but they might require me to work ER shifts on the weekends.  That’s kind of a deal-breaker for me.  I’ve done that in residency, I’m done with that.  This one is still in the running.  We might go back for a second-look interview at some point. 

Prineville, OR – After spending 4 days on the Oregon coast, and a drive through the beautiful Cascade Mountains, to come out the other side into the high desert was somewhat of a let-down.  As we drove into town we looked at each other and said, “Let’s keep an open mind about this place.”  They really impressed us with their community and the people we met there.  It’s a small town, but everyone we met really seems to have bought into the community.  They aren’t pretentious and are very down to earth.  They know what they can do at the hospital, and they try to do it very well.  We loved how they included other people from the community in the tour for Melinda and for the dinner the night of my interview.  The other places had varying amounts of including stuff for Melinda, but Prineville did a great job of selling the community to us. 

Orofino, ID – This is about an hour east of Lewiston/Clarkston.  It’s right in the mountains, and a very pretty drive up through the valley alongside the river to the town.  We got into town at around 2PM and spend the rest of the day on our own around town.  We decompressed a little bit and then took a walk to the “downtown”.   In a town of 3000 it isn’t much of a downtown.  Most of our walk was through the older part of town, and since this was/is a lumber town the houses are all small and on top of each other.  Not the best impression.  The next day however, we got a tour of the surrounding areas of town.  Wow.  You don’t have to go that far up on the mountain/hillside to find some nice houses with amazing views.  That was a relief.  One interesting thing about Orofino that we liked was that people that we talked with did a lot of outdoor stuff.  They didn’t just talk about doing stuff, they did it.  One member that Melinda met with at lunch says they are at the river all the time and out in nature 6 days a week.  One of the doctors was bicycling to Moscow, ID (60mi) the following day, and one of the other doctors just emailed me letting me know he would be out of town for 10 days on a backpacking trip to the Sierras.  It was pretty cool to see.  One of our concerns about this place is that it is pretty remote.  The nearest big town is Lewiston, Idaho with a population of 30K, with a Costco and such stores, but it’s an hour away. 

Anaconda, MT – This was our last interview.  Thankfully we only had 4 interviews this trip, it was grueling driving every other day and interviewing all the other days.  Anyway, we drove through town and the lower part of town is an old mining town (actually a smelter town where they refined the ore brought in) and looked like Appalachia in West Virginia; one house build almost on top of another.  Overall it was rough looking and a little disheartening.  Thankfully we went to church and saw that there was another part of town with much more normal houses.  Church had a lot of older people, but 3 younger families.  Unfortunately all three families were visiting their grandparents in the ward.  It’s a pretty aged town.  I liked the people in the clinic and the hospital, but we heard a lot of the same story from different people.  Summing it up was from a Nurse Practitioner that I spoke with.  He has lived in the town for 35 years and raised his kids there.  He posed the question to himself, “would I do it again if I knew what I know now?” [long pause] hesitatingly, “I suppose I would”.  He doesn’t like the town and the school district, but loves the outdoors and that’s what keeps him there.  Not a resounding endorsement of the town.  I think it’s pretty much off the list for us, but they almost have a guaranteed loan forgiveness.  Still not enough of an incentive to move there.

As of right now it goes as follows for where we're going to live

1 Orofino Idaho and Coquille Oregon

2 Prineville, Oregon

3 Bandon, Oregon

4 Anaconda, Montana

Further updates as they are coming.

Being (a) Patient

Young Caleb was born on August 2, 2011.  This was a wonderful experience in many ways, but not least of which was because I got to deliver him.  Not many people get to do this in their life, and I really enjoyed it.  However, the first thing I noticed about Caleb (aside from all the gross fluid and general gunk on newborns) was that his forehead was funny looking.  I believe my exact words to my faculty was, "He looks like a Klingon".  She did not approve.  In any case we waited a couple months to see if it would improve.  He was developing beautifully and meeting all of his milestones, but his forehead didn't get any better.  At our 4 month well-child visit we talked with our doctor and started to see what we needed to do.  Luckily there was a Pediatric Neurologist who would be coming out to La Crosse for his monthly visit the following week so we pulled a couple of strings and got in to see him the following week.  He diagnosed him with Metopic Craniosynostosis (the two bones on either side of the forehead fused in the middle sooner than they should have) and referred us to a Pediatric Neurosurgeon in Rochester, an hour and a half away.  This was also expedited because we were coming to the end of the year and our deductible had already been met for Caleb.  The Neurosurgeon also diagnosed us with Metopic Craniosynostosis and then we talked about surgical options
1) We could get an endoscopic surgery in the next month or so.  It would be a small incision on top of his head, they would surgically separate the bones of his forehead and he would have a quick recovery.  The only downside is that he would have to wear a helmet 23hrs a day for a year while the bones remodeled and grew back in.  These helmets would have to be replaced every 3 months at about $3000 per helmet and we would likely have numerous visits for fittings and the like.  Plus they end up stinking like crazy as you can imagine from being worn all the time.
2) We could go with the standard open surgery.  This is a more involved surgery but the outcomes are comparable.  It would be a one-and-done surgery.  This would also be costly and we would meet our deductible (so for us the cost would be the same).  For this one we would have to wait for him to be 9 months old so the bones are hard enough to change shape, but not so hard that they are like adult bones.  He would have to stay in the hospital a couple days longer with this one due to the surgery.
We opted to go with the second option as the results were the same and taking a bunch of trips up to Rochester all the time, dealing with a 1-year old in a stinky helmet for a year didn't sound great.  Let's be honest, neither of these options sounded great (who wants a head surgery for their little boy), but there you have it.
People have asked what would happen if he didn't get this surgery.  Bones grow out from suture lines.  Without a suture line (as it already fused) the bones of his face wouldn't separate from each other.  His forehead is already really pointy and would continue to get worse.  His eyes are already a little closer than they should be and this would also get worse as the rest of his head continues to grow.  Basically he would look really funny for the rest of his life.  The other medical complication is that he can have decreased room for his brain to grow and increased pressure inside his skull.  (this is why insurance will pay for it)

So our journey continued.

After our discussion with the Neurosurgeon he wanted to have us back for a visit within the month for some tests.  These included a CT scan to make sure there weren't any other sutures that were fused (and the last thing surgeons [or parents] want is a surprise when they're doing surgery on someone's head), a laser scan to see the outside contour of his head, a visit with the neurosurgeon again and a visit with the plastic surgeon.  The neurosurgeon is the one who opens up his head and removes the bones, the plastic surgeon is the one who reshapes the bones and makes them look like they are supposed to, which is the whole point.  The day went fine for the CT scan, and we really enjoyed talking with the plastic surgeon, but the other two events lacked a little something.  The laser scan for his external head shape is apparently for a study the neurosurgeon wants to do.  Of course, we have to pay for that anyway.  She also talked with us for 20 minutes about different helmets and things even though we had already decided to not do the helmet thing.  Whatever.  Caleb is tired and we're ready to meet with the neurosurgeon (who is late).  He breezes on in and proceeds to have a nearly identical conversation with us as he did a month ago.  It was painfully obvious that he had totally forgotten who we were or why we were there.  After we told him that we already knew the diagnosis he looked at us and asked us why we had come back to see him.  Really?!  Because you freakin' told us to!
One funny thing did happen this day that is somewhat redeeming of the experience.  Caleb is fine for most of the morning and does the tests fine.  We are then waiting for the plastic surgeon and Caleb starts getting fussy.  We look him over and discover a nice mess in his diaper that has leaked onto his pants.  We were just about to lay him down to change him when...of course...the plastic surgeon with his two nurses comes strolling in.  We explain the situation and they were very understanding and just told us to change him while we chatted.  I get his diaper off and start cleaning him off when he starts pooping again.  A lot.  I'm discretely trying to cover his butt with the diaper so it doesn't get all over their linen hamper (which is made of wood and a nice size for changing diapers) and trying to not appear panicked that it might cause a huge poop mess all over the room.  "Uh huh, that is interesting (oh geez, not on the wood hamper).  Yes, I understand what you are describing to me about the surgery (please don't notice how much is coming out and what a mess he's making).  Nope, we don't have any questions at this time.  (Gaaaah, it won't stop coming)".  For a brief moment there I really started to panic as it looked like the poop was coming too fast for the diaper and wipes to hold out against it's onslaught.  Thankfully we had enough wipes...just barely.  We finished with one lone wipe left over.  After the doctors and nurses left I went out to the front desk to ask for some plastic bags to handle the casualties from this battlezone and they hand me a ziplock baggie.  "Um, yeah.  [nervous chuckle] I'm going to need a much bigger bag...or two".
So a couple of months have come and gone and we're a mere 3 1/2 weeks from our surgery date when we get a call from the plastic surgeon's nurse.  Apparently the neurosurgeon thought his schedule was blocked out on the date of Caleb's surgery, but the computer showed it as open, and his nurse had scheduled in our surgery, and now we're going to have to reschedule.  WHAT?!  So I got on the phone and called this guy and basically said, this is a big deal, you need to find another neurosurgeon who can do this for us.  I don't have another time that I can take vacation for this and my mother has already bought her ticket from Utah.  After a long weekend of sweating it out, they called us back and had indeed found another surgeon to do his portion.
The week of the surgery, Melinda had to make a trip up to Rochester on Monday for a meeting with the doctor and to sign a bunch of paperwork.  We both came up on Tuesday to meet with the new surgeon.  Then we had to get up here at 6:15AM, Wednesday morning, to register and check-in for his surgery.  Seven hours later we're sitting here waiting for the surgery to finish in a couple more hours, but so far all is going well.

Some things I've learned on my journey as a patient-proxy.  It's is confusing and often not explained very well what you have to do and when.  We needed a referral to be sent from our primary care doctor to the insurance for the initial Neurologist visit because his visit wasn't going to be covered without one.  His subsequent referral to the neurosurgeon also wasn't covered including the CT scan and laser scan.  After some terse words with our insurance we finally got it figured out, but it was ridiculous.  I also thought the first neurosurgeon was a total jerk.  He wasn't very helpful and although I understand better than most how easy it is to run behind schedule, you could at least apologize for being late.  Plus not even remembering why we were there when you told us to come back for a visit...weak sauce.  I also learned that it's a mixed blessing knowing as much as I do about medicine and surgery.  I know that most surgeries go well especially in healthy individuals without a lot of other diseases or stuff going on.  But I also know what goes on in a surgery and where things can go wrong.  Overall I'd rather have the knowledge than not, but it is still enough knowledge to make me nervous.

Change

Much of what I do in my clinic with patients who come in is education, sometimes medication, and almost always trying to elicit change behavior. It goes without saying that America has something of a weight issue and a smoking problem and a poor eating habit and a serious lack of exercise problem and...you get the point. For me, this is one of the most frustrating and exciting parts of my job, and I LOVE it. In many ways I view myself as a health adviser; I give people health information and if they choose to follow my advice it will get them a host of benefits, and if they don't then at least they know the consequences of said choice.

This leads us to the real question; how does one get another people to want to change and to actually follow-through with the change. One fact it nearly universal with people, they hate being told to do something. People dig in their heels and even if you have authority over them they will only do it grudgingly and half-heartedly unless it comes from within as well. So simply telling people to quit smoking or start exercising or lose weight simply doesn't work very well at all.

One strategy is to ask people what they really want out of life (usually this is very different than a blood pressure of 120/80). It's usually simple things like being able to play with their grand-kids, or to have their clothes fit better, or because they hate doing what they do. Then you try to tie the change behavior to the goal that they really want. Unfortunately when you ask them what they are going to do about it they usually say something vague like "eat healthier" or "get in shape" or something unrealistic like "lose 60 pounds in 2 months" or "not eat sugar again". These either don't get people very far or simply aren't a sustainable way of life.

So that leaves us with our main question, how do I get people to want to change.

I recently read an interesting article about will-power in the NY Times about New Year's resolutions. It was very insightful. Combined with a recent book I read called "Switch: How to change when change is hard" has changed how I approach my patients and myself.
(http://www.nytimes.com/2012/01/08/sunday-review/new-years-resolutions-stick-when-willpower-is-reinforced.html?_r=1&scp=4&sq=new%20year%27s%20resolutions&st=cse).
Some of the most interesting points were these.
1. "To keep a New Year’s resolution is to anticipate the limits of your willpower."

2. "People with the best self-control, paradoxically, are the ones who use their willpower less often. Instead of fending off one urge after another, these people set up their lives to minimize temptations. They play offense, not defense, using their willpower in advance so that they avoid crises, conserve their energy and outsource as much self-control as they can"

How do you incorporate these into your life and actually have the changes stick. Don't overestimate your willpower for starters. People start out all full of spit and vinegar (as evidenced by the packed gyms around New Years or the first two weeks of a diet) and then quickly fade out. People need to admit that they have limits to their willpower and simply wishing it to be different won't make them less likely to be tired at times and likely to cheat on their diet or stop exercising. They also need to set up limits and avoid situations that will test their willpower.
- Set out your clothes the night before
- Agree to meet with a friend
- Have a workout plan already set up that is reasonable with your schedule
- Make a plan to go to bed early enough to not be tired in the morning
- Set up your meals ahead of time and buy the ingredients ahead of time to avoid simply ordering pizza and go grocery shopping when you are full and (relatively) well-rested.
- Get rid of the snacks in your house so you aren't tempted (people pay a lot of money for weight loss, just think of this as an investment ahead of time)
Our willpower has limits and is finite, people who overtax it or are overly tired will find that they will make poorer choices.

The last thing that has stuck out to me had to do with smoking cessation, but is applicable to many areas of life. The average smoker tries to quit 10 times before he actually does quit. Some only try once, some try twenty. If someone comes into my office and says, "Doc, I've tried to quit once and it didn't work", what do you think I'm going to say? Try again. The same goes for any change behavior, keep trying. Set up the path you want to go down to be as easy as possible and set up the path you usually go down to be harder one. If this doesn't work the first time, back up and re-assess the situation, analyze why it didn't work and then try a different tactic. Eventually one of these will work, but too many people throw in the towel with one failure.