The Medical Insider

The different faces of depression

Second in a three-part series on depression.

Most depression I diagnose does not start with, “I’m depressed; I need help.”

Some people know they have depression, which begins, like most mental illnesses, in the late teen years and early 20s. People get good at living with it, working through it, smiling, clowning, hiding and toughing it out.

Their problem: they come to me late. What’s late? When minor things like going to the mailbox or answering a social call requires a major mental deliberation.

Read Full Story
Volume 9, Issue 24, Posted 10:02 AM, 12.19.2017

When you are not the depressed one

First in a three-part series on depression.

Jo’s father was quiet, distant, worked hard and drank harder. After he stopped working, he drank less; instead, he sat in the living room and stared at a blank TV screen all day. One day, he lurched from the sofa, vigorously “beating bugs” off his arm, collapsed and died.

So when her son told her that he was an alcoholic – at 21 – she didn’t believe him. He was sweet, outgoing and funny as hell. Their family, including his three older sisters, doted on him. Then calls started coming: from friends, EMS, police. Soon long sleeves, caps and sunglasses couldn’t cover the cuts and bruises from falling.

Today she realized both men had been severely depressed. Liquor simply worked better than Prozac.

Read Full Story
Volume 9, Issue 23, Posted 10:36 AM, 12.05.2017

Ibuprofen in the age of opioids

My mom, age 84, and I don’t always have the easiest time. She doesn’t like me telling her what to do. I don’t like her dropping hints on how to raise kids. For sure, she missed the AARP memo on simplifying life after retirement.  

Months ago, in a freak accident mowing grass, Mom went airborne. I saw her in the ER, bruised and stitched. Two ribs and left elbow broken; left shoulder dislocated and broken.

Before I opened my mouth, she said, “Why the face? I’m not dead!”

Two month after her injury, she started painting her backyard fence. I asked how it went.

She said, “I hurt all over.”

“What pain med are you on?”

Her doctor prescribed piroxicam, a once-daily, nonsteroidal anti-inflammatory drug (NSAID), which she took – as needed.

“The drug works, Mom,” I said. “But you’re doing it wrong.”

Read Full Story
Volume 9, Issue 22, Posted 9:57 AM, 11.21.2017

Rain dance for a better Issue 2?

I stay out of political talks, not because I have no opinion. The real problem: being a woman of a certain age, I know I’m always right.

The few privy to my sparkles of wisdom – by “few” I mean Mark, my husband – said this early in our marriage, “We’re like a pair of old shoes. You’re always right. I’m what’s left.” I chuckled, submitted “the joke” to Reader’s Digest and was promptly rejected.

Starting weeks ago, whenever I put on my reading glasses, Issue 2 popped out. Except during election years, I mused, who’s ever cared this much what Ohio thinks?

I asked around, “What’s ‘The Ohio Drug Price Relief Act’ – or Issue 2?” and got two answers: “I’m not sure,” or “it’s confusing.”

Then I found out the pharmaceutical industry is behind the aggressive negative campaign. Last year, it spent $109 million (out-funding proponents of the ballot 10 to one) and struck down an almost-identical measure in California. It was the most expensive ballot battle of 2016.

Read Full Story
Volume 9, Issue 21, Posted 12:05 PM, 10.31.2017

Free medical care: Too rich for Medicaid, too young for Medicare

Months ago, Willie, 62, a diabetic, was laid off from her job assembling hydraulic pumps. Even before that, she hadn’t had health insurance or medications for over a year. She gets up four or five times a night to urinate, which she thinks is “normal” for women of her age.

Out of curiosity, I asked why she waited so long to come to the Lorain County Free Clinic, where I work.

She said she'd never heard of it, and she’s lived in Lorain for years. Last week driving down Oberlin Road, she happened to see a new sign for the clinic (it recently moved).

I know this story.

I’m a county-hospital-bred-and-trained workhorse. Yet I knew very little about the other clinic, until I started working there.

Read Full Story
Volume 9, Issue 20, Posted 9:57 AM, 10.17.2017

DIY diet with a prenup

Part two in a two-part series on weight management.

Too often, you plunge into a new diet with the fervor of a first love: desperate, excited; the hope and promise of lifelong change; the all-consuming obsession with gluten, fat or sugar. And when the heart cheats – and the heart always cheats – inevitable self-loathing.

I think you should start a new diet like it’s the seventh year of your second marriage: calm, wise, wrinkled but not totally cynical, routine, legally binding – albeit with a prenup.

Because while you wholeheartedly will the relationship to work this time, deep down, you know things will go wrong. But it’s OK. No diet plan is perfect. There are ways to modify a plan until it fits your lifestyle.

Read Full Story
Volume 9, Issue 19, Posted 10:10 AM, 10.03.2017

The skinny on weight loss

Part one in a two-part series on weight management.

The blistering thing about dieting: Everything works, and nothing works – long term, that is.

Successful dieting is more than an act of willpower; it’s a marathon game of playing cat and mouse with your body and mind. Setting a realistic and generously forgiving goal in the beginning is essential. Here’re some basic facts.

1. What diet plan works best?

A 2014 JAMA study (1) looked at 11 brand-name diet plans. The average weight loss (for those who survived) is 10 to 14 pounds after one year. (Yes, you read that right, that’s an average of one pound per month). Low-carbohydrate (Atkins-like) and low-fat (Ornish) diets fare slightly better. The authors concluded that the differences between plans are unimportant. It’s much, much more important that you pick a plan that you can stick with for as long as possible.  

Read Full Story
Volume 9, Issue 18, Posted 10:21 AM, 09.19.2017

Read this before you reach for the vitamin bottle

Forty years ago, my swim buddy Ashley (not her real name) was working too hard, worrying, smoking and drinking too much.

Concerned that the stress was “ripping” her health, she began a multivitamin/multi-mineral supplement “to bump me up.”

Years later, she drove off the road. Overnight, she stopped drinking, smoking, stressing and allowed her gray hair to show. But one thing she never stopped: her vitamins.

Read Full Story
Volume 9, Issue 17, Posted 9:43 AM, 09.06.2017

Zen and the art of backpacking

For our five-week trip to Quito, Ecuador, the kids, ages 18 and 15, and I competed for the lightest backpack. At 20 pounds and two ounces, mine weighed the most; the girl’s, at just under 16 pounds, the lightest. 

Quito, at 9,000 feet above sea level, sits in the foothills of an active volcano in the Andes. We had volunteered to work in a kindergarten for the indigent. Every morning, we took a bus and stopped in front of two huge dumpsters, spilling over with rotted vegetables, reeking of urine and fermented fruits. The street led into a huge municipal market. To the right of the entrance was the kindergarten, four big sunny rooms that were disinfectant clean.

My kids loved the one-year-olds. They didn’t mind changing diapers, spoon-feeding, and chasing babies who crawled, walked, got up and fell down like a scene from a zombie movie but with really cute zombies. After my last child, I’m very done with diapers. I stayed with the 3-year-olds.

Read Full Story
Volume 9, Issue 16, Posted 10:06 AM, 08.15.2017

Acne: Act Now

Adolescence – the reason I don’t need to be young again.

I’ve gladly grown out of many obsessions and predicaments: Having to read books that “inspire me”; home perms; Jimmy W., only the third most popular boy at Spackenkill High School; wanting to be the president; finding the perfect husband; being the perfect wife.

But I, along with many adults, never did outgrow the one bully that taunted our adolescence: acne.

Read Full Story
Volume 9, Issue 12, Posted 9:24 AM, 06.20.2017

Living with knee pain

I have a friend, in his 60s, who loves and owns many “World’s Best Grandpa” sweatshirts. He belongs to a softball team and – much to his adoring fans' delight and his wife’s chagrin – slides into bases.

His knees are knotty like cauliflower. I’m guessing with some certainty that his X-ray will show osteoarthritis: loss of cartilage and joint space, bony changes. But he’s never complained of knee pain (at least not within earshot of his wife). 

Knee pain and knee osteoarthritis are like kiwi and emu; these flightless birds are related but not that closely related. Osteoarthritis doesn’t necessarily mean knee pain.

Read Full Story
Volume 9, Issue 11, Posted 10:17 AM, 06.06.2017

Recommending marijuana not high on my list

A patient of mine said this about marijuana and his Tourette Syndrome: “The only drug that’s worked!”

I believe him.

Medical marijuana is now legal in most states, including Ohio. A physician cannot “prescribe” marijuana – it’s a federal crime. Marijuana is a Schedule 1 drug, same as heroin or ecstasy, with “high potential for abuse” and “no currently accepted medical use.” But for a patient to buy marijuana legally, the state requires a “recommendation from a certified physician.”

Read Full Story
Volume 9, Issue 10, Posted 9:37 AM, 05.16.2017

Statins: a simple proposal

I am the simple life.

I have but one winning formula: Set the bar low; pull the target close; paint the bull's eye big.

But I struggle to keep medicine simple. I believe, ultimately, a doctor’s decision should empower and enable you, not enslave, and sometimes it just might take a whole visit to get one simple thing straight – like cholesterol.

Read Full Story
Volume 9, Issue 9, Posted 9:55 AM, 05.02.2017

The vexing anti-vaccine crusade

I followed with mild curiosity the “Revolution for Truth” crowd protesting outside the White House last week. One sign read: “OUR BABIES Were Well. THEY HAVE WELL-BABY MERCURY VACCINE. NOW 1 IN 6 KIDS NEUROLOGICALLY DAMAGED.”

The first thing that popped in my head: What’s with the small letters in an all-caps message?

Then I thought: What mercury?

Aside from some flu shots and one preparation of tetanus shot, mercury (thimerosal), a preservative, has been removed from all childhood vaccines for over a decade. And vaccines for measles, mumps, rubella, chicken pox, and polio do not contain mercury – NEVER DID. The vaccines-cause-autism theory is a dead horse that’s been running wild for 19 years, defying logic, science and common sense.

Read Full Story
Volume 9, Issue 8, Posted 9:51 AM, 04.18.2017

What MRI can't tell you about your back pain

Who doesn’t know Miss Ruth?

At 86, she’s the reassuring voice that’s coaxed generations of Westlake toddlers to jump into the water. Recently, Ruth's sciatica acted up again. The pain starts at her buttock and radiates to her ankle. It’s been months. When she wakes up, the pain could make her cry. There’s no rhyme or reason to how the pain catches during the day.

And this pain has landed her in a crossfire between specialists.

Read Full Story
Volume 9, Issue 7, Posted 9:20 AM, 04.04.2017

What missing bumblebees are telling us

Months ago, the rusty patched bumblebee became the first bee species to be placed on the endangered list by the U.S. Fish and Wildlife Service. Ohio is one of its last sanctuaries.

For years, to attract bees I’ve flooded my yard with flowering plants. By June, tree-size honeysuckles choke the eaves with white, pink and yellow blossoms. Last year, I saw one or two bees inconsistently. And it’s not just bees, I rarely see butterflies and dragonflies around our neighborhood anymore. It hasn’t always been this way.

Two streets over, a neighbor keeps a beehive in his backyard, an optimist who despite losing hives two years straight is still trying. He described the day his bees came home, staggering like drunk, and died en mass.

What does science say?

Read Full Story
Volume 9, Issue 6, Posted 10:11 AM, 03.21.2017

The trouble with back pain

I was busily writing a beseeching piece on the health link between us and bumblebees when a news alert popped up. I dropped everything, and changed course to deliver you the newest on the oldest of health problems – back pain.

For decades, experts have pussyfooted around “pain” using language like “should, would, ought to consider” as they try to be sensible and sensitive, empowering, evidence-based and politically correct. The message was, as Tennessee Williams would have said, “all hawk, an’ no spit.”

The pain business remains murky water.

Read Full Story
Volume 9, Issue 5, Posted 9:26 AM, 03.07.2017

Keeping an eye on the 'silent killer'

My blood pressure shot up when I turned 41. For a year, I ran and swam, squeezed stress balls and ate low-salt coleslaw. It helped, but not all the way. Finally, I showed up at the office of my good friend, Dr. Bob Bahler.

He listened to my history, including the “everybody in my family has hypertension, but I’m too young...” line. He chuckled when he heard I’d signed up for a marathon just to scare myself into exercising more regularly. 

“How’s that working out?” he asked.

“A little too well,” I said miserably, waiting for the floodgate of testing to begin.

“Nah,” he said, “you’re just getting old.”

Read Full Story
Volume 9, Issue 4, Posted 9:52 AM, 02.21.2017

My favorite cancer test

No parent in their right mind will admit they have a favorite child.

But kids know. The boy says I favor his sister because the second something breaks, somebody cries or the dog barks, I always holler his name first. He gets punished more severely because he’s older, he’s bigger … he was there.

The girl says I favor her brother because – everybody knows Chinese favor their sons.

“You’re different,” I say. “I love you equally.”

But for what I do in primary care, I admit that I have my favorites, absolutely. Among the screening tests, an 80-year-old test for cervical cancer, developed by a Greek immigrant Dr. Georgios Papanikolaou, better known as the “Pap smear,” is it.

Read Full Story
Volume 9, Issue 3, Posted 9:51 AM, 02.07.2017

When doctors get it wrong

Medicine is a series of learning curves. Sometimes we land on our face.

We treated syphilis with mercury.

To reduce allergy, we said no to peanuts before the age of three; now we say yes to peanuts as early as you can.

We peddled estrogen to menopausal women as some fountain-of-youth elixir until 2006 when the Women’s Health Initiative showed hormone replacement could increase the very thing we’d tried to prevent – heart attacks.

We pitched a low-fat diet for those looking to lose weight, having high cholesterol or just good health metrics. It turns out the important thing about fat isn’t how much you consume but what type. Decades of high-carbohydrate diets fueled the nation’s obesity endemic. Yet we’ve done such a good job of hammering that message that when the new 2015-2020 Dietary Guidelines called to remove restriction on dietary fat; it had fewer “likes” than Michelle Obama’s mom dance with Jimmy Fallon.

But none compares to the current crisis of prescription painkillers.

Read Full Story
Volume 9, Issue 2, Posted 9:39 AM, 01.24.2017

Floating a relationship

What’s the best thing that’s happened to your relationship?

Don’t say kids.

While they’re the best thing to happen to us, they can glue and unglue a relationship. 

My husband, Mark, and I used to have deep and meaningful conversations about The X-Files, the best configuration for a Star Trek tricorder (bullet-shaped), and advanced alien form (fewer legs, more evolved). Now we agonize over who has the energy to start laundry.  

Thankfully, 10 years ago, our daughter, then five, did us a huge favor by failing – three times – Level One swimming, which, apparently, was a record of sorts.

Read Full Story
Volume 9, Issue 1, Posted 10:13 AM, 01.10.2017

Cutting Drug Costs, Part 3: Artichokes save the day

If I had to pick the two most effective, all-purpose health interventions, I’d say: start walking and eat three artichokes each day.

Drugs, all drugs, are a game of rolling the dice against the devil. Each therapeutic benefit comes with a price – cost and side effects. Most of the time, we get away with either nothing or a rash, dizziness a mild headache. But all physicians have stories of patients whose guts turned into the Mar-a-Lago of drug-induced bugaboos after a short course of antibiotics. Or the current 78.5-billion-dollar nightmare of our “first-do-no-harm” profession: the epidemic of prescription drug and heroin abuse.  

The best way to reduce drug costs is to minimize the need for them. Let’s see if you can’t drop a drug or two with these two maneuvers.

Read Full Story
Volume 8, Issue 24, Posted 10:10 AM, 12.13.2016

Cutting Drug Costs, Part 2: Seeking out safe online options

Part two of a three-part series on ways to manage drug costs.

Writing this piece, on the problems and possibly a very effective solution to rising drug costs, has given me an epic, ethical headache.

The good news: Earlier this month, Bloomberg reported U.S. prosecutors are going after generic drug companies in “a sweeping criminal investigation into suspected price collusion.” They won’t name names, but I can easily guess three.

EpiPen, whose active ingredient epinephrine was isolated in 1901, went from $100 in 2007 to $609 in 2016. In 2013, a bottle of doxycycline, an antibiotic, went from $20 to $1,849 in seven months. About the same time, digoxin, a century-old heart medication derived from foxglove, went from 17 cents per pill to $1.18.

Read Full Story
Volume 8, Issue 23, Posted 9:38 AM, 11.29.2016

Cutting Drug Costs, Part 1: Start with your doctor

Part one of a three-part series on ways to manage drug costs.

Some facts just throw me. Here’s one: The U.S. makes up less than 5 percent of the world population, but buys more than 50 percent of its prescription drugs. Are we that sick? Wealthy? Pill-happy?

Yet, according to a 2015 Centers for Disease Control and Prevention report, almost 1 in 10 Americans don’t take their medications as prescribed because they can’t afford to. As a veteran internist, I consider myself well-schooled and informed on this issue.

Last Friday morning, I was juggling two rooms and running an hour behind, when I got a call. It was about an antibiotic I’d ordered earlier that morning. Because of the patient’s drug allergies, I’d opted for an old timer: nitrofurantoin. This little beauty has been around since the 1950s—the days of jukeboxes and poodle skirts. Just right for the job.

Read Full Story
Volume 8, Issue 22, Posted 9:49 AM, 11.15.2016

A closer look at 100% fruit juice

The Westlake | Bay Village Observer is excited to introduce a brand-new column, The Medical Insider. Diana Pi is a Westlake resident and board-certified general internist in practice for over 24 years. Her column will share important information on personal health from an insider's perspective – mixed with the lighter side of life.

Last month, on World Obesity Day, the World Health Organization (WHO) went ape over sugary drinks and proposed adding a 20 percent tax on soda, sports drinks and – here’s an eye popper – fruit juice.

But isn’t fruit juice healthy? Loaded with vitamin C and such?

At one time, the answer was a life-and-death yes. Back when the shape of Earth, round or flat, was still a scientific curiosity. Back when sunbeat seafarers, embarking on months-long journeys, subsisted on sea biscuits, salted meat and a mid-day ration of rum – and died in droves from scurvy, a severe form of vitamin C deficiency.

Read Full Story
Volume 8, Issue 21, Posted 10:07 AM, 11.01.2016