On the way home from Rochester I wrote an absolutely beautiful and humble comment here, and lost it when I sent it not connected, and could not seem to recover it. You are going to have to be satisfied with a shorter and less beautiful and less humble message... sorry.
We stayed at Dave and Joleen Nelson's home, and had brunch with Phil Lombardo. We couldn't be more thankful for the support that we had from the Lombardos and the Nelsons during this ordeal.
It was good news from Dr. Truty on Tuesday afternoon, who explained no evidence for spread, infection, or problems. He said measure improvement by the week not by the day... expect 2-3mo... and he added pancreatic digestion enzymes before meals of snacks. And then he removed the feeding tube. Said exercise and nutrition...
The next morning we met with Oncologist Thor Halfdanerson, (Icelandic) who explained that the neuro-endocrine part of the tumor is low grade tumor and not a great threat. The accinar part of the tumor, however, is something had we know in advance we would have treated exactly the same way with the same chemo and radiation that I had. He said there is no scientific data to treat at this time, leaving me with no further plans except follow-up. He said I have a 50-50 chance for cure, better than lots of other options out there.
As I was thinking about the meaning of all this yesterday, I settled in on "FRIENDSHIP." That includes the love within family members. It is the spiritual sharing one has with another that seems to give everything color, humor, joy.
Here's to our friendship. Love you.
By Richard P. Holm
There is something about that word “cancer”; the big C.
When the pathology report displays those abnormal type cells on biopsy and the report spells out those six black letters, then, whether it is a simple treatable condition or one that will most certainly predict an earlier death, the patient hears cancer and it changes everything.
Through the years, I have had to inform too many patients about a diagnosis of cancer. I have learned there is often a paralyzing fear that comes with the word. Due to advancements in science, many more people are winning the fight against cancer compared to when I first started practicing medicine. Still, whenever I have to say, “you have cancer", often the word “cancer” is the only thing they’ll think about for next several days.
Unfortunately, some people who hear the word come to face their mortality for the very first time, even when the chance of cure is good. I dare say this goes for too many of us, resulting both from unrealistic expectations in this scientifically advanced world, and the cover-up of the dying process in this everything-is-going-to-be-alright society.
This week a friend told me she and her husband were preparing to sell their house by thinning out their stuff collected over 15 years and remodeling with that new carpet they've needed for a long time. It reminded me of a how a realtor friend of mine once told me how he keeps his house ready for sale at all times, even if he has no intention of selling it. Why not put in the carpet, paint the bedroom, and fix the steps so that he can enjoy it right now? Why put off until tomorrow what can be done today?
In a similar vein, I have heard it said that every once in a while, perhaps yearly, we should all have some kind of significant brush with death and then be rescued. Maybe that would help us to remember how impermanent life really is; maybe that would help us to get and keep our house in order. Then, when each of us has our turn to cross the river into that land of the Sweet Bye and Bye, we can feel what the young neurosurgeon, Paul Kalanithi, said before dying of cancer, "(I have found a joy)...unknown to me in prior years... a joy that does not hunger for more and more, but rests... satisfied in this time, right now..."*
We shouldn't have to come down with cancer to get our house in order.
*Paul Kalanithi MD, Before I go: A Stanford neurosurgeon's parting wisdom about life and time. The Washington Post, March 12, 2015
It’s Not Nice to Mess with Normal Flora
By Richard P. Holm, MD
An elderly hospitalized pneumonia patient was getting better after three days on powerful antibiotics when bloody diarrhea, cramping, and fever began and his overall condition started to deteriorate. His stool test was positive for C. difficile and he got better on a different type of antibiotic. This happened because the abundance of microscopic organisms which normally lived, grew, and replicated within his body were weakened or destroyed by the pneumonia antibiotics, resulting in the loss of an important balance of nature within our bodies.
It sounds like a sci-fi movie, but this is NOT fiction. Scientists have discovered large numbers of micro-communities around and within every living plant and animal. Surprisingly many of these ‘invaders’ are necessary and helpful to the host, although some have no known benefit and some are harmful. These microscopic organisms include bacteria, fungi, viruses, and parasites and are called the ‘normal flora’ or ‘microbiota’ (like oat-uh).
Helpful non-human examples of microbiota include bacteria that fix nitrogen on alfalfa, fertilizing plant and surrounding soil; or organisms living in the rumen of cattle that make grass turn into absorbable nutritious food. There are about 10X as many non-human microbial cells in our body as human cells, and they exist almost everywhere, including mammary glands, skin cells, lungs, mouth, and eyes. The area where most microbiota reside, however, is within the gut or gastro-intestinal (GI) tract.
From the first minute after birth, the baby’s gut is exposed to a microorganism-rich world following their travel through the vaginal canal, followed by exposure to skin and milk flora while suckling at mama’s breasts. Over the next year, the baby’s microbiota develops and helps the infant break down dietary fiber and fat while simultaneously serving as a barrier to invasive organisms. It also helps synthesize vitamins, metabolize harmful toxins, reduce inflammation, enhance immune activity, and produce hormones.
When human flora encounters radical changes, often resulting from non-specific destruction by antibiotics, inflammatory and autoimmune disorders may occur; antibiotics can cause overgrowth of invasive bacteria, the most common of which is called Clostridium difficile, or C. dif. This type of invasive overgrowth was responsible for about a half million infections in 2011, with 29,000 of those dying within the first month.
Take home message: avoid antibiotics unless necessary. It’s not nice to mess with normal flora.
By Richard P. Holm MD
During the summer after my freshman year of high school, my dad found me a job working on a farm, hoping it would teach me the work ethic. I remember hard physical work, long hours of hauling and stacking bales, and profound loneliness while painting farm buildings.
At the time, it was the most stressful experience of my young life, bringing me out of my lackadaisical youth and a tad closer to the world of a responsible adult. I have often referred to that time as the period in my life when I realized the value of hard work. It was a tough summer brought upon me by my dad and a kindly farmer, and I became the better for it. Of course, this was nothing compared to what some farm-kids experience, but I learned that summer stress and hard work could be a good thing.
There are many things that can cause stress: tension, trauma, aging, money pressure, worry, fear, and anxiety from big or only perceived problems. It is a pull-push force exerted on the body resulting in strain, with or without movement. One famous expert, Hans Selye, defined stress in two ways: there is distress, or bad stress; and eustress, or good stress. He found that bad stress results from being forced to face trouble without tools to cope or solve the problem. It is like being broken-down in the field, and you can't get the part to fix it.
A famous Harvard Study starting in 1938, which followed one class of sophomore men for the duration of their lives, discovered cholesterol, IQ, and childhood temperament had nothing to do with healthy aging; while smoking, alcohol abuse, and depression all had major negative effects. Healthy aging was best accomplished and measured, not by money, but by how these men coped with tough times while finding ways to connect with others.
Good stress is facing adversity and finding ways to either solve problems or accept them as unresolvable. Like exercise, it involves movement, and is something we can learn to accept and even enjoy. As Selye put it, good stress makes you stronger, and the opposite is also true: without stress, our muscles, bones, and hearts become weak. Indeed, the trials of life can become good stress if we can learn to deal with adversity. Stress can give us strength, direction, and even purpose.
Whether it is learning to work hard on a farm, dealing with broken down machinery, facing the inconsistencies of Mother Nature, experiencing long lonely hours in isolation, or tolerating cantankerous humans. Stress is part of this life, and coping with it is a skill we can and need to develop.
by Richard P. Holm MD
Mr. D, a diabetic patient of mine, came into the clinic with exercise induced leg pain. He told me that lately he could only walk about three blocks before the pain would come on, but it would go away if he stopped. He then told me that last week it came on after two blocks, and yesterday he could only go one. He said: “Now the pain is meaner and lasts longer.” With the diagnosis of claudication, a condition of blocked arterial flow to the right leg, I called the vascular specialist and we set up an appointment. Two weeks later the patient came into the office having had his blocked arteries fixed with a balloon and stents and he told me he could walk for miles again.
Narrowing of the arteries that feed the heart, brain, kidneys, and extremities can happen gradually, or can trigger a clot and a sudden complete blockage. This can occur in coronary arteries of the heart, cerebral arteries of the brain, renal arteries of the kidneys, or peripheral arteries of the legs. The narrowing process, called atherosclerosis, can result from things like diabetes, smoking, high blood pressure, abnormally high blood lipids, and even normal aging; In general, when it happens in any one of these organs, it happens to all of them.
Narrowing of blood flow deprives muscles, organs, and all living material downstream, of oxygen. When such tissue, which is networked with nerves, misses some of their blood flow, there follows an aching, anguishing, and agonizing hurt that would bring anyone to their knees. The classic example is heart pain, or “angina pectoris”, a condition that occurs due to narrowed coronary arteries, is triggered by exertion, and is relieved with rest. Another is leg pain, or “claudication”, which occurs when the arteries that feed the muscles and tissues of the legs become narrow and restrict blood flow. This is what was happening with Mr. D and is called peripheral artery disease, or “PAD”.
PAD affects five percent of all people over 50, but affects more than 30 percent of all diabetics in the same age group. Since diabetics often lose feeling in their legs and feet over time due to nerve destruction from elevated sugars, they may have PAD without pain and the presenting symptom can be in the form of painless sores on the feet that are very difficult to heal. This kind of presentation of PAD is treacherous because, without good blood flow, the healing process just doesn’t want to happen. What is more, a patient who is not experiencing pain is often not very motivated to do the work required to protect his or her feet so ulcers can heal.
Mr. D did very well with new blood flow to his legs, especially with his renewed ability to walk further, which allowed for tighter control of his diabetes.
By Richard P. Holm, MD
How do any of us cope with the catastrophes of life? Years ago, a couple faced the tragedy of an accidental death of their young, only child. Even though most marriages don’t survive such an insult, this one did. Between that woman and man, there was love, forgiveness, and the Church. The people of the congregation, like the wings of a mother hen, surrounded the couple with support, comfort, and warmth.
Some critics of organized religion say that we are hard-wired to believe in God. They say that it explains why religion exists but not why God exists. They point out that no society has survived more than three generations without a religious foundation including belief in prayer, the afterlife, and ritual, but just because we need God, doesn’t mean God exists. I contend that the opposite is true and am reassured of God’s presence by this and more observations.
I am reassured of God’s presence when watching a religious based rehabilitation program help men find their way back from drug or alcohol abuse. The leaders, who fill a mentor role, teach “It is not about you. . . it is about loving others and loving God.” I am reassured when studying the complexity of the human heart and the way the muscles, valves, and arteries interact while sending blood with oxygen and nutrition to every cell in the body. I am reassured when our Hopeful Spirit Chorale sings and brings spiritual connection to the hearts and joyful tears to the eyes of those listening and singing. I am reassured when a church, mosque, or synagogue full of people saying the Lord’s Prayer, or any prayer in unison, reverberates within the souls of the congregation. I am reassured when watching a flock of birds or a school of fish move together and change direction as if one organism, in sync by some ancient and holy spirit.
As a medical doctor caring for people through the years, I have had to rely on science with which to try to help resolve the health problems people face. In caring for people, especially at the end of their lives, I have realized that most times science is simply not enough. There is another place to where people need to go for help when the finale is near. The Spiritual realm, in my view, is all around us, if we listen very carefully for it, and this Divine Essence provides, for many, great meaning and help.
In one famous interview of Mother Theresa the interviewer asked her how she prays. “I listen” was her response.
“What does God say in return?” was the next question.
By Richard P. Holm, MD
The Patient Protection and Affordable Care Act, commonly called the ACA or Obamacare, could have been named the ‘Access and Cost’ act. It was successful in ‘protecting patients’ by guaranteeing access. . . making insurance available for more than 20 million people who were not able to get insurance prior to the ACA. The second part of the name, ‘affordable care’, referring to cost, has not been as successful, however.
Politicians have said, and this is correct, “since the ACA was implemented, increases in health spending have slowed.” Personally, I do not find this statement reassuring, when looking at the enormous cost of health care in the United States. We spend $3.2 trillion per year for health care, which is twice the average cost per person than that of the next ten most expensive countries and more than five times the outrageous $600 billion we spend per year on the defense budget.
Individual costs also grew during the last five years. Patient deductibles increased by 63% and premiums by 19% during a time when worker earnings grew only by 11%.
From an October 2015 Commonwealth Fund Report comparing the U.S. with 13 other rich countries, the data indicates higher spending in the U.S. happens in part due to excessive use of medical technology and higher health care prices, while there were LESS doctor visits, hospital admissions or spending on social services.
Despite all the health care spending in this country, we have poorer health outcomes, more chronic conditions, and shorter life expectancy. It’s like paying a high price at a fancy restaurant, expecting a perfect steak, and instead, getting meatloaf.
How should we fix the healthcare cost problem?
The ACA brought access. Now we need to control cost.
By Richard P. Holm, MD
As a teenager, like many others, I yearned for independence and resisted my parents’ rules and restrictions. Now I realize my parents struggled with how much freedom to allow me while best guiding me into adulthood. It’s an old story: kids want freedom; parents are reluctant to give up control. Think back when you first obtained a driver’s license and borrowed the family car. Remember, after some error in judgement or indiscretion, how the car-privilege was taken away and, even when justified, how devastating that was?
Now the tables may be turned, and the aging parent is threatened or devastated by losing the car-privilege after some error in judgement or just because of advanced age. As a Geriatrician, I have heard too many adult children ask me to tell their parents to stop driving. To the adult child, this is protecting his dad. To the elderly person, this is a double blow: losing the car-privilege feeling of independence AND the freedom to be mobile. Think about it, who’s more dangerous on the road: an 18-20-year-old male in a muscle car, a 16-year-old female with a cellphone, or grandma?
There are three lessons here. First, elderly persons who are ‘competent’ should be allowed to make their own choice when to stop driving. In my years of practice, I have advised many competent elderly people, “If you think you might be putting others or yourself at risk, then YOU decide when to stop or cut back on driving.” When night vision is poor, neck flexibility is reduced, reflexes are slowed, hearing is poor, posture is bad—then think about it. If you can’t decide or this is a borderline question, consider a ‘Driver Improvement Course for Seniors’ through the American Automobile Association (AAA) and test yourself. Then you make that choice.
The second lesson: elderly persons who are NOT ‘competent’ shouldn’t drive. When their ‘learn-a-new-thing’ memory is poor and when accidents start piling up, then it’s time for someone step in. The elderly person first needs to see the doctor for evaluation. Afterwards, if declared incompetent, it means no driving, will-making, check-writing, or consenting to an operation.
The third lesson is for everyone and every family to realize how important is the freedom to drive, especially for individuals trying to grow up with independence OR age with dignity. We should all recognize what a precious freedom and right it is to drive.[i]
Isn't it strange that in this era when there is an epidemic of obesity, our society seems to define beauty as thin? When there is such a difference between what's expected and what's real, it leaves people desperately in search for a solution to their problem. To add to the perceived beauty issue, several severe medical problems result or worsen from obesity, including diabetes mellitus, sleep apnea, weakness, and immobility, making weight loss as an important goal to enhance health not just for cosmetic reasons.
There seems no easy solution, not for any individual, and not for society as a whole.
Multiple studies show weight loss, even in highly motivated people, happens in about 30 out of a 100. After one year, only ten have kept it off, and in five years, only one. I know there are exceptions to this rule, but in general losing weight and keeping it off is a very difficult task.
Repeated studies show that for the most part adopted adults weigh what their biologic parents weigh, not their adopted parents. In the case of body shape, nature wins over nurture, as it seems we are destined to look a lot like our parents.
In addition, it's human nature to eat more than we need, and to rest whenever we are not required to move. That's old-world survival behavior that comes already set into our hard drives. However, it's a new world where too much food comes with too little effort. What’s more, our hormonal and metabolic systems seem to manipulate hunger, metabolism, and activity to maintain or even gradually gain weight, but not to allow weight loss.
Is this overweight destiny completely out of our hands? Does our hunger have to drive us to the fast food restaurant, or could we serve our family smaller portions of a healthier fare, especially with non-starchy vegetables? Does genetics chain us to that couch, or are we still free to get up and get moving with a daily 30-minute walk. Studies show that a heavy person, in condition and eating right, lives as well and healthy as a thin person.
Bottom line: we should not set our expectations toward looking like someone we are not, rather toward living a healthier lifestyle. We should do our best to avoid the up and down and up again weight rollercoaster, which can be harmful physically while worsening self-image. We can choose to realize that beauty is not defined by weight or size. Beauty is ‘health,’ which comes from exercising well, eating right, and then loving ourselves for it.
By Richard P. Holm, MD
The Patient Protection and Affordable Care Act, commonly called the ACA or Obamacare, could have been named the Access and Cost act. It was successful in “protecting patients” by guaranteeing access—making insurance available for more than 20 million people who were previously unable to get coverage. The second part of the name, “affordable care”, referring to cost, has not been as successful, however.
Politicians have correctly said: “Since the ACA was implemented, increases in health spending have slowed.” Personally, I do not find this statement reassuring when looking at the enormous cost of health care in the U.S. We spend $3.2 trillion per year for health care, which is twice the average cost per person than that of the next ten most expensive countries and more than five times the outrageous $600 billion we spend per year on the defense budget. Individual costs also grew during the last five years. Patient deductibles increased by 63% and premiums by 19% during a time when worker earnings grew only by 11%.
From an October 2015 Commonwealth Fund Report comparing the U.S. with 13 other rich countries, the data indicates higher spending in the U.S. happens because of excessive use of medical technology and higher health care prices, while there were LESS doctor visits, hospital admissions or spending on social services. Despite all the health care spending in this country, we have poorer health outcomes, more chronic conditions, and shorter life expectancy. It’s like paying a high price at a fancy restaurant, expecting a perfect steak, and instead getting meatloaf.
How should we fix the healthcare cost problem?
The ACA brought access. Now we need to control cost.