It was a gift from a patient who decided, after nearly 20 years of my encouraging, cajoling, and quite frankly nagging, that it was finally time to give them up. That’s the thing about changing habits. Sometimes it takes a long time.
We have different ways of understanding how people approach change. One of the most universally used is something we call “the stages of change.” People move from not being willing to even consider the downsides of their current habits, to seeing those downsides and weighing the advantages of a change, to making plans to develop new behaviors, and then to actively practicing these new habits. From my perspective, “practice” is the often under emphasized concept there. Developing new habits, and breaking old ones, takes lots and lots of practice.
Whatever your goal is— becoming a non-smoker, losing weight, completing your first marathon, or even cleaning out your garage— it helps to have a concrete plan of action. Expect setbacks. I like to tell my patients that babies don’t learn to walk overnight. First, they roll, then they sit, then they crawl, then they cruise along the furniture, and finally they take those first unsteady steps. It takes them about a year to get to that point. Along the way, they fall, a lot. But they keep getting back up to try it again, and in what seems like the blink of an eye, they start running away from you at bedtime.
There are some take home lessons in that story. First, change is a process. A daunting challenge is more approachable if you break it down into smaller, incremental steps. “Getting healthy” is hard. Getting to bed half an hour earlier is easier. Second, consider yourself a learner. I love to encourage smokers not to think of it as quitting smoking, but as learning to be a non-smoker. If you are quitting, and you have a cigarette with your coffee, it’s tempting to decide you’ve failed and throw in the towel. If you view it instead as learning not to smoke, it’s easier to finish that cigarette, and try again.
Learners aren’t failures when they haven’t mastered their topic. If you smoke that cigarette, ask yourself “why?” And then ask yourself, “what can I do instead, next time?” Keep asking yourself those questions. Keep getting back up. Keep trying again.
Tenacity pays off. I have a pack of cigarettes to prove it.
by Jill Kruse DO
When I was in my third year of medical school, I learned one of my most important lessons. It did not come from a textbook or from a teacher, but from a brief conversation with a patient on hospital rounds.
“How long have you had diabetes?” I asked. It was a simple enough question. Diabetes often progressed with time and the longer it was present, the longer the cumulative damage. I wanted to gauge if his foot infection was a new issue or part of a larger battle that had been going on for months to years. “Thank you,” he said. I was confused. “Thank you for what?” I asked. That was not the expected answer. “For asking me how long I had diabetes and not calling me a diabetic,” he said. For all intents and purposes, for me as a third-year medical student, the questions were identical. I did not realize there would be any significance to the phrase I chose.
My patient continued, “Diabetes is something that I have, not who I am. It does not define me. I am so much more than this disease.” This gentleman’s, my patient’s, comment made me pause. When I walked into his room I had a lot of data about him, but no knowledge of him.
He went on to tell me about his life, his family, his prior job. He spoke of all the things that changed after his diagnosis and all the things that stayed the same. He no longer was the “diabetic in room 26”, a task that I must complete, he was a person who needed my help. He had a name and a rich history that the medical chart did not record. This quick conversation completely changed how I interacted with him for the rest of his stay in the hospital and every patient I have encountered since.
I have a gentle reminder for you and me, like my gentleman gave me all those years ago: you are not a disease or a chronic illness; you are a person who is looking for help to improve your health. It is easy to let a chronic illness become one’s identity and become the only subject discussed at a clinic visit. Remind us that there is so much more to your story, because sometimes we get busy and forget; we are human too.
Throughout my years of caring for people, many seem caught in the deep-seated joy-starving depression. I have seen the devastation from that awful diagnosis involve not only those sad and melancholy, but greatly affect those around them. For those who are 18 to 45 years of age, depression is the number one cause for disability, resulting in an estimated 200-plus billion dollars of lost earnings per year. I have looked on aghast when depression caused such helplessness that the patient chose to escape life with suicide. There are about 40,000 deaths per year to suicide, which accounts for about the same number of deaths resulting from breast cancer. Despite a similar death rate, the money invested in depression research is about one percent of that spent studying breast cancer.
Science has not yet defined why depression occurs, but theoretical causes for this malady include a genetic predisposition, a learned process, a troubled childhood and adolescence, a stressful environment, sad or traumatic situations, addiction, or even not enough sun. Most of us periodically have what is called “situational depression,” such as the appropriate sadness that follows severe loss or death of a loved one. What is more typical of harmful depression is when there is no “situation,” no reason for it to happen, no sad story to explain why one is filled with sadness. When the patient says, “there is no reason for my being so sad,” then the clinician knows there is a problem.
The diagnosis is not always that easy. We physicians often suspect depression when people experience chronic pain, find it hard to concentrate, are without energy, have flares of temper, sleep too much or too little, have a loss of appetite or have over-eating binges, have unexplained crying spells, or become filled with anxiety for minimal reasons. People often make things worse by covering-up depression with alcohol, sleeping pills, anti-anxiety medications, or substance abuse, and these meds all make the diagnosis even more difficult.
Two-thirds of people with depression do not seek or receive help. But when the one-third that do get help follow-through with treatment, 80% are better in four to six weeks. There is help and hope for those with this miserable condition, but people need to be open to the possibility of such a problem (and men are usually the worst deniers). Treatment typically includes a half-hour of exercise or walking daily, someone to talk to, and often a medication with minimal side-effects.
If you are possibly struggling with depression, please get help. At least do it for those around you.
By Richard P. Holm MD
I first met Dr. Alonzo Peeke (AKA Doc Peeke) when he was already in his late 80s. It was 1982, just before the holidays, during a District Medical Society meeting in Flandreau. The meeting started with Christmas carols that were accompanied by Doc Peeke playing on his violin.
I later learned how Doc Peeke had been one of South Dakota’s truly rural doctors, practicing his whole professional life in the small town of Volga. He was entirely familiar with delivering babies at home and performing minor surgery on kitchen tables. He had to drive early automobiles on dirt roads and figure out ingenious ways to make house calls during dreary winter storms. He was famous for inventively transforming a car into a snowmobile so that he could provide home visits to patients when other doctors couldn’t make the trip. There are many stories about how he earned the trust and respect of many families in that small town and the surrounding farming communities; how he even started a hospital in Volga so that patients could receive their medical and surgical care there. The picture of his life was almost like a Terry Redlin painting.
It was a time when doctors knew their patients from the cradle to the grave and had a general knowledge of all medicine, only referring to specialists for especially complicated or peculiar cases. For Doc Peeke, this meant consulting the experts at Mayo clinic, the now world-renowned Minnesota based medical center.
Doc Peeke was a “General Practitioner” who provided rural health care in the Midwest. It was the end of an era. When many of these small-town doctors retired, there was no new doctor to replace their practice. And though the rural landscape has changed, the lack of competent doctors has remained the same. Patients now have increased mobility; the General Practitioners have become Family Practitioners, Pediatricians, and General Internists; and in this new era, we have expert sub-specialist doctors right here in South Dakota with specialty care centers in our cities, providing some of the finest advanced health care there is.
But with all this good, something important has been lost. The picture of a rural, all-knowing, and personal Doc Peeke is not to be painted again except by memory.
William Worrall Mayo had a curious and remarkable life, which included influencing the development of the prestigious Mayo Clinic. He was the descendent of famous English chemist John Mayow, who in 1668 first discovered spiritus nitroaereus, a component of air that would later be known as oxygen. W.W. Mayo was born in England in 1819 and before moving westward to the Americas, Mayo would study under John Dalton, the scientist best known for developing modern atomic theory.
Mayo left for New York City to work as a pharmacist but soon moved west to attend medical school. He first trained in Indiana but finished his medical degree in Missouri. There, he was troubled with recurrent bouts of malaria, which he blamed on the southern heat. This brought him to move north to Minnesota for a healthier climate.
He lived in several Minnesota towns including St. Paul, Duluth, and Le Sueur, before finally moving to Rochester. During those times, W. W. supplemented his medical practice by tailoring, farming, operating a ferry service, serving as a justice of the peace, and publishing a newspaper. He was called to serve as a physician during the devastating Dakota Indian War of 1862, which ended near New Ulm, Minnesota and concluded with the hanging of 38 Dakota Sioux Indians.
Dr. Mayo then moved his family to Rochester in 1864, bringing his wife Louise, their three daughters and a young son. He came for a job with the draft board, performing examinations for the Army. After the Civil War, Dr. Mayo, often called “the little doctor,” due to his height of only 5’ 4”, set up a medical practice of his very own and welcomed the addition of a second son to the family. While W. W.’s practice continued to grow, he also found time to serve as an alderman, a school board member, the mayor of Rochester, and a member of the Minnesota State Senate.
In 1883, a destructive tornado came through Rochester and Mayo turned to the Sisters of St. Francis for help, a teaching order with little medical experience. His eldest son, Will, had just returned to Rochester after medical training, and his second son Charlie, still in medical school, both joined W. W. to care for tornado victims. In response to this experience, the Sisters later built St. Mary’s, a twelve-bed hospital with the three Mayo doctors as surgeons and the Sisters of St. Frances as nurses.
The success of the Mayo Clinic is said to have happened because of W. W.’s early concept of a group practice and his appreciation for collaboration. It all started with the dad and two sons working together, along with the Sister-teachers turned nurses and the research and education that follows the shared work of a team.
By Richard P. Holm, MD
Despite the man's caring conversation, I heard very little of it because his large, rosy, bulbous, and bumpy nose had stolen my attention. Years later, when I met him again, he looked like a different man. The rosacea and rhinophyma skin condition, which had made his face so red and nose so massive, was calmed down with medication, and the excessive growth of skin over the nose had been trimmed away by laser scalpel. This time my eyes were no longer drawn to that globular and swollen proboscis and instead were charmed by his kind and wizened eyes.
Acne rosacea, or more commonly called just rosacea, affects 14 million people in the U.S., or five percent of the population, and is sometimes said to be an adult version of acne vulgaris. We see rosacea more often in 30 to 50-year-old women, and it can flair as menopause approaches. When it does affect men, it can be severe, and in a percentage of cases, rosacea can cause an ever-growing piling up of skin over the nose, called rhinophyma.
Rosacea usually targets fair-skinned, freckle-faced, blond or redheaded, blue-eyed people who flush easily. It seems triggered by sun exposure, hot drinks, hot baths and showers, hot spicy foods, stress, exercise, and steroid medications. Of course, one way to prevent rosacea is to try to avoid such triggers.
Acne vulgaris, or more commonly called just acne, is similar to rosacea, and seems also related to hormonal swings. Acne affects about 85% of all U.S. adolescents and, more often than rosacea, causes whiteheads and blackheads. Adolescents living in western modernized civilizations struggle with acne, however it rarely affects anyone living in non-industrialized societies. This has led some experts to believe acne and rosacea might be made worse by soap, excessive cleanliness, antibiotic use, and anything that alters the normal-flora living on our skin, which protects us from invasive bacteria. It’s like how grass on a lawn protects against weeds.
The two conditions of rosacea and acne have common methods of treatment. Over-the-counter lotions like benzoyl peroxide, prescription antibiotics, and Vitamin A, each in lotion and pill form, are still the mainstay of therapy.
In contrast, recently there is a trend to move toward supporting one’s normal flora, avoiding antibiotics, cleansing agents, or oil removing methods, and even trying probiotics. This is all in an effort to re-establish a lawn of protection to fight the invasion of weeds. Treatment is effective in most people, but not all. So if you don’t find relief with typical treatments, or your nose starts growing, it’s time to see your doctor and/or the dermatologist.
A friend gave me feedback a few days ago, "Some people say you are arrogant, but I tell them ‘No—he is just self-confident.’" He followed, "We need that in a doctor, but, you know, there is a fine line between those two characteristics."
Uff da! That threw me for a bit. After thinking about it, I took it as an honest comment and a chance for me to improve myself. A physician/philosopher once said: "A true friend will help you grow by pointing out your warts. Instead of getting angry, one should take it as an opportunity to get better."
What is arrogance? The dictionary’s definition is harsh: "An offensive display of superiority or self-importance; overbearing pride." I see it in people who treat others poorly, especially those who are lower on some hierarchal level. Examples would include an employer who expects sexual favors of some kind, a prison guard who harasses a prisoner hatefully, a teacher or parent who supervises a student or child unjustly, or, to make the point, a doctor who treats a nurse or patient poorly. I believe nothing indicates the true color of an individual more than how he/she treats someone who may be lower on the totem pole.
I have seen examples of physicians acting this way: when a surgeon threw a scalpel across the room; when a specialist spoke negatively to the patient about a primary care physician; and when a surgical resident treated a young inner-city woman, infected by gonorrhea, with disdain and contempt. I am not proud that my profession probably deserves some of its reputation for being arrogant. On the other hand, part of the value provided by a physician comes from the sense that she or he is competent and knowledgeable. A humble physician is one thing, but an unsure and uncertain doctor is another.
Perhaps sometimes I have come off as a know-it-all. I need to work on that because I do not know it all. In fact, it seems the more I do know, the more I realize my inadequacies. My folks came from humble backgrounds, and I was drilled on the Golden Rule. The last thing I want to do is to portray myself as a physician who thinks he is more important than anyone else. Rather, I would like to be known as someone who is both competent and cares.
Richard P. Holm, MD
As part of our Prairie Doc volunteer work to spread science-based public health information, we have assembled a group of pre-professional college women and men to help us out. Almost every Thursday night at 7 PM (6 mountain time), these young “Prairie Doc Assistants”, or PDAs, answer telephone call-in questions for our TV show on PBS. This changing group, initiated by our friend and advisor Mr. Judge Kelley, has been helping us for more than four years.
These kids not only help answer phone calls during live shows, but they help research medical topics, and even help others during medical mission trips. In return, we give them the opportunity to meet our medical guests for 30 minutes before the show, and we help them find shadowing experiences with physicians. They need to experience a taste of what it would be like in med school and in the real world after starting practice, before they commit to it.
My first two years of medical school, back in the 70’s, required putting my nose into books, memorizing how the normal human body works, and understanding what can happen when illness strikes. The second two years, and the internship and residency that followed, were spent learning from an older and experienced master who taught by example. This mentor-based teaching style is a lot like the medieval way of learning, like being an apprentice to a silversmith who knows what he’s doing, and who guides you in making your first silver tea service. In medicine, I think the hands-on, one-on-one, mentoring experience is what matters the most, but the book-learning part is still necessary. Now, med schools are mixing together the book-learning and the mentoring throughout the four years of education, which is a better deal in my opinion.
During my life of medical practice, I have mentored many apprentice nurse practitioner students, P.A. students, medical students, and medical residents; all while I was caring for patients. I asked the patient permission first and very rarely had anyone say “no" to having a student in the room. How else are they to learn how to listen, examine, and think in their quest to become a high-quality care giver? Besides, having a student watching can only make a doctor try harder and be better.
Now, I find myself encouraging college students into the glorious and rewarding field of medicine. Indeed, what an honor it has been to have a treasure chest of knowledge that can be used to help others!
By Richard P. Holm, MD
In 1966, a ten-year-old boy from Hamlin County, South Dakota was sleeping out with his buddies when a skunk crawled into his sleeping bag and bit the boy aggressively near the face. Despite providing the child with old-style vaccinations, the boy succumbed to rabies within a month. Even with present day technology, once rabies gets to the nerves it is at least 96% fatal in humans. rabies is believed to kill more than 55,000 people every year in Africa and Asia alone—most of them after a bite from a rabid dog. By comparison, in the U.S., rabies kills only about two or three people per year.
Over the last 50 years, effective vaccination programs for domestic dogs and cats, along with improved rabies post-exposure prevention (PEP) treatment, has significantly reduced the number of rabies-related deaths in the United States. Domestic animal vaccination has been quite successful in containing rabies exposure to humans, but minimally affects the risk of rabies in wild animals and thus they remain a reservoir for the disease. This and the newer PEP, which is easier to take and more effective, has also helped radically reduce human rabies.
We still have plenty of animal rabies, however. In SD, over the last ten years, we tested 6,500 animals suspected of rabies, since they were seen in unnatural hours acting sluggish or aggressive. They found five percent tested positive. Specifically, 195 skunks, 48 bats, 47 cows, 22 cats, 16 dogs, eight horses, three goats, and two raccoons were rabid. Please take note that none of the 16 infected dogs had been vaccinated, giving credibility to the value of vaccination. Of all the bats tested, only three percent were positive, while 48% of the skunks tested were rabid. These were selected due to bizarre behavior and thus the percentage affected is artificially high. Still, this gives another reason, besides bad odor, to avoid skunks.
Just last week a Sioux Falls man was walking his dog late in the evening near many evergreens, when he noted something was crawling on his forearm. When home in the light, he noted tiny double bite marks, highly suspicious for bat bites. Since SD bats are usually bug eaters, not arm chewers, this incident was worrisome. The doctor recommended rabies PEP.
Bottom line: Vaccinate your pets, avoid messing with wild animal, and seek immediate medical care whenever bitten by any animal.
By Richard P. Holm, MD
In the U.S. there are almost five million people with mild to moderate dementia. Studies show that about 70% of these people are at home, either alone or with a caregiver (often a spouse). If more people with mild to moderate dementia could stay home safely, this would save Medicare and Medicaid a great deal of taxpayer money. More importantly, this would provide those affected by dementia with their preferred environment. Indeed, it is important to allow all people the chance to stay at home whenever possible.
Recent Johns Hopkins research studied more than 250 people with dementia and found that 99% of the demented and 97% of their care givers had at least one unmet need. The foremost unmet need was safety issues which increased risk of falling, such as poor lighting in walkways. Other unmet needs included not performing regular exercise, poor follow-up with health care providers, not having prepared legal and estate planning, and not receiving needed help with medications and daily living activities. Researchers found that individuals with lower income, with depression, and/or with borderline—rather than severe—dysfunction, had significantly more unmet needs.
When there were at-home caregivers for these folks with early dementia, the caregivers were often not aware of these deficiencies. Add to all of this, the needs of the caregivers were often ignored or unrecognized. Remarkably, at-home caregiver stress and depression was one of the strongest predictors for an earlier move of the person, with dementia, to the nursing home.
Methods to enhance a person’s chance of staying at home are not difficult. Preparation for legal issues and estate planning should be done early and BEFORE memory loss. Other methods include providing raised toilet seats, grab bars in the bath and bedroom, properly tacked down carpets, adequate night-time lighting, and proper day and night time footwear. Researchers also strongly advise providing enhanced support for caregivers, such as educating them about support services available, like social services, occupational therapy, and caregiver support groups. In addition, screening for and treatment of any caregivers’ depression should be provided. This would go a long way in helping people stay at home as they age.
Bottom line: most of us (and our families) are not prepared for the possibility of dementia as we age. If we prepare, we greatly improve our chances for staying at home.