By Kelly Evans-Hullinger, M.D.
 
It was my first month in the hospital as a new internal medicine intern at a large university hospital.  Upper-level residents that I met during orientation asked me, “What is your first rotation?”  When I answered, “hepatology,” the looks I got in response told me I was in for a tough initiation.

The hepatology service included some of the sickest patients in the hospital. Each one had either end stage cirrhosis or a liver transplant, plus some acute condition requiring them to be in the hospital. They were so complicated, making clear to the newly minted Dr. Evans that a healthy liver is critical for the body to function normally.

Cirrhosis (scarring of the liver) is the undesirable result of many types of chronic liver disease. Many causes of liver disease occur at random, related to autoimmune or genetic origins. However, the most common reasons patients develop cirrhosis are alcohol related liver disease, hepatitis C, and non-alcoholic fatty liver disease, all of which might be controlled if we catch them before cirrhosis develops.

Most people know that chronic heavy alcohol use can result in cirrhosis. We don’t fully understand why some heavy drinkers develop cirrhosis and some don’t, but longstanding alcohol abuse does typically result in some degree of liver damage. Though it can be very difficult, stopping alcohol intake can, in turn, stop progression of liver damage in most patients with alcohol related liver disease.

Hepatitis C, a viral infection which in some people becomes chronic and can ultimately lead to cirrhosis, has been the most common reason for liver transplant in the United States in recent years. With major developments in treatment for this disease over the last decade, we now have highly effective and well tolerated antiviral treatments to cure hepatitis C. This virus can reside in the liver and bloodstream without causing symptoms for decades. Current recommendations advise that we screen for hepatitis C in patients who have significant risk, including all Americans born between 1945 and 1965 in addition to other high risk groups. Talk to your doctor if that includes you.

Nonalcoholic fatty liver disease (NAFLD) is increasingly prevalent and now is among the most common reasons for liver failure. NAFLD is thought to be due to metabolic factors resulting in fatty deposition in the liver. It commonly occurs along with other metabolic diseases such as obesity, diabetes, and high cholesterol. Treatment of NAFLD is focused on diet and exercise and controlling those other metabolic diseases.

That one month as a new physician on the hepatology service was enlightening. I learned so much about the importance of a healthy liver, and I continue to use those lessons regularly in primary care.
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Kelly Evans-Hullinger, M.D. is part of The Prairie Doc® team of physicians and currently practices internal medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central. 

By Debra Johnston, M.D.
 
America is grappling a difficult legacy. Our society was built by the blood and sweat of slaves, on land previously occupied by Native Americans. When we won independence, only white male property owners were fully enfranchised. Enslaved peoples were not fully counted under the constitution. Married women had no legal identity.
 
Immigrants, particularly from Ireland, southern Europe, and Asia faced open hostility. Catholic Churches were vandalized. Nearly 1000 Jewish refugees fleeing Nazi Germany were turned away in Miami harbor. Japanese Americans were forced from their homes and into internment camps.
 
We have a proud heritage of noble ideals, but we have often failed to live up to them. We have emphasized our differences, not to celebrate the rich tapestry of life they create, but to divide ourselves into “us” and “them.”
 
In the last 250 years, our society has moved in meaningful ways toward equal participation. Slavery is illegal. Women can own property. People of different races can marry. We still face the consequences of generations of discrimination, but most of us find we have opportunities our grandparents did not.
 
The LGBTQ+ community is the most recent to demand an end to discrimination. Awareness is increasing, but many people still have little information, or have misinformation, about the diversity of human sexuality and sexual identity.
 
Three years ago, a high school friend shocked me when she revealed that she was, in fact, a trans woman. I wonder how many other people I’ve met and cherished have felt compelled to hide something so important. We know that suicide attempts in the LGBTQ+ community are higher than in the general population, particularly for young people who are bullied in their communities or rejected at home. LGBTQ+ individuals are more likely to be victimized by violent crimes.
 
I often think of the saying “a rising tide lifts all boats.” It reminds me that working to improve my neighbor’s wellbeing makes my own more secure. This is especially true for the neighbors who don’t look like me, who don’t pray like me, who don’t vote like me, who don’t love like me. If their rights are threatened, it is only a matter of time before mine are, as well.
 
We can all look back in our family trees and find someone who faced discrimination for their race, religion, or class. And of course, we all have mothers and grandmothers! Let’s remember those struggles and extend compassion. We are more alike than we are different.
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Debra Johnston, M.D. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.        

By Jill Kruse, D.O.
 
One definition of the word murmur is “to express one's discontent in a subdued manner.” So, it makes sense that a heart murmur is often a soft-spoken signal that something may be going on in the heart. The heart does not always shout to get our attention like it does with a heart attack. Sometimes it quietly whispers to those who will listen that there might be an issue. The murmur itself is not the problem, rather, the murmur is telling us to look for one. 
 
Some murmurs are called innocent or benign. These are murmurs when the heart is normal, but the blood is flowing over the valves rapidly which causes a sound. About forty to forty-five percent of children will have a murmur at some point in their life. No treatment is needed for these murmurs and children will often outgrow them, but up to ten percent of them do persist into adulthood. 
 
Murmurs that indicate more serious issues are often associated with valve disorders in the heart. The valves are the areas that open when the chamber of the heart beats and close when the heart is between beats, to allow the chambers to relax and refill with blood. Sometimes a valve does not fully close, or it will balloon backwards and allow blood to backflow across the valve. This back flow causes a murmur. This is called valve prolapse that leads to blood regurgitation or “regurg” which requires medical attention.
 
A different type of murmur is caused by mitral or aortic valve stenosis. Stenosis is when the valve does not fully open, so the same amount of blood is forcing itself through a narrower opening in the same amount of time as it does in a normal valve. That extra pressure causes the murmur because the heart must work harder to push the blood through the valve. Over time if this is untreated it can lead to damage of the heart muscles.  
 
The most common murmur is aortic sclerosis, which happens when the aortic valve develops scarring, stiffening, or thickening. This can occur with age or after infections such as rheumatic fever or endocarditis.  This is not dangerous by itself, but if it progresses to stenosis, it can be cause for concern.
 
Often when a doctor hears a murmur, we may want to get a better look with a special ultrasound called an echocardiogram to see if we can find the cause of the noise. Once the cause is found, a follow up plan can be made.
 
When the heart whispers, we must always listen. By doing so, we may avoid further discontent, forcing the heart to raise its voice over a larger problem.  
 
Jill Kruse, D.O. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.  

By Debra Johnston, M.D.
 
Some health problems are much larger than the health care system and cannot be fixed by doctors, nurses, hospitals, and the rest of the traditional health care team. 
 
In our physician peer group sessions, my colleagues and I often share the agony we feel when sending people out of the emergency room, knowing that the patient is going right back into the conditions that contributed to their crisis in the first place. Perhaps they could not afford their insulin or have no refrigerator in which to keep it cold. Perhaps they are going home with the person who hurt them. Perhaps they don’t have a home to go to and are trying to care for their wound while living on the street. These situations are real, and they exist in rural areas, small towns, and big cities alike.
 
I often urge my patients to get more exercise, and we brainstorm ways to overcome the barriers they face. But options are limited for the person whose neighborhood has no sidewalks or isn’t safe to stroll through. We talk about good nutrition, and most patients know it’s best to eat plenty of fresh fruits and vegetables. But what if the only store they can reach is the convenience store which doesn’t stock healthy options?
 
Some of my patients come to me having researched their symptoms, and we talk about how to find reliable medical information on the internet. But what happens if they don’t have access to the internet? Sometimes I print out educational material, but that has no value for the patient who cannot read.
 
Almost everyone has stress in their lives, but for some people the stress is unremitting and severe. They deal with poverty and the attendant evils of housing and food insecurity, with limited education that restricts their options. They lack reliable transportation which keeps them from school or work or regular healthcare. They suffer from chronic diseases, racism and other forms of discrimination while separated from the support of family and community.
 
Research reveals that these chronic stressors have significant adverse effects on the health of not only the individual, but their descendants as well. We have a label for these stressors. They are called “social determinants” and we are increasingly aware that they play an even bigger role in a person’s wellbeing than all the things that health care providers do. 
 
Protecting and promoting the health of our patients and our communities is a sacred mission, but we need to expand our perspective beyond medicine and surgery and helping one individual at a time. Health is larger than the health care system. We each have a role to play in recognizing and reducing the impact of social determinants for the wellbeing of our entire community.
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Debra Johnston, M.D. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.        

By Jill Kruse, D.O.
 
When I teach medical students, I always remind them that we will see people on the very best days of their lives and the very worst days of their lives. As a result, we will see every range of emotion in our patients and feel every range of emotion ourselves. This is especially true when giving someone a diagnosis of cancer.
Telling someone they have cancer is a daunting mission. Often, the patient suspects something serious when they are asked to come into the clinic to review results in person instead of getting a letter or phone call.

I always make a point to ensure my patients are accompanied by a family member or friend. Having another person in the room to support them is important, because often the person diagnosed with cancer does not always hear or remember much after the “C word” is spoken. The word can land a visceral reaction. And, while most of us know someone who has been affected by cancer, it is difficult to imagine what it feels like to have those words directed at you, until it happens.

After a diagnosis of cancer is given, the next steps can happen quickly. There may be referrals to a specialist. Sometimes follow up exams and tests are done as soon as they can be scheduled, even on the day of the diagnosis. Having someone else in the room to help keep track of the information and offer support is helpful.
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When the diagnosis of cancer is first spoken, there is usually one of the five emotions of grief that Elizabeth Kubler-Ross described. Most often, I see denial and anger. Later there is bargaining and depression, but on occasion there is acceptance. I have told people they have cancer only to see them smile, nod their head, and tell me that they already knew, and I confirmed their suspicions. Each person has an individual journey, and they will cycle through all these emotions, often more than once.

My hope as a primary care physician, is to never let my patients be alone in this journey. After a diagnosis of cancer, I refer my patients to specialists, but I am not done caring for the person. I let the oncologists take over in the fight against this disease. But I, and most primary care physicians, will always be there as a trusted advisor and friend who can help coordinate care and answer questions.

Jill Kruse, D.O. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.  

By Andrew Ellsworth, M.D.
 
Depending on where you live, it looks like we may not have a “picture perfect” white Christmas this year. It seems fitting given the many things about 2020 which were not what we imagined, let alone “perfect.”

While the holidays can be a season of happiness and joy, for many they are accompanied by anger and sorrow. Missing loved ones from the past, remembering relationships that soured, thinking of hopes and dreams that never materialized can make customarily joyous Christmas carols sound like fingernails on a chalkboard. 

It can be hard to appear festive when inside we feel down. It may be tempting to hold our fears, failures, and bad thoughts to ourselves. Indeed, we may not want to broadcast our problems to the world, however, hiding and suppressing our feelings is not what the doctor recommends. Letting things build up and fester is not a good idea whether it be a boil on our skin or a strong emotion. 

If you are feeling low, talk to someone. Call a family member or a friend. If you do not have a particular person in mind, talk to a counselor, your doctor, your pastor, or call 1-800-273-TALK. It can also help to put your thoughts on paper. The point here is to let it out, identify it, talk, or write about it, and disarm it. Do not let dark thoughts overwhelm you and control you.

Exercise can help, too. Moving your body triggers your brain to release endorphins, the brain chemicals that facilitate feeling good. Activity gets your mind off things that cause you to worry and on to a brighter, healthier cycle of thoughts. 

Meditation, prayer, or yoga may be helpful. If you are not sure how to meditate, consider watching a how-to video on YouTube. Reach out to a church leader for guidance on prayer. If you’ve never done yoga, contact a local yoga studio or sign up for a class online.

People do care about you. I know there are many caring people in our communities. We see them unselfishly serve others time and time again. But they may need someone to talk to as well. If we all strive to open up to the people around us, we may find that we are all feeling a mix of emotions during the holidays.  

Yes, the days are short, and the darkness is long, but it will not last. December 21 marks the first day of winter and the shortest day of the year, after which the days get longer, and light extends the day. This year, on this same day, something called a “Great Conjunction” will occur. The planets Jupiter and Saturn will appear the closest they have been in almost 400 years. To the naked eye, they will look like one, bright star, thus earning the nickname the “Christmas Star.” Years ago, a star guided wise men toward a new hope. We too, can look for the light in and around us, bringing hope to our days ahead.  
 
Andrew Ellsworth, M.D. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.        

By Kelly Evans-Hullinger, M.D.
 
In a truly grand feat of modern science, The Human Genome Project, an international collaborative effort, set out in 1990 to map our genetic makeup using diverse human genetic samples. In 2003 the project was completed, ultimately showing about 20,000 human genes. Since that project’s completion, with ever-improving DNA sequencing technology, genomics researchers continue to gather more and more information about human DNA.
 
A single human cell contains a mind-numbing 6 billion base pairs (each base pair is one of four types of nucleic acid molecules) in its DNA, organized into 23 pairs of chromosomes. Fascinatingly, only about 1.5 percent of our DNA actually codes for proteins, while the vast remainder is noncoding DNA, serving a regulatory function or, at least as far as we understand, no function at all.
 
In 2007 the first individual human genome was sequenced and published. In 2008, James Watson (as in, the 1962 Nobel Prize winning Watson and Crick model of the DNA double helix) poetically had his genome sequenced and published. The ability to sequence an individual human’s genome held much promise, we hoped, in regard to predicting illness and personalizing medical interventions. But in 2020, this promise remains very much unfulfilled. In most cases primary care physicians don’t yet utilize genomics information in our daily practice. Why is this?
 
The short answer: It’s complicated. In some specific instances, genetic information can clearly convey an increased risk for disease. One example of this might be the BRCA gene mutation and associated risk of future breast or ovarian cancer. Because this specific gene mutation is so tightly linked with elevated risk, testing and finding the mutation in an individual (based on their family history or known relative with a mutation) can have direct practical implications on strategies for cancer screening or even consideration of surgery to remove the at-risk tissue.
 
Scenarios like BRCA mutation are outliers, however. When we look to common diseases, such as cardiovascular disease or diabetes, finding genetic information useful gets, well, complicated. In these cases, what we have found is that many genes are involved, and it is extremely difficult to estimate how much a mutation in one of those genes affects overall risk. That’s not to mention all the environmental factors which may affect risk as much or more than the genetic profile.
 
Genomics remains a vast, new, and thus-far difficult to access specialty of medicine. At its current rate of growth, however, I am confident my previous statement will not remain true during my career in medicine.
 
Kelly Evans-Hullinger, M.D. is part of The Prairie Doc® team of physicians and currently practices internal medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.

By Andrew Ellsworth, M.D.
 
Success in life and all its phases can be measured in many ways. Some reminisce of their glory days in high school. Maybe they were captain of the football team or homecoming queen or won the state chess championship. Others excelled in college, graduated summa cum laude, were invited to all the parties, or landed the dream job. Some worked their way up the corporate ladder or took on a big loan and built a successful business over years of hard work or taught multiple generations of students. Hopefully, most have worked and saved enough through the years to finally retire.  
 
After accomplishing the prior phases of one’s life, what does a successful retirement look like? Sure, we plan and save for retirement all the time, but when it finally comes, are we ready for the next phase of our lives?
 
There are many ways to thrive and enjoy retirement. Some savor time on hobbies, travel, play cards, sew, enjoy gardening, get involved in a church, or volunteer. Some make things or fix things or find a part time job and have some enjoyment while also earning a wage. Some surround themselves with family, helping to connect the generations.
 
Unfortunately, some do not enjoy retirement. Health issues, financial troubles, and relationship problems are just some of the ways that can make it difficult. Some people, despite the best ways of planning and saving for retirement, may have lost identity and have no idea what to do next. As in any situation, to be successful, one must find meaning and purpose.  
 
It must be extremely hard to dedicate one’s life to a calling and purpose, only to one day be told to move on. It must also be particularly challenging to have a plan for retirement, only to have those dreams set aside due to changes in health or financial hardships. 
 
Covid-19 has certainly put a wrench in many people’s plans for retirement, as well as most everyone else’s plans. Certainly, with many things postponed, changed, or cancelled this last year, we have all had a chance to reconsider what we spend our time on and what things may be worth a risk.  
 
As we enter a new year and changes ahead, whether that be retirement, a new job, a new relationship, or a new normal, I would encourage you to find purpose and meaning in what you do. When you get up for the day, set a goal or find some way to make it meaningful. That is how we will all excel in this new chapter of our lives. 
 
Andrew Ellsworth, M.D. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.        

By Jennifer May, M.D.
 
As a rheumatologist, I often get the question, “What do you do?” According to my kids, their mom does “something with joints.” At the conclusion of patient visits, when I propose a diagnosis such as polymyalgia rheumatica or PMR, I often hear, “What is that?” The fact is most people do not think about rheumatology until they need a rheumatologist. And then, learning the lingo about disease, medications, and lab monitoring can be a challenge.

Rheumatology is a relatively new specialty in the world of medicine. Focus on the disease in America began in the early 1920s with initial definition and discovery, followed by the famous breakthrough of cortisone at Mayo Clinic in 1950, and grew to a deeper scientific understanding of arthritis diseases today. Treatments have progressed from cortisone and aspirin to immune system modification with biologic medications. Future therapies will involve genetics, engineering new cartilage, and creating cells that rheumatologists will command to do our bidding upon the immune system.

Today we work to manage autoimmune diseases such as rheumatoid arthritis or lupus with medications that adjust the immune system response. Symptoms that can occur in association with some of these diseases are rashes, joint swelling, fevers, lung problems, and kidney issues. By adjusting the immune system, we can change the symptoms, hopefully lessening their impact on the patient.   

In our fast-paced world, we often want answers and quick solutions to our problems. However, rheumatology cases require persistence. There are no blood tests that specifically diagnose the problem. Rheumatologists must take time to talk with and examine the patient. We gather additional information from labs tests, studies, and x-rays. Once all the data is available, sometimes the condition is clear. But other times, the case is more challenging and requires several visits before making a firm diagnosis.

Like most health providers, I enjoy solving patient problems and making a diagnosis. We get satisfaction from figuring things out and our reward comes when a treatment improves a patient’s function or quality of life. Our goal in rheumatology is to help patients achieve remission, or better yet, to predict who is likely to get rheumatoid arthritis in hopes of preventing it from starting in the first place.

So, when patients look at me with that expression that asks “rheuma-what?”, they don’t necessarily want to hear about the science of what I do. Instead, I assure them that we will keep working together with the same goal: To get the immune system to quiet down, and help the patient feel better so they can get back to life.
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Jennifer May, M.D. is a contributing Prairie Doc® columnist. She practices rheumatology in Rapid City, South Dakota and serves on the Healing Words Foundation Board of Directors, a 501c3 which provides funding for Prairie Doc® programs. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.   

by Joanie Holm, R.N., C.N.P.

A three-pound baby entered the world in recent days. This precious child was born after his Mom spent seven weeks in the hospital on bedrest. At home, Dad and two siblings were working, going to school, and worrying. Surrounding the family were two sets of grandparents who ensured that the pieces all fell into place. From meals and lawn care, to virtual school, from evening shifts and overnights to early mornings, these grandparents were there every step of the way. They will continue to offer support while the baby remains hospitalized and growing, and after he comes home, because that is what grandparents do, if they are able.
 
Grandparenting can be an awesome stage in life, benefitting the grandchildren, the parents, and of course the grandparents in significant ways. Grandparents are known to influence values and behaviors and provide valuable life experiences. A child who has a connection with grandparents may have increased self-esteem, with better emotional and social skills. A relationship with a grandparent can give a child strength and comfort into adulthood.
 
In an article titled “Why Grandparents are VIPs,” social researcher, educator and author, Susan V. Bosak writes, “The special kind of love you get from a grandparent is a love you can't get anywhere else. It is an important kind of love – in fact, a very important kind of love. Parents have to worry about who children will become in the future; their role is to be providers and disciplinarians. Grandparents can just enjoy children for who they are in the moment. The love of a grandparent is often freer, more unconditional, and far less psychologically complex than a parent's love. The love of a parent and the love of a grandparent are different, second in emotional importance only to the parent/child relationship.”
 
In a world of many dual-career families, the benefits of active grandparents can be lifesaving for parents. Often grandparents fill in the gap between school and the time parents get off work, driving kids to different events or helping them with homework.
 
Lastly, active grandparents report less depression and a higher degree of life satisfaction and a hopeful feeling for the future.
 
Margaret Mead, a well-known American cultural anthropologist, said the connection between generations was “essential for the mental health and stability of a nation.”
 
This Thanksgiving, may we celebrate the grandparent-grandchild relationship with gratitude.

Joanie S. Holm, R.N., C.N.P. is co-founder and president of Healing Words Foundation, a 501c3 which funds Prairie Doc® programs. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.