By Richard P. Holm, MD
 
During the South Dakota Festival of Books, I listened to a group of five successful novelists discussing the art of writing and what they gained from creating their works. They all seemed to agree with journalist Malcolm Gladwell who said that it takes some talent, but more importantly, about 10,000 hours of practice to become good at anything. They each also said that writing has given them joy, humor, an understanding about life, and a sense of meaning.       
 
Hearing all this, I reflected on how much room I have for improvement in my own writing. On the other hand, I realized my compositions are not for a novel but for self-help, and the goal of my latest book, Life’s Final Season, is to help people during their aging and dying process. As opposed to a novel, my writing has a different purpose. I also thought of how therapeutic my own writing practice has been for me since my cancer diagnosis.
 
There is a lot out there about writing as therapy. Orthopedic surgeon Dr. David Hanscom, in his book Back in Control, provides for us a writing method to help people in chronic pain. He advises those in pain to write down any random thoughts for ten to thirty minutes once or twice a day for at least several months. Hanscom reports the theory that when pain becomes chronic, the signals change from damage pain activity in one part of the brain to an emotional (fear and anxiety) response in a different part of the brain. Hanscom asserts that the daily writing exercise truly helps people break the pain cycle when nothing else helps.
 
Professor Dr. Gillie Bolton also recommends a daily writing program for chronic pain. She says not to worry about grammar, style, or spelling. Dr. Bolton advises starting by unloading and dumping negative thoughts, followed with expressive and explorative writing about any topic. She suggests that we focus on the writing without distraction, finding time to do it once or twice daily, and doing it for yourself (not others). Her contention: writing helps us illuminate our own suppressed feelings, thereby helping us deal with chronic pain, depression, and other miseries of life.
 
I truly hope my book helps caregivers and people who are aging and dying, but my writing has had the added benefit of helping me cope with a deadly diagnosis.  A daily writing exercise may just help you too.
 
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By Richard P. Holm, MD
 
South Dakota has the 14th highest suicide rate in the U.S., and, during this last year, suicide as a cause of death has grown faster here in South Dakota than most places. Two SD counties rank in the top one percent in the nation. I have heard that, in general, the highest risk individual for suicide is the widower, the elderly male who recently lost his wife. But the South Dakota public health department tells us that suicide rates are higher here in younger people than in most other states. For example, men aged 19 to 21-years-old, are at the highest suicide risk. In addition, American Indians are at 1.8 times higher risk than other South Dakotans.
 
Risk factors for suicide include: a family history of suicide; a history of abuse—be it the abused or the abuser; previous suicide attempts or a history of mental disorders (particularly depression) and especially if the individual has difficulty accessing mental health treatment when needed; a history of alcohol and substance abuse; feelings of hopelessness and loneliness especially with isolation; recent loss (whether it be the death of a family member, a friend that moves, a divorce, or a large financial loss); any new and significant physical illness; and access to lethal methods. There is also a higher risk is for anyone present during local epidemics of suicide, especially where cultural beliefs suggest that suicide is noble. All this multiplies when the person is reluctant to seek help because of the stigma attached to mental health disorders.
 
The challenging concern is that suicide remains extremely hard to predict. Even when we’ve identified who is at risk, suicide can be difficult to prevent. We know that “talking about it” is probably our most important means of helping someone who is suicidal. Although we should all try to guide these at risk individuals to talk about their feelings with a professional, the most important preventer of suicide in many cases is not the doctor or the care provider, but the kindly neighbor who can give that person an ear, offer true friendship, and call for help when red flags are flying.
 
 You may never know it, but you might save a life by listening and just being a friend.
 
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By Richard P. Holm, MD
 
The word “chronic” means persistent and unrelenting; something that doesn’t go away quickly. When you preface that word with “pain”, you have a potentially crippling condition which affects too many people in too many guises.
 
Chronic pain can develop in a variety of conditions: headaches, lower back pain, herpetic pain following shingles, neuropathic foot pain resulting from diabetes, and the body-wide muscle pain of fibromyalgia, to name a few. The bad news is that it is often very difficult to get rid of chronic pain, like an unwanted guest who never wants to leave.
 
Surgery or medicines (especially opioids) are often minimally effective at treating chronic pain and sometimes make things worse. Even injections of steroids, which is an invasive, expensive and overused procedure, is typically useless for chronic pain. In the end, too many people continue to suffer. The pain can eventually take control and cause the person to become helpless, inactive, and shut down completely.
 
It is important to understand that immobility often makes the situation worse. If a joint or muscle is not used regularly, it barks and bites when called upon to be moved, the pain of which can dissuade further use. This cycle, if unbroken, can result in an increasing level of immobility, severe disability, and more time to dwell on the pain. This is exactly the reason they say “use it or lose it!”
 
Paradoxically, one of the most effective ways of breaking people out of this cycle is for them to change negative habits and to become more active.  Again, the best answer for CHRONIC pain is usually not surgery or more pain medicines. Regular stretching, good posture, adequate sleep, a good diet, and regular exercise can work wonders where modern medicines fail. Of course, each case is different, and sometimes a trapped nerve needs release or severe inflammation needs to be turned down and rested. However, carefully moving through stiffness and discomfort can give us considerable relief. It will be tough in the beginning, and results may not be instantaneous, but the struggle of starting healthier habits in the face of chronic pain can be well worth the long-term benefits.
 
Studies show that return to function, although not easy, is the key to rehabilitation. Chronic pain doesn’t have to mean progressive immobility, disability, and hopelessness. We should remember to accept the pain when we have to, and, when advised by the doctor, to move those muscles.
 
Use it or lose it.
 
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By Andrew Ellsworth, MD
 
Wind Cave National Park is an underground maze of narrow passageways and chambers located under the prairie just on the edge of the Black Hills of South Dakota. My family and I took a tour of the park this summer and were astounded at how expansive and complex it is. Established as the 8th national park in 1903, Wind Cave National Park is one of the largest and most complex underground cave systems in the world. There are over 140 miles of interconnected passages compacted into approximately one square mile. They are still exploring and finding more!
 
One of the early explorers of the cave was Alvin McDonald. He was only 16 when he began exploring the cave for miles at a time by candlelight. He eventually knew the cave so well that he began to guide tours through it. As the story goes, he once left a group alone for a bit as he explored a new passageway. He made his way back to the surface and back home, only to realize later that night that he forgotten his group! Upon realizing his mistake, he immediately went back for them. Imagine being lost in an underground cave without a guide!
 
Much like the complexity of Wind Cave, our healthcare system is an expansive maze of diseases, tests, hospitals, specialists, and medications. It is difficult to imagine someone being able to navigate this confusing system without a trusted primary care provider to serve as their guide. Primary care providers are the medical professionals you choose to be in charge of your personal care. They can be a doctor, nurse practitioner, physician assistant, medical home, or clinic. People who have a primary care provider for the majority of their medical care, who have continuity of care, are healthier. Studies have found that if you have a primary care provider to help guide you, you are less likely to go to the emergency room, less likely to be hospitalized, more likely to trust and follow medical advice, and are happier, healthier, and will be generally more satisfied with your care. Your primary care provider is your Alvin McDonald, guiding you through the healthcare maze and helping you avoid those dead ends. But unlike Alvin McDonald, they won’t forget about you! Your primary care provider can be your first stop for care, catching problems early on, and keeping you on track for a lifetime of good health.
 
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Recently, I received a (meant to be humorous) email that explained why life is simpler for men than for women. “Our last name always stays the same; the garage is mostly all ours; mechanics tell us the truth; we get extra credit for the slightest act of thoughtfulness; our underwear is only $8.85 for a three-pack; we can play with toys all our lives,” and, finally: “We do the same work but get more pay.” The last zinger struck a dissonant chord.
 
I know that, even though things have been getting better over time for women, equal rights and equal pay is a glass ceiling that has not yet been broken. After all, it has been less than 100 years since women have had the right to vote; the gender wage gap continues; violence against women persists; and poverty and homelessness is worse for women, especially single mothers. Plain and simple: unfair discrimination toward women persists.
 
Because of these injustices, there has been some societal rejection of discussion about the differences between the sexes as politically incorrect. I get that, because, despite some improvements in societal equality, there remains perpetrated bigotry against those who some consider “different” (be it because of their sexual orientation, sexual identity, or race). However, from a medical standpoint, there are important and real dissimilarities between women and men which are solely based on physiology, like hormonal differences that influences behavior and size.
 
For example: in a study applying topical testosterone to half of a large group of normal men, the men with increased testosterone were less willing to check themselves for mistakes and appeared over-confident. This could explain why men, who naturally produce more testosterone than women, are sometimes more reluctant to admit when a problem becomes obvious and less willing to seek help or ask for directions. Another example: the average U.S. adult man weighs 196 pounds and is 5 feet 9 inches tall while the average adult woman weighs 168 and is just under 5 feet 4. (Incidentally, average U.S. people weigh about 30 pounds more than they did 50 years ago.)
 
Recognizing the physical differences between the sexes should not mean either sex is inferior. We should combat unjust inequalities while embracing what makes us unique. Understanding the biological differences between the sexes should simply allow us to find treatment for medical and behavioral problems and to best love and support each other.
 
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I’ve lived a life formulated for longevity: eating right, exercising daily, and savoring friendships and family. Despite this, I still came down with cancer two years ago. I’ve been treated with chemo, radiation, major surgery, and now, with spread to the liver, I’m back on chemo. I’m still here and truly feel blessed and thankful for every day, but you can understand why lately I’ve been thinking about death.
 
Loving my enemies has made this easier. As our kids were growing up, I would find myself saying to them I will always love you unconditionally, but sometimes I don’t like what you are doing.” We should say that to our enemies, too. Here is the lesson: hate is poisonous, especially to the one who harbors it. Remember what Jesus said (as did Mohammed and Buddha), “Love your enemy.” I believe hating others, even when justified, only destroys us. When angry, we should point the anger at what he or she is doing, not at the person. Use it as propulsion to fight to the tooth for the cause . . . but let go of hate. How is this related to death, you ask?
 
When people ask me how I contend with the prospect of my dying sooner than expected, I go right to the opposite of hate which is love. I know it sounds clichéd and unoriginal, but the word love embraces the spiritual, inner-warmth I feel when I value the other person (even if he or she is my enemy). Truly valuing others gives more meaning to my time limited life and helps take away the fear of my own death . . . but there is something more.
 
Some say, “One day, you'll be just a memory for some people.  Do your best to be a good one." That’s not bad advice, but I think the measure of our worth, after we die, has less to do with being remembered and more to do with the reflection of our actions in others. It’s that Pay it Forward or that Jimmy Stewart Wonderful Life sort of thing. I believe meaning and purpose comes with the good that we do and how that moves others forward (whether they’re aware of it or not).
 
Our lives are all like a book that becomes more precious as it nears the end, especially by savoring friendships and family, by letting go of hate and by paying good deeds forward. Why waste any time fearing death?
 
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Vaccines protect people from illness with minimal risk.
 
Smallpox has been around for many millennia. For thousands of years, the virus caused a deadly illness that killed more than 35 percent of adults and 80 percent of children who contracted the disease. That is until the smallpox vaccine was discovered in 1796. Noting that milk maids rarely got smallpox, British rural physician Edward Jenner found that deliberate infection with the milder cowpox disease provided substantial immunity to smallpox. After decades of improvement to the vaccine and a campagin lead by the World Health Organization, global deaths from smallpox were reduced from two million per year in 1967 to zero in 1977. Human smallpox infections were virtually eliminated from this world because of vaccinations.
 
Another example of clever manipulation of the immune system is the story of a pneumonia vaccine. In a 2003 study, researches noted there had been a huge drop in hospitalizations of the elderly for pneumonia, with 12,000 fewer yearly deaths—especially in those older than 85. This is the result of routine childhood pneumonia vaccination. Although we now encourage two different pneumonia vaccines for those older than 65, the authors of the study claim that it was the routine vaccination of children that was responsible for the reduction of pneumonia in the elderly. Thus, herd immunity profoundly protects immune deficient adults by reducing their exposure to sick kids.
 
There have been dangerous and untrue rumors that vaccinations in children are responsible for autism. Despite the natural human wish to find something to blame for this condition, autism appears in similar rates in children who are given and not given vaccinations. Don’t get me wrong, some vaccines carry risks, but it all depends on the specific type of vaccine and what disease it is treating. Most vaccines are incredibly safe.
 
Take for example the vaccine for Dengue fever, where the risk of side effects is significant. With Dengue vaccine, ten children are saved for every one child who is harmed. Compare that with the measles, mumps, rubella (MMR) vaccine series given in the U.S. which has mild temporary side effects including fussiness, mild fever, injection-site soreness, affecting one child in four. There is temporary mild joint pain, rash, mild glandular swelling, and loss of appetite affecting one in 50, and high fever and platelet problems affecting one in 25,000. Much better than Dengue vaccine. The benefits of the MMR vaccine far outweigh the risks. That is why we routinely give people the MMR vaccine and only give people the Dengue vaccine if they have a high chance of exposure.
 
Vaccination, a clever manipulation of our immune system, protects us from the scourges of the future.
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Early one morning, I was heading through the kitchen toward the back door on my way to work when I realized there was a large bat flying around our breakfast room, swooping around like in a Dracula movie. As it flew at me, I reactively swung at it and, like hitting a Nerf ball, the bat was thrown across the room, landing on the kitchen floor a little stunned. I closed all doors to the rest of the house, locked open the exit outside, washed my hands thoroughly, and as the bat started flying again, I shooed the creature out into the early morning darkness.
 
Bats are a marvel of evolutionary diversity with something like 47 different species in the U.S. alone. They are important to our ecosystem as they eat their weight in bugs every night, carry seeds which reforest depleted woodland areas, and pollinate plants. Experts believe that these winged mammals first developed powered flight about 60 million years ago and later the capacity for radar-like echolocation to allow nighttime hunting and flying in a cave without any light.
 
About one percent of bats carry a deadly virus called rabies. Any victim stricken with rabies (whether bat, dog, skunk, cat, or human) will eventually become confused, agitated, aggressive and infectious until they die. This is not far off from cinematic portrayals of zombies who change into confused and aggressive monsters after being bitten. The difference is that we have a rabies vaccine that can save the bitten victim from an awful death.
 
So, after striking down the bat, did I need to receive rabies shots (post-exposure prophylaxis) to gain protection from developing the disease? This would have involved four doses of rabies vaccine over 14 days, and one injection of active immune globulin. I checked out the last 15 cases of rabies that had occurred over five years in the U.S. and 9 were from bat exposure, 4 from dogs, 1 from a fox, and 1 unknown. All but one died, and the one survivor remains severely disabled. The CDC recommends having rabies shots “if there’s been a bite or an exposure to saliva into eyes, nose, mouth, or open wound.” I did not seek out rabies shots as I did not receive a bite, the bat was acting normally, and I thoroughly washed my hands after touching the bat.
 
Although I did become irritable following a few restless nights, I did not turn into a rabid or rabies-like Zombie.

Hardly any clinical problem demands more from a patient AND a physician than diabetes. The condition demands a special diet, significant exercise, lots of monitoring, expensive oral and injectable medicine, and a rescue plan when things get out of control.
 
Regarding the need for a special diet, there are different ideas about what is the correct for a diabetic to eat. There are low carbohydrate plans, low fat plans, low meat plans, high fiber plans, and the list goes on. Whatever the plan may be, the biggest challenge, and probably the most important one, is to eat less and to do that forever. However, asking someone to always eat less seems almost too much to expect.
 
Regarding the need for a special exercise plan, there are different ideas about what is the correct way to exercise and often the capacity of the individual to exercise is limited. Whatever that plan may be, the biggest challenge is in the doing. People with (and without) diabetes need to get enough exercise and to do it regularly (daily), but that also seems almost too much to expect.
 
When exercise and a special diet are not enough, various diabetic medicines or non-insulin injections can be prescribed. When these fail, various types of insulin are added. Some are long-acting, and some are short-acting. Another challenge to this condition is that medicinal treatment options seem more expensive over time, not less, even though the patent for these pills should have run out.
 
Regarding the need for monitoring, people with diabetes and their doctors are asked to keep track, not only of blood sugars, but also of cholesterol, blood pressure and the condition of their feet, eyes, and kidneys. Physicians and other care providers are under the gun by insurance companies and the government to meticulously monitor diabetics and are even being graded on how well they do this monitoring. Therefore, care providers are bugging the person with diabetes to carefully monitor themselves too. It almost seems too much to expect.
 
People with diabetes sometimes have out-of-control blood sugars despite doing everything right. It’s been my experience, especially when insulin is being used, that sometimes there is no rhyme or reason for a person’s blood sugar to be too high or too low, but it still happens. Rescue plans must be made and practiced.
 
Hardly any clinical problem demands more out of a patient AND a doctor than diabetes.
 
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The oldest known lens was found in the ruins of the ancient Mesopotamian city of Nineveh and was made from polished rock crystal. The Greek playwright Aristophanes mentions the use of such a lens to burn holes in parchment in one of his plays. Allegedly, Pliny the physician used a similar lens to cauterize wounds. A thousand years later monks started using "reading stones" which were sliced off sections of polished quartz spheres. Sometime in the latter half of the 1200s the monks put these reading stones up on their noses in what today we would recognize as spectacles.
It was in Venice, Italy, where glassmaking was (and still is) an art, that convex reading and magnifying glasses were refined. About three hundred years later, concave lenses were used to help the near-sighted Pope Leo the 10th. He apparently wore his special spectacles to aid him while hunting. It took just about three hundred more years for bifocals to be invented by America's own Benjamin Franklin.
It was in the mid 1800s that a protective lens was made to fit directly over the eyeball of a man who had lost his eyelid from skin cancer. This first "contact lens" protected his eye from drying out, which would have resulted in blindness. Over the next 150 years, contact lenses came into commercial use and moved from blown, to ground, to molded glass lenses and then to a whole variety of hard, then soft, plastic lenses.
The knowledge of refracting light with lenses has, more recently, brought us to correct vision by surgically altering the shape of the cornea with laser beams. Where will we go next?
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