Although I completely agree with Robin’s feelings voiced in the prior blog, that we need some type of medical insurance coverage for everyone, I have another concern. Everything you read or hear these days seems to refer to uninsured people as “them.” As in “them” versus “us.”  As if it could never happen to those of us lucky enough to have healthcare insurance right now.

That’s such nonsense. Depending on the circumstances, any one of us could become uninsured at any time. Look at Robin’s example of the young college-age student with the main option of declaring bankruptcy due to a complicated illness that still needs treatment. Most people without insurance are just like you and me; not the nonworking lazy folks that others would have you believe. I know exactly what I am talking about. Why? Because for the past 3 years I have exclusively worked at a clinic for people without insurance.

Let me tell you about the circumstances of some of my patients. One lovely man is in his 50s, and has for years worked at the airport as a skyhop. That’s right. He’s the one who lifts your heavy bags onto the scales and then onto the dolly to roll it over to the check-in desk.  And sometimes, when no dolly is available, he carries it himself to the check-in desk. He usually works 12-14 hour days, and has been healthy for years. But now, he’s been having back pain, and his weight has crept up causing him to develop high blood pressure and high blood sugar.

Easy you say. Give him something for his back pain, put him on blood pressure medicine and tell him to lose weight. Not so fast. He doesn’t have health insurance because it is too expensive for him to buy, and it is not an included benefit with his job. He has children at home and a wife who is ill. Medications are expensive. And what happens if his back “goes out” so that he can’t work for awhile? He will probably lose his job as he has no medical leave; in addition, he cannot pay for physical therapy or other treatments for his back. He’s a hardworking, diligent, and responsible citizen who helps you and me out when we fly. And, do you think he shouldn’t be offered healthcare coverage he can afford?

Another patient of mine worked for years as an administrator for a nonprofit organization that gave out grants to needy people. When her arthritis got so bad that she couldn’t stand up or sit down without excruciating pain, she had to go on disability. But it’s not enough to allow her to pay for medical insurance. She desperately wants to work, but can do little because of her constant pain.  And she definitely can’t afford joint-replacement surgery herself. She shouldn’t have an affordable option for medical insurance?

Yet another patient is a fine piano teacher trained at the best conservatories in the country. Never ill in her younger years, she didn’t have medical insurance because she couldn’t afford it but blessedly didn’t need it. Now she’s in her 50s with all the illnesses that come with aging, and has had to slow down her teaching. And she still can’t afford insurance. She’s very important to many young piano pupils and to their parents; she is literally teaching how to have joy in their lives through music. And she doesn’t deserve to have affordable medical insurance?

As I said originally, these people are not “them.” They are us. Think about it.

Many of my patients have asked me what I think about healthcare reform.This is what I think:

I listen to the Sunday morning pundits and they talk about the majority of Americans who are happy with their healthcare. Where are these people? Even the patients that I see with health insurance are not happy.They are worried about losing their insurance.They are upset that the insurance companies are dictating what medications they should be on. They are upset about the rising insurance costs and premiums.They are upset that their doctors do not have time to address their problems in ten-minute visits.

Those without insurance or insurance that have high deductibles and minimum coverage are facing horrible decisions.These include decisions between medications and eating and paying rent. Many with unexpected illnesses are facing bankruptcy.

Just last week, I was advising one of my son’s friends who just turned 21 on what to do regarding his medical care.He developed severe, intense chest pain. He was hospitalized with a diagnosis of pericarditis (inflammation of the lining around the heart).He spent five days in the hospital out of state where he is in school and working.Two of those days were wasted by cancellation of procedures and tests.He has insurance that caps out at $50,000.His hospitalization will cost at least that amount.It turns out that the pericarditis may be due to Hodgkin’s disease.This is a curable, treatable form of cancer. His insurance is used up. He has no idea how he is going to pay for this treatment.Now he faces the decision of filing for bankruptcy at the age of 21. Here is a young, vital person, who has the potential to be a valuable contributor to society, one of our children, yet he is faced with the decision of bankruptcy or no treatment for a treatable disease.

I just want to scream. It is time to wake up America. There is no reason why we cannot all have affordable health care. When we take care of each other we are all going to benefit! No one should have to face financial ruin due to health problems. When we have a healthy population, we will have a productive healthy society. The time for a national healthcare plan is now.

In summary, as a practicing physician, I support and applaud the President for proposing a national healthcare plan. I shudder to think what will happen if something isn’t put into place soon.

 The FDA just approved the H1N1 influenza (Swine flu) vaccine, and the companies making it say that it will be available to pass out to local health agencies in 2 weeks.  The seasonal flu vaccine should be available from doctors’ offices, clinics and other commercial places sometime in October.

Here, again, is what you need to know about flu season this year.

1) The H1N1 (Swine) flu virus was first seen causing infections last spring, continued throughout the summer, and is supposed to cause even more infections this fall.

2) The Swine flu has been infecting children and young adults much more frequently than adults. This is thought to be due to the fact that we older folks have some immunity to Swine flus in general because of having been exposed to it years ago.

3) The Swine flu vaccine will only be distributed by the Federal Government to local health agencies. They will then make it available to those most likely to get infected (see prior blog for a listing of who this includes) FIRST, and then, to everyone as supplies last.

4) The Swine flu vaccine should be available in 2 weeks. Ask your doctor IF and WHERE you should get it. Also, do make sure your kids get it, as their doctors recommend.

5) The regular flu, known as “seasonal” flu will be present this year IN ADDITION to the Swine flu. It usually infects mostly older people and the youngest of children.

6) The seasonal flu vaccine should be available sometime in October. It will be available through doctors’ offices and other commercial clinics.

7) BE AWARE of the things that can spread the flu(s). WASH YOUR HANDS; STAY HOME IF YOU HAVE FLU SYMPTOMS.

STAY HEALTHY now by eating well, exercising regularly, and taking your prescribed medications regularly.

See the blog just prior to this one for more information on this year’s 2 flu viruses.

It’s that time of year again when we have to start thinking about flu season and the flu shot. Only this year, there’s been so much news over the past few months about the HINI (Swine) flu virus infection and the vaccine against it, that the entire topic of the flu shot is confusing to many.

Let’s make it simple. This fall and winter season we are at risk of getting infected with TWO different influenza viruses – the H1N1 influenza virus, also known as the Swine flu  virus, AND the “regular” winter flu virus that comes around each year, which is known as the seasonal influenza virus. These two viruses are different, and yes – we are risk of catching either or both of them, depending on our age and our health. Let’s talk about each virus next.

The H1N1 flu virus reared its ugly head last spring and has continued to infect people all through the summer. Even last spring, the experts predicted that its biggest appearance would be this fall. And here we are. The good news is that because it showed up last spring, we were able to get a jump on making a vaccine against it. In fact, that vaccine has been made and is being tested right now. And the news about it continues to be positive. Just in the last week or so, scientists found that the recently- made H1N1 vaccine is strong enough so that a person will need only one shot to be protected, rather than 2, as previously thought.

The official name for this flu shot is the Influenza A (H1N1) 2009 monovalent vaccine. A real mouthful. But, most everyone calls it the Swine flu shot, or the H1N1 flu shot.  Although  this vaccine has not been licensed yet, the first supply is expected to be available in mid-October. Important to know is that, unlike the regular flu shot which is available from many places including your doctor and local hospitals and other organizations, this one will be distributed only by your local health department. So, where you will be able to get will depend on the plans of the local health department in your area, and may include schools and health department clinics, among others. This should be well publicized in your locale when the vaccine is actually available. Be on the lookout for it.

Who should get the H1N1 flu shot? The Centers for Disease Control has made official recommendations on this topic just recently, and has targeted five groups of people to get this vaccine first. These include: 1) pregnant women, 2) people living with or caring for infants younger than 6 months, 3) healthcare and emergency-response personnel, 4) children and young adults (age range 6 months–24 years), and  5) other adults (age range, 25–64) who have medical conditions that put them at high risk for complications associated with seasonal influenza. People over the age of 65 are not included in these groups because they have not been nearly as susceptible to this virus as younger people have. (Finally, something good about being older!)

What about the other flu I mentioned above, the “regular” or seasonal influenza virus that we’ve come to expect a visit from each winter? Unfortunately, it is still expected this winter too.  The vaccine against it will be available at the usual time of year – sometime in October – and will be given as usual through January. It will be available as it is every year, from your doctor’s office, various clinics, and hospitals. Most everyone usually gets this flu shot each year, but of relevance to us – those especially recommended to get it are older people (especially over the age of 65) and people with chronic medical condition. Yes – this is confusing because it’s the opposite of who is especially recommended to get the H1N1 flu shot. This is because older people and those with chronic illnesses are more likely to get infected with the seasonal flu virus.

Here’s my main message. Since the seasonal flu virus is entirely different from the H1N1 flu virus, some people will need to get 2 flu shots this year.  The best thing to do if you’re confused about what you and your family members should do is to ask your doctor or clinician.  And do it soon since flu season comes very quickly this time of year.

One last thing to know.  The H1N1 flu vaccine may not be available by the time someone in your neck of the woods gets a case of H1N1 flu. So, be aware of this and put into play all the healthy practices that you already know to protect yourself and your family. Especially – WASH THOSE HANDS FREQUENTLY!

To stay up-to-date about the Swine flu and its vaccine, go to:

http://www.cdc.gov/H1N1Flu/

For information about the seasonal flu and vaccine, go to:

http://www.cdc.gov/flu/

As you can probably guess, long working hours can have negative health effects. Studies to date have shown that putting in long hours at work is associated with reactions by the cardiovascular and immunologic systems, sleep disturbances, depression, and obviously, fatigue and an overall unhealthy lifestyle.

On a different topic, there have been research studies in recent years showing that certain factors present in midlife cause one to be at increased risk for dementia later in life. One of the risk factors for developing dementia in our later years is the presence in our middle years of a decline in mental functioning. This means that if some of our mental faculties have already begun to go downhill when we are middle-aged, then we are at a greater risk for developing dementia when we get older than those people whose mental capacities are stable in midlife.

In a recent multicenter study* – done and analyzed in London, Finland, the US, and France – researchers examined, in middle-aged people, the association between long working hours (ie, working overtime, or greater than 40 hrs/week) and a decline in mental functioning (also known as a cognitive decline).  A group of five cognitive tests was administered to 2,214 middle-aged British civil servants at baseline and then five years later. Compared with working 40 hours/week, working 55 hours/week and more was associated with a decline in two of the tests over time, including a test of reasoning ability.  This means that those people who worked more than 55 hours/week during the five years of the study suffered from a decline in their ability to reason shown by their test results at the end of the five years. 

Of note, the many factors which could potentially affect these results were taken into consideration (controlled for) in the analysis including: physical diseases, education, occupational position, sleep problems, psychosocial stressors, and health risk behaviors.  There were several limitations to the study, such as the fact the number of work hours was self-reported by the participants which is dependent on the person’s ability to recall accurately, and that this study included only civil servants, and thus does not represent the entire working population. 

Since we know from other studies that the presence of cognitive decline in midlife is a risk factor for later dementia, it’s very important that we continue to learn to what are risk factors for an early-onset of decline in our mental capabilities. This study suggests that – in midlife – continued long working hours (in this case, greater than 55 hours per week) are associated with decreasing mental functioning over time.

Something to think about, right?

*[American Journal of Epidemiology. 2009; 169(5): 596-605.]

Since we’ve been writing this blog now for over a year, I decided to look back to last Labor Day to see what I wrote about. And there it was, yet again – a piece about regular exercise/physical activity, its health benefits, and my relationship with it. If you’re interested, here it is: http://www.smartwomanshealth.com/horn_miller_blog/?p=11

So, where am I this year in my quest/fight to do regular exercise? First let me mention some recent findings about regular physical activity and its effect on older individuals. In the summer of 2008, the American College of Sports Medicine and the American College of Cardiology came out with a first: official and specific recommendations on how much regular exercise each person should do to get the most beneficial health effects. These recommendations specified how much each age group should do, and discussed the different types of exercise that needed to be done. The latter included: aerobic exercise (also known as “cardio”); resistance, (also known as strength training); balance exercises; and flexibility exercises. We have an entire section in our book that discusses these recommendations.

Just a few months ago in the July 2009 issue of Medicine and Science in Sports and Exercise, the American College of Sports Medicine came out with newer findings about the benefits of regular exercise for older people. (FYI – they did not change any of their prior recommendations, however). 

Many of these we already know about from prior studies; more recent studies serve to confirm these.  A few of these include:

1)Regular longterm participation in aerobic exercise for at least 3 months is associated with actual positive changes in heart function at rest and with exercise; 

2) Regular resistance exercise over the longterm increases bone and muscle mass, and strength;

3) Regular exercise and physical activity are linked to significant improvements in overall psychological well-being, possibly via effects on self-concept and self-esteem;

4) Physical fitness is linked to a lower risk for clinical depression or anxiety;

5) Cardiovascular fitness and higher levels of physical activity lower the risk for cognitive decline and dementia, based on epidemiologic studies;

6) Beneficial metabolic changes associated with regular aerobic exercise include improved blood sugar control and clearance of fats after meals;  

7) In populations at increased risk of falling, multimodal exercise, including strength and balance exercises, and tai chi may decrease the risk for noninjurious and sometimes injurious falls;

In summary, this article concludes that no amount of physical activity can stop biological aging but that research studies show that by limiting the development and progression of chronic disease and disabling conditions, regular exercise can reduce the physiologic harms of an otherwise sedentary lifestyle and improve active life expectancy. Older adults who engage in regular exercise may also experience significant psychological and cognitive benefits.

Whew! Convinced that you should get regular physical activity?!

What about me a year after my meditation on my own exercise schedule? I’m definitely much better – I do regular sessions of resistance training, balance and flexibility exercises. And I’m better about regular aerobic activity, but still not wild about it. How about you?

I was so happy to be home. However, although I knew that I had changed in a big way, it was hard for others to see that I wasn’t up to snuff and couldn’t do my usual activities. My dogs were totally confused. They angrily barked for me to take them out for a walk. My husband, who had the best of intentions and a touch of ADHD, would forget that I was up in my bed for hours at a time. My teenage sons were off with their friends. It was time to call for reinforcements. My mother came in to help me recover. She helped to keep me from overdoing it and to keep me company.We watched a lot of really horrible movies and laughed, reminisced and rested. No matter how old I get, my mom can always make me feel better. Now, two weeks post op, I am up and around, walking daily, and have about 80% of my energy back.

I was so distressed when I found out that I needed the hysterectomy. I was upset that I was going to miss work and that I couldn’t continue to do all my multi-tasking. I was upset that my body “failed” me. I felt powerless. The funny thing is that in losing my uterus, I found my power. I learned so much about “the patient” experience. I understood the frustration that my patients express with the way the whole medical system is set up. I learned how to work with the system to get what I needed. I experienced the therapies that I regularly recommend to patients first hand and realized their potency. I was able to reconnect with my mother in a way that we never could have done if I weren’t confined to my bed. Most importantly, I learned to ask for and accept help. How amazing that in losing an organ that has meant so much to me throughout my life that I would gain power, knowledge, wisdom and grace.

Have you ever had a procedure done or gone to the doctor and had them tell you that whatever they were going to do was going to hurt? Of course, when they tell you that, it almost always does hurt! This is what we call “Medical Hexing”. From the outset, I was told that I would be in a lot of pain after the hysterectomy; I was going to feel really tired and wiped out, and that I was not going to be healed for at least six weeks. In a way, I felt set up. I realized that there were things I could do that might help me avoid or cope with pain and improve my healing in ways that conventional medicine couldn’t or wouldn’t.

In my clinic where I work, we have a wonderful psychologist who is a guided imagery specialist. I knew that he could help me. Guided imagery is a method of treatment that uses your mind to take you to a calm, relaxing wonderful place. It induces a state of relaxation and helps your mind to direct pain control and expedite healing. I had a session with him at which time he had me relax and took me on a journey in my mind to a beautiful beach. While on the beach he had me see myself relaxed, healing quickly and experiencing very little pain. The tape was about 30 minutes long. I listened to it every day for a week before the surgery and I listened to it during the surgery. There are many medical studies that have shown this to be a very effective method to reduce surgical complications, reduce the need for pain medication, and improve the speed of healing.

In addition to the guided imagery, I went to our clinic acupuncturist. She treated me for a two-hour session the day before my surgery in which she worked on the acupuncture points to help prevent nausea, boost my immune system, charge up my adrenal glands and help with pain control. I walked out of her session feeling great. The session had the added benefit of stopping the bleeding that had been going on for almost two months! Between the two therapies, I felt really good and I wasn’t upset or scared anymore.

I was able to do one other thing that helped. I insisted upon being able to choose my anesthesiologist. Once I asserted myself, guess what happened? They let me choose! When you have surgery the anesthesiologist is just as important as the surgeon. I chose the anesthesiologist who was recommended by other doctors and one who understood my need to listen to the guided imagery tape during surgery. He was also trained in acupuncture just in case!

The day of the surgery I felt calm, and I told my doctor all the things I had done to prepare. I predicted to her that I would need very little pain medication, I would have very little bleeding and that I would be out of the hospital in two days. She looked at me as if I was nuts. That was the last thing I saw before the preoperative anesthetic went into my arm and I was in la la land.

Although my doctor wanted to take my uterus out as soon as possible, I talked her into waiting a couple of weeks to give me a chance to prepare. I needed to prepare my family and my practice. I also needed to prepare myself emotionally. She said that as long as my endometrial biopsy was negative, I could wait. It took two days to get the biopsy results back. I walked around for two days thinking that I probably had cancer and going through a mental checklist of what I was willing to do for treatment and what I wasn’t willing to do. I couldn’t sleep, and I couldn’t eat. When the biopsy came back negative, I was incredibly relieved.

I was informed that I was going to need an abdominal hysterectomy since the mass was too large to be done vaginally. They wanted to take my ovaries, just because they were there and I was insistent they leave them in along with my appendix that they wanted to take out! Although I was no longer worried about cancer, I had surgery and the knowledge of the zillions of complications that could occur to contend with.

I realized that I had little control over what was about to happen to me, or so I thought. I could however stop them from taking out healthy organs that would otherwise be taken out simply because they are there. I was told initially that I could not choose my anesthesiologist. I wanted to listen to an audiotape during the surgery and was told that it was up to the doctor in charge of my head (the anesthesiologist). If one doctor was in charge of my head and one was in charge of my uterus, who was in charge of the whole body?! I was told to register for surgery over the phone. I called at the given time and was told that since I was healthy and the registration department was so busy that I didn’t need to go through the procedure. Unfortunately, that meant I had no idea what to expect!

I realized that although this surgery was major to me and would have an impact on my body and my life, for those doing or participating in my surgery, this was routine. It’s their job. Sometimes, I think, those who do it every day forget the true impact of surgery and its implications for the patient. My patients had expressed frustration with various hospital procedures and experiences to me and I have a new understanding of what they were talking about. I decided I needed to take charge and get some of my control back! So, I did.

I have always considered myself to be very healthy. In fact, I have prided myself on staying fit, eating a healthy diet, and being as proactive as possible regarding my health. Of course, when, a few years ago at age 53, I started having vaginal bleeding AFTER going through menopause and my life was out of control, I managed to ignore what was going on. When it continued on and off for a couple of months and I caught myself chiding a patient for not letting me know about her intermittent post-menopausal bleeding, I realized I had a problem.

Even then, I was in total denial about anything being wrong with my “very fit” self. I called my doctor and arranged for a pelvic ultrasound. When the ultrasonographer gasped at the site of my ultrasound, I knew I was in trouble. I could see that there was a very large mass filling the space that used to be my very petite uterus. My heart sank. It was so bad that the ultrasound technician walked my ultrasound and me over to my doctor’s office and insisted that my doctor needed to see me right away. I have a doctor who is very calm. When she got upset, insisted on doing an endometrial biopsy and wanted to take out my uterus the next day, I freaked out. She said she didn’t think that I had cancer, but her eyes told me that she was worried.

I am a doctor, I am not supposed to get sick or have problems, right? I realized I had a health issue that I needed to take care of, and I knew it was time for my uterus to come out. I was no longer the doctor I was now the patient. All kinds of feelings were stirred up for me. I have two sons and they were both hatched in my uterus. Now this very important part of me was going to be removed. It is hard to describe, but I felt a deep sadness mixed with a sense of gratitude.. I got very nostalgic when I thought about the births of my children and what I was able to do with the help of the organ I was about to lose. I also was hit with a sense of humility. I realized how insensitive I had been to others who had lost theirs. So many of my patients have had hysterectomies and I dutifully recorded it in the past medical history section of their chart. I never thought about what it meant to so many of those women. Clearly, this was one of many learning experiences for me on this surgical journey.

STAY TUNED FOR PARTS II – V…