Tuesday, September 20, 2011

I couldn't have said it better!!!

I have helped a great number of patients over the last ten years, but only Eric David has had the ability to crystallize the Brentwood Diet in all of its essence.  Eric's blog article masterfully takes you along his journey with the spellbinding captivation that keeps you wanting more.  I found it not only brilliant and inspirational, but ground breaking and humbling. 

As the title of this post states, I couldn't have stated it better.  I urge you to read it and dare you to not be moved by his heroic struggle.  I wish I could tell you all that we are all unique, to some degree we are, but truth be told we are more alike than different and those similarities among us allow us to lead one another to a better place.  If in the most adverse of circumstances Eric can do it, then you too must certainly be able as well. 

I have tremendous respect and admiration for Eric, not so much because he has done well on my program, but because each time I see him, I am reminded why God loves us so much. 

Eric, may God bless you and your family.  Thank you for all that you do.

Your biggest fan.


How Drugs Affect Us!

I have wanted to write this blog for a long time, but recent events and troubling conversations with patients compel me to address this issue now.

First what is a drug?  The classic definition states that any substance with the ability to alter ones state may be defined as a drug.  With this definition, even water qualifies as a drug.  Indeed water can actually be lethal if ingested to excess.  Diabetes insipidus creates such inordinate thirst that patients literally drink water to death.  Excessive consumption of water severely dilutes the electrolytes in the blood and leads to brain edema (swelling) causing death by herniation of the brain stem.  It is not uncommon to remove the faucets from the sinks in the hospital rooms of such patients to prevent them from drinking.   I once had to treat my sister’ acute renal failure when she returned from a medical spa.  She was hyponatremic (when sodium level is too low) and hyperkalemic (when potassium level is too high) from over hydration.  Her sodium and potassium had been so altered that she fainted and needed emergent resuscitation with aggressive intravenous fluids and electrolytes.

If something as seemingly inoffensive as water can be so potentially dangerous, what are we to say about sleeping pills, marijuana and Vicodin?  I will focus the remainder of this article on those three as they seem to be the most sought after prescriptions.

Ambien and Lunesta boast non-addictive properties, but in fact, these were designed for short term use and were approved by the FDA for such labeled use.  In reality, most patients using Ambien and Lunesta have done so for years and refuse to stop using them.  The refrain is a well rehearsed chorus, “I don’t use them every night!”  I have yet to find this retort convincing or satisfying.  The truth remains whether chemically addicting or addiction by habituation, these individuals have become chemically dependent and will not stop their; not every night routine.  Of note, if recollection serves me well, non-addiction was based on a six to twelve week trial.  I can count on one hand the number of patients who request sleeping pills and use them for a short term.

Marijuana has the reputation of being a benign drug; really?  As one of the on-call ER admitting physicians at Saint John’s Health Center in Santa Monica, California, I can assert by actual experience that marijuana is not a benign drug.  The fact that most people would think that it is remains most alarming to me.  Very little is said of THC related intractable nausea and vomiting.  I recently admitted a 27 year old gentleman whose career was taking off with a once in a lifetime job offer.  He was brought in to the emergency room by ambulance after being found down and unable to come out of the fetal position.  Initial evaluation revealed a severely dehydrated young man in acute renal failure.  His main complaint was intractable nausea and vomiting so severe that he was now throwing up blood.  He was aggressively resuscitated with intravenous fluids and given large doses of Zofran (anti-nausea medications) but alas, this treatment which would suffice to treat chemotherapy patients did not alleviate his symptoms in the least.  Other than treating him with sedatives and narcotics, there was little else we could do.  Had he been unable to reach help, he could have died.  So short answer, marijuana is not as safe or benign as one might think.   Like a lot of things in life, personal experience of others is not a predictor of your actual life.  I drive across railroad tracks often.  I have seen cars pulverized when struck by a train, it has never happened to me, most likely won’t, but  am I one hundred percent certain that it can’t or won’t? 

Finally let me address pain killers; and leading the pack, the one with the catchy name Vicodin.  I think it is helpful to understand how pain is perceived and why narcotics although very potent and powerful medications have such a narrowed useful range.  Most common pain conditions result from acute trauma, chronic aches and pains, surgery and cancer.  Acute pain occurring in the setting of kidney stones, chronic back aches and arthritis actually respond poorly to narcotics and are much more effectively treated with non-steroidal anti-inflammatory medication like ibuprofen and naproxen.  All NSAIDs have common side effect profiles including gastrointestinal bleeding and renal mediated hypertension among others, but they are non-addicting and actually treat inflammation;  the cause of the pain.  The use of narcotics for these types of pain, although effective in the short run because they address the pain perception centers in the brain, do nothing to treat the actual cause of the pain and do not alter the course of the disease causing the pain.  So what are we actually achieving with narcotic use?  We don’t treat the disease, we don’t address inflammation and in the case of the kidney stone, it’s still in the urinary tract, it still hurts, you just don’t care.  Compare that to using an NSAID like Toradol which when given intravenously actually relaxes the ureter and releases the stone and treats the inflammation mediated pain.  I am not averse to  the use of narcotics in the indicated setting, immediately post surgical, in cases of rib trauma in order to be able to take deep breaths to prevent pneumonia, but the rampant  “I have a boo boo reach for the Vicodin”, when an ice pack would have done the job is an abuse of the drug. 

Parting story, beautiful 34 year old young woman with history of severe emotional trauma seen by a pain specialist for severe back pain which developed shortly after her husband’s death.  MRI of her spine revealed a 10 mm disc herniation in her lumbar region and she was consequently placed on increasingly large doses of narcotics to include Percocets, Percodan, Vicodin as well as Fentanyl patches.  To my amazement, these did not fully address her pain.  She came to see me wearing high heels seeking my help.  The instant I saw her I told her that it would be quasi impossible for that disc to be an issue at the present time if she was able to wear high heels.  We repeated the MRI and in fact the disc herniation had resolved as most would with time, but what was causing her pain now?  The addiction to the narcotics created a pathway where as soon as the drugs wore off, she would experience a phantom like pain that was indistinguishable from the initial pain and only high doses of narcotics would keep the pain away.  She agreed to undergo detox and has been narcotic free ever since.   She is but one among many such stories. 

My advice is simple; narcotics only when absolutely necessary for the shortest duration possible and only when no other modality is suitable.  Two exceptions, it is true that narcotics do not tend to be addicting when used for the treatment of true pain for short durations, and in patients facing end of life issues where comfort measures supersede all other concerns, narcotics are perfectly appropriate.

I welcome your comments.

Wednesday, September 7, 2011

Are men really better at losing weight?

I can’t believe how time flies.  It has been a long time since my last post but at the urging of one of my readers in Florida, Caroline; this one is dedicated to you. 

To those disappointed that I took so long between posts, I am truly sorry.  I started chasing too many rabbits only to realize that by the time I caught one, it was too lean to eat.  My analogies tend to annoy my wife enormously, but as you may gather from previous posts, I am a visual

Not unlike the book by John Gray, Men are from Mars, women are from Venus, I think that the issue differentiating men and women with regard to successful weight loss is a matter of taking turns.  When I make lunch or dinner for the kids or the family for that matter, not that this occurs often mind you, but when it does, I notice a significant difference from what happens when my wife Anita prepares meals.  In contrast to my wife who as we start to eat still runs around the kitchen frantically serving, or cutting up fruit for dessert, I am actually sitting with everyone during the meal.   Another way of looking at it would be to imagine a family boarding a train.  The dad gets on the train first while mom on the platform hands him the suitcases and the kids to load onto the train.  As the train starts pulling away from the station, she is buying snacks for the kids at the concession stand still making sure that everything and everyone ishappy, instead of making sure that she has also boarded the train.  Now imagine this happening train after train.  The problem with this altruistic behavior is that it perpetuates the belief that everyone else’ needs come first.   Is this really the message we want mentor for our children or publicize to the world? 

What are we instructed to do on board an airliner as the oxygen masks pop out of the ceiling?  Place the mask over your mouth and nose, pass the elastic band over your head, pull the ends snuggly and breath comfortably, THEN, ASSIST  YOUNG CHILDREN AND THOSE NEAR YOU WHO MAY NEED ASSISTANCE.  If you are incapacitated, while trying to assist others before you put on your own oxygen mask, no one survives.  The assumption made at the train station is that mom can always catch the next train, what if you are going away for one week, and it’s a weekly train? I know what you are thinking; that’s one way for mom to get a break!  Not the point I am trying to make here. 

My recommendation is take your turn first so that you can best help others.  I have been taking
Wednesdays off since the day I opened my practice.  I am in solo practice, it has been this way
since the beginning almost ten years ago.  Twenty four hours a day, I answer my phone.  No answering service screening my calls after hours, nights and weekends, no cross coverage.  In the beginning, I didn’t have any patients on Wednesday except the occasional hospital patient, but by principle I didn’t go to the office on Wednesdays.  Since the practice got busier, I round at the hospital and see emergencies only on Wednesdays, but that is all I do.  The rest of the time I go sailing.  When I need to go to the hospital and round on Wednesdays, I dress very casually, shorts and T-shirt, and I stop in on my way to the boat.  The way I dress is not meant to be disrespectful, but rather serves as a reminder to myself and others that this is still technically my day.  I still get teased by staff members at Saint Johns, who used to kid;  ”you  don’t need to take Wednesdays off, you don’t have any patients yet.”  But the rule is no work on Wednesday.  I also shared the fact that once you start making money on Wednesdays, it’s hard to stop.  Weekends tend to be devoted to family obligations, so without Wednesdays off, I would burn out.  By now, my patients know not to call me on Wednesday unless it is an emergency; they too recognize that I am a better physician to them if I am able to take care of myself FIRST. 

This is not an original thought on my part.  It’s a hybrid from the first law of savings; first pay yourself, then pay your bills.

So whether you are starting the diet, or an exercise plan or a new hobby, take your turn first.  There
will be a lot of resistance, but change always brings resistance, we are creatures of habit.  Stick to what you need and others will respect your determination.  Make it a rule and if you need to justify it, use the line from Dangerous Liaisons when John Malkovich says: “It’s beyond my control.” 

Monday, April 20, 2009

What is all of this I hear about “The Brentwood Diet?”

Before I answer that question, a little background information will help.  When I started practicing internal medicine in Brentwood, I started the practice from scratch; that is to say, no patients followed me from a prior practice.  I managed to pay the rent by doing what is called locum tenens.  Locums are temporary employment assignments in various settings.  Some were emergency medicine opportunities, while others were substitutions for physicians going on vacation or taking maternity leave. 

 One of these jobs consisted of replacing an endocrinologist in the South Bay area.  I had always enjoyed endocrinology and the office was a very nice setting in which to work. 

 On my first day there, I met a patient named Dino.  He was in his early sixties and was nearing retirement.  Before entering the examination room, the practice manager gave me a little background on Dino.  He said, “Dino is a very nice person.  He has been a patient for many years and is very compliant with his medications.  His blood work today is very good.  His hemoglobin A1c is in good range and his cholesterol is well controlled on Lipitor ”. 

 I entered the room and was taken aback.  As I was introducing myself to him, a loud voice was shouting in my head,  “How could this be? He must weigh over 300 lbs.  How could his numbers be in normal range at that weight?  Does it even matter?” 

 Because I was just substituting, I had rehearsed a whole speech to the patients to minimize disruption in the office routine.  I couldn’t do it.  As I began to speak to Dino, I could hear my wife tell me, “Can’t you just leave well enough alone?  Can’t you just leave things the way they are and just do the job that was asked of you?”  Obviously, I couldn’t.  So I asked Dino, “Dino, where do you see yourself five years from now?”  He told me, “Doc, I am retiring after working at the same place for forty years.  I have a heck of a retirement pension coming my way and life is going to be great.”  To that I replied, “Dino, at the rate you are going, you will be barely functional in five years.  Most likely, your wife will enjoy your pension with someone else.  You are close to three hundred pounds and climbing, seriously where do you think this is going to go?”  He looked at me perplexed.  “Doc I am doing everything I am told.  I take all of my medications.  I show up to all of my appointments, what else can I be doing?”  I told him, that the insulin he was taking was acting like a growth hormone.  The more he uses it, the hungrier he gets, and the more he eats, the more insulin he needs.  It’s a vicious cycle.  “Are you willing to try something new?”  He said sure.  I stepped out of the room and hand wrote the first version of the diet.  It was limited to lean protein, zero or near zero calorie vegetables and eliminated all traces of carbohydrates. 

 I returned to the room and explained to him what I needed him to do.  He would start right away and would return in one week.  I gave him my cell phone number and instructed him to call me should he have any questions or concerns.  He called me on Saturday morning, almost two days after meeting him, and he told me,  “My sugar level this morning is 70, what should I do?”  Celebrate?  “No seriously Doc, how much insulin do I take?”  I told him to stop all of his diabetic medications and let’s see what happens tomorrow.  The rest of the day he kept checking his sugar before each meal, and he called me on Sunday with the results.  His sugars had normalized and he did not need to take his Avandia or insulin.  I had instructed him to continue taking Glucophage, as there is no risk of hypoglycemia with this medication, but all others had to be stopped.  I waited anxiously for the week to pass to see him again.  As I was about to walk into the room, the practice manager told me, “You won’t believe this, Dino lost 12 lbs this past week.”  I stepped into the room and asked Dino “How do you feel?”  I feel really tired but I can’t believe that I lost 12 lbs.  Do you think that you can do this for another week I asked him?  He said sure.  The following week, he lost an additional 8 lbs and his blood pressure had dropped so low that I had to stop his blood pressure medications as well.  He felt a little better, but still a bit tired.  Again, I asked if he could continue another week, and he did.  He returned the following week, wearing shorts and reported that he had walked the length of the Strand in Redondo Beach, approximately one and one half mile each way with his wife on Sunday.  He told me that it had been over fifteen years since he felt like doing anything like that.  He had lost another 5 lbs and looked like a completely different person. 

 Diane was the next patient to try this program.   She became angry that no one had ever suggested to her that she there was an alternative approach to treating her diabetes, hypertension and dyslipidemia.  This combination of diabetes, high blood pressure and elevated cholesterol is also known as Metabolic Syndrome.  Diane is an engineer, and until her move to Arizona, she kept meticulous spreadsheets of her blood pressures, and glucose levels.  We still e-mail each other and she has continued her new lifestyle ever since.

It is easy to get people who are very sick to make dramatic changes, but how do we succeed with individuals who are not yet sick, but who will inevitably get there on their current path? 

 Many patients come to me after trying the diet on their own, but to a great extent, it is the advice I give them in the office that facilitates their success.  You are more than welcome to try this program on your own, but please, have your physician monitor your progress, your renal and liver function, as well as your lipid profile.

 Who should not be on this diet?  This diet will trigger an Atkins-like state of ketosis, a state of high fat burning.  Ketosis needs to be closely monitored in patients with heart problems, especially arrhythmias.  Individuals with renal failure should be monitored closely with regular renal function studies.  Type I diabetics would not need to consider this diet as they tend to be lean.  But if tempted to try it for nutritional purposes, Type I diabetics, need to be followed by their endocrinologist.  Pregnant patients should avoid ketosis mainly because we do not know the effects this would have on the fetus, although my bias is that it wouldn’t be harmful, but I do not know this with certainty. 

 It is my intention and my hope that with this blog, I will help a greater number of people than I am able to see in the office.

Sunday, April 19, 2009


When I graduated medical school, I made a deal with God.  I told Him, “You deal with all of the big stuff, and I will deal with all of the little stuff ”.  So, contrary to popular belief, I do not save lives for a living.  I don’t think that I have that power.  What I can do is enhance quality of the life of the people seeking my help.  I have to be honest; they are not always “seeking” my help.  Sometimes I just volunteer it because they aren’t able to run away fast enough!  Those are the times my wife tries to reassure them, “He really is quite good at this, you know.  He is able to cut to the core of things, able to focus like a laser beam!”

 I am frequently asked by patients, “Why are you so focused on weight, when I have so many other medical issues I need to deal with?” The answer is quite simple.  Imagine the plumbing in the house needs reworking because the old iron pipes are corroded and prevent good water pressure.  Simultaneously, the home inspector tells you that your home is horribly termite-infested, and if repairs are not undertaken at once the integrity of the house may be jeopardized.  (In California, the main destroyers of our homes are termites.  They will rot a house from the foundation up without ever being noticed.)  What would you address first?  The termite issue, of course.  Even though the low water pressure is the most noticeable problem every time you get into the shower, the termites are the more threatening issue.

 People are like houses.  Some are in move-in condition, some need a little clean up, and some need a lot of work.  Then again, some need so much work that tearing them down and starting over is a wiser approach!  The art of medicine is choosing when to use a broom, a hammer, or a bulldozer.

 In my patients’ cases, as in the majority of the American population, the overriding problem is obesity.  For many patients, it’s morbid obesity.  Morbid obesity, defined by a Body Mass Index (BMI) greater than 30, means that the weight is so high that the weight itself contributes to disease processes.

 To be clear, termites are not always obesity; they can take the form of depression, substance abuse, self-deprecation and sabotage of one’s happiness, and the inability to regulate the stressors in one’s life, to mention but a few.  In future postings, I will address The Brentwood Diet came to be.  I will walk you through the diet and show you how my patients are able to regain control of their lives. 

 Hilary Smith, one of my patients, has created a blog, Surviving The Brentwood Diet, http://survivingthebrentwooddiet.blogspot.com.  I found it very accurate and insightful.  I enthusiastically refer you to her blog and encourage you to use it as a forum to exchange ideas and recipes that you have found helpful.

Thursday, April 16, 2009

Welcome to the Brentwood Family Health Center

I was asked today why I spent so much time talking to my patients and not as much time examining them.

I was taught long ago that the history portion of a patient visit provides 90% of the information needed to arrive at a diagnosis and that the physical examination and the tests used to confirm the diagnosis account for 10% of the encounter. I still believe that this is true. I must admit that I cheat a little.

The way my office is designed, the waiting room is about forty feet away from my office. There are a couple of turns along the way, and since I usually escort patients from the waiting room to my office, I get to see how they get out of the chair in the waiting room, I observe the way they take their first steps and how steady their gait and balance are that day, as well, I smell them as I greet them with a hug. To most people, this wouldn't add up to much, but in those few instants, I have already determined whether or not they have a fever, if they have a streptococcal infection or diabetes, as well as the state of their hygiene. All of this and they haven't even embarked on the long walk to my office. This dynamic assessment of patients is more accurate and informative than the traditional disrobed patient waiting in an examination room. As we walk to my office, we talk and I assess the state of their mood, and vigor. Can they keep up with me or am I steps ahead of them? Do they stop at the corner to negotiate the turn or are they swift? Do they bob from side to side or do they use the wall to steady their steps? Are their hips level as they walk or are they favoring a particular side, or joint? Are they dragging their feet, or flapping them? You get the idea... By the time we sit down, I already have a pretty good general assessment of how they look and must feel. My first question: How are you doing?, is almost redundant, but it opens the conversation and allows the patient to fill in the blanks. While we talk, I study the rate of their speech, the tone and quality of their voice, their choice of words, and whether or not they are using first choice words or the ones that come first, because they are blanking on the word they actually want to use. Are the hands shaking, is the face quivering? Are they fidgety, anxious? Is their complexion normal or sallow? Are the conjunctiva icteric (jaundiced)?

There is so much information I gather during the talking part of the visit, that the examination is an opportunity to take a closer look at things I suspect are going on and to reassure the patient that I am actually doing something.

I ask my patients not to wear perfume prior to seeing me, and I would advise you to do the same. Along the same line, for those of you who still smoke, it's a good idea to try to not smoke prior to your visit as the cigarette smell on your clothes is overwhelming and distracting.

Lastly, I order the fewest tests possible, and this tends to bother some patients. I use tests to confirm or rule out what I already suspect. If I can't figure out what I am looking for; that's the time to send the patient to someone smarter than me.