My comments from the Envision Adult Support Group

I had the pleasure of speaking at Envision this morning about diabetes awareness. Here are my comments:

Thank you for having me. This is not my first time speaking at Envision. It’s always a pleasure to be here. There’s an old joke that the moment a speaker steps to the lectern the crowd wonders: will this be a short, informative talk, or are we stepping into a low-key hostage situation? I promise this is not a hostage situation.

This is the story of Victoria. When we tell biographies, one of our first instincts is to say when and where someone was born. “Robert Goddard was born October 5, 1882 in Worcester, Massachusetts.” You know what I’m saying. But here’s the thing: Victoria hasn’t been born yet. Yet we already know some things about her, assuming she’ll be born in the United States. We know she’ll have a lifetime risk of developing diabetes of around 50%. A coin toss. We know she’ll have a lifetime risk of being overweight or obese of at least 70%. Way worse than a coin toss. We know that these risks will be less related to any specific decision Victoria makes than to the environment in which she is conceived, gestated, born, raised, and in which she ultimately works.

But before we get to that, you deserve to know how I make my money. I have a strange career. I’m an endocrinologist by training. That’s a doctor who specializes in metabolism and hormonal disorders. I’m still board-certified, and I still see patients at Guadalupe Clinic. But the much bigger fraction of my career is spent trying to change the way care is delivered. That sounds too simple. You know the frustration of calling for a doctor visit, waiting on hold, getting an appointment months from now, then waiting in the waiting room for a half an hour while you do paperwork, then waiting in the exam room in a paper gown for another twenty minutes, and then never even getting a copy of your labs once you’re done? That’s what I mean. That’s what we’re trying to change. More care can be delivered by non-doctors in non-offices and at the convenience of you, the patient. 

One of the organizations that pays me to try to affect this change is the Centers for Disease Control, the CDC. Specifically, they along with the Kansas Department of Health and Environment pay me to try to encourage more doctors to offer care like the Diabetes Prevention Program or Diabetes Self-Management Education, or the Diabetes Self Management Program, all of which we’re going to talk about today. So be a cautious consumer. As I talk, ask yourself if you think I really believe the things I’m saying, or if I’m just a government stooge repeating words put into my mouth by my benign overlords.

I originally called this talk, “Should I go to diabetes education?” But I’ll talk about more than that.

Let’s get back to Victoria, our future, not-yet-even-a-twinkle-in-her-mom’s-eye. When Victoria grows into adulthood she’ll be told by her doctor that she needs to take in fewer calories and burn more calories in the form of physical activity or exercise. Good advice. We call these the “Big Two”: diet and exercise. And historically we’ve blamed the obesity and diabetes epidemics on decreased physical activity and increased caloric intake. The physics of it just make sense: you can’t make fat out of air. But there’s a big problem with limiting our explanation of her risk to this simple “calories in, calories out” model: the math doesn’t add up. 

Intentional leisure time physical activity--that’s the kind that takes equipment, like shorts or special shoes or a bicycle or a pool--has gone up (way up) since the 1980s. Yet as a nation we’re fatter than ever. Investigators writing on the findings of a 2016 study in Obesity Research & Clinical Practice noted, “A given person, in 2006, eating the same amount of calories, taking in the same quantities of macronutrients like protein and fat, and exercising the same amount as a person of the same age did in 1988 would have a BMI that was about 2.3 points higher…about 10 percent heavier, even if they follow the exact same diet and exercise plans.”

Why is this? Why are we punished for having habits that are objectively better than those of our parents?

Well, it is no one thing. Anyone who tells you that they know the exact problem and have the precise solution is lying or excessively optimistic or both. It’s the combination of a lot of things, and like Victoria’s, our risk is teetering one way or the other long before we’re conceived, let alone born. Let’s go back to pregestational Victoria. 

If Victoria’s mom is anything like most of us, we know a couple things. First, she probably carries a few extra pounds. And we know that those extra pounds carry just the slightest advantage in reproduction. That is, Victoria’s mom is ever so slightly more likely to get pregnant and carry a baby than a woman who is of a normal body weight or who is too thin. So Victoria is simply more likely to be born than someone with a very thin, non-diabetic mom would be.

The second thing we know about Victoria’s mom is that she has probably had some chronic, low-grade lead exposure, especially if she has lived her life in an urban center where dense car traffic spewed leaded exhaust into the air for decades and let it settle into the soil. The higher the lead level in Victoria’s mom’s blood, the higher Victoria’s risk for obesity, even if mom never had enough lead in her blood to be considered “lead poisoned,” and even if Victoria herself never had enough lead in her own blood to be considered dangerous by current standards. 

And birds of a feather, well, you know…flock together. Victoria’s mom is likely to choose a mate whose body in some way matches hers. Or he chooses Victoria’s mom. Either way, since we know that something like two-thirds of body weight is heritable (that is, two-thirds of your risk of being thin or being heavy), having both a mom and a dad who carry extra weight puts even more pressure on Victoria’s future weight.

Since Victoria’s mom and dad have bills to pay, there’s a big chance they put off having a family. That’s the new American way. Not only the American way; the western way. The age at first birth in the United States has gone from 22 to 26 since the 1960s. And every five years parents wait to have a child, the risk of obesity in the child may go up fourteen percent

Five years after they marry, Victoria’s mom and dad decide to get pregnant, and they have good luck. But during Victoria’s gestation, her dad encourages her mom to “eat for two.” We now know that increased fat and sugar in mom’s diet can cause “epigenetic effects” in the fetus. Remember the way DNA is put together, with A and T and C and G all writing a code that turns amino acids into proteins? Epigenetic effects aren’t changes in the A-T-C-G order of base pairs in the DNA itself; these are modifications of those base pairs, like sticking an extra branch onto the side of the “A” to keep it from coding quite as efficiently as it should. And we know one of the possible effects of these epigenetic effects may be to make Victoria more prone to weight gain and diabetes.

Finally, Victoria is born. Her mom breastfeeds her, like most moms do now, and which may have some protective effect. But after that Victoria eats what her folks buy for her: a largely government-subsidized diet that is >50% highly processed, has little fiber, and contains >2x the meat needed. We now know that this highly processed food dramatically increases our risk for weight gain and diabetes.

Investigators at the NIH recently paid twenty volunteers (ten men, ten women) to live in a research hospital for a month. They were randomly assigned to eat either an “ultra-processed” diet (think packaged meat, gravy, and potatoes) or an unprocessed diet (like fresh broccoli, cooked rice, and frozen beef) for two weeks. The diets were identical in the number of calories and amount of nutrients like fat, sugar, protein, and fiber. The volunteers were observed closely for food intake, and frequent testing was done to determine how many calories they were burning. After two weeks each person in the study was “crossed over” to the  opposite diet from what they’d started on. That is, the processed diet folks started eating the unprocessed diet, and vice-versa.

What the investigators found was dramatic. In spite of having equal  numbers of calories available to them at every meal and snack, the people eating the processed diet ate about 500 calories per day more  than the people eating the unprocessed diet. This showed up in their weight: the processed dieters weighed, on average, 2 pounds more at the  end of two weeks than they did at the start of the diet. All their extra weight was in the form of fat. And this may not have even done the effect justice: since the processed food had so little fiber, investigators had to sneak fiber into the processed food just to bring the level up to the unprocessed diet’s fiber. Without that, the results probably would have been even more dramatic. 

When young Victoria turns twelve her parents decide to reward her for her good grades with new cell phone. To keep up with the social scene at school she starts sleeping with it, checking social media when she wakes up at night. As a result of this she ends up sleeping less than seven hours per night. This disrupted sleep has a measurable, clinical effect on her appetite, probably because of changes in hormone levels like ghrelin (from the stomach) and leptin (from fat). 

In addition to the effect of abnormal hormones, Victoria is exposed to a lifetime of endocrine disrupting chemicals like those in air pollution, pesticides, flame retardants, and food packaging. Endocrine disruptors are chemicals that mimic or block the effects of naturally occurring hormones. Investigators in 2017 measured the amount of bisphenol A, a chemical you’ve heard of as “BPA,” in the urine of volunteers. They noted that people in the top quartile of BPA excretion, that is, the people who had more BPA in their urine than 75% of their peers, had a mean body mass index (BMI) a full point higher than people with the lowest BPA level. And BPA is one of thousands of potential chemicals we are exposed to now that were not in our environment even a few decades ago. 

While Victoria eats her processed diet and takes in a strange brew of endocrine-disrupting chemicals, she lives and works in a strictly air-conditioned, heated car, office, and home that block any exposure she would normally have to hourly or seasonal temperature excursions. She’s almost never hot and almost never so cold that a cardigan can’t fix it. The effect of this may be to increase hunger. Researchers in the journal Physiology and Behavior noted that people in an office experimentally heated to 81 degrees reported decreased hunger, decreased desire to eat, feeling fuller longer. Not surprisingly, they were thirstier than their cooler peers. 

Because she lives in a cul-de-sacced suburb that is poorly designed for walkability, Victoria does not have the opportunity to walk anywhere. Not to the store, not to work. Her only opportunities for meaningful physical activity come from going to the gym. She cannot spontaneously exercise. The effect of this can be dramatic. In 2014, engineers reported in the Journal of Transportation and Health that going from an intersection density of 81 per square mile to 324 per square mile dropped was associated with a reduction in obesity from 25% to less than 5%. Similarly, going from a community design that made walking difficult to a grid-like walkable layout cut the obesity rate by a third. 

Perhaps in part because of her poor sleep, processed diet, lack of exercise, Victoria becomes depressed and is put on an SSRI medication by her doctor. These medications and many others have the effect of a small but predictable amount of weight gain.

Depressed yet? Don’t be. There’s not a thing on that list that we couldn’t fix if we wanted to. But I’m not here to talk politics or policy. I’m here to talk about things you can do personally to change your risk of weight gain, diabetes, and complications of diabetes. And anyone in the room with type 1 diabetes, which is less affected by weight, don’t go away. A lot of this applies to you, too. 

If you’ve heard me talk before you might be aware of Justin’s Rubric for Quality Health Care. Any potential medical test or treatment should meet one of three standards. Either:

  1. It should make the patient feel better. This includes hundreds of treatments, like using medications and physical therapy for pain, prescribing inhalers for asthma, giving antidepressants and therapy for depression, and replacing knees. It does not, unfortunately, include much of diabetes care. Any person in the room who takes multiple doses of insulin per day and checks her blood sugar even more often than that can attest to this. Or:

  2. If it does not make the patient feel better, the test or treatment should make the patient live longer. This applies to everyday things like checking and treating high blood pressure and high cholesterol (neither one of which make most patients feel any better or worse today) to surgery and chemotherapy for cancers (most of which make patients feel much, much worse at least in the short-term, but prolongs many lives). Or finally:

  3. If a treatment makes no difference in how the patient feels and makes no difference in how long the patient lives, it should at the very least save money. The best example of this may be diabetes screening. As far as we can tell, screening for diabetes does not prolong life, at least not in the two or three trials that have specifically addressed the question. But diabetes screening linked to preventive measures like the Diabetes Prevention Program clearly saves money.

Diabetes was once a syndromic diagnosis, usually diagnosed when someone presented with epic amounts of urine, extreme thirst, unintentional weight loss, and sometimes strange infections. The very words we use to describe this condition give the crudeness of the diagnosis away: diabetes is from a Greek word meaning siphon, “to pass through.” Mellitus is from a Latin root word meaning honeyed or sweet. Because once upon a time, the diagnosis was confirmed by your doctor tasting your urine for sweetness.

But as our ability to test became more sophisticated, we began finding asymptomatic people with elevated blood sugars, and we had to decide who was normal and who was abnormal. It’s a tougher question than you may think, and we may still not know the answer.

So when should Victoria be screened? Or should she be screened at all? Like many questions in medicine, it depends on who you ask. Every test has risks and benefits. In the case of diabetes screening, the risks are small. There is the issue of the needlestick, but beyond that you mainly risk having an abnormal lab value on your chart. The primary benefit is financial. If Victoria is diagnosed with diabetes she can expect to spend $8,000-12,000 dollars more on medical care than the average non-diabetic person, with 12 percent of that coming out of her own pocket. Unfortunately people who are screened for diabetes and catch it early don’t seem to live longer than those who are caught according to symptoms, but they may feel better in the long run. And if we’re lucky enough to catch Victoria’s blood sugars before they rise into the frank diabetes range, we have things we can offer her.

With this in mind The United States Preventive Services Task Force (USPSTF) says that anyone between the ages of 40 and 75 should be screened at least every third year. The American Diabetes Association says that screening should begin at age 45 but expands this to say that anyone as young as age 10 with certain risk factors like family history; Native American, African American, Latino, Asian American, or Pacific Islander heritage; or certain signs of insulin resistance in the skin or reproductive organs should be screened. They’ve developed a tool alongside the American Medical Assocation and the Centers for Disease Control called the Diabetes Risk Test--you can take it yourself at preventdiabeteswichita.com--that asks a few questions (some demographics, your family history, your physical activity, your height and weight) and tells you whether they think you ought to be screened.

Screening generally means a check of Victoria’s first-morning blood sugar after fasting overnight. It can’t be done with a fingerstick, so Victoria has to resist the urge to borrow a machine from her mom. It needs to be done in the lab with blood drawn from a vein.The cutoffs that we set for pre-diabetes and diabetes are, naturally, semi-arbitrary, but they’re ultimately based on the eye. If Victoria’s result is a blood sugar of 126 or above repeatedly, it means she’s diabetic. If you think 126 is kind of a strange number, you’re right. That number is set at the point where she’s more likely to develop diabetic eye disease. So it’s the eyes that make all the difference in how we define diabetes.

If her blood sugar is below 100, she’s normal. But again, if she’s over 40, most people think she should get it repeated at least every third year.

If Victoria’s blood sugar falls into that range of 100 to 125, between “normal” and “diabetic,” her best bet is to seek out the Diabetes Prevention Program, a one-year program designed to help people decrease their risk of going on to develop diabetes. The DPP, as it’s called, is sixteen weekly one hour visits with a health educator followed by eight monthly visits. In those visits you learn problem solving strategies around food choices and physical activity with the support of your coach and a team of other patients. The program has been shown to reduce the risk of going on to develop diabetes by almost sixty percent, roughly twice as effective as metformin, a common diabetes medication. In addition to simply making your numbers look better, the DPP has been shown to improve cholesterol levels, to reduce absenteeism from work, and to increase patients’ sense of well-being. For anyone insured by Medicare, the program is a covered benefit. 

But what about the unlucky folks who go on to have diabetes?

We have a great program available here in town called the diabetes self-management program, or DSMP. It was developed by researchers at Stanford who were interested in making people with chronic diseases feel more in control of their lives and their destinies. It is 2.5 hours a week for six weeks, and it is taught not by a nurse or a doctor, but by a person who has diabetes herself. Investigators have determined that going through a self-management program like this reduces days in the hospital by almost two per year, probably cuts ER visits, cuts the risk of depression, and reduces low blood sugars. Best of all, it is free! If you’re interested, either ask your doctor or go to selfmanageks.org.

Last year investigators looked for randomized trials--that is, studies where patients are randomly assigned one treatment or another--of diabetes education. They included only trials that compared diabetes education with usual care, and they included only trials that lasted at least a year. Ultimately they found 42 trials that met these criteria, enrolling just over 13,000 patients and lasting an average of a year and a half. What they found was striking: diabetes self-management education significantly cut the risk of dying of any cause in type 2 diabetes patients by 26 percent. That is, a patient in the diabetes education arm of one of these studies was 26% less likely to die, by car wreck, chocolate poisoning, diabetic ketoacidosis, or any other cause, than a person receiving usual care.

In spite of this evidence, the utilization of diabetes education is disappointingly low. Only about one in five patients with diabetes ever attend. 

So let’s review, very briefly. Our risk--and Victoria’s--for being overweight or obese or having diabetes begins to accrue long before we’re even conceived and is constantly modified by our environment as we age. But many of the things that affect that risk--the cleanliness of our air, the foods available for us to eat, the design of our streets, and others--are modifiable. If in spite of optimizing all those things you still find yourself with an elevated blood sugar, you have several options.

So if you think you might be at risk for diabetes, get tested. If you’re pre-diabetic, ask for a referral to the diabetes prevention program. If you’re like Victoria, if your diabetes is out of control--if your hemoglobin A1c level is higher than what your doctor would like it to be, or if you have low blood sugars--ask your doctor about getting into a diabetes education program. If your diabetes is well-controlled numbers-wise but you feel out of control, also consider going to the  diabetes self-management program. The risk of the program is vanishingly low, and the potential benefit is large.

Examining Executive Physicals

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Fifteen years ago it was common to see parked semi trucks with CT scanners in the trailer, advertising “whole-body CT scans” as a preventive measure. Thankfully the trend eventually petered out. I can’t find reliable information on why the practice died. It’s possible that the worried segment of the population simply all had their CTs done, and no one else was willing to pay. But from a medical safety perspective, I hope the practice died because people–patients, regulators, or others–decided that the risk of “false positive” tests, with their necessary biopsies and follow-up testing, all of which carries its own risk, was not justified by the small chance of finding a potentially treatable abnormality. Or people simply decided they didn’t want the relatively large radiation dose (a whole-body CT exposes a person to ~15 mSv radiation, roughly a tenth of the exposure of Hiroshima survivors).

But the practice of whole-body CT scans lives on in the tiny corner of the market known as “executive physicals.”

In a recent paper in JAMA, Deborah Korenstein, Maha Mamoor, and Peter Bach used a combination of internet searching and phone calls to identify highly ranked hospitals offering executive physicals. Executive physicals at these prestigious institutions routinely offered:

  • Electrocardiograms (USPSTF grade D or I for low-risk patients)

  • Chest x-rays (not addressed at all by the USPSTF, but not generally paid for by any insurance company in asymptomatic patients)

  • Pulmonary function testing (USPSTF grade D for asymptomatic patients), and

  • You guessed it: whole-body CT scans.

Unnecessary testing has downsides

The unnecessary testing of anyone–let alone your most highly-paid employees–is a three-headed spear. First, the exams themselves are expensive: around $5,000 each. Second, much of the testing that is unsupported by evidence is likely a waste of money, as we’ve discussed in a previous post, especially since your highly paid professionals are likely to outlive your other employees based on their income alone. But maybe more important is the potential real harm done by unnecessary testing.

A well-known example of this comes from South Korea. That country’s national health insurance program initiated an aggressive cancer screening program in 1999 that screened for breast, cervical, colon, gastric, and liver cancers, mostly free of charge. With certain cancers this is a potentially good idea, even though cancer screening doesn’t seem to make people live longer as a whole. But patients in South Korea were frequently offered thyroid cancer screening with neck ultrasound as an optional add-on for a modest cash price.

By 2011, the rate of thyroid cancer diagnoses in South Korea had jumped 15-fold. This was not because of a new toxin in South Korean drinking water or because of radiation exposure. The entire increase was due to the new detection and diagnosis of “papillary” thyroid cancers that were too small and slow-growing to be felt on physical examination, but were easily detected with ultrasound testing. Because they were small and slow-growing the cancers were also unlikely to ever kill the patients in whom they were discovered.

So what was the downside? All the surgeries to remove cancerous thyroids had consequences (in addition to the surgery’s ~$5,000 cost). In addition to thousands of people who now needed to be on a daily thyroid hormone pill for life, South Korean patients experienced a huge increase in common complications of the surgery: two percent experienced permanent hoarseness due to paralysis of one of the vocal cords, and a whopping eleven percent now needed to take high-potency vitamin D and high-dose calcium multiple times a day for the rest of their lives to prevent muscle cramping because of damage to the calcium-controlling parathyroid glands that lie next to the thyroid.

This might be acceptable if a significant number of years were added to patients’ lives as a result of this. But that has not happened. A person in South Korea has the exact same (very small) chance of dying of thyroid cancer now as she did before this movement. That is to say, all this testing had only downside; there was no upside.

So the next time your company is negotiating the health benefits of its executives it might be worth asking what evidence supports any additional testing offered to C-suite folks. It may cost more than you think.

Health literacy is not just important for C-suite individuals.  Considering that only 12% of Americans having proficient health literacy, and that health-illiterate people spend 80% more on healthcare than their health-literate counterparts, it’s crucial to educate your employees!  The Kansas Business Group on Health offers discounts on resources to educate you employees on how to be better consumers of healthcare.

Should Your Company Cover Stem Cell Therapy?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

This summer Hy-Vee stores announced that any employee must undergo stem cell therapy prior to being considered a candidate for joint replacement.

That’s worth repeating:

The 102nd-largest retailer in America now mandates that employees undergo injection of stem cells obtained from their own fat or bone marrow into the joint, a therapy which has never been approved by the Food and Drug Administration (FDA), before they can be considered for a joint replacement. Simultaneously, the FDA is warning patients of the dangers of such therapies and actively sending letters of warning to practitioners of stem cell therapies. Regenexx, the very company contracting with Hy-Vee to do the therapies, has been sued by the FDA in the recent past and lost.

This is astonishing. But let’s back up.

What are stem cells?

Stem cells are cells that have not yet differentiated into the cells that make up tissues like blood, bone, brain, or skin. As such, they’re sometimes called the body’s “master cells,” since they have the potential to turn into, and therefore theoretically regenerate, damaged or missing tissue such as cartilage.

Do we use stem cells for anything in mainstream medicine?

Stem cells are frequently used in the treatment of cancer. Since chemotherapeutic drugs are so toxic to bone marrow, oncologists often take bone marrow from patients before treatment, remove any cancerous cells, culture the stem cells to increase their number, and transplant the cells back into the patient after chemotherapy. This so-called “stem cell transplant” or “bone marrow transplant” allows much higher doses of chemotherapy to be used. It is the only FDA-approved use of stem cell therapy.

If stem cells are not FDA approved for other treatments, how are doctors using them?

American medicine gives wide leeway to doctors in diagnosis and treatment. Around 20 percent of all drugs in the U.S. are prescribed “off-label,” for instance. This means that the drug is being used for something that its package insert does not indicate the drug has been FDA approved for. A good example is the use of gabapentin (Neurontin) for the neuropathic foot pain that bothers some people with diabetes. Gabapentin is approved by the FDA for only two indications: postherpetic neuralgia (pain that often lingers after a bout of shingles) and prevention of a specific type of seizure. But there is modest evidence that gabapentin is slightly better than placebo at treating diabetic foot pain, so it gets used pretty extensively for that purpose.

So even treatments that have not been definitively proven helpful can be prescribed or rendered by licensed physicians willing to accept the potential liability.

Is there potential for stem cell therapy, or is it all a scam?

We have seen unorthodox therapies be vindicated in the past. Electroconvulsive therapy, known popularly as “electroshock” therapy, is a very effective treatment for depression (and nowhere near as dramatic or barbaric as it appears in movies).

There is definitely potential for stem cells. We’re just not at a point yet where we can say with any certainty when or how they should be used. A recent review by Dr. Scott Rodeo concluded that “…there is little evidence in the scientific literature for many of the available cell formulations that are currently offered to patients.” A search for a meta-analysis of the use of stem cells for joint pain, for example, reveals that fewer than 600 patients have been included in trials that (marginally) met quality criteria. Compare that to the tens or hundreds of thousands of patients that have been included in the evaluation of more mainstream treatments. This is why almost no insurance provider covers their use.

You could say that stem cell therapy is at the peak of the old Gartner hype cycle:

Gartner-Hype-Cycle-graphic.png

Don’t look for stem cell therapy in this figure; it’s not there (the “cultured or artificial tissue” refers to growing organs in the lab). But if stem cell therapy were present, it would be at the very Peak of Inflated Expectations, and we’re years or decades from the Slope of Enlightenment. Between here and there is the Trough of Disillusionment, and that’s a bad place to be if you’re Hy-Vee in a couple years.

So what should employers do? 

The Kansas Business Group on Health shares employers’ frustration with the cost and inefficacy of the healthcare system. But we believe that patients—your employees—are better served by attacking the problem at its source, with increased funding of research and improved market transparency, than by promoting the use of alternative treatments that have not yet been proved effective.

If your employees come to you asking for stem cell therapies, encourage them to look for a clinical trial. Their enrollment would increase the knowledge of all of medicine, and it would be free.

If somehow, against the advice of the KBGH, a company decides to be more permissive of stem cell therapies, we would encourage that the company insists that the doctor use informed consent documentation that complies with the standard set forth by the International Society for Stem Cell Research so that they know what they’re signing up (and paying) for.

What’s the Value of an Annual “Checkup”?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Are annual checkups all they’re cracked up to be?

Remember Cigna’s “Doctors of America” ads?

“We are the TV Doctors of America,” says McDreamy.

“And we’re partnering with Cigna to help save lives,” says Dr. John Carter.

“By getting you to a real doctor for a checkup,” chimes in Cuddy.

But to put our “Devil’s Advocates of America” hats on: what if this annual checkup business isn’t all it’s cracked up to be?

It is reasonable to hold any potential medical test or treatment to one of three standards:

  1. It makes the patient feel better. This includes hundreds of treatments, like using medications and physical therapy for pain, prescribing inhalers for asthma, giving antidepressants and therapy for depression, and replacing knees, for starters. It could even apply to things like bone mineral density screening, sometimes referred to as “DXA,” which linked with osteoporosis treatment may make no difference in the risk of death, but clearly prevents hip, wrist, and spine fractures.

  2. If it does not make the patient feel better, the test or treatment should make the patient live longer. This applies to everyday things like checking and treating high blood pressure and high cholesterol (neither one of which make most patients feel any better or worse today) to surgery and chemotherapy for cancers (most of which make patients feel much, much worse at least in the short-term, but prolong many lives).

  3. Finally, if a treatment makes no difference in how the patient feels and makes no difference in how long the patient lives, it should at the very least save money. The best example of this may be diabetes screening. As far as we can tell, screening for diabetes does not prolong life, at least not in the two or three trials that have specifically addressed the question. But diabetes screening linked to preventive measures like the Diabetes Prevention Program clearly saves money [disclaimer: the KBGH is closely linked to Health ICT through the Medical Society of Sedgwick County, which receives CDC funding to promote things like blood pressure control, cholesterol management, and diabetes prevention].

Many of the tests and treatments medicine offers do not live up to that rubric. This may be why the Cochrane Review, which many consider the highest level of evidence in medicine, published a review in 2018 stating that “Systematic offers of health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments.” So when the TV Doctors of America say you need an annual checkup, what they surely mean is not that you need an old-fashioned sit-down with your doctor where, at the end of the visit, she gives you a “clean bill of health.” No. What I hope they mean is that you need to have access to a primary care provider. Investigators in 2019 found that every 10 additional primary care physicians per 100,000 people was associated with a 51-day increase in life expectancy, which doesn’t sound like much, but is pretty big by medical standards. Some estimate that a doctor practicing at the top of his license adds about 4.5 net years to the average patient’s life. Not too shabby.

“Systematic offers of health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments.”

What actually improves or extends someone’s life?

What the TV Doctors of America really mean is that you should have certain preventive services like immunizations and periodic screenings for health conditions that, if left untreated, can profoundly shorten your life. Most of these aren’t sexy. Probably the most effective preventive medical intervention, for example, is a simple periodic blood pressure check with medications if your blood pressure is too high. Sexier things like cancer screenings tend to have a “disease-specific” benefit, meaning they prevent you from dying of colon, prostate, cervical, breast, or lung cancers specifically, but they may not make people live longer as a whole.

If there is doubt in your company about what services you should be providing, a good place to start is with the United States Preventive Services Task Force (USPSTF), a rotating group of doctors that follows very specific rules to evaluate the risks and benefits of specific screening. Their opinion holds a lot of weight because any test given a “B” or better rating is mandated to be covered by your insurance. Examples of “A” rated services are things like tobacco use counseling and interventions, blood pressure screening in adults, and screening for cervical and colon cancers, which are all strategies that easily conform to our rubric. Cholesterol testing in people without diabetes or heart disease gets a “B.” Screening for prostate cancer in men aged 55-69 with a prostate specific antigen (PSA) test is a good example of a “C” rated service, since it has no overall mortality benefit and its disease-specific mortality benefit is largely offset by the harms that screening can cause (prostate biopsies and surgeries can cause bladder leakage and erectile dysfunction, among other things). PSA screening for prostate cancer in men aged 70 or older gets a “D” rating because it appears, in the hive mind of the USPSTF, to cause more harm than it prevents; that is, it violates rules #2 and 3.

What does this mean for employers?

How do you apply this to your workforce? Start by being an informed shopper for any workplace wellness services being offered to your company. Whenever a wellness provider tries to charge you a lot of money for offering annual “wellness checks” or “health risk assessments,” check their recommendations against the opinion of the USPSTF (or have us at KBGH check them for you). If the amount of testing they’re charging far exceeds what the experts recommend, ask them why.

Second, work on the health literacy of your employees (we can help with this). It’s hard as a patient to turn down testing or treatment your doctor offers if you don’t have the background to know what works and what doesn’t. I’m a doctor myself, and even I’ve felt vulnerable being squeezed through the gears of the medical-industrial complex.

The Health Benefits of the Great Outdoors

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

A prescription for going outside

Your doctor has probably never prescribed you “outdoor time.” The thought of it sounds like a joke Jerry Seinfeld would make about being sent to the yard in prison. But that may change soon.

Researchers recently reported in a cross-sectional study that those who spend at least 120 minutes out in nature each week were more likely to report good health and high life satisfaction.  In the study, about 20,000 subjects in the U.K. were surveyed about their health habits in order to get a “snapshot” of their lives for the previous seven days.  The group was then compared to people who spent no time in nature and to people who spent at least 120 minutes in nature. The benefits continued to increase up until they reported 200–300 minutes per week outside. More than 300 minutes a week outdoors didn’t offer any additional health or satisfaction.

The investigators defined nature broadly as “open spaces in and around towns and cities, including parks, canals and nature areas; the coast and beaches; and the countryside including farmland, woodland, hills and rivers.” The researchers controlled for other things that could have affected the subjects’ perception of their own health and life satisfaction, like physical activity and “residential greenspace,” which is the space around a participant’s house itself. Even after controlling for those confounders, spending time outside was associated with a benefit about as big as what can be expected from regular physical activity.

Even after controlling for those confounders, spending time outside was associated with a benefit about as big as what can be expected from regular physical activity.

Confirming what we already know

This is not a new finding. Research published in the 1980s showed that surgical patients in the hospital used fewer pain medications if they had a window that looked out on green space. And multiple experiments show that people find walks in nature more restorative than indoor walks. So powerful is the association between exposure to the natural world and our health that a term has been proposed for it: psychoterratic, meaning “earth related (terra) mental health (psyche) states or conditions.”

The Kansas Business Group on Health is working to define common goals among our membership. We believe urban design that gives people access to safe, well-lit, attractive places to experience the outdoor world may be one of those goals. With the guidance of our Advisory Council, we hope to refine what advocacy toward that goal looks like. For example, Wichita is notoriously “under-parked,” with under 5% of the city’s area devoted to parks, compared to 9.1% in Kansas City, 6.9% in Oklahoma City, and 7.6% in Tulsa. A push for more green space should happen alongside advocacy for new street designs and changes to how we park cars. In the meantime, though, businesses can make employees happier and more productive by giving them access to green space, even if it’s through a window.

Fiction: 9.8 meters per second per second

Travis wouldn’t—or couldn’t—turn down a challenge, so he jogged toward the tower of the center-pivot irrigation system. The tower was on the north side of a tailwater pond dug thirty feet down into the western Kansas sand. A similar wheeled tower was on the south side, and between them was a six inch galvanized pipe meant to carry hundreds of gallons of water a minute for delivery to the corn in the field below. That much water is heavy, so the pipe was girded by a skeleton of galvanized steel brackets and rods. Those were Travis’s real destination. His soundtrack was the rustle of corn leaves and the wind’s harmonic hum through the cables and beams of the giant sprinkler. Unfortunately for Travis, who was nursing a bit of a hangover, the soundtrack also featured the juvenile prods of two lunatics who, along with Travis and not coincidentally dovetailing with their status as the starting backfield on the football team, counted themselves among the social elite of Sellers High School.

“I’m sooooo bored,” Jake, a brawny, red-faced kid in cutoff jeans and nothing else, had complained upon reaching the field. Travis’s mom had taught him that only boring people are bored.

“Chill,” Travis had said.

“That’s just the problem, broheim,” Jake had responded. “I’m so chill that I might as well go home and sleep it off. What are we doing out here?”

Travis’s stepdad, the owner of the field, had tasked him with checking the oil level in the tailwater pump motor, a relatively minor piece of routine maintenance that needed to be done before tonight’s forecast rain. Minor tasks were all his stepdad trusted him to complete with any degree of competency. “I’ve gotta check on the pump,” Travis had said. “It’s important.” 

“I’ll tell you what’s important,” had responded Tanner, the starting fullback, who enthusiastically and unironically preferred to be called “Buck,” a piece of trivia that was no surprise to anyone privy to his wardrobe of Ed Hardy shirts with the sleeves cut off. Today’s ensemble featured a screenprint, stretched over his somewhat over-developed pectoral muscles, of a “Love Kills Slowly” banner pinned to a heart with a dagger. It would be similarly unsurprising to learn that Buck’s “pecs” were a frequent topic of conversation. 

“It’s important that I lift today,” he’d said, stretching his shoulders. “It’s even more important that I get back into Leah’s pants tonight.” 

Travis had quickly checked the oil and reinserted the dipstick. Buck’s dalliances with his father’s hired help were a source of some consternation for Travis, so he had worked his brain quickly for a change of subject. A ski rope hung from the center of the span of the irrigator. There was no reason for it to be a ski rope. It was bright red so you could see it. Orientation could be tough when walking in 12-foot tall corn. That, Travis had thought, would be a very suitable rope to swing from. And farming competency aside, the one discipline in which Travis had proven coldly proficient time and again was the ability to pull a good time out of thin air. Entertainment, usually at the expense of others, was practically the currency of Sellers High.

“See that rope?” he’d asked, pointing. “Dare me to swing into the pit from it?”

Jake and Buck had in fact thought that a swing from the center of the span on a frayed ski rope into the muddy water below would be a suitable diversion from the boredom of the day. Yes indeed.

So it was that Travis found himself stumbling hungover and barefoot through the subtropical heat of a western Kansas mid-summer afternoon toward an immense tubular steel structure resembling ten or eleven praying mantises stood head to tail, rubber tractor tires replacing their feet. The primary purpose of the giant sprinkler was the redistribution of 900 gallons per minute of fresh water from the Ogallala aquifer onto a 126-acre circular field of corn, but not today. Today it was to be repurposed as a launchpad. 

Travis’s desire for unity in the group having won out over his instinct for self-preservation, Buck’s and Jake’s whoops and yelps prompted a nervous resolve. A Tarzan-style swing on a frayed ski rope into the shallow water would be legendary, after all.

He arrived at the tower and pressed his wet, muddy, bare left foot against the hot galvanized angle iron of the first rung of the irrigation system’s tower, grabbed the fifth rung with both hands, and clambered up the ladder ahead of the next insult. 

“What’s the hold-up, Nancy?” Jake yelled. 

“Who’s Nancy?” Travis replied, his slippery, nervous feet now prehensile against a narrow piece of round steel extending over the water 30 feet below. “I’m up here and you’re down there. Maybe you can high-five me when I swing down, since watching me’s about the most extreme thing you’ll do today.”

“Maybe your mom will high five me after I make sweet, sweet love to her tonight.”

Travis’s face reddened. “Maybe your girlfriend will high-five me after I kick your ass,” Travis said. Then, mentally thumbing through his card-catalog of toilet humor and softly racist ethnic jokes and not finding an easy path forward in the conversation, he turned toward Jake and Buck, leaned against the heavy pipe, and unfurled his penis in their direction.

“Put that tiny thing away,” said Buck. “You’re embarassing yourself.

Travis coolly urinated toward them, but the wind prevented a satisfying parabola. So he redirected his urine toward the metal of the irrigator, its moisture turning the steel a satisfying gun-metal gray. He closed his eyes.

“Less pissing, more swinging, Tarzan,” said Jake.

“Did you say swinging?” said Travis as he opened his eyes. He theatrically twirled, then shook, his penis before pushing it back down into his decommissioned SHS Boys Basketball shorts. He smiled and felt the skin of his neck tighten. Ready or not, it was showtime. 

As Travis pushed off and pivoted toward the rope, his left foot slipped on the wet urine stain. Both feet came off the rail in one astonishingly smooth and graceful arc, his head moving forward and his feet backward, inverting and momentarily suspending his body in the air. He reached for but missed the handle of the ski rope, and at that point he began to accelerate headfirst toward the geometric center of planet Earth. 

Between Travis and the center of the earth lay several obstacles which, in combination with the trajectory of his fall, allowed for three distinct phases of recall and reflection: the almost ten meters through Earth’s atmosphere, which from his known rate of acceleration through space must have lasted approximately one second, and during which time Travis still had some involuntary control over his thoughts; then a fraction of a second of slow deceleration of his blonde fauxhawk, underlying scalp, and head through approximately 15 centimeters of shallow, muddy, sour water, during which the random execution of stored media in Travis’s mind began; and finally the abrupt deceleration of his head as it made contact with the hard clay that constituted the impermeable bottom of the man-made body of water. This would prove to be the most enlightening phase of the three. For as his head abruptly decelerated, his brain continued accelerating at 9.8 meters per second squared until it came into abrupt, violent contact with the dura mater covering the interior of the frontal bone of Travis’s skull, leaving a fingerprint of emotions and memories on the overlying bone. What with the teenage brain being quite resilient to mechanical deformation, much more rubbery and elastic than the brain of Travis’s middle-aged teachers, the physics of the situation dictated that the cerebrospinal fluid that had been displaced posteriorly by the sudden anterior movement of his brain should then rush forward into the contused interface between bone, dura, and frontal cortex, and the brain should rebound posteriorly toward similarly abrupt, violent contact with the dura overlying the parietal and occipital bones, imprinting the occipital lobe of his brain, the bundle of neurons through which every photon that had ever landed on Travis’s retinas had been processed into a clear picture, onto the posterior wall of his skull.

On the first and longest phase of his journey, Travis simply felt hatred. Uncomplicated, limbic hatred for the gape-mouthed buffoons at water’s edge whose undeserved judgement had led him to this. 

On the second leg of his journey, though, as his brain and skull rattled through the water’s surface and time further compressed, he saw the bamboo-like corn plants rushing toward his feet. He thought of how they’d been introduced from the Balsas River Valley of south-central Mexico into the American midwest for purposes of feeding cattle. He considered with remarkable detail and clarity the environmental and socioeconomic ramifications of the use of precious groundwater for the irrigation of an introduced species, and he considered the conditions in which the animals fed the corn were kept, and he considered the conditions in which the workers charged with slaughtering the animals were employed; all conditions over which neither the corn, nor the cattle, nor the workers exercised any control. So when his eyes were finally covered by the muddy water, dead catfish, denatured chemicals, and bloated frogs, his final corporeal vision of Buck and Jake dissolved his hate into pity. Pity that they were not going where he was, pity that their vision would not soon be obscured.

Then on the third and final phase of Travis’s transition out of the physical realm, it being his head’s contact with the clay at the bottom of the pond, with its recoiling avalanche of blunt flesh, bone, and bleeding neural tissue--a crumple zone traveling and rebounding at 9.8 meters per second--that the final, random pattern of neurotransmission within the trillions of synapses connecting the billions of neurons composing Travis’s brain began. By sheer randomness, this brought to his frontal lobe, stamped against his forehead (coup), the thoughts and emotions associated with an obscure, long-forgotten scene from more than a decade prior, then the scene itself stamped onto the occipital bone, just above his neck’s hairline (contrecoup). And though 9.8 meters per second was a velocity at which the amount of energy transmitted to Travis’s brain was certainly going to prove fatal, it represented a plodding pace compared to the sizzling synaptic activity of the brain inside Travis’s head, marijuana- and alcohol-addled as it were. Time had collapsed at first contact, giving Travis ample time to consider, recall, and reflect upon the events leading to the rapid cycling of the first two phases of his fall. 

He did not think of his relationship with his biological father, with whom he had regarded with anodyne but sincere affection until his parents’ divorce at age 5. He did not recall the casual cruelty with which is stepfather would adopt a Tonto-like voice and describe him to neighbors as “Strong like bear, smart like tractor.” He did not consider his revulsion at his mother’s habit of chewing food, remarking on its good taste, then spitting it into a napkin at the dining room table. He did not recall the eye-watering sting of psychic pain and regret he had felt at the sound of his friends’ laughter at their sight of the crumpled, red, moist face of the freshman to whom he had administered a wedgie last year, a wedgie applied with sufficient force to have caused superficial bleeding. He did not recall the hundreds of broken promises he’d made to God during endless sessions of hungover vomiting: promises to abstain from alcohol and sex, to attend church, to be a better person, to be a better student, to be nicer to his mother. He did not recall the warm blush of blood in his cheeks as a classmate easily answered questions in a biology lab for which Travis had not bothered to study. He did not remember the secret envy he’d felt at an upperclassman’s letter of acceptance to a prestigious college. He did not remember the admiration he’d felt for the local nurse who competently cleared Travis for participation in sports year upon year. He did not remember the state championship football game or the disorienting, concussed buzz and echo of the crowd chanting his name as he plunged headfirst into the guard-tackle gap over and over. He did not reflect on the lump in his throat at the sound of the alcohol-muffled voice of a junior varsity cheerleader, her father inconveniently one of the hired hands of Travis’s stepfather, whispering, “Buck, wait...Buck.” He did not remember when he started to fear the future.

This is what he remembered: August morning sunshine, red bricks, crayons. A new backpack. The yawning door of a kindergarten classroom. Travis stands before it and beholds a room of screaming, beanbag-throwing boys, Jake and Tanner among them. He retreats, terrified, to his mom’s skirt. He yearns to return home, to play with Lego, and to watch Sesame Street and Wild Kingdom. He longs to have time to himself with his thoughts. His vision is obscured by pleated navy polyester, but he overhears the tonal shift in the casual conversation between his mom and his teacher, then feels the grasp of his mother’s hand on his wrist, pulling him around to look at her son one last time. As she turns him back toward the door, she says in a voice that is somehow more forceful, higher, harder, more impatient than what he has known before this day: “There’s nothing to be afraid of. Don’t be shy. Make friends. Make sure everyone knows your name.” 

The laws of motion are already acting on his brain, reflecting it off the surfaces of his cranium, shearing blood vessels and activating cascades of inflammatory chemicals. They will do their irreversible damage before the kinetic energy in his brain is entropically degraded to a lower, less organized form. But there is still plenty of time for Travis to walk slowly ahead and hang his backpack on the wall. He hears the soft thump of a beanbag falling at his feet and turns to see a smiling boy with glasses. He picks up the beanbag and throws it back, accidentally knocking the boy’s glasses off. The boy falls to the floor and begins to scan the carpet with his hands. Travis kneels to help, but then hears the safe approval of Jake and Tanner laughing, and the sound washes over him.

What's the Deal with Pharmacy Benefit Managers?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

What are pharmacy benefit managers?

Pharmacy benefit managers (PBMs) arose in the mid-1980s as third-party administrators acting as intermediaries in the drug supply chain. Their original purpose was to manage patient access to specialty drugs like insulin and chemotherapy agents through coverage and formulary design on behalf of payers. Medicare and Medicaid, for example, are forbidden by law from directly negotiating drug prices with manufacturers. Instead they rely on PBMs to negotiate on their behalf.

But many say that PBMs have grown too powerful and opaque. The three largest PBMs—Express Scripts, OptumRX, and CVS Caremark—now control more than 85% of the market, with revenues that exceed the very drug companies with whom they negotiate. For example, Dr. Trevor Royce and others reported in a recent JAMA editorial that in 2017, Express Scripts alone reported $100 billion in revenue, almost double Pfizer’s $52 billion. A business may find the sources of this revenue frustrating.

How PBMs make money

First, PBMs charge “supply chain fees,” theoretically in exchange for their information and efficiency advantages in running and managing the underlying prescription drug supply chain.

Second, PBMs traditionally engage in “spread pricing,” a fancy name for the simple practice of pocketing the difference between the manufacturer’s and insurer’s prices. Royce cites an Ohio Medicaid analysis that found that the cost to a pharmacy for a 30-day supply of the leukemia drug imatinib mesylate (Gleevec®) was $3859, with a cost to Ohio Medicaid of $7201, a difference of $3342, all of which went to the PBM.

Finally, PBMs take in substantial revenue from manufacturer rebates. The average rebate in 2008 was 10.4%. By 2019 the average rebate had grown to 26.1% (with an average of 66% for insulin). This would be great if that rebate were going to the employer. But instead the vast majority of those rebates go back to the PBM, which has caused administrators to label these rebates “kickbacks” instead. To make matters worse, some PBMs have used “gag clauses” to prevent pharmacists from telling patients when the out-of-pocket payment for a prescription would be less expensive than getting the drug through the patient’s health insurance drug benefit coverage.

Why does this matter to your business? Lauren Vela of the Pacific Business Group on Health said at the Kansas Business Group on Health’s 2019 Roundtable (paraphrased lightly):

“If you’re working with one of the Big Three PBMs, you’re not getting a good deal.”

What’s the solution?

We are unaware of any pending legislation in Kansas, though Ohio Medicaid managed care providers ended their contracts with PBMs in January 2019 and replaced them with a transparent “pass-through” pricing model.  In this new “pass-through” model, a managed care plan pays the PBM 1) the exact amount paid to the pharmacy for the prescription drug, 2) a transparent dispensing fee based on survey data of pharmacy dispensing costs, and 3) a transparent administrative fee (replacing the “spread pricing” revenue).

Federal legislation prohibiting “gag clauses” was signed in 2018. Early in 2019, Health and Human Services proposed legislation that would eliminate the practice of kickbacks to PBMs through drug rebates, but the legislation was abandoned due to significant pushback from insurers and hospitals.

So what can you as an employer do with your current PBM?

  1. Challenge clinical approvals for new drugs that are added to the formulary

  2. Buy generics directly from the manufacturer (yes, you can do this!)

  3. Look at your PBM contract to ensure:

    • You have access to your data.

    • You are allowed access to underlying contracts of your PBM (they may be incentivized to push certain medications if they have an agreement with a certain pharmaceutical company).

    • You can get out of your contract at any time.

For ways to cut your pharmaceutical costs by 5-10% with ZERO risk and without having to change your PBM or your formulary, be sure to check out [KBGH’s] Right Rx program that is available to our members.

What are processed foods, and are they bad for us?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Are Processed Foods Bad for Us?

We hear a lot about eating “real” foods and avoiding overly processed foods. Food writer Michael Pollan famously said his rules for the ideal diet were to 1) eat food, 2) not too much, and 3) mostly plants. He went so far as to say that any food with more than five ingredients, or an ingredient you can’t pronounce, is probably bad for you. But what’s the evidence that this is right?

Thanks to the work of investigators at the NIH, we have new evidence that processed foods should not make up the bulk of our diets. Researchers paid twenty volunteers to live in a research hospital for a month. Ten of them were men, and ten were women. The volunteers were randomly assigned to eat either an “ultra-processed” diet or an unprocessed diet for two weeks. The diets were identical in the number of calories and amount of nutrients like fat, sugar, protein, and fiber. The volunteers were observed closely for food intake, and frequent testing was done to determine how many calories they were burning.

An example “ultra-processed” meal was:

  • steak (Tyson)

  • gravy (McCormick)

  • mashed potatoes (Basic American Foods)

  • margarine (Glenview Farms)

  • corn (canned, Giant)

  • diet lemonade (Crystal Light) with NutriSource fiber (researchers had to add fiber to the drinks in the processed diet to match the fiber of the unprocessed diet)

  • low fat chocolate milk (Nesquik) with NutriSource fiber.

In contrast, the unprocessed meal on the same day was:

  • beef tender roast (Tyson)

  • rice pilaf (basmati rice (Roland) with garlic, onions, sweet peppers and olive oil)

  • steamed broccoli

  • side salad (green leaf lettuce, tomatoes, cucumbers) with balsamic vinaigrette (balsamic vinegar (Nature’s Promise)

  • orange slices

  • pecans (Monarch)

  • salt and pepper (Monarch)

In spite of having equal numbers of calories available to them at every meal and snack, the people eating the processed diet ate about 500 calories per day more than the people eating the unprocessed diet.

After two weeks each person in the study was “crossed over” to the opposite diet from what they’d started on. That is, the processed diet folks started eating the unprocessed diet, and vice-versa.

What the investigators found was dramatic. In spite of having equal numbers of calories available to them at every meal and snack, the people eating the processed diet ate about 500 calories per day more than the people eating the unprocessed diet. This showed up in their weight: the processed dieters weighed, on average, 2 pounds more at the end of two weeks than they did at the start of the diet. All their extra weight was in the form of fat.

This finding could have a real impact on your employees’ health. When you are thinking of food for a large function, or thinking of how to contract food in an on-site cafeteria, it may be worth looking at the NOVA food classification system and working to increase the availability of Group 1 foods, those that are “unaltered following their removal from nature.”

Examples of these would be:

  • vegetables

  • fruits

  • potatoes (fresh, packaged, cut, chilled, or frozen)

  • whole-grain wheat, oats and other cereals

  • eggs

  • fresh, chilled or frozen meat, poultry, fish and seafood

  • pasta, couscous, and polenta

  • milk or yogurt without added sugar

Bon appetit.

Fiction: The Dispensation of Hugs

To better understand Dr. Philip Cox’s sudden activism, it’s worth putting yourself in his shoes. After yet another strained call with a clinic administrator who insists that you need to see more patients, to increase your “productivity,” you knock twice on an exam room door. You enter to the smell of mint and ashtrays, and you greet a rail-thin woman who appears at least ten years older than her stated age. She has scheduled this appointment because she is in desperate need of a prescription for medical marijuana. Through the standard give-and-take of the usual rushed interview and examination, she describes hours upon hours of physical therapy daily for her chronic back pain, so much therapy, in fact, that it leaves little time to do anything else with her day (you know, she says, because she’s too busy with the therapy and whatnot. And besides, she thinks she might have the glaucoma. And she’s been a little nauseous.).

You do your best to let her down easy. You explain that her other medical conditions--to say nothing of the drug enforcement laws in your state--collectively constitute a set of strict contraindications for the prescribing of medical cannabis. And maybe since you’ve made the decision not to mention her history of repeatedly positive drug screens (positive, that is, for a number of synthetic and naturally occurring substances that neither mainstream nor holistic medicine have found to be of therapeutic value), she becomes tearful and thanks you for the seven minutes that the modern medical-industrial complex allows for such interactions.

She stands and strategically positions herself between you and the exam room door. You extend your hand and offer a final “Try these suggestions and we’ll see where you stand in three months.” But so thankful is she for your time and attention, you think, that she grasps your extended hand and pulls your body toward hers. There’s some initial confusion in regards to which arm goes over and which goes under, and maybe this results in some unintentional contact with her hips or flank. You worry about what the risk management department would have to say about such intimacy. Then you wonder: What does she want?

Suddenly (though time compresses a little here) your necks are in contact. There’s the blanch of a tear between your skin and hers, and her makeup stains your collar. Her hair crunches against your temple. Her breath warms your neck. You awkwardly place your hands over her shoulders and feel the crease of her bra strap over a shoulder blade. After three or four seconds of embrace, heavy sighs, the styptic smell of burnt tobacco, the sweet top notes of cheap perfume, and the casual exchange of bodily fluids, the patient takes a deep, premeditated breath.

“You know what? I lost that last prescription for my pain pills. Would you mind giving me a new ‘script now?” As you release and back away, she unleashes a hollow, rattling, expectorating cough into an unwashed hand, and you feel the mist on your face. You don’t have the heart to show her the pharmacy’s record of the last narcotic prescription having been filled or the missed appointment slips from the physical therapist’s office. Here is a patient who wanted a hug.

So enough with hugging, Phil had decided. There would be exceptions: he felt a sincere, oxytocin-tinged pleasure at the contact of his wife’s body against his. And he felt nothing uncomfortable about hugging his children, not even his awkward, blossoming tween daughter. But the rest of the world was, he had decided, going to have a hard time meeting the Phil Cox threshold for hugworthiness.

...

As Phil pedaled home from that day’s clinic he rode a steady, floating wave of euphoria. He parked his bike in the garage and almost skipped to the door. He approached his wife in the kitchen embracing their tearful eleven-year old daughter.

“I’ve made a decision,” he said. He was pleased with the Churchillian commitment of his voice in his head.

His wife looked up from the soft receding sobs of their daughter. “I can’t wait to hear all about it,” she said. Phil couldn’t quite interpret the look on her face.

“No more hugs,” he said. He couldn’t help but smile as he said it. “I’m on the first train out of huggy-town.”

“What are you talking about?” she asked. She let go of their daughter, who heel-toed down the hall toward her room, crying as she went. Phil’s wife began assembling grilled-cheese sandwiches.

“All the hugs. I’m done with them. I’m the newly elected Mayor of Mind Your own Business City.” His wife looked past him down the hall.

“You mean the kids? She was just upset about an audition. Wizard of Oz. Dorothy.”

“No, no, not the kids,” he replied. “All the other people that are always trying to hug me. Do you know that of the twenty people I saw today, fourteen tried to hug me on the way out? Men, women, everybody.”

“It just means they like you,” she replied.

“That’s just the thing. It has nothing to do with liking me. I’m the messenger of doom in there. I spend all day telling people what I won’t or can’t do for them. They have no reason to like me at all. They hug because they’ve somehow been programmed to hug. It’s the new handshake. And let me tell you: I for one do not want our kids growing up in a world where hugs replace handshakes.” He was happy with this little piece of improv. He’d managed to bring the kids’ welfare into the argument. He went on: “The entire patient interaction is driven by me right up until the end. The patients hardly talk. I keep doing what I’m doing, and people seem pretty happy, and then…” he paused. “They all of a sudden try to hug something out of me.”

“That seems a little dramatic. I hardly get hugged at all,” she said.

“But you’re a gynecologist.” Phil made a pointing gesture with the first two fingers of his right hand. “Half your patients feel traumatized by you by the end of the visit, what with the specula and the probing and whatnot.” His wife tilted her head. He could feel his  argument getting away from him. “I’m just saying, my patients and I have an implicit understanding that most of my job is to protect them from themselves: don’t smoke, don’t drink, take your medicines, but don’t take drugs.” He framed “medicines” and “drugs” with air quotes. “You, on the other hand, are coming at half-naked people with medieval torture instruments. Is a patient in a paper gown, open in the front,” he drew his hands across his chest and posed Mick Jagger-style to insinuate breasts exposed by the flimsy gown, “going to de-stirrup, jump off the table and give you a good, old-fashioned bear hug? No, of course not. So you’re protected, at least at work.”

“Well, I don’t get hugged that much outside of work, either,” she said as she reached for the bread.

“Um, your brother-in-law? I wouldn’t be surprised if that guy hugs the drive-through cashier. I’m always fighting him off, and I’m not an attractive…” he started to say ‘middle-aged woman,’ but stopped himself. “...hot little thing like you.”

She furrowed her brow and shook her head. “You know Dwayne comes from a tough background. He’s just happy to be in a family now where he’s loved. He asked if you were coming to the wedding next weekend. Are we still in for the $500 for a gift?”

“I suspect that decision’s not up to me. But if I go, I could stand a little less of the physical act of love from him. When two men hug, it’s like 75, 80 percent erection.”

“Dwayne gets you going, huh?” She aggressively flipped a grilled-cheese.

“No, God, no. Not even if I was gay.” Phil pantomimed a dry-heave. “Goatee and belt buckles? But you know what I mean. Or maybe you don’t. As a male, you spend most of your life trying to avoid public erections. It’s just the facts of life. One day you’re hugging your aunt and you feel this little acorn in your pants, and then...well, men just don’t like having their stuff touch. The other day I was at QuickTrip using the urinal. I heard this guttural noise--’gllrrgh’--behind me. I had no idea. I shook it off, zipped, and turned around, and there’s this smiling guy, Down’s Syndrome, maybe? He smiles really wide and makes eye contact with me. His pants were around his knees. He didn’t wait for me to get out of the narrow little stall thing, and as I tried to wriggle out, his penis brushed against my thigh. I thought I might die.”

    “For God’s sake, Phil. You’re a doctor. Get a grip. And what on earth does some poor mentally handicapped guy accidentally touching you with the distal point-oh-one percent of his penis have to do with hugging?”

    “Maybe it’s not a perfect illustration. I got distracted by all the Dwayne talk. But what about the overweight middle-aged guy the other night in the ‘Free Hugs’ tee-shirt?”

“You mean the school custodian? He moonlights at Red Robin as a balloon artist, and he offered to cover the school carnival. All he got out of it was a meal.”

“Yeah, well you know what exchanging physical intimacy for money is called?” Phil asked. “Prostitution. So thank goodness Pervy Custodian Balloon Man was giving the hugs away.”

“Would you calm down?” his wife said. “You’re overthinking this.”

“Did you notice what happened whenever he tried to hug a kid? Who had the power in that situation? Was the kid going to fight him off? No! That hug might have been the cost of doing business to get a balloon giraffe; total power play. The kids were just relieved when it was over. Look, I know ‘hugging’ sounds all nice and innocent, like Dwayne with his ‘Get over here, you,’” here Phil gave a small Nixonian jowl-shake. “But there’s no such thing as a free hug, trust me.”

She sighed. “Oh, I trust you, alright. Is this another phone thing?”

Phil knew what she meant. Last year, in an attempt to meet his corporate overlords’ demands for productivity, he'd decided that he could save a few minutes a day by discontinuing the use of a parting word on the phone. No more goodbyes. It hadn't been a disaster, and he liked the old-timey detective vibe it gave off when he simply ended the conversation and hung up, but Phil had needed to resort back to traditional sign-offs when patients started calling back the office thinking they'd been cut off, thinking that they'd missed out on some little nugget of information that would make their sex life better or get them out of an upcoming CT scan. And one of the office staff had misinterpreted his brusque phone manners as a sure sign she was going to be fired.

“Not even close. I’m taking a stand against the transactional embrace. No emotion, no purpose other than to make people uncomfortable. If you commit and really try to show some sincere affection for the other person, you’re a creep. If you try to abort the hug, you’re an asshole.”

Phil’s wife did not seem impressed.

“Look: I’m trying to get things done in clinic. Real work. And all this hugging gets in the way. And outside of work, well, we’re suffering a crisis of personal space.” He pointed his index fingers toward the floor and drew a circle around himself the diameter of his outstretched arms. “And I’m taking mine back.”

...

Phil’s wife’s niece’s wedding would be a test. He knew what he’d see: the drunken tandem bump-and-grind on the dance floor, the same-side arm neck-crane air-kiss, the shoulders-only three-pat fake embrace, the one-armed “take our picture” and its trashy cousin the “let me feel the outline of your underwear through your satin dress.” Maybe a few bro hugs. The awkward mixing of friends, extended family members, dates trying to fit in, the receiving line: weddings were to hugging what the Javari Valley was to uncontacted tribes. Except that the Javari Valley didn’t have Dwayne Moberly. To Phil, Dwayne was the lost, untamed frontier: a man that came from nowhere and is going nowhere, but is doing it as loudly, and while taking up as much space, as he can. To spend any time with Dwayne was to experience a full-on frontal assault to the senses.

It is worth considering an altogether unremarkable encounter with Phil’s brother-in-law. Maybe you’re at a relative’s house for Thanksgiving. You’re passively learning about the wonders of the Turducken when you’re suddenly thrown off center by a hard slap to the shoulder. Your first instinct is to turn against the perpetrator, but before you can even turn your head you fall prey to the sonic disorientation of Dwayne’s voice in your ear.

“Sonofabitch, great to see you! I wasn’t sure you’d be able to get away. I know you’re busy. Leaving the office costs you guys a lot of money.”

“Uh, good to see you, Dwayne. How about those Sooners, huh? You guys might have a chance this year.”

“Need a running game,” he says matter-of-factly. Then he grasps you by the left shoulder and squares you toward him. Tiny droplets of sweat on his forehead and nose wink in the light. He has tears in his eyes. He initiates intense, uninterrupted eye contact and lowers his voice. His breath reeks of Wild Turkey.

“You don’t know how much it means to me to have you guys as family,” he says, all Hee-Haw and Toby Keith in whispered basso profundo. He puts his left arm over your right shoulder and hooks your left shoulder with his right elbow, wrapping his right arm around your neck. You smell the leather of his Marshall Dillon vest and feel the humidity of his skin through the cotton of his Harley-Davidson shirt. He spills a little of his cocktail on your back, and you, possessing neither the protection of a leather cowboy vest nor the confidence to wear one in public, feel the cold droplets trace a path down your back. Dwayne doesn’t notice. Then he squeezes you. Tight.

“Great to see your wife and kids here. Everybody ok?” you say as you struggle for breath. “How’s the satellite dish business?” The stubble of his beard scratches your cheek and the bristle of his handlebar moustache tickles your ear. The buttons of his vest dig into your chest. His protuberant abdomen juts out over a turquoise belt buckle and presses against yours.

“New belt buckle, Dwayne?” He exhales heavily and steps on your toe. The embrace lasts two seconds too long, and just before you’re released from the maw, he gently sways you to the left, then to the right.

“Grrr,” he says as he shakes, then releases. Axe body spray sticks to you like tar. Here is a greeting from Dwayne Moberly.

...

Nine times out of ten, Phil would go through the receiving line of a wedding reception without complaint. Back-pat hugs would be transacted with unknown relatives from the other side of the wedding aisle, and faux debutante thanks would be sniffled from the bride.

But tonight was not nine times out of ten. Tonight was the debut of Phil 2.0, upgraded to a faster, more efficient operating system that effortlessly deflected intrusions from outsiders into its personal space. He touched the cold, moist corsage pinned to his chest and whispered to himself, good, good. He knew people would want to avoid crushing it. Furthermore, he’d not only steeled himself against unwanted intrusions, practicing eye contact and a firm, extended-arm handshake in the mirror in the days leading up to the event, he’d made the decision to temporarily suspend oral hygiene. Granted, it wasn’t a strategy that had perfect long-term consequences. He couldn’t skip brushing his teeth forever. But he figured that it could be a reasonable strategy to employ for special occasions, like a relief pitcher who is employed only to face left-handed pull-hitters in late innings. His halitosis hadn’t yet been noticed by his wife or kids, and he had a twinge of disappointment that the buffet wasn’t Mediterranean, Italian, or some other cuisine with the punch of onion and garlic behind it. But he could taste three cups of coffee in a battle royale with a bourbon neat and a caesar salad, and his tongue was the battlefield. Morning breath in the afternoon, he thought. He ran his tongue over his teeth and felt an uneven sheen of plaque. He was ready. He took his weaponized halitosis toward the receiving line.

“Hi Dwayne,” Phil said, emphasizing the “H” from the back of his throat. He crossed his arms and kept his mouth open, directed toward its target. “L’chaim! Hhow’s it hhanging hhombre?” He uncrossed and took Dwayne’s right hand in his and held it firm. He figured if he couldn’t fight off a hug from his brother-in-law entirely he could at least limit the damage to a homie hug. He immediately regretted not having called Dwayne “Homie.”

“G-good, Phil,” Dwayne said. He squinted his eyes and flared his nostrils slightly. He turned his head slightly to the right, then looked again at Phil. “The kids sure appreciate you being here, I can tell you that.” Dwayne seemed to recover slightly from the initial onslaught of Phil’s breath and started to bring his chest toward Phil’s.

“Hhell, Dwayne, hhowever we can hhelp we’re hhappy to.” Phil gave Dwayne’s hand one last shake, let go, and moved on to Dwayne’s wife. He grabbed her by both shoulders, kept her at just under arm’s length, and said,”Hhappy wedding. Hhow’s it been, hhot stuff?” He saw a fine mist of saliva enter the air between them as he finished off “stuff.” It had been unintentional, but he wasn’t displeased with it. She flinched, then recovered and responded that she was tired but happy, and that it had been a great day, and it was going to be a great night, and she was so happy to have another person in the family, and she was so happy that Phil had been able to make it.

“Hhallelujah,” Phil responded as he gave her a little stiff-arm shiver, and he moved on to the bride and groom. He was pleased with his ability to keep both of them at arm’s length, so he then briefly hit the bar before the dollar dance.

Phil was at ease with the extravagance of his family’s gift for the bride and groom. Part of it was good old-fashioned pragmatism: young people needed money more than they needed another place-setting, and maybe Dwayne would see it as a peace offering. But a bigger part of his tranquility was the idea that he could exchange the money at the dollar dance and, in the process, disrupt what he saw as a time-honored paean to wasted false intimacy. High on his newfound dominion over his personal space, and through the magic of a twenty dollar tip to the deejay, Phil had conspired to replace the usual swaying, hands-on-hips ceremony of false affection with an opportunity for an improvised pop-and-lock routine. No way his money to the bride could be seen as being in exchange for anything.

Phil approached the bride in line and nodded to the deejay, and the DJ transitioned abruptly from power ballad to the steady, four-on-the-floor thump of a rap song. Phil initiated his dance. Then, as Phil looked up from his robotic march across the dance floor, he saw his niece looking toward Dwayne. He turned toward Dwayne, raised a finger, smiled, and turned on a heel toward the bride. He had something in mind that was going to make Dwayne very happy. He Dougied toward her, pulled a neat roll of $100 bills out of his breast pocket, and held it between his fingers at arm’s length. She reached for the bills, and Phil stylishly dropped the wad into her hand. She stared at it and held her arms out to him. He reached out with the index finger of his left hand, gently placed it on her chin, and pushed her away as he playfully shook his head. He turned back toward Dwayne and couldn’t quite place the look he got. Phil finished his last, choreographed ten seconds of walking it out to the edge of the dance floor.

As Dwayne walked toward him, Phil turned toward the bride and saw the curl of her lip and a first glistening tear. Dwayne cornered Phil near the deejay booth.

“Phil, we got a problem here?”

“Not unless the happy couple has a problem figuring out how to spend five hundred big ones,” Phil said.

“Well, she don’t look none to happy to me, Phil,” Dwayne said as he tilted his head at his daughter, now soldiering on with a wheelchair-bound great-uncle. “Seems like a girl ought to get a little more attention on a day she’s planned for a year.”

“Dwayne, I think the kind of attention you’re talking about oughtta be reserved for the hotel room.” Phil smiled. Dwayne lurched forward and put his face directly in Phil’s.

“I think you’re treading on mighty thin ice, doc. You might wanna think about the next thing that comes out of that mouth.” Phil suddenly felt a strange sense of respect for Dwayne; this was a side of his brother-in-law he’d never seen.

“I...I just wanted her to know that we love her, no strings attached,” said Phil as he looked over Dwayne’s shoulder toward the dance floor. Dwayne’s daughter was back to slow-dancing with a boy of about fourteen. The boy had a noticeable bulge in his slacks.

Phil looked directly at Dwayne: “I think everybody’s having a good time, Dwayne. Great wedding, really. You nailed it. I’m gonna hit the head.” He patted Dwayne on the shoulder, gave an appreciative point to the deejay, and steered toward the bathroom.

Phil’s wife followed him. “Whatever that little ceremony was, knock it off,” she whisper-yelled to Phil through her teeth, her voice echoing off the tile and painted cinderblock of the back hallway.

“Just giving the bride her money for the dollar dance,” Phil said.

“I saw her try to hug you. You had to be cute, didn’t you?”

“Why do you like hugging so much?” Phil said. “You hate smells. Do you like somebody putting their body against yours so you smell like them the rest of the day? Aunt Sallie smells like cigarettes and onions. They aren’t even serving onions here! You hate onions! Why couldn’t you have given her the money?”

“Certain things like hugging or giving the bride money at her dollar dance are just part of the modern social contract,” she said. “The cost of doing business. Like the ‘Would you like to donate a dollar for starving orphans?’ button at the grocery store checkout. Sometimes if the cashier’s looking at you, you just gotta push that button, Phil. It doesn’t matter if you’ve already given a million dollars to charity. Doesn’t matter if you like it. You gotta push it.”

“Well, maybe my job is to shape, not follow, social norms. Maybe that’s my gift to the world.” Phil straightened and puffed his chest a little.

Phil’s wife’s shoulders slumped a little. “Your ‘gift to the world?’ Thanks a lot, Bill Gates. Dwayne asked me if you were okay. What am I supposed to say? That you’ve had a head injury or something? His feelings are hurt. Here he is, biggest night of his life, and he’s the unwitting subject of your little experiment.” Her voice softened a little here. “And Jesus, Phil, chew some gum or something. Your breath smells like the dog’s.”

...

As Phil brushed his teeth in the cold, blue light of a hangover the next morning, he conceded the bad-breath trick had probably been a step too far. And the cell-phone footage of his dollar dance routine was a little incriminating; he seemed to be a minor local YouTube sensation. Hurt feelings had not been his intention. He’d given his wife’s comments some thought. The social contract, she’d said in regards to hugs. But what about the rest of his contracts? Phil wasn’t paid for hugs in his professional life, after all. He did the math quickly: twenty patients per day at twenty seconds per hug equalled at least another patient interaction. Another interaction whose care could be quantified, whose outcome could be neatly defined, and whose data could be shoved back at his masters and their push for efficiency. Last night had been a minor setback. He felt he was ready to move forward, and he was ahead of schedule, to boot.

Phil’s wife had scored tickets to see a stand-up comedian, “Mickey Mac.” Mickey was known for his interaction with the crowd. This led to each show having its own signature moment, many of which were catalogued on Mickey’s website. Phil found seats near the front, stage right. To their left sat a couple with an impressive number of drinks already on their table by the time the opening act wrapped up: two empty beer bottles and two cocktails in varying stages of consumption, along with the drinks the couple were working on now. The couple had mostly ignored the first act, a red-haired prop comic that Phil agreed had leaned a little too hard on the bagpipe/Scottish jokes. But when Mickey Mac took the stage, the couple cheered so loudly that Phil wondered if they were aiming to be part of Mickey’s signature moment that night.

“Mickey! Hey Mickey! Let me take your picture!” the man yelled as the woman leaned over the tiny pedestal table, nearly knocking all the dead soldiers off as she tried to get her face between the camera and the comedian. “Let me take your picture!”

Phil’s face got hot. This was not what he’d paid for. Why were they hijacking the show like this?

“We gotta tell them to shut up,” he whispered to his wife. She shook her head and squeezed his hand. Phil craned his neck and looked for the bouncer. This was exactly what happens to me at work, Phil thought. I know exactly how Mickey feels right now.

Mickey marched on into his set and was well into the setup of his first series of jokes, a series of observations about how men could always tell if they were touching boobs, even through a raincoat, down sweater, and sports bra. You can’t fool a man with shoulder or hip-he knows if that’s tit he’s touching, Mickey said. And after the third or fourth “...take your picture!” Phil couldn’t take anymore. He squirmed in his seat.

“Let him do his job!” Phil yelled. He slapped the table and his drink spilled  onto the floor. The crowd, for the first time all night, fell silent.

Mickey turned to Phil and said, “You mean my man Gordon Parks here?” He pointed at the couple. “Let’s all thank him, everybody, for taking time out of the principal photography for ‘Shaft 2’ to come to the show.” Mickey put the mic on the stand and clapped. The audience hooted and clapped along. Then Mickey squinted at the woman and put his hand over his eyes to block the stage lights.

“And is that Twiggy?” he said. “You’re holding up alright, sister. You be good to my boy Gordon there.”

And that was it. Phil felt a soft rush of relief. The couple hadn’t suffered harm. Mickey had gone on autopilot, had recruited the rest of the crowd to his side, and had made the intruders  melt away. They hadn’t been kicked out of the show. They hadn’t even been treated particularly poorly. Mickey had simply redirected his show by a few degrees to take them on and, in turn, had actually made his show a little better. By the end of the show, Phil wasn’t sure he’d even remember the intruders had been there. And it had happened in no time! Phil figured the whole interaction, the whole process of getting the couple to sit and watch the show like everyone else, had taken less than two minutes.

Phil couldn’t help but compare this to his experiences with patients, whose insincere attempts at goodbye-hugs seemed to drag on forever. And after all, what real value, what therapeutic code, was there to apply to uncomfortable forced embraces? His mind wandered to a gray office cubicle where a mid-level administrator was assigned to the procedure: “CPT Code: 847xx – Embrace, therapeutic; Procedure includes: Qualitative report as positive or negative.” As Phil thought of this, and as Mickey stabbed ahead with his next setup for a series of jokes about how octopuses must have sex, Phil laughed as hard as he’d laughed all night.

...

The next day of clinic proceeded mostly without incident. Phil noticed the first patient of the day seemed a little confused by the abruptness of his goodbye, so he decided to spend just a few seconds longer with each patient as they left the room. He had refined his technique into what he called “The Presidential,” a handshake that involved the placing of his left hand on the patient’s right shoulder for depth control as he shook hands with his right. Then he would move his left hand from the shoulder to the patient’s right hand, clasping and cupping her hand with both of his. Two beats of solid eye contact from a comfortable distance, then break. Politicians used it all the time, and people seemed to love it. His life would no longer resemble an infinite junior high dance. He was a solid, reliable component of the medical machine: all business. He thought of changing his practice to an all-telemedicine venture, felt a blush of excitement, and sent a text message concluding with an emoji (of a woman with her arms crossed in front of her) to his wife. She did not respond.

Not even the prospect of Dwayne on the schedule could dampen his spirits. Dwayne was a bit of a handful to take care of, but not because of the usual reasons. He wasn’t addicted to prescription narcotics, which Phil granted might as well qualify him for sainthood in their city. He wasn’t particularly pushy, nor did he have unrealistic expectations of modern medicine. Phil figured this was because while most fifty-year-olds were watching new episodes of House or marveling at the unrealistic speed and tidiness of forensic medicine crime procedurals, Dwayne was watching reruns of John Wayne epics and Elvis teen beach movies. But still, conversations about erectile dysfunction had their place, and that place was not with your wife’s sister’s redneck husband. And, of course, Dwayne had a particular penchant for the visit-ending hug, a tradition by which Phil 2.0 would not abide. Dwayne was always scheduled for the last visit of the day. Unsurprisingly, he never complained about waiting; he seemed to draw his very life force from conversations with random strangers in the waiting room. Phil was consistently amazed at the depth of knowledge Dwayne had in regards to his patients’ private lives.

By the time he got to Mrs. Beekhuizen, the patient a slot or two ahead of Dwayne, Phil really felt like he was getting somewhere. “Look at me,” he triumphed to his nurse as he curtsied a little. “My shirt collar: unstained. My tie: unwrinkled.” He swept his hands from his chest down past his flanks. “My sense of sovereignty over my personhood untrampled upon. And oooooooon schedule!” He smiled a wide, almost surprised smile, walked to the room, knocked twice, and entered.

Mrs. Beekhuizen’s visit promised nothing out of the ordinary: she was an unlucky sixty-something lady with a smoldering case of terminal breast cancer who’d called wanting to be seen for “sadness.” In the gears of the modern medical machine, this generally meant a diagnosis of depression quickly followed by a prescription for one of several interchangeable, mostly benign drugs.

“Since my husband died, I’ve just been so irritable,” said Mrs. Beekhuizen. “I called the girl who bumped into me in the grocery line a ‘little bitch’ yesterday. Who would do that?” Phil turned to the tablet computer he used for charting and made a couple of jabs and drags with his index finger.

“Hmmm. What else?”

“I don’t sleep at night. I’ve been up since two this morning,” she said. Phil noticed his fingernails needed trimming. His right foot was asleep, so he straightened his leg. He pulled the lever to raise his stool a little.

She sighed. “I’m probably making too much of it all. I just feel so emotional; I cry at nothing.”

She kept talking. Phil looked back up at her. He thought about her mastectomy. Had it made her self-conscious? If he didn’t know about her history, he would not be able to tell she’d had the procedure. He thought about intimacy with such a person. Would it feel lopsided? He stole a glance at the clock. During the final years of hers and her husband’s intimate life, had she taken off her shirt during sex?

“Maybe we’d have both been better off if we’d just died together,” she said.

Phil stood up. “I think you’ll feel better soon,” he said. “I just sent in a script for Zoloft. One a day for three weeks and call me back. Don’t give up on it before then. It takes a while for it to get into your system.”

“Is that all, Dr. Cox?” Mrs. Beekhuizen stood and faced him, smiled softly, and nodded. She started to lean in, but when Phil deployed The Presidential, she startled slightly and looked down. Phil released his two-handed grip and waited for the turn toward the door. He saw the glisten of tears in her eyes, then the slow rise and fall of a first sob. She turned toward the door, whispered,”I’m a monster,” and since it took Phil a half-second longer than normal to interpret the language through the crying, her hand beat his to the doorknob.

“What do you mean, Mrs. Beekhuizen?” he asked, but she was on her way out, her back to him, headed toward the nurse’s station.

“I’m a monster and an amputee,” he heard her say to his nurse as she past.

“You’re all woman,” Phil said in response, then cringed as the words left his mouth. You’re all woman? What is wrong with me?

“She’s all woman?” his nurse whispered to him as she gave him a baffled look, then she and Phil watched Mrs. Beekhuizen take her appointment card and open the door to the clinic lobby.

“Words are hard to choose,” Phil said.

...

It is worth relating the experience of confronting death with a person with whose care you have been charged. You meet, usually in the clinic or in the hospital, but always in a setting in which you as the physician have the power. Your view of the person is focused by the lens of statistics: no advice, no drug, no intervention at all is going to change the cold, hard numbers undergirding her prognosis. She looks at you. Maybe you look over her shoulder and try to feign eye contact. Her eyes find yours again. What is she looking for? What does she think she’ll find in there? Her face slowly transforms from bravery to panic, then maybe to a steady state of fear. You wonder if the loneliness of losing her husband is speeding her death. You move closer to her to show that you’re not afraid of her. You let the catheters and the asymmetry of her body and the smell of iodine and the crust of sanitary dressings touch you. You hear the friction of your hands against the tasteful blouse she’s wearing to cover up the signs of her illness. You don’t move them away. You feel a strange comfort in knowing that vanity persists even to death.

You wonder what else she cares about. Not work, taxes, corporate outsourcing, ISIS, retirement, or an open internet, you think. Her grandchildren? Her cats? The Sunday paper? Good coffee? God? Maybe how many good days she has left? Whatever you feel, whatever oily taste or lump in your throat you swallow, whatever thoughts you have about her or your kids’ school or your wife’s discontentment with your marriage or your own mortality stay a secret.

Your job is to reassure her by your touch that you sense her dignity and her purpose. Your job is to reassure her that she is loved and that people will forgive her for whatever she thinks she’s done wrong. Your job is to ignore the number of beats of the embrace and let her release first, so that by the time you part, by the time she lets go, maybe the tears have started to dry. Your job is not the completion of a simple transaction; it is not the negotiation of some big, sloppy, forced, insincere act. Your job is the dispensing of a therapeutic dose of a medicine that is complex, relational, intense and personal, and it is as carefully dosed as the chemotherapy for which the patient is no longer a candidate. When you release, it is not the patient’s odor or desperation that sticks to you. If dosed carefully, it is some piece of you that departs with the patient. Here is a person who needs a hug.

Phil strode past his nurse without noticing the fleeting brush of her hand against his moist underarm. He pulled open the lobby door, and its moan swiveled the heads of the stragglers in the waiting room.

He started to say,”Mrs. Beek-,” but then he saw Dwayne. Dwayne Moberly, early as usual, in a standing bear hug with a depressed, self-loathing terminal cancer patient, rocking slowly side to side.

“I tell you what, Audrey, Dr. Cox has some unusual methods sometimes, but I tell you, I wouldn’t trust my care to anyone else,” Dwayne said. Mrs. Beekhuizen said something back, but Phil couldn’t hear it. Her voice was muffled by Dwayne’s neck against her face.

Words for a friend

Last week my mentor and friend Dr. Joe Meek passed away. Today I had the real honor of delivering some words at his funeral. This is what I said:

Over the last few weeks, near the end as Joe was declining I called Bette a few times to warn her I was coming around. A couple of those times I got her answering machine. I’m in the bad habit of hanging up on most people’s answering machines or voicemails. I just prefer to try again later. But I didn’t hang up on hers. I listened. Because the message on the Meek family answering machine was recorded by Joe. Some people have the ability to bring the pulse in the room down a few beats, to calm us down just by the way they sound, or the way they interact with others. It turns out that Joe Meek’s ability to do this extends beyond death. I found comfort in hearing his strong voice telling me to leave a message.

Most of us set out to accomplish something in our short lives, even if it’s just the simple pursuit of happiness. But I don’t need to tell you that Joe accomplished more than most. He married Bette young and had kids, Tom, Nancy, and Kathy. Then he spent the rest of his life talking about them. Or at least the years from 2001 through 2019. I can’t speak for the time before then. But I have my suspicions. He was a Lt. Commander in the United States Navy. As an endocrine fellow at Scripps he discovered that Graves disease, the most common cause of an overactive thyroid gland, was the result of a confused immune system. It was the beginning of a life-long love affair with the thyroid gland. Bette was his wife, but that little butterfly shaped gland in at the base of your neck? That was his mistress. He studied dizziness in astronauts in the Mercury space program and once appeared in Life magazine examining astronaut Scott Carpenter. He was department chair of Internal Medicine, then Vice Chancellor to Academic Affairs, then medical school dean. He was a delegate to the American Medical Society and the Director of Rural Health Care and Outreach. He not only earned the University of Kansas Distinguished Service Medallion; he had at least one award named after him, which may be the most apt description of all, since he never seemed to meet a leadership position he didn’t like: Alpha Omega Alpha, Kansas Medical Society, Medical Society of Sedgwick County, Wichita Grand Opera, Sedgwick County Zoo, and others. Depending on your tastes or your line of work some of these acronyms and organizations may not mean anything to you. Don’t worry about it. It doesn’t matter. What matters is how his position in those organizations reflected his life’s philosophy. He considered himself so privileged. Not in the high income, private school, trust fund sense. Privileged in the sense that he had these opportunities. Joe once told me that there are people in the world that wanted to be somebody, but who didn’t want to do anything. “Justin, don’t be one of those people,” he said. In retrospect, I have to wonder what it was that I said or did that made him say that!

He did it all without ever taking himself too seriously. If you don’t mind, let’s all geek out about hormones for a minute. Remember: he discovered thyroid stimulating immunoglobulin, the antibody that confused immune systems make that overactivates the thyroid gland. But his paper describing TSI only beat a competing paper into the literature by a few weeks. Once, while humoring my questions on his discovery, he confided in me that he thought the main reason his paper was published in the Proceedings of the National Academy of Sciences a few weeks before Joseph Kriss’s competing paper in the Journal of Clinical Endocrinology and Metabolism was that his own mentor had a contact within the National Academy that expedited editorial review and the penning of the accompanying editorial. He thought this was hilarious. But it says something about his character that from then on, he happily shared credit for the discovery with Dr. Kriss. And that picture in Life magazine? The one of he and astronaut Scott Carpenter? He loved to tell the story of how hard they’d worked to get a good camera angle for the photographer once the initial data collection was complete. And it is a dashing picture. There’s just something about those Navy whites.

I loved his sense of humor, but I admired his enthusiasm. He struck you as the happiest person alive. He was immune to questions of fashion. He flashed his crooked-toothed smile at everyone--and I do mean everyone--he met. He was not a creature of irony. He was sincere to a fault. The act of engaging in our cultural default setting for David Letterman-esque cool, ironic snark would have been like a trip to Mars. Because in my experience with him he almost always took people at face value. I say almost. Once as a student, I reported to him that a patient’s chief complaint was “an impending sense of doom.” He looked at me as he put his hand on the door to go into her room and said, stone-faced, “Justin, she’s not the only one.” But seriously: he operated in good faith, and he expected the same from others. I can’t imagine that anyone else’s opinion of his vocal love for opera or medical history or brown loafers or obscure thyroid diseases ever crossed his mind. I have no doubt that people--maybe even some in this room--had periodic dustups with Joe Meek. That’s the cost of doing business in leadership. But if you managed to make yourself a lasting enemy of Joe Meek’s, I’m not saying you’re a bad person, but I’d encourage a sincere evaluation of your life philosophy. There. I said it.

That makes him sound boring. He wasn’t. He and Bette shared the trait of being great storytellers. Fifty years of medical students, residents and fellows--not to mention patients--know how much he loved to tell the story of Dr. Hashimoto, the so-called “thyroid hero of Japan.” And of Robert Graves, whose grave--ironically--he’d visited in Dublin. I actually stole that joke from Dr. Meek, and I’ve used it over and over. It goes like this: Graves disease doesn’t mean you’re going to the grave. It’s just a guy’s name. Okay. So maybe he wasn’t a comedian. But he was funny. He used words that I’d never heard anyone use before. You may know somebody who routinely uses the phrase “to wit.” It means something like “that is to say.” But I dare you to find another person who uses the word “folderol.” That’s f-o-l-d-e-r-o-l. It means “a trivial or nonsensical fuss.” He pronounced “helicopter” “heel-i-copter.” He sprinkled these kinds of words into conversation the way most of us reflexively use “like.” The effect was thrilling. Even through the ravages of a degenerative neurologic disease and sometimes through swollen lips and bandages from accidents and falls, he routinely told me stories that made me giddy.

He once told me a story about a brittle diabetic he’d taken care of named Dora. Even though I’m not sharing it with you today, he still knew her last name, decades later. He wasn’t sure that was a good sign. Dora was in the hospital a lot because of complications of her diabetes, and one day she asked Dr. Meek: “We raise a lot of our own vegetables. Can I bring you in some vegetables?” He wasn’t sure if it was a peace offering or a way to try to get special treatment. But he said yes, stressing to her that it was not a requirement, and she said, “I’ll discuss it with mother, and I’ll bring you in something.” And so Dora showed up to her next appointment with a sack of Brussels sprouts. Not long after, Dora’s mother began calling Bette and Joe’s home phone. One time she called in the middle of the day and Bette answered and said, “Ma’am, he’s at the medical center, and I do not welcome you calling his home like this.” Mother said, “Mrs. Meek, you remember them Brussel sprouts?” Bette’s abject lack of gratitude for the Brussels sprouts was a joke between Bette and Joe after that. Joe admitted in confidence that the Brussels sprouts were really, really good.

He was my portal into a different era. Like a time machine. I don’t mean just to say that he was old. But he had once taken care of a patient who had been cared for at age eight by Dr. Arthur Hertzler, the famed Horse and Buggy Doctor from Halstead. Dr. Hertzler had told the patient’s mother that the daughter needed a goiter operation, and the mother said, “Well, should we make arrangements at your hospital for surgery?” And Dr. Hertzler said, “Madam, I said your daughter had a goiter and it needs to come out!” So mom served as the anesthesiologist, presumably with ether, and Hertzler did the thyroidectomy on the kitchen table. When Dr. Meek took over her care sixty years later she was in good health, with no complications of her procedure. He remembered her name, too.

It was all a reflection of his sense of wonder. He once told me regarding his discovery of TSI, and this is a direct quote: “Leaps forward in medicine were sitting there, just below the surface, waiting to be unearthed.” In clinic he would stand behind patients with his fingers delicately around their necks, feeling the thyroid gland. When a patient swallowed and he felt a thyroid nodule move under his fingers, Dr. Meek would sometimes say “There it is!” And then he’d almost always reassure the patient that it was only a matter of getting a needle biopsy to diagnose the problem, and that it wasn’t a big deal, and that most people with thyroid cancer--if that’s what it was--did just fine.

One time we saw a patient together that had acromegaly, a pituitary condition of excess growth hormone. All that extra growth hormone causes the hands and feet to enlarge, and causes the patient’s skin to take on a particular texture. He and I were examining the patient, and he put my hand over the patient’s and said, “Feel this, Justin. It’s like she’s made out of warm dough.” The patient asked “Is that okay?” And he said, “It’s great.” And then he reassured her that we would get to the bottom of her pituitary issue, and that she would do okay. And she did.

That confidence came with experience. Like any doctor, he often saw patients for whom there was no simple answer. They had problems that were hard to fix. Bad eyes from pituitary tumors or Graves disease. Metastatic thyroid cancer. He would evaluate them and simply lay it out there: We don’t have a perfect answer for you. We have a lot of bad options and one decent option, and the decent option is the one we’re going with. Modern-day practitioners trained in shared decision making--that’s the generally sound principle that patients should have more of a say in their own care--would have raised an eyebrow at this. But I think there was comfort in that approach for a lot of patients. Because this wasn’t some stranger telling them the bad news. He’d never met a stranger. Most of these patients had already been on the business end of one of his so-called “hundred-dollar hugs,” as the nurses called them. So by the time the hard decision making really kicked in I think people thought, “That’s okay. I know Dr. Meek. I know he’s got my best interest at heart. I know that my friend wants the best for me.” Or my group, or my organization. In preparing for this I spoke to a couple docs in town who’d worked with Dr. Meek. He’d had the same effect on them. They would go to him with a tough decision about a patient or their career, and he would have an answer, often quickly, based completely off his own instincts and extensive experience. And more times than not his instincts were right.

In saying my own goodbyes to Joe over the last year or so, I was struck by his dignity in the face of an illness that spared him nothing, dignity least of all. The disease even took his voice, then his laugh, then his crooked-toothed smile. But to the end he insisted on brown loafers, slacks, and a tucked-in shirt. Maybe he was a fashion icon after all.

“I don’t fear death,” he told me once, though he did say how much he would miss seeing friends, his kids and grandkids, and Bette. But I’m comforted by the thought that old endocrinologists never really die. If cowboys ride off into the sunset, endocrinologists just shuffle off into a bright hospital-fluorescent light. And if there is justice in the universe, someday we’ll meet again. He’ll be under that fluorescent light in a perfectly pressed white coat and brown loafers, telling the staff about Dr. Hashimoto, the thyroid hero of Japan, and patiently waiting for the arrival of the next data set.

Old endocrinologists don't die. They walk off into the fluorescent light of the big lab in the sky.

Last night one of my mentors passed away. Dr. Joseph Meek was a lot of things to a lot of people. To me, he was the Dean of the School of Medicine at the University of Kansas in Wichita when I started school there, then an attending endocrinologist who wrote me a letter of recommendation for fellowship, and later in life a friend.

After he left the medical school to ride out the last few years of his career in private practice we lost touch for a year or two. But then in 2015 I became interested in his role in discovering the autoimmune cause of Graves’ disease.

I started visiting him every week, and every week I seemed to get a better story. So I asked if I could start recording them, and he consented. Dr. Meek told the stories with remarkable enthusiasm. He was a gifted storyteller, even the times he was speaking through a forehead bandage and a crusted upper lip from a recent fall. (note: I’ve not fact-checked these. I’m not a journalist. If anyone finds an error, please let me know so I can note and correct it.):

He had a lot to say about the discovery of thyroid-stimulating immunoglobulin:

Meek: ...at that time, the cause of Graves disease was entirely unknown. And since such luminaries as--I haven’t thought of his name--Sydney Warner felt it was due to a pituitary factor, and the TSH was involved.

Moore: So they thought some over-secretion of TSH was involved?

Meek: Yeah. And about that time a guy by the name of Brown-Dobbins discovered what he regarded as the exophthalmic factor. And so the hyperthyroidism was explained by an oversecretion of TSH and the exophthalmos of Graves disease was explained by the exopthalmic factor, “ES.”

Moore: Okay

Meek: And so that was where it stood to 1964. Well, McKenzie had developed a TSH assay, bioassay, that involved the preparation of mice.  You injected radioactivity into the mice and it was recorded as an uptake. And then the mice were bled and two hours after the injection of TSH or Graves disease patients [ed: I assume he means the plasma/serum of Graves patients] they were bled--the mice were bled--and there was observed a rise in the radioactivity level of the mice.

Moore: That’s interesting.  Okay.

Meek: Yeah. And the mice had to be prepared in a special way, and ruled out that it was a stimulation versus an infectious agent that caused the destruction of the TSH. The mice were initially prepared that stimulation was proven and the mice did stimulate and discharge radioactivity.

Moore: And the source of the stimulation was either the TSH or some other stimulation factor in the serum that had been injected?

Meek: Yes

Moore: Yeah.  Yeah.

Meek: And in Graves disease patients there was evidence of a long-acting stimulator, LATS.

Moore: Yeah, yeah.  Uh-huh.

Meek: Yeah. And the mice would stimulate sort of at 2 hours, and there was increased activity in the blood 7-24 hours afterwards. And Van der Laan [ed: 4th author on the paper above] came up with the idea (that’s my mentor)...

Moore: Was that in San Diego?

Meek: Yes.  At the Scripps Clinic and Research Foundation in La Jolla. ...that it would be explained by an antibody.  That was a unique observation, although it was copied by a Maxwell McKenzie and, oh gosh...well, this was a race.

Moore: Yeah.  I bet.

Meek: Yeah. And the work that I did was to prove that it was an antibody, that it was a 7-S-gamma globulin that was present in the serum of mice and the serum really came from patients with Graves disease. And the stimulator was an antibody. Well, the man’s name was--from San Francisco, and he’s dead now--he came out with a publication about the same time that I did, and he is given credit for this work that he did, and it was published in the Journal of Clinical Endocrinology and Metabolism [ed: I think it was this paper]. But I beat him by a month through the National Academy of Sciences.

PNAS 1964 Aug; 52(2): 342–349.  PMID: 14206601

PNAS 1964 Aug; 52(2): 342–349. PMID: 14206601

Moore: That was the journal that you published in?

Meek: Yes.

Moore: A better journal! You got it into a better journal. (laughs)

Meek: And it was not peer-reviewed to the extent that it was in the Journal of Clinical Endocrinology.

Moore: It wasn’t? That’s interesting.

Meek: And it was introduced by Dr. Astwood, who was a member of the National Academy of Sciences, and so there was a race on, which fell in my favor due to circumstances beyond my control by senior men Van der Laan and Astwood. And they had known each other through their collaboration prior. The competitor just won’t come to me… And it culminated in review in Atlantic City. And that was when Atlantic City was meaningful as the senior moment of the Central Society for Clinical Research. They would hold their annual meeting in Atlantic City, NJ, and I was invited back in May of 1964 to give a paper. And so I did. And I remember an anecdote that before I left Scripps I was rehearsed by Dr. Van der Laan and Igray Diamond, who knew me from, because of, medical school days.  And he was back in Kansas at that time as chairman of the Department of Internal Medicine.

Moore: And you had gone to medical school at KU, correct?

Meek: Yeah. And he was the speaker at Alpha Omega Alpha (AOA) when I was President of the AOA. And I introduced him as saying that--it was a brash statement on my part--as the erstwhile, but seldom seen, member of the faculty because he was gone so much of the time. (laughs). And he got up and said after that introduction that he had secured a spot for his residency in my favor and he was considerate of my position and he gave me the position as resident in Internal Medicine right on the spot. And so he knew me and said that my slides had not been acceptable because they were all on blue. At that time I couldn’t do anything about it.

Moore: (laughs)

Meek: Yeah. He went on and on in remorse, it caused remorse in me, because he said that was not acceptable.  They should be in black and white. Yeah. And I came to give the talk in Atlantic City and found out that blue was more or less the outstanding color.

Moore: The industry standard.

Meek: Yeah.

Moore: Good.  It was really hard to change slides back then I’m sure. You had to go back to the photography place.

Meek: The plates were in evidence and I couldn’t--I had to board the airplane to Atlantic City the next day and there was no way I could get the slides done. Well, that’s an anecdote. The work of mine was justified in my way of thinking because I had done some biochemistry and proved that it was a 7-S-gamma globulin.

Moore: That the stimulator was a gamma globulin?

Meek: Yes. That LATS, as defined by the mouse response, was due to an antibody in patients with Graves disease. And so from that point on the, and subsequent work, and I did a a little of this, was to see if you could convert TSH to a long-acting thyroid stimulator, and conversely, you could modify the 7-S-Gamma globulin by fragmentation and show that it was an antibody on that basis and convert short-acting thyroid stimulator by modifying the gamma globulin.

Moore: Uh-huh.

Meek: Well, then I went back to Kansas and did some clinical work and that was my highlight. And I am proud of the fact that I contributed something to the medical world.

Moore: A pretty big thing, I think.

Meek: Yeah.

Moore: Did they--I assume it was pretty well established by this point that antibodies were responsible for other autoimmune diseases, like Rheumatoid arthritis and whatnot?

Meek: Yes. Rheumatoid arthritis. Although they never--RF factor, which is an antibody in rheumatoid arthritis, was never injected into a patient and produced the joint destruction. And I, for long time, believed that the uniqueness of Graves disease was due to two factors: one, it was proven to be an antibody, and two, that it was a 7-S-gamma globulin antibody that was unique to, based on the fact that it stimulated the thyroid gland.

Moore: So you could actually reproduce the disease by introducing the antibody?

Meek: Yeah. And that sort of is where it was in 1964.

Moore: You know, the fact that it was a race, as a lot of these things are, interests me. Nowadays when you submit a paper to a pretty high-end journal like the Proceedings of the National Academy of Sciences, you have a response back in hours to days, at least an initial response.

Meek: Yes.

Moore: So you can go from a completed paper to having something submitted for publication in the course of a few weeks. If you’re lucky.  I assume that back then there was a huge element of faith involved. You had to send off a manuscript that got distributed out and it might take months to get edits back.  Is that how it was?

Meek: Yes. The editorial that the edited version of the paper came out in the Proceedings of the National Academy of Sciences pretty much on--I think it was accepted for publication in May of 1964, and published in July issue. Whereas Kriss! Joseph Kriss! That was the author that did the companion.  He did the work about the same time that I did, but he went through the channels of the JCEM, and got his published in September (laughs) [ed: it was October]

Moore: Somebody held up the editing process, somebody didn’t get their edits back in time.  That’s the way it always goes.

Meek: Yes. Well, Chris is subsequently referred to--what’s the word? Referred to as the contributor to that just as frequently as I am. And to this day it’s still holding up. It’s an antibody, and the locus is sort of where TSH is, and it stimulates the patient to develop hyperthyroidism, and it, based on the TSI (thyroid stimulating immunoglobulin), it’s pathognomonic for Graves disease.  So it’s still valuable information.

Moore: Yeah. I agree.  Someone at the time must have thought that it was important to have solicited an editorial to accompany the paper.  That doesn’t happen every day.

Meek: No. And subsequently the EPS, the Brown Dobyns work, has faded from the scene.  I know that his assay was an Atlantic minnow, and the Atlantic minnow developed exophthalmos (laughter). The lateral displacement of the minnow’s eyes was measured with a micrometer.

Moore: That’s amazing.

Meek: Yeah.

Moore: Would they just put the stimulator in the water?

Meek: They injected it into the animal. The Atlantic minnow.

Moore: Very interesting.

Meek: Yeah.  I never did that assay. But I remember hearing about it.

Here’s one about the Mercury Program:

Meek: Yes, and I was found to be acceptable, and so Diamond wrote down to Captain Greybill, that was a Navy Captain, and he was in space medicine at Pensacola. And accepted me to avoid the draft and I went into the Navy and was assigned to Pensacola dispensary or flight aviation for two years. Well, Greybill was into flight disorientation.

Moore: OK

Meek: Now, it was kind of ironic that my trouble--current trouble [ed: at this point, Dr. Meek was suffering from frequent falls and dizziness]--preceded that. And his claim to fame was disorientation about space sickness, which was brought about by circular rotation of the spaceship to create artificial gravity so the astronauts would have an up-down location/knowledge base.

Moore: So they were thinking of designing spacecraft that rotated to generate centrifugal force so that an astronaut would have some artificial gravity as it were?

Meek: Yes.

Moore: OK.  I’m following.

Meek: So the work really was brought to a head for NASA’s standpoint by the space race which we were engaged in in 1962. We participated in that because we in the Army and Navy were the only ones doing disorientation. So I was appointed as a research assistant, a typical post-doctoral fellowship.

Moore: You were out of residency at this point?

Meek: Uh-huh.  Although just out of residency. And it was before I had seen Van der Laan [ed: 4th author on the above paper] and before I arranged for my endocrine fellowship at Scripps Clinic and Research Institute. Well, I thought that was a pretty good deal to be established in the Navy stateside for the following reason: captain Greybill had an understanding with the United States Navy that he would never be transferred from Pensacola.

Moore: That seems remarkable.

Meek: Yeah. And they were willing to do that because he was a student of Paul Dudley White, and White was Mr. Harvard Medicine at that time. And they wanted somebody to head up their space program, so many of the astronauts were navy recruits or marine recruits, including Scott Carpenter and John Glenn. So we did some preliminary data on the original seven Mercury astronauts, and, so, NASA was in a race with the Russian cosmonauts, and the cosmonaut fell into space at that time, certainly in the capsule…

Moore: Gagarin?

Meek: Yeah, Yuri Gagarin. That name is familiar to me only because the space race was going on in full intensity at that time, and NASA had not considered it until Gagarin became violently ill in space because of the tumbling.

Moore: Did the Soviets admit that he’d been ill, or was it just intelligence? Somebody on the inside who’d passed along the information?

Meek: Yes.

Moore: Wow.

Meek: That’s how it all happened. So NASA said, “Where is our counterpart to this space station to be?” And the answer was Ashton Greybill.

Moore: He was the guy to solve this problem?

Meek: Yes.

Moore: got it.

Meek: And so I was assigned to the recovery of Scott Carpenter on the space flight. I went for seven days on special assignment to sea. And I was assigned to the recovery ship the Intrepid.

Moore: Very famous ship.

Meek: Yes. The Gray Lady. Had a colorful history of being sunk but not being sunk, and being towed into Australia and refitted, and went out to sea. She is parked in the--because of her history--she is parked in NYC, and I went aboard her some years after I got out of the Navy. Well, there is a little anecdote around that which I will refer to at a later date. So the recovery mission of Scott Carpenter ended up 40 miles off range. 40 miles.

Moore: 40 miles away from the intended spot of impact, or whatever?

Meek: Yes. Drop. And so we were on the flight deck of the Intrepid and craning our sights to the skies and seeing if we could see the ship come down. Only to learn later that she had--that Scott Carpenter had landed 40 miles downrange, 40 miles off the target area. And the plans were diverted on the spot to a destroyer picking up Scott Carpenter. Well, the Navy, in contrast to the marine corps, had Jet-assisted helicopters [ed: he pronounced “helicopter “heel-i-copter,” which is officially the most Kansan thing ever], and that was in the early days of jet-assisted helicopters, and Huey current breed of helicopter which followed that. And that had the range of 40 miles. But the Marines didn’t have that, so the Navy left the Intrepid the original plans were adhered to. Well, there was a big folderol and I was in my moment of glory, and I gave Scott Carpenter the original assessment to see if there were any remains of space sickness occurred. Including a ice water bath to induce nystagmus.

Moore: You mean irrigation into his ear canal?

Meek: yes. I only mention that because my hands were steady during the entire procedure and the intrepid was under full steam to make it to the islands, Grand Turk Islands, and the ship just yawed and strained and it was awfully difficult to hold a steady hand.

Moore: Well that’s a very difficult environment to evaluate someone’s balance, I’m sure.

Meek: Yeah! And Scott Carpenter was a wonderful guy, and he’s still alive--or just died [ed: he died October 10, 2013]--and he played it to the hilt. Now there was this about it: Scott Carpenter had been out on the Caribbean sea for a long time waiting for his recovery. So if he did show any deterioration in his baseline figures, including the threshold caloric test, it would have been seasickness rather than space sickness.

Moore: Because he’d been bobbing in the water forever waiting for someone to come pick him up?

Meek: Yeah. But we played it to the hilt and I received some notoriety about that. Because you can’t imagine how the people stateside were enamored with the space program.

Moore: Those guys were the rock stars of their day.

Meek: They were, and they handled their fame beautifully, as would be expected, as they had so much training to do prior to the selection for the space program, and even today the space station is not accommodated to generate artificial gravity. And that remains to be seen, whether NASA intends the space station to be constructed to generate artificial gravity or not. It doesn’t take much: 3-6 rotations per minute in weightlessness corrects artificial gravity to a point that, up and down, is reproduced artificially.

Moore: Was that at a specific radius?

Meek: Well, we did some preliminary space sickness, and we felt that everybody was subject to space sickness, although you adapted to it over the long haul.

Moore: How long did it take?

Meek: 72 hours, +/- their sensitivity, as determined by the threshold caloric test. And whether you had been a seasoned aviator or not, that helped.

Moore: Meaning experienced pilots got over it a little more quickly?

Meek: Yes.  They were subject to less of it, although the seasoned aviators, including the astronauts, could always manifest space sickness by sweating.  They couldn’t control that. But the nausea and vomiting that accompanied that--car sickness would be the closest we could come, land-locked selection, and not everybody was subject to car sickness, but everybody would, if they had normal semicircular function, was subject to nausea and vomiting.

Moore: Did you guys consider using anti-cholinergic medications?

Meek: Yes. Scopolamine. And that masked it, but it brought out some undesirable side effects from the scopolamine. And the patients were subjects in the slow rotation room environment, and then re-adapted to space sickness symptoms upon entering weightlessness. And there was a little readaptation.  And I think it’s been proven enough of a problem that they don’t create an artificial environment because of that single effect. And they always give the astronauts time to re-adapt to weightlessness and following their return to earth. You aren’t aware of that, but they sit out on the space recovery mission after that, and they’re a little wobbly.

Moore: You mean after they launch they get some time to adapt before they’re assigned any tasks, and after they re-enter they get a little while to re-adapt before anyone asks them to do anything else? I see.

Meek: Yes.

Moore: That seems cheaper than building a rotating spacecraft.

Meek: The human is--particularly the seasoned aviators--used to that through their flying

Moore: Was the idea with this slow rotation room, was that something they tried to do pre-launch to get them accustomed to it?

Meek: Yes.

Moore: From what you’re telling me I assume it didn’t work very well.

Meek: No. Well, the history of the intrepid was such that its glory days were extended through the second World War, the Korean War, and other war duty.

Moore: All the way into Vietnam, right?

Meek: Yes. They put a pictorial essay, pictures, up when we, just prior to when we went aboard the time it was tethered in NYC. And you could go aboard and see the Intrepid. The pictorial essay of space was pictorially depicted about the Intrepid’s life at sea. And the time aboard we took time aboard, they had just done the pictures--taken them down--and so we thought that it was all over, although we had no idea that they’d depicted the shot that showed me administering the Heath Rail balance problem to the astronaut, to Scott Carpenter.

Moore: So there was a photo in the exhibit showing you doing this with Scott Carpenter? How about that.

That’s Dr. Meek on the right with the clipboard. From  https://bit.ly/2Bespfg

That’s Dr. Meek on the right with the clipboard. From https://bit.ly/2Bespfg

Meek: Yes. And it had been in Life magazine.

Moore: Wow!

Meek: And the Life photographer, who was a neat guy, captured that when Scott Carpenter was interviewed after the tests were administered. And so sick bay was converted into the ability to do the threshold caloric test and the Heath Rail. So Scott Carpenter came in to pictures being taken, flashbulbs going off.

Moore: (laughs) More things to add to the validity of the testing.

Meek: Yes. And because the Navy wanted maximum publicity on this, the results were negative plus or minus three, the threshold caloric and the Heath Rail test was administered by me, and you had to stand up on the rails, which looked like a railroad yard, for so many seconds, and there’s Scott Carpenter with his arms folded and looking intently down on the Heath Rail and balancing. Now, that wasn’t the purpose of the picture, to get my picture in with Scott Carpenter, but it added to my luster. (laughs)

Moore: I would have put that in my application to fellowship, for sure.

Meek: Well, that was it.  That was my claim to fame. Six days aboard the Intrepid, and subsequently the falderal and attention that I got as…

Moore: Were you allowed to publish any of the data you got out of this experience? It wasn’t classified then?

Meek: No. Although my publications were on the experience I had in the slow rotation room in Pensacola. That’s in Aerospace Medicine. [ed: paper regarding monkeys and slow rotation here: http://www.ncbi.nlm.nih.gov/pubmed/14472044] And that was one of the publications I got out of it in my quest to enter academic medicine.

Moore: How much time did you have in the Navy after this experience was over? Was this near the end, or was this...

Meek: This was right during the end.  I got out in July of that year, ‘62, and went to my fellowship and discovered the antibody formation of LATS [ed: long-acting thyroid stimulator] that we have discussed prior to that. But even though the ENT work was instrumental in that period, it was never exposed beyond the publicity on that, although when we went to Pensacola some years thereafter, after I got out of the Navy, the slow rotation room was still in operation.

Moore: Is that right? Were they using it for just routine flight medicine stuff then, or was it still affiliated with NASA?

Meek: No, the building was semicircular, a full circle, and that was constructed because of the human centrifuge that had gone on prior to that. But Captain Greybill slowed the centrifuge down and found out that we could reproduce the symptoms at a very slow rotation. So he had done all that work prior to my entering the Navy. And I developed the threshold caloric test and Heath Rails that were part of the experience--part of the “package”--that astronauts were put through as well as the Navy recruits that came in.

Moore: I’m sure they cursed your name if they knew.

Meek: Yeah. (laughs) They did. They forced me to ride aboard the spacecraft, slow rotation room, and experience first hand the adaptation that occurred. And we had dials that you had to set up here and over here to bring out the case of space sickness.  Because if you kept your head in the plane of rotation you could avoid the adaptation.

Moore: You had to move around?

Meek: Yeah.

Moore: That is so fascinating.

Meek: The experiments at that time were pretty crude, and they consisted of a water bath and temperature adjustments which were displayed on a human--I forget what we did to keep the water bath temperature and they syringing adjusted to threshold as determined by nystagmus.

It was so fantastically great hearing those stories and others. It was good even after he lost the ability to talk and we just watched baseball together for 30 minutes a week.

I’ll miss him. I’ll miss his excitement at nailing down a straightforward diagnosis of Graves disease. I’ll miss the enthusiasm with which he told the story of the time he discovered and successfully treated a case of thyroid lymphoma. I’ll miss the way he tried to hug everybody, including me, even though I hate hugging.

But I won’t forget him, and that’s all most of us can wish for.

My own, personal e-bike: How to riide

After my excitement about dockless e-bike share in Washington, D.C. last spring, I started shopping around for an e-bike for Double Arrow Metabolism to use for short business trips.

I wanted a bike that was adjustable so that more than one person could use it without much trouble. I tried to find refurbished Jump bikes, but I struck out. I think they’re just too new. Many of the purpose-built bikes on the market are really expensive and/or look like Kawasaki motocross bikes (you really get how some people are complaining about e-bikes being e-motorcycles in disguise).

So it took some looking. I really like the retro fabulous looks of Faraday bikes. I love the looks and techie features of Stromer bikes, but the price is way too steep (especially for Stromers), at least until I really know what I want. And for the money, the looks of the mainstream bikes like Specialized and Trek just aren't what I’m looking for.

I considered building my own e-bike by adding an aftermarket hub motor and a battery to a bike I already have. Then I looked around and found a page for refurbished Riide bikes. The price on these was what really attracted me. They don't cost the three or four grand that some of the other bikes mentioned above cost. In fact, they're within a few hundred bucks of the Money Mustache conversion that piqued my attention toward e-bikes in the last couple years. Riide has an interesting subscription-based business model for its new bikes, but more important to me, they’ll sell their old ones: 

Screen Shot 2018-05-13 at 6.16.12 PM.png

They'll allegedly fit a rider between 5'2" and 6'2". That easily fits my wife’s and my height, and it gets close to my daughter's. So I hit the Add to Cart button and waited. Unfortunately, when I ran out giggling to greet the FedEx guy, I found an open box and no front wheel. Somebody decided they needed it more than I did:

IMG_1661.JPG
The front wheel is apparently in the same place as Jimmy Hoffa.

The front wheel is apparently in the same place as Jimmy Hoffa.

But not to worry. I got to spend some time talking with Riide founder and owner Amber Wason via email (and even with a personal call to my cell phone [!]), and we got it straightened out. We got the missing wheel replaced, and we had a new e-bike in no time. 

If you doubt the size difference in riders the Riide can accomodate, that's a 4'7", 60 lb human riding the same bike that'll haul my 6'1", 180 lb corpus around.

If you doubt the size difference in riders the Riide can accomodate, that's a 4'7", 60 lb human riding the same bike that'll haul my 6'1", 180 lb corpus around.

The ride of the bike is different than the Jump tanks I rode in D.C. First, the bike is a fair amount lighter, since it doesn't have the built-in racks and electronics of the Jump. Also, Riide isn't controlled by pedal assist. Instead, you twist the throttle like you're riding a Yamaha.

This doesn't really affect the sensation of riding the bike. When you twist the throttle you still get a satisfying little kick from the motor. It does affect the appearance of the bike, though, since you can easily cruise along without even turning the pedals. I’m not in love with the twist throttle, though. My thumb and forefinger get crampy from holding it in place. I think I would like a thumb throttle better.

One feature I really like is that the brakes kill the motor. My son learned the value of this the hard way on about day two, when he accidentally twisted the throttle as he was dismounting and skinned a knee. Use the brakes. 

I eventually rode it to work:

Screen Shot 2018-06-18 at 3.07.26 PM.png

After taking these pics, I immediately deleted the rides from Strava. Strava is the de facto place to log rides, but it doesn't feel right to post e-bike rides on it. Strava's for human power only. But I can't help but obsess over data, so I put Map My Ride on my iPhone for ebike use only. Then after a few hundred miles I deleted it and just let the abject lack of data wash over me. Digital minimalism forever.

The advertised speed of the bike is ~20 mph, but I think that estimate assumes a new bike and battery, and I think it assumes a smaller rider than me. I can only get ~17-18 mph out of the Riide on flat ground. That’s still pretty good. It gets me to where I'm going faster than I could get there on the fat bike I often commute on: 

Sure, a different route. But a significant increase in speed, with a significant decrease in sweatiness.

Sure, a different route. But a significant increase in speed, with a significant decrease in sweatiness.

At the end of the day, I think the Riide may be what I want, not the bike I ride while I'm deciding. It looks good in a way that doesn't draw a lot of attention, it is inexpensive and comes with a warranty that I've already tested and that works, and it gets me around in a satisfyingly blue-collar way.

IMG_1849.jpg

Now I’ve ridden it a thousand miles, maybe, and I feel pretty good about it. The bike didn't come with any rack or panniers, so I had to add one. No problemo. Because buying bike stuff is. The. Best. The front rack from Velo Orange. It looks great and can hold a ton (or at least a case of beer). I’ve found it easier to strap my soft-side briefcase to the front rack than to stuff it in a pannier bag or strap it to a skinny rear rack like I do on my fatty.

A few Riide-specific tips, if you care:

Don’t air the tires up to the maximum pressure. It’s tempting to do this to try to maximize battery efficiency, but the bike rides like a lumber wagon that way. And remember that higher pressures aren’t always better. It’s way, way more comfortable to pump the tires up to a nice, soft-ish pressure to allow a little give over the bumps.

The battery is really glitchy about over-charging. I’ve found that if I accidentally leave it plugged in overnight it’s out of commission for the day. I don’t know why, and I’m no stranger to plug-in electric vehicles:

IMG_2544.jpeg

The phenomenon is reproducible. In my mind it’s a complication of over-charging. But that could be my imagination running wild. Anyway, either set up the charger on a timer that shuts it off after ~3 hours or set a manual timer to remind yourself to unplug your Riide.

Finally, if you have multiple people using the bike you’ll need to put the brake levers in a medium position. Since I’m a foot-and-a-half taller than the other people riding it but I use it 90+% of the time for work, I keep the levers pointed down a little. But not as far down as I would if I were the only rider. I tip them up just a little to make them reachable by everybody else.

Riide on!

The pleasure of going deep

I took the ABIM endocrine maintenance exam a couple months ago.

I love the ABIM logo. It reminds me of the logo for the  Southeastern Conference .

I love the ABIM logo. It reminds me of the logo for the Southeastern Conference.

Spoiler alert: I passed. But this isn’t about my ability to pass a standardized test designed to fail only the small number of docs who can’t achieve a minimum level of competence. This post is about how good it feels to set aside the distractions of the world for a fraction of the day and really concentrate on learning something.

Ironically, the format of the exam was new. The test now includes sections in which UpToDate is available for reference. These were tricky because the availability of a reference was so seductive, much like the availability of the internet in your pocket at all times is so seductive. Lucky for me, my preparation had somewhat steeled me against this. I forced myself to use the physical version of the Endocrine Self-Assessment Program (ESAP), and I forced myself not to look up answers on the computer or my phone willy-nilly. I read through the questions, answered, read the responses, and took old-fashioned analog notes that I reviewed later. I studied around 30 minutes a day, five days/week for September and October. I kept a “30 min board review” item on my daily to-do list. I attended the Cleveland Clinic review course, which was helpful. I was amazed at the new diagnoses that have come about since I last did full-time endocrine practice. Pigmented macronodular hyperplasia? Okay then.

Analog study materials.

Analog study materials.

Ironically, I’ve somehow activated notifications on my computer so that Apple News headlines keep popping up in the corner of my screen as I’m typing this, which only serves to show how much attention residue I avoided by doing it the old-fashioned way. But even still, the first section that allowed access to UpToDate almost tripped me up. I found myself second-guessing even simple answers and clicking on the UpToDate icon to double-check myself. Even though I’m a pretty fast test-taker, and even though every UpToDate check took only a minute or so, they really added up, and I had to really hustle toward the end of that section to get done on time. For the next two sections I forced myself to finish the questions to the best of my ability and then go through any that I’d marked as potentially wrong to check them. This method left me much, much more time.

When I finished the test, mostly sure that I’d passed, I felt a sense of satisfaction that only intensified when I got my test results back. I had prepared for the test, performed well enough to pass, and legitimately increased my knowledge of endocrine diseases and their treatments. As big a pain as the board certification process is, it ultimately made me a better doctor and reinforced some of my technological minimalist views of the world.

Many of us do the same job tasks day after day. I’ve warned med students and residents about the “Groundhog Day” phenomenon. If you go into general surgery, you better like gallbladder disease, because you’re going to see it all day, every day, forever. If you become an endocrinologist you better like hyperthyroidism, because again, it’s gonna take up a lot of your day. (I would have said diabetes there, but it’s so rapidly automating that I’m not sure it will be part of the day-to-day of endocrine practice for much longer.) I’m sure the same thing is true of banking, law, manufacturing, farming, or a thousand other professions. But by going deep, you can find new sources of pleasure and satisfaction even in work that has a tendency to become rote.