People with neurologic symptoms that require an excessive number of terms to describe them are not having a stroke. Patients who are actually having a stroke most often have one extremity that simply doesn’t work. It is functionally weak, paralyzed, or flaccid—it simply does not move. Speech is slurred, and the face often droops, most noticeably at the corner of the mouth.
I had a patient last night with a history of migraine headaches. With this particular headache, she complained of pain that radiated down her neck into her right arm and hand. She described her hand as “hot” and provided an excessive number of additional descriptors for her arm: tingling, “not there,” fuzzy, warm. I’ve heard other patients use similar terms like “off” or “buzzing.”
People are very unwilling to let go of their opinions. I see this most commonly when it comes to abdominal pain. I have many discussions with patients about abdominal pain. I do large workups for abdominal pain regularly. Many of the patients I see have already had extensive workups by gastroenterology— they’ve had blood tests, cameras shoved down their throats and up their butts—but no one has any answers. I have patients with ulcerative colitis whose GI specialists tell them that diet has nothing to do with their disease. It is baffling to me that this became the standard teaching for most of the GI doctors I’ve interacted with. How is it possible that things going wrong in your gut are not related to what you put in your gut? It seems like the most intuitive thing imaginable, yet we ignore it.
I have a friend whose dad has been in the hospital for 10 days because of high blood pressure. Nothing the doctors have tried seems to fix it. He’s on multiple medications with very little progress. The prolonged hospital stay has drained his motivation; he’s clearly more depressed than he was. They’ve accomplished very little, and there’s been almost no communication with the family about what the end goal even is. His blood pressure is still running high, so not much has really been accomplished.
“Eat a balanced diet.” It’s a common phrase that you hear from experts. But what does that actually mean? The word “balanced” is vague and lacks any meaningful value.
When someone says “balance,” what exactly are they referring to? Does it mean that your food generally contains each of the three macronutrients—carbs, protein, fat? Does it mean that it only contains what is essential for nutrition, specifically certain fatty acids and amino acids? (I.e. protein and fat; there are no essential carbohydrates.) Does it mean balance in terms of micronutrients, vitamins, and minerals?
I spend more and more time with patients talking about their medical problems that are not emergencies. The vast majority of the time, any actual emergency condition is ruled out very quickly. Occasionally, a critical diagnosis is found after quite a long time in the ER, but that’s the exception rather than the rule. So once the actual emergencies are no longer part of the discussion, we can focus on other things.
There’s a billboard near my house advertising a science college. It has a catchy phrase about making breakthroughs. The picture is of a young, bright-eyed college student wearing safety glasses and a white lab coat, holding a beaker—reminiscent of bench science like one would see in a high school chemistry lab. It gives the impression that any college student can make world-changing breakthroughs. And although that is technically true, it’s not even remotely realistic.
When you get old, you will need help. The vast majority of us will die a slow death. That is to say, we will have medical problems that slowly get worse until at some point one of them manifests itself in an acute way, such as a heart attack or stroke. Hopefully that end is not actually slow, but not living well for some months to years is the norm. By not living well, I mean not living independently, not doing the things you want to do, not having the capacity to attend to your own needs. Peter Attia has written about the Centenarian Olympics, with the idea being that most of us want to do activities and be able to function well when we are 100 years old. But as he points out, most of us can’t do those things in our 60s or 70s, and we certainly are not going to suddenly regain capability we lost decades ago.
The advice to ask your doctor before starting an exercise program has no basis in science, as far as I know. It’s primarily a CYA (cover your ass) disclaimer. Virtually everyone in the fitness industry has adopted it, so it’s stated almost everywhere:
Gyms, fitness centers, and health clubs
Fitness equipment: weight-lifting machines, treadmills, stationary bikes, elliptical machines, etc.
Websites
Magazines
Fitness books
Apparently, we assume people are too incompetent to exercise without first consulting someone else. Ironically, they’re instructed to ask a physician, a person unlikely to have expertise in exercise unless they’ve pursued it independently. As I mentioned earlier, my medical education included no lectures on exercise. I suspect that hasn’t changed much in most medical schools today.
The ER is not for chronic diseases. The acute recognition of a chronic condition does not make it an emergency. It doesn’t matter how you describe it, how distressing it is to you, or that today is a worse day. Acknowledging that everyone feels better or worse on some days than others also holds true when you think about your disease process. Your arthritis will be better or worse on some days. Your residual symptoms from your prior stroke will be better or worse on some days. Your chronic chest pain, whether it’s from angina or any other cause, will be better or worse on some days. Your IBS, which, as I mentioned, is a controversial diagnosis, will be better or worse on some days. Virtually every condition you have has better or worse days. But at the end of the day, it’s still a chronic medical condition and not something that requires emergency attention.
The ER is not for second opinions. Particularly after a patient has seen multiple specialists, coming to the ER because you’re unhappy with the answers or frustrated with your ongoing condition is unlikely to yield the results you seek. I have a limited set of tests, which are designed to detect specific conditions. Strokes, for example, are easy to identify with imaging, but seizures are not. Heart attacks are easy to diagnose; other causes of chest pain are not. It’s highly unlikely that the specialists you have previously consulted are withholding tests or deliberately avoiding certain procedures. In our litigious society, doctors tend to over-test and refer to specialists more often than they did in the past. When you come to the ER, I don’t have any secret tools. There’s no secret sauce or hidden test. Longevity discussions may involve highly detailed tests at the cellular level, testing for specific toxins, or whole-body MRIs… these are all things that exist. However, none of them are available in the ER. For example, I can check your thyroid function, but I cannot perform an in-depth study to determine if your cells are effectively utilizing thyroid hormones. I cannot test your mitochondrial function. I cannot test for the myriad viruses that cause influenza-like illness (ILI).