Thursday, May 15, 2014

Team S.J.G.R. Thursday Huddle: Do the right thing.

Do The Right Thing (a Ra joint)

I saw this patient today who was smart. Far too smart for what he was doing and, in addition, asking his doctor to do as well. I was seeing this gentleman with a resident physician and before going into the room his provider reviewed the plan of care with me.

"His hemoglobin A1C is over ten and his blood sugar today is in the 400 range. That said, he's not too keen on insulin so I guess we'll try to up is pills. And then as far as his cholesterol goes, he's said he doesn't want anything and that he'd watch what he eats."

"Wow. What about the blood pressure?" I asked.

"It's almost controlled but not perfect. He would likely benefit from a second agent since he smokes but he's not having it. So I guess I will just work with what I have. Maybe refer him to nutrition to lower his salt and give the quit line number to quit smoking."

"That's it? This plan sounds kind of bootleg, man." (Yes, this is how I speak to my residents sometimes. #dontjudgeme)

"I mean. . . what can you do? He doesn't want what I'm recommending. So I guess I just have to work around that, you know?"

Now. Let me just unpack on this for a second. Would that be okay? Don't mind if I do.

But before I do, let me tell you a little more about what happened when I met this patient. Honestly, I was expecting some overweight dude who would appear older than his age. Thick middle, thinning hair, and a defiant attitude. What I found was nothing like that.

This man wasn't too overweight at all. Sure, he smoked but he didn't look very old. And that's good because he was actually a little younger than me. And really, he wasn't difficult to interact with or any such thing. Matter of fact, he was a pretty cool dude.

I asked him some questions and he gave me answers. I explored his family situation (married with high school and adult kids and five grandkids) and his siblings, parents, and upbringing. Part of a big family. Lots of love and support. Used to be an athlete. Works a good job with benefits. And seemed to have plenty to live for.

But then, upon further questioning, he reveals to me that not only his father but recently his brother passed away from a heart attack. Both of whom were under the age of fifty.


Now. Despite all that, he was refusing insulin ("I don't do needles!"), pushing back about blood pressure pills ("Those things is 'dick killers.'"), shutting down cholesterol management ("I'll just skip eggs") and still smoking ("I try to quit but my nerves get too bad.") And this? This right here--when coupled with his family history--wasn't just unfortunate. It was stupid.

Yeah, I said it. Stupid.

We all do stupid things. Like, I remember my first year of medical school when I was madly in love with this guy for like six very intense months almost to the point of messing up in school. Oh, and I also racked up a ridiculously high phone bill despite zero income coming in. And even with my phone about to be disconnected, I kept accruing more charges. Plus I kept catching him in tall tale lies which were red flags, but I ignored all that. And that? That was unfortunate, yes. But mostly, it was stupid. You know what, though? That shit wasn't life or death. And it wasn't threatening to rob a family of their patriarch.

It's the same with people shaking salt and drinking sugar and never exercising and then either avoiding their doctor or blaming them for confronting them about it all. Not just unfortunate--but stupid. Especially when the person KNOWS the right thing to do.

This man knew what he needed to do. But he was resisting. And yes, we talked about his feelings and trepidations and excavated why he felt the way he did. We uncovered some things and got at a few things but he still threw up road blocks to allowing us to offer him the standard of medical care. Instead he wanted us to come up with some cockamamie plan B.

"You know? This is like somebody asking you to paint their house and giving you a tiny paint brush and some first grade tempera paint. It doesn't make sense. At all."

That's what I said. And I said it because it was true. Because this man knew better. He did. So I flat out told him that we will make recommendations that do right by him and that he is grown and can decide how he'd like to proceed. But as far as this play-play regimen he was asking his resident doctor to piece together for him? Like the Grady elders say: "That dog don't hunt."

Now the good news is that the patient came around. We had a good talk and we connected and he agreed to do the right thing. But really that isn't the point. The point is that this--this knowledge of the right thing to do but a refusal to do it-- is so, so common and is probably responsible more than anything else for killing us softly when it doesn't have to. I do give this brother credit for at least coming to the doctor. Turns out that for his job, they check blood pressure so the necessity of being signed off forces him in to see us. So he tries to go for the minimum. A la carte medical management, if you will.

I will jump on my primary care physician soap box and say that it's not fair to your doctor when this happens. Asking us to offer you substandard care because you aren't ready to accept what is tried and true. Or what will work. And I swear that I am also guilty. My doctor tells me to get certain lab tests or exams and I factor whether or not it is worth getting socked in the pocket for. Sometimes I'm a good egg and sometimes not. Now I have a great PCP that holds my feet to the fire. She ignores my BS and nudges me to do the right things.

And so I do. (Mostly.)

We need to cut this shit OUT. This practice of highly, highly intelligent people making stupid choices when they know better. Like knowing that your family history is effed up but eating high fat, salty things every day anyway. Or having high ass blood pressure and other risk factors for heart disease yet operating as if you don't. No, that's not just unfortunate. That's stupid.

And doing all of those things AND not being under a doctor's care? That makes you more than stupid. It makes you an assassin. Yes. THAT. An assassin of yourSELF. Which is a damn shame.


In the movie Forrest Gump (one of my favorites, along with Do the Right Thing) Tom Hanks' character Forrest was a simple guy. There was a lot of stuff he just didn't know or get. So if, say, Forrest Gump decided to drink sweet tea and full sugar sodas and eat french fries and not exercise in the face of crappy genetics, a spare tire, and cardiovascular risk factors at least we could chalk that up to him not knowing better. So here is my question: What is our excuse?

If you are savvy enough to read a blog or be on Facebook or click on Twitter or whatever techie things you do, then surely--SURELY--you are among those who are learned enough to know the right things to do. And see, at some point when we keep ignoring what we know to be right, something unfortunate happens.

With that boy, I failed a biochem midterm and got called into the Dean's office. I also got confronted by the ("Oh, I forgot to tell you that I sort of have a"-)girlfriend. Yes. The one that he'd had the entire time we'd been together (unbeknownst to me) which was as awkwardly bad as it sounds. And yeah, all of that was unfortunate. But it wasn't life threatening. It wasn't.

This? This avoidance, denial stuff when it comes to cardiovascular risk? That's not awkwardly bad. Instead, it's just sad. Or least, it will become that way eventually.

Damn. I'm all up in your faces, aren't I? But I guess I'm just frustrated with this crazy do loop we get into. And this do loop becomes a death spiral if we don't grab the handles by both hands and right the plane back upward.


I broke up with the boy, got a tutor and ended up doing just fine in Biochemistry. I became a doctor, I got to marry Harry and, allegedly, that girlfriend became that boy's wife at some point. So hallelujah that all of that worked out. For everybody. And hallelujah that nobody got really, truly, severely, irreversibly hurt in the process.

I wish heart disease was that simple. It isn't though.

Ask yourself: Do you know what "the right thing" is when it comes to your health? Or at least sort of, do you? If not, find out. If so, ask yourself this out loud:

"Am I an assassin?"

If you aren't raging against this machine called heart disease with all of our might? That answer is YES.

Sorry to unpack. And yes, my toes hurt after this one, too.

Shit Just Got Real, y'all. Let's do the right thing, a'ight?

Happy Huddle Day.

A reminder from da mayor. . . . 

Love and hate. . . . . often how we feel about the balance between doing right and doing not-right. Right?

Remember Radio Raheem's good word about how love wins: "Left hand hate K.O.'d by love."  Say word! We can DO this.


  1. Whoooo.....thinking, thinking, thinking... We all don't have a Dr. Manning in our corner and wish we did. I know what is the best thing....most time I do it....sometimes I can't afford it....And yet in the end we know we have to or we will be dead or worse...wishing we were dead.

  2. Sometimes you think you know the right thing and sometimes you get the wrong information. Your patient has an A1c of 10 and I'm taking it from your conversation that his lipids were upside down. He tells your resident that he will watch his diet, but he tells you that his idea of watching his diet is to skip the eggs. He has an impaired ability to metabolize carbohydrates, why would he need to cut out protein? He's got the wrong nutrient and he was told that by the medical industry.

    We had our annual Health Fair yesterday and I was working in the room with the diabetes educator, Noro Nordisk, Life Scan and the ADA. Every single one of them were telling diabetics to eat 60 grams of carbs in their meals. Why would someone who can't metabolise carbohydrates benefit from that message? No body wanted to talk with the diabetes educator so I spent quite a bit of time talking with her. I told her about my diet and she told me that my diet of 100 grams of carbs was to low and that it would put me in danger of getting high cholesterol. I made a bet with her. I went to the room with the screenings and took the cholesterol screening. My total cholesterol was 183 (a bit higher than what it usually is.) and my HDL was >100. I've been eating like this for 5 years now. I just proved her wrong. But she has to go with the ADA reccommendations to keep her licsence. And the information is wrong.

    With an A1c of 10 he's eating a great many more carbohydrates than 60 per meal, and he's probably drinking sugar too. But skipping the eggs isn't going to help him.

    1. Lisa, i think he wasn't thinking of it from a diabetes management perspective when he said that. For what it's worth, I think an HDL of 100+ has far more to do with genetics than food intake. It's pretty hard to achieve that with lifestyle or meds. As one who also inherited a high HDL, that's when family history can be a good thing.

      A lot of us providers tie carb control to management of hyper or hypoglycemia. Maybe I misunderstood your comment-- it generally isn't a part of my discussion of lipid control even in diabetics. I think his egg comment was referring to the longstanding idea that eggs equate with high cholesterol.

    2. Dr. Manning, the idea that I have good genetics anywhere is almost laughable. All my ancestors married cousins. The gene pool never got stirred and I jumped into the murky end of it. My father and three sisters and two brothers have all had heart attacks or strokes before the age of 55. Of all my siblings only my brother who died at the age of 19 and I are the only ones who haven't had a heart attack or a stroke. On 5/14/2009 my HDL was 44, my LDL was 180 and my triglycerides were 203. To top it off my A1c was 6.6. I was so frustrated I knew that I couldn't change this on my own. I decided to find a medical doctor who could help me lose weight. I didn't want bariatric surgery and I didn't want someone who had miracle shakes or shots either. The only doctor I found worked along side Georgia Lung Associates in Austell. She did a large amount of blood work and put me on a very low carb diet. Three months later she did the blood work again. Everything had turned around. My HDL was 93 my LDL was 29. My triglycerides were 101. Not only that my frozen insulin levels dropped from 18 to 6, and my A1c was 5.2. My A1c hasn't risen above 5.4 since then. Am I cured? No. I am controlling it with diet and exercise and medication. It is a lot of work and I get burned out and angry, but I know this is what I have to do. Unfortunately for me Dr. Caren Beasley left Atlanta and moved to Virginia with her husband. I still believe that your patients isn't going to help himself by eating a lot of carbs and cutting out protein.

    3. That's great, Lisa. Again, I'm not sure if we were talking about the same thing but I am super proud of your great report!

  3. Mmmm hmmm...preach!! Way back in Oct '13 I had bloodwork done and my triglycerides were off the map at 318 (borderline is like 159 or so). It scared me! SJGR!!

    I ACTIVELY cut out saturated fats (butter, chips, cheese, anything 1% or higher). In April, I went back for bloodwork, trigylcerides down to 176!!! Even the doctor wrote a note on my letter stating great job! I felt good. I did something, accomplished something. I felt good!!! I even lost roughly 20 lbs on the side.

    It's a choice. You have to make up your mind to do the right thing. You really do!

    Thanks Dr. K for all of your encouragement and str8 talk!



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