passion is somewhere between fear and sex and cigarettes

I am in Africa. I am alone. I am alone in Africa. Today I went for a hike with a friend and left him on Mt Kenya to keep climbing so that I could come down to meet someone who would not arrive. I am reading books and drinking chai because somewhere India got mixed up with Kenya.

My guide down the mountain was Samson, a 25 year-old Kenyan, shorter than me with skinnier legs than mine. I had teased him on the way up about smoking cigarettes and being a mountain guide and he laughed. On the way down in English without articles we talked about how many babies women in America have and how proud Barack Obama’s Kenyan family must be and if I have a English football club I follow and cigarettes. He brought them up. He asked me why they were bad.

I explained that cigarettes are bad for your lungs of course but also your eyes and your stomach and your heart and your skin and your mind and a few other things. He asked how to quit. He said he tried once and it was really hard. He smokes 10 cigarettes a day.

I have no basis for this other than quitting diet coke a few years ago, but I told him do the following. Start tomorrow and have only 9 cigarettes a day for a week. Then go to 8 for a week, then 7, and so on. If he gets to a sticky point at say, 4, and breaks the rule and goes up to 5, just try to stick at 5 for 2 weeks, then go down again. Try to avoid other smokers too. He said, yeah but when I pass guys on the street and smell the smoke I want one. Yes, but it’s ok, just try to go down to 9. He smiled and when we got to the park gate started to light up but then looked at me and smiled again and put it away. I have no idea whether he felt inspired or guilty or afraid of offending the girl who was supposed to tip him or something else.

In med school we are told to measure someone’s desire to quit whatever their vice is in some oblique way, and if the vice is alcohol and you need to assess the overall life-affliction quotient, to ask the “CAGE questions” - Have you ever tried to Cut down on your drinking? Has anyone ever Annoyed you by asking you to cut back? Have you ever felt Guilty about drinking? Ever needed an Eye-opener?

To me these are for doctors who have an emotional IQ of negative and need formulas for everything.

Vices are about needing to feel. Passion is somewhere between fear and sex, and without war or religion or love it is hard to find passion, but there are drugs and alcohol and cigarettes and diet coke and bad relationships that go on when they should be quit; all modicums of feeling, temporary ones.

Motivation comes from feeling differently about yourself than you did before. A change in course in the ever shifting mapless interior self. Where this comes from is up for argument. People disagree with me on this but I think it comes from experience rather than intellect. You travel, someone dies, you fall in love, you are loved or recognized in a new way. Someone you care about cares if you smoke or not. You suddenly believe yourself to be someone who deserves to not be smoking. Or maybe more accurately the ego decides it would like to think of itself in a non-smoker’s light.

I don’t think it comes from someone explaining to you why smoking is bad for you. And if Samson quits it will have nothing to do with me and if he doesn’t it won’t have anything to do with me either. But I still hope he finds the motivation, discovers his passion somewhere else. Cigarettes or whatever it is, I hope we all do.

good medicine in the far far away

i’m working from senegal this month. my friend joe and i are doing a one-month rotation for med school at the clinique borom darra-J in tivaouane, a small town about 95 kilometers north of dakar. the town is a road lined with corrugated tin shacks and stacks of tires and sonatel mobile credit vendors and women in bright red/orange/black wild print dresses with matching headscarves that leap out at you from the dust. there is no beer. no internet cafe. no hot water. but many small children who run up to slap your hand and say bonjour and then run away screaming. and many white goats ambling in the streets. and every morning the minarets shout what sounds like the entire koran at 6am when i am for some reason always in my deepest sleep under my bugnet. ive gotten used to showering a fraction of the amount i do in new york, which is probably good for me.

the clinic where we are working is the project of an investment group, aventura invest, started by a friend of joe’s. mostly they are working on developing agricultural projects but their mission also includes developing a chain of rural health clinics to support those projects, modeled on a franchise that has been successful in southern nigeria. they have plans to get this flagship clinic to use standardized forms, so they can follow patients over time instead of just managing the traditional stream of walk-ins. they eventually want the clinic to achieve enough efficiency be profitable, and then serve as a model to others.

after working there for a week, the phrase that comes to mind is, the best intentions, the gravest consequences. this is not because of anything aventura invest is doing wrong - although getting anyone we have worked with so far to stick with a complicated standard form for more than a week in the absence of someone hovering who is invested informs seems completely dicey - but more the reality i’m personally finding as i throw my fancy US medical education at the maladies of the people in this town and watch what happens.

everyone here speaks wolof, the local language, and the better educated also speak french, like the clinic’s midwives and nurses. i speak pretty good regular french, sort of terrible medical french, and joe speaks only english. so each patient visit is this assembly line of translation, including me physically demonstrating things i can’t think of the word for in french. that part is ok. my head kind of hurts by the end of the day, but it works.

the harder part is that up until now joe and i have spent 99% of our medical education at the bottom of a very tall totem pole of doctors, in a place where decisions are based on an average of three body scans like MRIs and X-rays and CTs, and about 100 variable blood tests. almost every patient we’ve seen is super sick, admitted to a hospital stocked with the highest level of medical technology, and has about 6 very complicated things wrong with them and is on at least 10 medicines at once. on top of that we have worked almost exclusively with adults, and the kids we have seen had things wrong with them ranging from the genetically catastrophic to the run-of-the-mill for washington heights, like RSV brionchiolitis, a viral respiratory infection that lands some little kids on ventilators but is always treatable. to top it off we’ve always been in a place we we can do next to zero besides the obsequious fetching of coffee and rubber operating room gloves, without someone else giving the ok.

here at clinique borom darra j, we have no supervision, no blood tests, no body scans, no ventilators, and very few medicines. we also don’t have the internet to fall back on as our tutor, when even the sort of expected like malaria and malnutrition walk through the door.

and then the director of the clinic, who has no medical training, refuses to triage patients, and spends most of her time nursing her way too old to be breastfeeding son, sends us patient after patient with “douleur au tout le corps” (pain all over the body) for mysterious reasons that the one MD who stopped by called the “disease of Africa,” and we turn to our very kind midwife/translator and after 35 minutes of questions that would take 5 minutes at home, and a physical exam yielding only pterygiums of the eyes, ask her to prescribe advil and maalox and tell the patient to come back next week when the “real doctor,” who is coming from nigeria to assess the clinic, will be in town. it would be comical if we weren’t earnestly trying to be of help and if at least i weren’t feeling like 4 years at columbia med has, in this particular setting, left me with many well-informed questions with few legit answers.

one success though. a very sweet 80 year old man from the neighboring town of thies. he complains he has lost his vision. we pull out our cards and do a vision test and our lights to see the clouds adrift in his pupils and determine he has cataracts, complete on the left, partial on the right. he says he has no money for the operation. the midwife says it costs about 50,000 CFA, or $100. we tell him to come back next week to see the nigerian doctor, to confirm, because we still don’t completely trust ourselves after this great week of medical-ego deflation… but if all this is what it seems to be, joe and i will split it and buy the operation. our education might not help this guy as much as our dollars. which is fine.

this same man also complained of pain in his legs. so i taught him a little yoga, like a forward fold and some side stretches to relieve what we determined was not sciatica but tight hamstrings. afterward he said we had lit up a light in his heart. i hope this will change when i have a bit more training in residency, but for now i am definitely a way better yoga instructor than doctor.

the brain benefits from being used

i just read this article from the NYTimes magazine on weight lifting rats. the article summarizes some interesting research being done on whether bulking up impacts the brain in a positive way. it has already been shown that running and other aerobic exercise leads to neurogenesis - ie growing new neurons - in parts of the brain involved with thinking and memory. scientists think this increased growth is probably due to increased blood flow to the brain, or at least that’s what they posit. no one actually knows why. 

what’s new here is the research showing that weight lifting - as modeled by brazilian rats running up ladders with weights strapped to their tails and japanese rats running on weight-loaded wheels so they bulk up their little rat quads - has the same effect. rats with extra muscle at the ends of the studies had more of a chemical called BDNF (brain-derived neurotrophic factor) in their brains. and BDNF is known to stimulate the growth of neurons and and the underlying gene activity such growth requires, genes being the computer code of sorts behind the constant building of the body’s new parts. 

i hope more research like this comes along with more sophisticated hypotheses and better evidence as to why exercise has such strong effects on brain plasticity. that said, the conclusion of this research seems like a bit of common sense. while there is always benefit to better understanding things like the link between muscle mass and BDNF, because this teaches us a little more about how the body works, there is already a lot of evidence for the impact of exercise on the brain, in particular good research showing that exercise slows cognitive decline. most of that research is on alzheimer’s disease, the most common cause of dementia. while there is no cure for alzheimer’s, regular exercise slows it down. and actually, so do friends. people with strong social networks fare better than those without. 

if you’re unsure of what alzheimer’s is, you’re not alone. really no one else does either, but here is my basic explanation. for reasons we do not yet understand, alzheimer’s is the filling up of the brain with junk proteins that get in the way of information transfer between neurons. when the information flow stops the neurons die and the brain shrinks. when you look at an alzheimer’s patient’s brain on a CT scan compared with a normal brain, the alzheimer’s brain is strikingly shrunken with big empty fluid pockets - everything black is fluid - in the middle and around the sides.

but back to exercise. the applied principle of all this - meaning like, how does this research relate to me today - is what i think is most useful. when you don’t work out, your muscles shrink. and when you don’t read or study or talk to people, well, simply put your thoughts shrink - the arc of things you think about and say becomes a little narrower. the human brain has 100 billion neurons and a 100 trillion points of connection with each other. neurons are living cells that talk to each other through little pulses of chemicals between them, forming thoughts and memories and work patterns through the brain. if your body is healthy and active and your blood is relatively clean and your heart is strong and there are friends and laughter and love in your life, and you maintain a healthy dose of daily challenges for your brain to puzzle through, it makes sense that your neurons are better off too.  

which is why this article’s concluding sentence, “the brain benefits from being used,” makes me smile. in yoga the mind and the body are one. in western culture we’ve separated the two and it’s considered novel research to show that what’s good for one is good for the other. 

comfortably numb

i just watched this TED Talk by a woman named brene brown on the subject of vulnerability. my favorite point she made was that we americans are currently the most in debt, obese, addicted, and medicated group of adults in history. i’m not condemning our modern lives - there are a lot of unprecedentedly good things about living the USA in 2011 - but on the whole i believe this observation is true and i really like her theory as to why. 

the reason for all the debt and drugs, brown says, is that we as a culture work really hard at squashing our own sense of vulnerability. she defines vulnerability as a willingness to bear discomfort - physical, emotional, or otherwise, a willingness to invest in someone or something even if there are no guarantees, and an acceptance of your own imperfections.

brown argues that vulnerability is fundamental. it’s the basis for connection to others, and for living life wholeheartedly. but vulnerability manifests itself in us as daily fears and anxieties around things like initiating sex, getting fired, confronting someone, getting bad news from a doctor, losing weight, gaining weight, being smart enough or good enough or stable enough, being wrong. 

so in response, our culture numbs vulnerability, or at least tries. we use things like beer, cocaine, marijuana, fast food deep-fried whatever, sugar, shopping, pills prescribed or stolen, certain brands of religion, gambling. i would actually add a few - including work, tv, facebook voyeurism, and the endless mountains of contentless content the internet provides. this leads, brown says, to a vicious cycle of feeling miserable and hungover and devoid of purpose and meaning, and therefore more uncomfortable and more in need of feeling numb. never mind that joy and wonder and curiosity get numbed away too. 

also never mind that brown’s theory is another articulation of a basic premise of buddhist/yoga philosophy. i think the indian philosopher osho said it best - “the root of all neuroses is the avoidance of the self.” for more on this check out osho or eckhart tolle on youtube.

brown ends by exhorting everyone to embrace our imperfections and consider ourselves worthy of love and be honest about our mistakes and “practice gratitude and joy in moments of terror.” and here i get critical because here i think she leaves us hanging on sort of cheesy generalities. 

to weather the internal storms of vulnerability we all experience in the presence of an endless list of external stresses, i think it helps to have some tools. by tools i mean actual concrete real things you can do in place of over-eating, smoking pot, boozing, spending hours pointlessly on the internet, working all the time, or buying stuff you don’t need. probably none of us does all of these things and doing any one of them here and there is fine, but when they become the regular outlet they wear you out as much as stress does.

so how to go beyond the abstraction of “practicing love and joy”?

for me, it’s a sweaty hour and half yoga class at kula in williamsburg or strala near nyu. for my friend carolina it’s cooking with her friends. for my friend molly it’s a walk - like the 6 mile loop around central park. for other friends it’s painting or writing or music or even reading the magazine they subscribe to and never actually read. i listen to TED talks and radiolab online when i’m bored and i usually end up inspired and smiling. there’s whatever sport you don’t need a whole team lined up to play, whether it’s yoga or rock climbing or biking or running or crossfit. there’s also meditation, which comes in a lot of varieties and is probably the most powerful thing i’ve found, if you can commit to slowly building up the kind of concentration it requires, which definitely took me a while but has been worth it. 

it’s whatever is there all the time, free, and feels really good to you without being destructive. it’s what gets you up and energized. it’s usually stuff that makes you feel the opposite of numb. 

i think finding at least one healthy, non-destructive, easily accessible thing - a thing that you know, no matter what you’re freaking out about or how out of it you are, will make you feel at least better if not totally amazing 99% of the time - is the one most important thing you can do for your health in your lifetime. that thing can change. that thing can be five things. but finding at least one will save you - maybe not make your life perfect - but for sure you won’t need to be numb. 

if you have other examples of things that get you there - please send them my way!

the deal with anti-biotics: the pill, the runs, the pros, the cons

antibiotics. they are possibly humanity’s biggest scientific breakthrough. but like all of humanity’s big breakthroughs they come with a price. here are some of their most popular unintended consequences and what to do about them.

1. the runs. antibiotics for more than a couple days can mess up your belly, and give you the runs. they do this by killing your gut’s good guys, ie the bacteria you need to keep your system running smoothly. if you’re taking antibiotics i suggest taking lots of probiotics both simultaneously and afterwards. the best kinds are in yogurt, refrigerated kombucha drinks like GTs, and my new favorite, this fruity drink called Good Belly. or just buy the pills from whole foods or a supplements store. this will restock your gut with the good bacteria it needs. 

2. the pill. if you’re on the birth control pill, you’ve probably heard that some antibiotics can screw up the way you digest the hormones in the pill, because your gut’s bacteria are actually an important part of this process. so, first off, TELL whoever is giving you antibiotics that you’re taking the pill. second, the only antibiotic that really has been shown to mess with the metabolism of the pill is called rifampin, and if you don’t have tuberculosis you’re probably not taking this drug. the other antibiotics that could hypothetically mess with the pill are penicillin and the tetracycline family, which includes tetracycline, doxycycline, which people take for acne and lyme disease and other things, and minocycline. when i say hypothetically i mean that there is no actual good evidence that these antibiotics will mess up the pill, it’s just theoretically possible. if you are on the pill and taking one of these particular antibiotics and on a low dose pill, just use condoms from when you start the antibiotics until they are finished AND you start your next pack of pills. the mayo clinic has the final word, on this and pretty much everything else.

3.  alcohol. it’s a myth that drinking alcohol makes the antibiotics you’re taking not work. but the reason you’re told not to drink when you’re taking antibiotics is that first of all, alcohol is a toxin and it’s inflammatory and it dehydrates you, none of which you need on top of fighting some other illness. second of all, some antibiotics, like metronidazole, ie flagyl, tinidazole, ie tindamax, and the commonly used trimethoprim-sulfamethaxazole, ie bactrim, can in some people have side effects that are very similar to the side effects of alcohol or to a hang-over - these include a fast heart rate, a flushed face, headaches, nausea, and vomiting. it’s better not to combine the two and give yourself a double whammy.

4. allergies to antibiotics. pay attention to your body. you may already feel crummy but taking antibiotics should not make you feel worse. if you take antibiotics and within a few hours or a day day feel a lot worse, especially if you get a rash or a fever, you could be allergic to them. other allergy-to-medicine symtoms are itching, hives, diarrhea, a fast heart rate, swelling, or difficulty swallowing or breathing. if anything like this happens call 911 and get to an emergency room asap. and bring the drug you took with you. people at the hospital can’t help you that easily if they, and you, have no idea what the name of the drug you took was. and always tell doctors if you’re allergic to medications. ever if they don’t ask. they should always ask, but if not, pipe up. it’s super important for you to keep track of what your body can and can’t handle, and without a national electronic medical record system, it’s up to you to have this info on hand. 

the most common antibiotic allergies are to penicillin and a class of drugs called “sulfa” drugs. but different people can be allergic to different things. and, some people have bad reactions to an antibiotic for unknown reasons - it may be a one-time thing, rather than a true allergy. 

sick this winter? mystery solved

this month i’m working at NBC in the medical center they have for their employees. NBC and Universal are one company, and they have their own fully-staffed medical center for their workers around the world, from the SNL grips to the CEO. the medical director here has taken me under her wing, and she is awesome, not only because she’s young and super fun to hang out with, but also because she is teaching me the ABCs of medicine, which ironically med school hasn’t. 

in med school you learn about patients who are so sick they need to be in a hospital. at a place like Columbia this means they each have about 8 things wrong with them, like obesity, and obstructive lung disease, and heart failure, and liver failure, and maybe some weird infection because their immune system is surpressed because they had a transplant of some kind, so there’s like, a fungus ball growing in their brains and that’s why they have a headache. fungus balls or weird tumors or rare bacterial infections are NOT why most people get headaches. but as a result of my highbrow education, when a friend tells me they have a headache, those are the first things i think of. it’s embarrassing but honestly when people ask me what to do about headaches, or sore throats, or sprained knees, it’s sometimes a stretch for me to tell them what’s wrong and what to do about it. 

this is why this month at NBC medical is great. i’m finally learning some of the basics. and while i’m at it, i think that it’s important not just for doctors and nurses to have the basics, but for you to have them too, so you can take better care of yourself. and so your own body isn’t some strange robot-entity you lost the user’s manual to. so with that, here are some bits on winter’s worst, strep and flu! strep and flu are the big winter bugs.

strep and flu both make you feel especially crappy, but there are big differences between them, starting with what they’re made of. strep (ie streptococcus) is a bacteria, and the flu (ie influenza) is a virus. one of my patients the other day, who is one of my favorite SNL guys, asked me, what’s the difference between bacteria and viruses? at the time i didn’t have a good answer, but i thought about it more and here are the differences that i think matter to you. 

both viruses and bacteria can cause disease. but bacteria are 100x bigger than viruses, and unlike viruses they can thrive for long periods of time outside your body, like in the faucet or on the fridge handle. once they get in your body they live between your cells, not inside your cells. most important of all bacteria have teeny tiny internal organs, and these organs are the reason anti-biotics work - the drugs go in and jam up bacterial guts in various ways, so the bacteria get sick and die and mopped up by your immune system. 

viruses, on the other hand, are way smaller than bacteria. in this way they’re more fragile, but in another way they’re hardier because they can hide - viruses literally live inside your cells. also, viruses don’t have internal organs, so anti-biotics don’t work. the only way your body can get rid of them is by killing the cells they’ve set up house in. lastly, viruses can’t live on surfaces like the bathroom doorknob all by themselves - they have to be inside you or your liquids to survive. so for instance, the way you get the flu is literally by inhaling somebody’s sneeze drops. really. the virus is in the drops. this also explains how HIV is transmitted in body fluids like blood, but not from touching someone who has it or their stuff. 

unfortunately when it comes to a virus as catchy as the flu, some people don’t wash their hands after they cough or sneeze into them, and then they go slime the bathroom doorknob, and if you are unlucky enough to get there in time you get the virus-loaded drops on your hands and then you go and touch your face or bite your nails or grab the mouth of your kleen canteen and get the flu that way. all great reasons to cough into your elbow and sneeze into a tissue instead of using your hands as a hanky, and to wash your hands a lot. 

if you really need more than than, check out this explanation 

what does this mean for you? well, in terms of what bacteria do to you, i think of it this way - they cause crud. by crud i mean pus and mucous and the nasty greeny-yellow stuff you cough up when you have bronchitis or sinusitis and the stuff that weeps out of an infected cut or a zit and the white junk that sits on your tonsils when you have strep throat. ick. i saw the nastiest tonsil the other day… this poor girl. it was this red swollen wet blob in her throat covered in white goo bits. yuck. (that photo isn’t her) 

viruses cause lots of different diseases, from flu to measles to HIV. but when it comes to the winter bugs like the flu and the common cold, think fever, aches, clear stuff coming out of your nose, and dry cough. essentially, if you’re not snoting out or coughing up yellow/green stuff, your doctor isn’t giving you antibiotics. or at least they aren’t supposed to.

STREP! do you have strep throat? these are the 4 things you should have. 1. sore throat, 2. fever, 3. swollen glands, 4. NO cough. the biggest tip off is the sore throat is happens all of a sudden, like it’s really bad and out of the blue. if you’re coughing a lot or super congested and your throat hurts from post-nasal drip, you probably don’t have strep throat, and you probably don’t need antibiotics.

what strep can unfortunately do too is close off the tubes leading to your ears, from all the swelling in your throat, and so your ears may pop or feel full, and this may go away when things calm down. if your ears really hurt, or are draining something out of them, then they may actually be infected. either way get checked out!

FLU! do you have the flu? you should feel super tired and achy, like bodyachy and headachy, and definitely have fever and chills. maybe a runny nose, maybe not. your doctor can’t do anything for you, but if you’re on your deathbed and worried you have swine flu and you’re a kid or pregnant or really old, go in. 

A COLD! do you have a cold? you probably don’t need this post for this, but just in case - stuffy runny nose, dry cough, maybe a headache, maybe a mild fever. basically flu light. 

for the last two, all you can do is take care of yourself. lots of sleep and soup and juice and tylenol for fever and steam showers to soothe your nose and sudafed to open things up. you will be fine. wash your hands. for strep, you need anti-biotics, so go see a doctor right away and get a culture. 

if you’re really really not sure, go see a doctor but hopefully reading this demystified some stuff. 

your body, your $

being in med school i get asked a lot about healthcare reform. i definitely believe in offering some form of universal healthcare, but strangely medical education doesn’t do a lot to teach future doctors about the realities of the world they will be working in.

but i was reading this article from the NYT about doctors rationing healthcare, and i think the point it makes is something i, and all doctors, and all my friends and family, and all patients everywhere should absolutely understand. your body and your dollar are inextricably, inevitably, and intimately linked, not 20 years from now, but now. here’s how. 

being sick is really, really expensive. and it’s expensive whether you have health insurance or not.

case in point. my friend is 28, and for unknown reasons has chronic sinusitis. he freelances, and a year ago he didn’t have health insurance. but the constant congestion and sore throats and rounds of antibiotics and his addiction to Halls were driving him crazy, so he went to see an ear nose and throat doc who he had to pay out of pocket. the visit itself cost $250. a CT scan of his nasal passages cost $600.  the MD read the CT and said, well, your nose is shaped just fine. and my friend said thanks, what a waste of a grand. (had the inside of his nose not looked so fine, whatever surgical procedure that doc would have prescribed would have been prohibitively expensive and could possibly have caused more damage than good, since digging around in people’s sinus cavities can be tricky…) that’s how being sick, even low-grade not really disabling sick, is expensive in terms of money.

now my friend has health insurance through his union, and it’s really good, if good is defined as no co-pays. nothing in the past year has improved my friend’s sinusitis, so armed with his insurance plan he made an appointment to see another ENT. my friend choose this ENT at random, out of the list of ENTs acceptable to his insurance company. there was no way for him to read reviews or know about the guy’s reputation. there is no national registry. despite the fact that the qualities blue cross/blue shield looks for in an ENT might be very different those he might like in an ENT, my friend had no way of telling one from another on his list. so he chose by office location. (anyone want to start a Yelp for docs?) the visit to this second ENT was free in terms of dollars, but cost him about 5 hours of waiting and travel time for a 3 minute visit in which the ENT offered him a CT, which he would have to schedule for another day, and no practical advice whatsoever. this is how being sick is expensive in terms of time, stress, redundancy and futility.

i’m starting this friend on a regimen of industrial grade probiotics and olive-leaf nasal spray from the vitamin barn, and we’ll see how he does. but being sick in this case, which is not something he could have prevented, has been crazy expensive, and he’s someone who has both financial and intellectual resources in life, and has at least found his way to a few doctors.

now factor in that we have a doctor shortage - we will be short 150,000 MDs in the next 15 years as the overall and elderly populations expand, and demand further outstrips supply. this means that now, and in the coming years, if you are poor, you are sort of screwed in terms of access to healthcare. here’s why. 

a bit of vocab helps explain: medicare and medicaid. medicare is for old people. medicaid is for poor people. medicare reimburses doctors 80% of the cost of their services. medicaid reimburses only 40%. private insurance pays 80% or better. the elderly vote a lot and have way more political sway, so they are better covered. as demand for medical care increases, many docs don’t and won’t have much incentive to take medicaid patients. if the healthcare bill goes through and we add a bunch of people to the medicaid and private insurance pools, the people who end up on private win, and the people who end up on medicaid lose.

essentially, at the moment in this country, if you are rich you can always get healthcare, though it will cost you a lot in private insurance and fees and possibly time. if you aren’t rich you face long waits, hard to come by primary care, and even if you have decent insurance, you may not necessarily find the medical help you get to to be of much help at all. 

what’s the takeaway for your wallet? don’t get sick. i know, this is completely impossible sometimes, like for my friend with sinusitis or my other friend born with cystic fibrosis who just had a lung transplant. often illness isn’t avoidable or fightable without modern medicine. nonetheless, if we’ve ever had incentive to stay as healthy as we can, and prevent illness as much as we can, we have it now. this comes down to the usual stuff you hear about all the time for a reason - healthy eating, frequent exercise, keeping your weight down, good sleep, and hand washing. 

i think we tend to have this notion in america that doctors and drugs are cure-alls and our health is in their hands. really the opposite is true - our health is first and forever in our own hands. rich or poor, at the end of the day your body is your dollar. you can save a lot of those dollars by taking care of yourself. 

flying high

every time i think about flying overseas, which in a few days i’m very happily going to do, i think about my friends who drink on the plane. i think about this because i’m always kind of nervous about flying - both conceptually and literally when it comes to long hours so confined. drinking is always really tempting and a ton of people i know do it to pass the boredom and the fatigue. and i’m the first to admit that when i fly long distances i take a pill to sleep because i’m not one of those supremely gifted people who can snore away soundly on public transportation.

but, flying in itself is a little toxic. there’s the frisk-up in security, the recycled air, the inevitable germ swap with seatmates (pass my drink…oooh you’re sick…), the bone dry atmosphere that leaves faces and hands flaking, the pre-packaged food, the cramped space, the white noise… ugh. and while totally i understand the appeal of a stiff drink to get through the stress, i think there are better ways to beat the tension AND take care of my body, which is basically under assault on a long flight.

here are my tricks for feeling like a close to normal person when i roll into baggage claim. try one or more or all of the following, and let me know how it goes!

1. skip the booze. planes are dehydrating enough. you don’t need a double hangover.

2. drink tons of water. set a goal of downing at least one of those little 8 oz bottles per hour. i take them like shots. yes you have to get up a lot to pee, but that helps beat the stiffness later. or i bring my kleen canteen and fill it up in the water fountain in departures

3. get up! walk around, stretch, hover awkwardly in the galley with the flight crew. i once met a cute boy doing this! but social opportunities aside, moving around at least once every hour that you’re awake, for at least 5-10 minutes each time, makes the clock go faster and really saves your back the next day.

4. bring lotion. my hands and face get soooo dry. a little lotion feels like a spa treatment half way through.

6. bring a toothbrush! and a little toothpaste. after you eat, cleaning your palate with a good brush kisses memories of a less-than-4-star plane meal goodbye

7. bring your own food. i always bring snacks - fruit, crackers, cheese, sandwiches. this way i get to eat what i want and eat something healthy that isn’t totally soaked in salt and preservatives. avoiding the packaged-food salt-bombs we’re fed on planes also wards off post-flight bloat

8. bring a sleep-aid. if you’re like me and sleep just isn’t happening in that lawn chair-esque seat, bring help. melatonin is sold over the counter. or ask your doc in advance to write you for a few ambiens or another prescription sleep aid. actually sleeping on a long flight (vs sort of dozing here and there) can be life saving

9. cover up. eye-mask, scarf, and ipod. i pretty much look like a mummy on flights and i don’t care what people think. i have to block everything out. i wrap a big scarf or hoodie around my head, don a comfy eye-mask, and make sure my ipod is stocked with calming music. this knocks the stress level down immensely

10. forget the purel. i think hand sanitizer is pointless. we doctors coat ourselves with it in the hospital, but in less controlled environments there is no way that every time you touch something new you use it. just wash your hands whenever you leave the bathroom, and chillax. that last bit probably will do you more good than anything else!

salty balty

i grew up on Old Bay. if you have never had steamed blue crabs caked with Old Bay and felt the burn in your fingers where the claws nick them open, you should try it. it’s so good. and it’s crazy salty. which i love. in addition to loving every kind of sea salt i know. 

but ive been interning at the NYC Department of Health on their national salt reduction media campaign, which sounds impossibly bossy and automatically gets the “but i love salt!” response whenever i tell people about it. and because i agree, this post is about salt. and what’s good about it. and what is bad about too much of it.

fun stats! about 77% of the salt in the average american diet is from processed, packaged, and prepared food. something like 12% occurs naturally in food, and only 11% or so is from people adding salt to food they cook themselves. so hit the salt shaker as much as you want. really.

what isn’t fine is all those P’s - processed, packaged, prepared. this goes way beyond fast food. if you’re someone who lives on a combination of restaurants, take-out, frozen dinners, crackers, cereal, canned soups, the prepared foods section your local grocery store, stuff that comes in shrink-wrap or cardboard, and even Pinkberry, then even if it says organic all over it, it’s probably still jammed with hidden salt.

here is the short on why too much salt is a problem. think of salt as the pied piper, and water as the village children. water follows salt blindly. so the more salt you eat, the more water you retain to keep the balance of salt to water in your blood in a good spot. your body keeps this in close check - too little salt in your blood, or too much, and you could have a seizure.

your kidneys are in charge of maintaining this balance. if you eat more salt, they hold onto more water. and more water means more volume for your heart to push around. 

over time your heart and your blood vessels beef up to handle all that extra volume. they get thick, and crusty, and dysfunctional, and this leads to strokes, heart attacks, kidney disease and all the stuff your doctors and the government worry about. actually you should worry about it too, because thick junky hearts and vessels don’t work very well and make you feel like crap. 

the point is, in the long run it’s fine if you eat a lot of salt once in a while, like the classic eggy, bacony brunch that satisfies your hangover, but if more of your diet than not consists of the processed/prepared stuff i mentioned before, your salt load is through the roof all the time. 

my answer to this situation is cooking your own food. you have control that way, and it’s way cheaper!

the boozey blues

my first post is a note on booze. from adventures and misadventures with the substance, ive come up with this rule: have at least three full days a week without any alcohol. not one beer. not one glass of wine. definitely no johnny on the rocks. totally clean.

if you’re a social drinker like i am, this can be harder than it sounds. there are so many excuses: “my boyfriend just got back into town”… “i’m meeting a friend”… “today at work sucked”… “it’s somebody’s birthday”… “i’m eating out” etc.. .etc.

this advice is not a judgement on alcohol. i love good red wine and cold beer and the instant relaxation they deliver as much as anyone else.

but alcohol is a also like a drain you pour your energy into. along with your clarity, your patience. and your immune system. day in and day out booze saps you. it’s a proven depressant. it clogs up your system with the tedious busy work of detoxing so it can never properly heal itself. it leaves you cranky. it definitely messes up your sleep cycle. it gives everyone a belly, which might be burnable in your 20s, but is usually permanent thereafter. alcohol gives you the boozey blues, that hard-to-shake, the-world-looks-a-shade-darker phenomenon. (thanks to my friend Willy H. for coining the the term)

so if you want more energy, or to loose weight, or to maybe just to sleep better, or to ward off a cold, or to feel baseline happier, or to stop snapping at your coworkers, or stop having a meltdown when you can’t decide what to wear, my advice is to stop drinking. not entirely, but for 3 solid days out of any 7. they don’t have to be 3 days in a row. just three booze-free days a week. 

i recently challenged a friend to do this. she was in the habit of drinking most days and was looking for a general life pick-up. she was under enough stress as it was, so offered her some solidarity and matched her day for day. after 3 days she felt the world looked a bit brighter, and that sense of impending dissolution had abated. and it was fun doing it together. we both felt like we’d accomplished something.

booze is just a habit, and humans are creatures of habit. if you can get in the habit of one thing, you can get in the habit of another thing too. 

try it, and let me know if you feel any different. and if not, you are lucky lucky lucky.