I read this article on “Health at Every Size” back in July 2005, took some notes and then put it in my “To Blog About” Folder. In the “I’ll get to it … eventually” category, here are my notes from 16 months ago:

Here’s a really interesting take on the problem of obesity. The movement is called “Health at every size”. Proponents argue that society and the medical establishment is too concerned with getting people to lose weight.

Quick Notes from the article:

• losing weight is a multi-billion dollar business
• medical studies have linked obesity to multiple conditions, including HTN, hypercholesterolemia, diabetes, and arthritis, but these links only prove association, not necessarily causation
• even if it could be proved that obesity causes these conditions, our current methods of treating obesity are clearly ineffective and likely are harmful to patients
  • 95% of patients do not lose weight
• studies suggest that patients who are obese but that pursue healthy lifestyles are at lower risk for chronic diseases than are nonobese patients with poor lifestyle habits
• focusing on weight as a goal causes patients to be unhappy with themselves (whether or not they meet their goals)
• patients should be encouraged to incorporate healthy habits into their lifestyle without being concerned about their weight or appearance
  • focus on being functional
  • on listening to signals of hunger, appetite and satiety
  • unrestricted diet

Now, I do believe that obesity probably causes these chronic diseases. Studies to definitively prove causation would be difficult to conduct. In any case, it is uncontroversial that the combination of poor eating habits and a sedentary lifestyle leads to these conditions, not to mention to unhappiness.

So I would love to help my patients change their lifestyles. And so far, I have failed at that. Recommending diet and exercise has, as a whole, been quite ineffective.

I really like the approach of getting patients to be happy with themselves as people, first and foremost. I know the approach sounds hokey, but I think it’s important.

This approach also resonates with my own personal approach to weight. I am somewhat concerned about the actual number that shows up on the scale, but I’m much more concerned about the way I feel. I want to be able to bound up stairs and take off for long stress-releasing runs whenever I feel like it. I also want to be able to eat whatever types of food that I want, concerning myself more with eating reasonable portions based on how my body feels.

It’s been more than a year since I read and wrote this. I’ve made some small changes in the way that I counsel patients. I have tried to be less focused on weight, and more focused on healthy lifestyles, but it’s been difficult. I certainly don’t think my results have been that much better. To be fair, it’s a more difficult process. It’s easy to check a patient’s weight, give them some dietary and fitness instructions and let them loose. It’s harder to assess, in detail, what their habits are like and whether they are truly changing. Of course, there is no silver bullet to a problem like this, but I still like the Health at Every Size motives. It’s more a “positive thinking” approach and that fits my personality more.

Steve Yegge wrote about the expressiveness of Ruby as compared to Java. He used this simple problem as an example:

How about if we write a program that will print out all the words in the dictionary starting with the letter ‘Q’ (case-insensitive), grouped by increasing length, and sorted alphabetically within each group.

The Ruby version was about 12 lines of code and Java version about 43. Of course, the point of the exercise wasn’t simply the difference in LOCs, but in the overall simplicity of dealing with collections of data. Still, I wanted to see how Tcl would deal with the same problem. Here’s the simplest version I could come up with:

set f [open /usr/share/dict/words r]
set words [read -nonewline $f]
close $f
set qwords [lsearch -all -inline [split $words \n] {[Qq]*}]

proc compare_length {a b} {
    if { [string length $a] <= [string length $b] } {
        return -1
    } else {
        return 1 
    } 
}

set sorted_qwords [lsort -command compare_length [lsort $qwords]]
set max -1 foreach qword $sorted_qwords {
    if { [string length $qword] > $max } {
        set max [string length $qword]
        puts "Words of length $max:"
    }
    puts "  $qword"
}

About 19 lines and pretty simple to write and read. Can this be improved?

use strict;
open W, '/usr/share/dict/words' or die $!;
my @words = <W>;
chomp @words;
close W;

my $max = 0;
for my $word (sort {length $a <=> length $b} sort grep { /^q/i } @words) {
    if (length $word > $max) {
        $max = length $word;
        print "Words of length $max:\n"
    }

    print "$word\n";
}

open W, '/usr/share/dict/words';
    
length > $max ? print 'Words of length ' . (($max = length) -1) . ":\n$_" : print

for sort {length $a <=> length $b} sort grep { /^q/i } <W>;

This is one of the most amazing things I’ve ever seen. An autistic man takes a 45 minute helicopter ride over Rome and recreates what he sees with near perfect accuracy on paper. More information about him

This guy’s brain is structurally the same as mine, yet its capabilities make my brain seem like it’s broken. It’s not unreasonable to think that my brain could have the same capability if it were exposed to the proper conditions. I have no idea what those conditions are, or else I’d be able to cure autism. But seeing feats like this show me that there is so much that we don’t know about our brains and their function. And that’s kinda exciting.

Dave referenced an interesting article in the NEJM titled “Primary Care – Will it Survive?" These two quotes summarize the problem:

A 2006 report from the Center for Studying Health System Change reveals that from 1995 to 2003, inflation-adjusted income decreased by 7.1 percent for all physicians and by 10.2 percent for primary care physicians.

and

It has been estimated that it would take 10.6 hours per working day to deliver all recommended care for patients with chronic conditions, plus 7.4 hours per day to provide evidence-based preventive care, to an average panel of 2500 patients (the mean U.S. panel size is 2300).

Compensation is down and responsibilities are up. I’ve been especially aware of this as more than a few of my colleagues have left, without being replaced. So not only do we have more to do per patient, we have more total patients per doc. This will worsen as the population ages. These conditions are leading to a decrease in the number of students and residents who choose primary care, which of course creates a vicious cycle.

One of the interesting solutions proposed in the article was a heavier use of web-based solutions:

A more thoughtful solution to physicians' time constraints requires a combination of team care and electronic encounters. Nonphysician team members working with Web- and e-mail- based patient portals can perform routine preventive care functions and manage less complex chronic care. However, forging cohesive and efficient teams is a challenge, and few payers adequately reimburse these services.

I’m interested in creating those types of solutions. The problem is that when you use these solutions and begin to speed up patient care, the temptation will be to increase the number of patients seen, rather than to spend more quality time with each patient. If you do that, you begin to break the doctor-patient relationship - a relationship that is more valuable than the purely technical aspects of care alone.

I love taking pictures with my trusty old Canon S200. It takes great pics and I get to take the credit. I’m just horrible about getting them off my camera and onto my website. I finally uploaded a whole bunch today, dating back to early May when we went to Philadelphia for Kevin and Joanne’s wedding. The next group is from Brooklyn and Staten Island for Mary Ann and Benjeil’s wedding. We interrupted wedding season to watch Ethan graduate from law school in Minneapolis. While in the Twin Cities, we got to spend a few minutes with Ajay. Back home, we started Memorial Day in the Cloisters, had lunch in the city (photo above), and finished the day by meeting a cute girl named Amalie (of Amalie & Ivory fame!). A week later we were back in the Midwest for Sivan’s cozy high school graduation. Nothing like watching your nephew graduate from high school to make you feel old. Mike and Susan threw a barbecue in Long Island to celebrate their farewell. Asha was there too! Next up on the wedding circuit were Russ and Michelle. They were nice enough to get married in DC, so we were able to stay with Puja and meet Loki. Mala interviewed in Norfolk where we were introduced to Kylee for the first time.

And if that’s not enough for you, here are some random pics from the Bronx. I’m sad to say that I’ve yet to take any photos of Hunter June, so I’ll point you instead to her parents' photos.

Can you believe that it’s been a year since we got married? Me neither. For our wedding, Mike and Ellie gave us a generous gift certificate to the bed & breakfast of our choice. It took a while to find the right one. We started at bedandbreakfast.com and surfed dozens of listings. This industry really needs some web consulting advice. Most B&B websites don’t provide nearly enough information. I want more photos, more reviews. I want to get a feel for the atmosphere.

We finally found a website that showed off those things and made a reservation at Ecce. We had high expectations, but I’m happy to say that they were exceeded. You won’t find more hospitable proprietors than Alan and Kurt. Our room was tastefully designed and was stocked with a gourmet coffee machine, TV/DVD/VCR, fridge and jacuzzi! It was pure luxury. The breakfasts were over the top. Definitely try the french toast with chocolate.

The house sits on a bluff overlooking the Delaware River. The view is amazing. I tried to take one of those panorama pics, but I don’t think it does it justice. This place must be breathtaking in the fall. We saw 4 or 5 bald eagles and numerous hawks from the house. We also saw a lot of deer hanging out near the highways.

Tropical Storm Ernesto was winding through the region this weekend, so we didn’t do too much in the way of outdoors stuff. We did enjoy the Harvest Festival Market and had some great fried food at the bar at Lackawaxen House. We were less impressed with the Front Porch Cafe, but it was very busy and had gotten good reviews, so maybe we just got unlucky.

So thanks again, Mike and Ellie. I’m certain we never would’ve otherwise explored this paradise just 2 hours from our front door. And thank you Mala, for the best year of my life (so far!)

Mala finishes her fellowship in July 2007, so we’ve entered job search mode. We’ve got a few interviews scheduled, but it just seems harder than it should be to find out who has positions available.

Some criteria:

• focus on clinical practice
• location with a lower cost of living than NYC (I guess that rules out … NYC)
• friendly colleagues, staff, environment
• family friendly
• location near friends or family

So if you know of someone that needs hard-working, intelligent, caring pediatric endocrinologist, let me know. Act now and we’ll throw in a computer-programming, marathon-running internist!

One of my favorite podcasts is going on hiatus. (A podcast is basically a fancy word for a radio show that you can download to your MP3 player.) Talking History is produced by the Organization of American Historians and because of budget problems, they cutting funding for Talking History.

The host Brian LeBeau is the epitome of a great interviewer. He mostly stays in the background, giving the stage to the historian, but when he asks a question, you immediately feel like it’s a question that you would want to ask. He makes interviewing seem simple. It’s clear that not only has he read the work of the historian he’s interviewing, he understands the impact of their work. But most of all, the show is great because of the content. They choose great topics with great authors and historians. If you have any interest in history, go back and listen to their shows for the past couple years (which will remain up despite the hiatus). Hope the hiatus is short…

(Don’t forget to donate to their cause if you enjoy the content as much as I do)

Milla correctly points out that she is my blogging inspiration. Not just for telling me to blog more, but for providing the inspiration in the form of the most promising blog-start ever! My favorite so far:

I turned on 1010 Wins “you give us 20 minutes, we’ll give you traffic updates from yesterday for roads you don’t drive on” and heard nothing at all about the mudslide on the Saw Mill River Parkway, which turned my road home into a parking lot.

Someone put her on a reality show, already!

The duration of treatment for a deep venous thrombosis (DVT) is problematic. Most patients who have one will never have another one, yet those who do have a 5% risk of death due to their recurrent DVT. We need a simple test which separates one group from the other.

This weeks JAMA (no link as issue is not online yet) reports on an article claiming that thrombin generation may be that test. Thrombin is one of the key factors in coagulation and the theory is that patients who generate excess amounts of thrombin are predisposed to developing blood clots. This cohort study showed that patients with peak thrombin generation below 400 nM had a 60% lower risk of developing a recurrent DVT over the course of about 5 years of follow up.

The limiting feature of this study is that they excluded patients with Protein C deficiency, Protein S deficiency and SLE. They also excluded patients with cancer, recent pregnancy, recent trauma, or recent surgery.

That means that before we use this test, we need to make sure that we’ve excluded all of the above diagnoses first. That doesn’t make it such a useful screening test. It would be useful to know is whether patients with Protein C deficiency (as an example) with low thrombin-generation values are at high risk for recurrent DVT. That is, does thrombin-generation trump Protein C deficiency, or vice versa.

What I’d like to have is a test that told me either 1) The patient is low risk or 2) The patient needs further testing. Then, I could do a simple test in all patients with DVT and only send the complicated hypercoagulable workup in patients who had a positive screening test. It seems like thrombin-generation may eventually be that test.

Also in this issue of the journal is a nice quote from Thoreau:

Write while the heat is in you … The writer who postpones the recording of his thoughts uses an iron which has cooled to burn a hole with. He cannot inflame the minds of his audience.

Good advice, which I need to take more often.

Reference: JAMA 2006-07-26 296:4 page 397