During my urgent care shifts, I see 20-30 people with viral upper respiratory infections. They are all feeling miserable, and they just want to feel better. They want an impressive-sounding diagnosis to justify their suffering to themselves, their spouses, and their bosses. They want a prescription medication which will immediately cure their illness, so they can get back to their lives. Their faces fall when they receive their diagnosis and recommendation for over-the-counter cold medications. “Just a virus?” they cry! “Then why do I feel so terrible?”
There seems to be a public perception that bacterial infections are serious and viral infections are not, but this could not be further from the truth. Nobody would refer to HIV, Hepatitis, or Ebola as “just a virus”. HPV causes over 40,000 cases of cancer in the U.S. annually. Tens of thousands in the U.S. and hundreds of thousands worldwide die from the influenza virus every year. Over one million die from the malaria virus every year. The measles virus caused 2.6 million deaths annually prior to the invention of the measles vaccine in 1963. Vaccination has eliminated the crippling effects of the polio virus and has significantly decreased rates of death, disability and birth defects due to varicella, mumps and rubella.
Doctors hate viruses as much as patients do. We love to help people feel better, and we feel pretty helpless when our patients or our family members are suffering from viral illness. We especially hate it when we have a viral infection because we are notoriously bad patients and do not give ourselves time to rest and recover. My colds always last at least 2-3 weeks. I’m on the tail end of one now and have been coughing for over a month! A post-viral cough can last for up to three weeks after the infection has resolved. We believe that you are suffering; we have all experienced it, too.
Viruses cause over 98% of sinusitis and over 90% of bronchitis. Antibiotics only treat bacterial infections; they do nothing to treat viral infections and can cause potentially severe side effects. If it’s not effective or safe to prescribe antibiotics for viral infections, why do so many doctors do it? Simply, it’s the path of least resistance. With a click of the mouse, you can give a patient what they came for, make them happy, and move on to the next patient without any argument. Most of the time, the antibiotic seems to work because the patient is seen mid-way through their illness, and the viral infection resolves before the antibiotic course is finished. Also, the placebo effect is real, so patients who believe that an antibiotic will make them well, will start feeling better after they take it. However, patients who come in on the first day of their cold to “nip it in the bud” or “get ahead of it” will inevitably get worse on antibiotics and then call back to get “a stronger antibiotic”.
The problem, in addition to the risks for individual patients, is that bacteria are becoming resistant to antibiotics, and we could face a future in which we are unable to treat serious bacterial infections. The most popular “placebo” given for colds is a Z-pak (azithromycin). Bacteria in the upper respiratory tract are resistant to this antibiotic, so it does not work for bacterial sinusitis. In the U.S., azithromycin is used to treat Chlamydia, but in Europe, Chlamydia is now resistant to azithromycin due to inappropriate overprescribing for viral illnesses. Azithromycin is a potentially dangerous medication and can cause a fatal heart arrhythmia, so using it as a placebo is not just bad medicine, it’s malpractice. So next time you’re sick, and your doctor does not offer you an antibiotic, thank him or her for caring more about your health and about public health than about patient satisfaction scores.
Gender politics aside, let’s talk about why the way doctors get paid matters to you as a patient. Female physicians don’t just get paid less because they prioritize their families, they get paid less because they prioritize patients. In the fee-for-service model, doctors are paid per patient visit, so the more patients they see, the more they get paid. This means that the worst doctors are paid the most. Healthcare administrators love “productive” doctors like Dr. Tigges who see 40-50 patients per day in 5-10 minute visits. These doctors make a ton of money rolling patients through the assembly line, and they produce even more money downstream with all of their referrals and tests and frequent return visits since their patients’ problems are never adequately addressed. One local hospital group times all patient visits, and any physician who spends longer than 15 minutes with a patient is reprimanded. The best physicians are literally punished for prioritizing patient care over profits.
Doctors who spend more time with their patients are better diagnosticians because they listen to their patients, get a thorough history, and perform an appropriate exam. They are less likely to need to order expensive tests or refer out to a specialist. The best doctors consider the cost of care and take extra time to ensure that their patients are getting the most affordable medications and that they are not subjected to costly and unnecessary testing. The best doctors respect their patients’ time and avoid making them return for another appointment for a skin biopsy or joint injection. Spending more time with patients is also important in building trust and motivating them to make healthy changes, such as smoking cessation or weight loss. Female physicians have been proven to have lower mortality rates, probably because they choose to spend more time with patients, make thoughtful diagnoses, order testing judiciously, address financial concerns for patients, and make sure that their patients understand and agree with the treatment plan.
I know many excellent physicians, both male and female, who make patients their priority and give them the time they deserve. However, this is very difficult to accomplish within the current system, and many good doctors get swept up in pleasing their bosses and paying off their medical school loans. The solution, for doctors and patients alike, is Direct Primary Care. By paying an affordable monthly fee, patients get access to a doctor who has plenty of time to give them the best possible care. Doctors are paid fairly because they are providing a valuable service directly to the patients who pay them.
The first time I tried meditation, I thought it was a waste of time. I was an intern, and as usual, I had a long list of work to complete. I wanted to get my discharge summaries dictated, but instead, I was being forced to count my breaths. I suppose I did waste my time, since I spent the entire session stressing myself out over how much I had to do and how I would never be able to complete it all. Of course, I did everything I needed to do, but my agitated internal dialogue was not a motivating factor; it was a distraction.
Years later, I finally discovered the benefits of meditation. At first I was doubtful when I read that meditation could help with mood disorders, addiction, pain relief, insomnia, and weight loss, in addition to increasing productivity and joy. In fact, Headspace is currently working on FDA approval to designate guided meditation as an official medical treatment. I started using the Headspace app this year, just ten minutes per day. Similar to physical exercise, this mental exercise is not enjoyable at the time, but its benefits last all day. I have noticed increased kindness and patience for myself and for others. I intentionally pause to enjoy moments like bedtime snuggles with my boys who won’t be little for long.
Most of our suffering occurs when we are thinking about the past or the future. We may be experiencing shame about something we said or did. We may be experiencing anger over something someone else said or did. We may be anxious about a future meeting or conversation or overwhelmed with tomorrow’s to-do list. We may feel fearful over the possibility of a car accident, a cancer diagnosis, or a terrorist attack. Our thoughts can become habitual, neural pathways carved into our brains. We may find ourselves thinking the same string of thoughts, which results in anger with a spouse, impatience with our children or frustration with our job. Even when we are experiencing physical discomfort, the majority of our suffering is created by our thoughts. Thoughts about how our pain is debilitating or unfair result in worsening pain, especially if there is anxiety over how long the pain will last or whether it’s a sign of a serious medical condition.
If we can let go of all those thoughts about the past and the future, we are left with a fairly neutral present moment. In the present, we experience only our senses. With our eyes closed, we can hear the sounds around us, smell any scents, and feel the weight of our body, the temperature of the room, and the air entering and leaving our lungs. This is a skill that takes a long time to develop, but it’s extremely useful. You can use it at any time to interrupt your current thoughts and allow the accompanying negative emotions to drift away. You can change the way you feel and react to the people and events in everyday life. You can change the way you respond to urges to snack, smoke or check your phone. You can learn to control your pain rather than letting it control you. You can learn how to let go of your thoughts in order to fall asleep more easily. Over time, you can literally rewire your brain to create new thought patterns and habits.
I was miserable for the first two months of my “diet”. Although I physically felt better and was pleased to see the numbers on the scale dropping and to feel my body shrinking, I was in a state of emotional turmoil. I grimly ate my grilled chicken and salmon and salads and steamed broccoli while watching others enjoy pizza and French fries and cookies and soda. I told myself sternly “You can’t eat those foods” and I suffered from this perceived deprivation. I had to wrestle with my desire for sugar and use huge amounts of willpower when anyone offered me a delicious forbidden treat or when the donuts called to me from the breakroom or the Girl Scout cookies beckoned from the freezer.
My plan from the very beginning was to reach my pre-pregnancy weight and then return to all of my favorite comfort foods. In fact, that was my main motivation. “Hurry up and lose the weight, so you can have ice cream!” my brain shouted. As someone who has always struggled with my weight, gaining and losing the same thirty pounds over and over again, I knew this was not logical. However, I could not conceive of a life without sugar. The prospect seemed so bleak.
When I had lost over half of my excess weight, I discovered a weight loss podcast by a fellow physician, Katrina Ubell, MD. Her words completely changed my perspective. She said “I want your food to be boring and your life to be exciting.” I teared up thinking of all of the times I declined invitations to go swimming because I did not want to wear a swimming suit in public. I even stayed home when my family went to California because I was overweight and did not want to pose for vacation photos in shorts. I realized that I was hiding from my life and that only by releasing this obsession with food would I be free to chase after the things I truly want.
I started working on my thoughts about food with the help of Katrina Ubell and Brooke Castillo, life and weight loss coaches. I stopped saying the word “diet” and starting thinking about what I ate in terms of an eating protocol: all of the foods that I choose to eat on a regular basis because they make me feel good physically and support a healthy weight. I stopped telling myself that I can’t eat certain foods. Instead, I tell myself that I can eat anything I want whenever I want, but there are certain foods that I choose to avoid most of the time because they make me feel poorly and will lead to weight gain if consumed regularly. Instead of “cheating on my diet”, I plan ahead to eat off my protocol. I find that I make much better decisions ahead of time than I do in the moment. I have also noticed changes in my body every time I consume processed carbohydrates. For two days after eating Halloween candy as planned, I experienced nausea, stomach discomfort and fatigue. When I eat popcorn at the movies, my allergy symptoms worsen with increased post-nasal drainage and a dry cough.
Slowly but surely, these techniques have decreased my desire for sugar and flour. I used to believe there were only two ways to respond to an urge to eat a certain food: eat that food or use willpower not to eat the food. Eating the food does not decrease your desire for the food, and using willpower actually increases your desire for the food. There is a top secret third way to respond to an urge which decreases your desire: simply allow it. Even now as I search for the right words, I have an urge for that leftover Halloween candy. Amused, I relax and allow myself to want the candy. Of course I want Halloween candy. I have always loved candy and maybe always will. I check with myself to make sure that I’m not hungry. Nope, not hungry at all, I just want candy and am feeling a little restless as I write. I am not surprised, frustrated or disgusted by my desire for candy. As I explore this desire, I realize that my desire not to have any candy is stronger than my desire to eat candy, and the urge fades away. I feel so confident in my ability to maintain my weight because I love the way that I eat and think about food. I no longer feel restricted or deprived because I can and do eat whatever I want, I just want to eat healthy foods most of the time. The urges still occur, but not as often as they used to, and the drama has been quieted.
As a family physician, patients are always coming to me for help with weight loss. Until this year, I felt incapable of helping them since I was struggling with my own weight. During my first three years as an attending physician, I had two babies and thirty pounds of excess weight accumulated while pregnant and breastfeeding. I was twenty pounds overweight, exhausted, achy, and constantly sick with every cold virus my babies brought home from daycare. There was no mystery to my weight problem. I was eating a diet consisting almost entirely of processed carbohydrates, working 12 hour days, sleeping a maximum of 5-6 hours a night, and not exercising at all. I gave myself all the same excuses my patients gave me: I have no time to exercise, I cannot eat healthy because the drug reps bring donuts and bagels and pizza and pasta and cookies to work, and my husband cooks unhealthy food and brings home chips and cookies and candy and ice cream. Deep down, I knew that I did not want to give up these foods because eating had become my only pleasure. I did not enjoy exercise, and I wanted to spend the little free time I had sitting on the couch watching Netflix and eating.
Most physicians do not get much training in nutrition, obesity and weight loss, and we give the same bad advice that you hear from non-physicians: always eat breakfast, eat small meals and snacks throughout the day, follow a high-carb, low-fat, low-calorie diet, and exercise daily. I knew that this advice did not work because it had never worked for me or for any of my patients. I read several books and was surprised to learn that the medical literature has always supported a low-carb, high-fat diet for weight loss and that exercise does not play a significant role in weight loss.
The most influential book I read was The Obesity Code by Jason Fung, MD, a nephrologist. He explains the role of insulin in weight gain and how weight loss can be achieved by lowering your insulin level. Insulin is a hormone which causes weight gain through building muscle and storing fat. Insulin levels rise when you eat, so the more often you eat, the higher your insulin levels get. Insulin rises more with higher glycemic index foods, such as processed carbohydrates, specifically foods containing sugar and flour. Insulin rises the least when you eat fat, followed by protein, then low glycemic index carbohydrates like leafy green vegetables, then higher glycemic index carbohydrates like fruit, grains, and starchy vegetables such as corn and potatoes, and finally by highly-processed carbohydrates such as alcohol, sugar and flour. Another great book which explains the relationship between insulin and the foods we eat is The Thinsulin Program by brothers and physicians Charles Nguyen, MD and Tu Song-Anh Nguyen, MD.
In addition to choosing foods which are less likely to spike insulin levels, it is also important to decrease the frequency of eating to keep insulin levels low. The concept of fasting often freaks people out, but you probably fast every day. Most people fast for approximately 8 hours daily while sleeping and pretty much eat constantly during the other 16 hours of the day, which ensures that the body has a constant fuel source and that weight loss remains impossible while weight gain is likely. Just eliminating snacks helps to decrease insulin levels and allow the body to burn fat stores between meals. Intermittent fasting is nothing more than an extension of the normal daily fast and may involve eating breakfast later and dinner earlier without any late-night snacking resulting in an 8 hour eating window with a 16 hour fasting window each day. It may involve skipping breakfast altogether and eating two meals daily during a 6-8 hour eating window. Once you are fat-adapted, meaning that your body preferentially burns fat rather than sugar for fuel, your body will more readily access your own fat stores for fuel during a fast, and you will not feel hungry during fasting.
Insulin is also affected by stress and sleep deprivation. When you get less than 7 hours of sleep per night or when you are under constant emotional stress, your cortisol levels rise. Cortisol is a stress hormone, and higher levels of cortisol produce a rise in insulin levels. Getting plenty of sleep and finding ways to reduce emotional stress are important for weight loss. If exercise is enjoyable and helps with stress-reduction, it may be helpful for weight loss. However, exercise may actually impede weight loss for those who do not enjoy it or who sacrifice sleep in order to make time for exercise. Also, weight training will raise insulin in order to build muscle, which will cause weight gain rather than weight loss.
In six months, I lost over 30 lbs, mainly by eliminating sugar and flour from my diet. I try to get 7-8 hours of sleep every night, but I rarely exercise. In a typical week, I do one yoga class. I have a ton of energy, no pain, and I have not been sick once this year. I think I’ve actually had a few viruses, but my symptoms were so mild, that it’s hard to tell. Sugar and other processed carbohydrates have an inflammatory effect on the body and are the main cause of diabetes, heart disease, liver disease, kidney disease, autoimmune diseases, arthritis, and even dementia. I am so excited to share the cure for obesity, chronic fatigue, chronic pain, and most chronic diseases: eliminate sugar and other processed carbohydrates from your diet. It sounds impossible, but if I can do it, anyone can, and it is SO worth it.