Inertia

Isaac Newton’s first law says something to the effect of, “An object in motion tends to remain in motion, and an object at rest tends to remain at rest, unless acted on by an outside force.” This is true in physics. This is true in managing a chronic health condition. This is true in life. The course we are on (or that we set ourselves on) tends to remain, unless we make an effort to change it.

Most people will stick with a current job (even if its lousy!) unless really compelled to change for some reason. People will stick with a broken system (ahem, healthcare), unless really compelled to change. People will continue exercising (if that’s the habit) or not exercising (if that’s the habit), until something spurs change. The interesting thing is, even when you recognize that something is not working, the perceived effort to change it is often greater than the perceived benefit. 

Change is hard. Always has been, always will be. The good news is that the effort to change is not required all the time. For example, when I see patients who have been using opiates or alcohol, they have been using consistently for quite some time. Why? Because change is hard, and inertia is working against them. Inertia is pulling in the direction of continuing to use. However, once people start treatment, inertia is working for them.  While things don’t always go smoothly, life is now moving in a better direction, and inertia will likely keep things moving in that better direction. 

So, its important to get  on a good path, to let inertia be your ally, not your enemy. If your inertia, your habit, is to buy healthy food at the grocery, odds are you will continue to do that. If you habit is take your insulin regularly, odds are you will continue to do that. 

Is inertia working for you, or against you? Is your daily routine bringing you happiness, or bringing you closer to your goals? 

The Chains of Habit Are Too Light To Be Felt Until They Are Too Heavy To Be Broken (attributed to many people, including Samuel Johnson, Benjamin Franklin, and Warren Buffett)

The Scientific Method (part 2)

To review from the last post, the scientific method is essentially a 4 part process that can be applied almost anywhere, or to anything: 1) ask a question, 2) create a hypothesis, 3) do an experiment to test the hypothesis, and 4) analyze the results and drawn conclusions. In this post, we will use this approach to explore how to make become happier. 

The method first starts with a question— Am I happy? If the answer to this is yes, and you do not feel like you have improvements to make, you can skip the rest of this article. If you feel there is some room for improvement, continue asking questions: What is causing my unhappiness? Why am I not content? Asking these questions should lead to a hypothesis about the problem you are facing. 

An alternative way of approaching this is to examine the life of someone whom you admire, and ask what is different about the way that person lives, compared to myself. If taking this approach, be careful— our temptation is to focus on abstract things, like “She’s got more money than I do,” rather than concrete things, like “She exercises every day.” Try and focus on the latter. 

Once you’ve formulated your hypothesis, its time to do an experiment to test it. This is key. Absent winning the lottery, its hard to test the hypothesis that a bunch of money will make you happy (the data says by and large no). But, if your hypothesis is exercising every day will make me happy, try it. If you hypothesis is that spending more time with my family will make me happy, give it a go. Do it for a while, a couple of weeks at least. Then, reflect and analyze what you have tried in order to draw a conclusion. Did exercising every day in fact make you happier? Did working longer hours make you feel better? Did spending more time with your family improve things? There is now way to know for sure except to try it. 

I understand this whole process may seem kind of silly, or a bit forced and contrived. I know you may be thinking to yourself, “I can figure it out without trying it.” Or, “I don’t want to try it.” Or, “I know what would happen anyway.” I would argue that until you actually try making a change, its difficult to know if it is, in fact, beneficial, or to know just how beneficial it is. So, here’s an idea. Commit to try the process for one month. Pick two areas where you will experiment, and use the method. See how it works. Instead of trusting me about whether or not this whole idea works, try it for yourself. Come up with your own conclusions about if this process is helpful.

The Scientific Method (Part 1)

The scientific method is amazing. It is a process that has given us everything from penicillin to internal combustion engines, from  the internet to solar panels. Most of the modern world we live in, and the advances we take for granted, have been driven by this method. 

The scientific method is essentially a 4 part process that can be applied almost anywhere, or to anything: 1) ask a question, 2) create a hypothesis, 3) do an experiment to test the hypothesis, and 4) analyze the results and drawn conclusions. If it sounds simple, that’s because it is. It is also incredibly powerful. Most of us learned about this in school, but we often think about it only in the context of a classroom, or a lab, or things that feel like “science.” In fact, it can be applied much more broadly. 

Let’s take a hypothetical problem of having trouble falling asleep at night, and apply the scientific method. First, we would have ask a question, “Why am I not sleeping well?” Then, we would need to develop a hypothesis as to why this is so. Perhaps, “I drink coffee too late in the day” or, “I watch TV too late at night.” Which of this is the answer? The scientific method teaches that the next step is to do an experiment. In this case, the experiment might be to stop drinking coffee after 11 AM. Lastly, we would analyze these results and draw a conclusion. My sleep is better (or not) because I was drinking coffee too late in the day (or not). If this answers the question, great! If not, the process can be repeated with the next hypothesis.

One of the pieces that makes this so powerful is that it systematic. In our example, not drinking coffee for one day is unlikely to yield useful data. We would have to stick with it for a few days to really test the hypothesis. Similarly, making several changes, such as not drinking coffee, starting to exercise, and not watching TV late at night would make it challenging to figure out what was actually causing the sleep difficulties. Was it the coffee? The TV? The scientific method also depends on our ability to observe what we experience. The practice of paying attention, of really noticing what is happening, can be challenging— particularly if we are not sure what to pay attention to, or if we are not sure what, in fact, is important. In this case, noticing changes in sleep is something that we could really focus on. 

In the next post, I’ll talk about how this same approach can be applied not just to challenges like sleep, but bigger obstacles we face as well.

Eight Seventeen

I recently saw a patient in the office who sees a specialist. His specialist had started him on a new medication (that I also prescribe sometimes), but the patient hadn’t picked it up from the pharmacy. He said it cost too much. This man is not particularly well off, but does ok. So I asked him how much it cost. I was thinking maybe I could convince him to pay for it for a month, see if it worked, and then make a decision. 

“Eight seventeen” he replied. “Can you believe that?”

That didn’t seem too expensive to me, I  though he probably could afford it, but maybe it just wasn’t worth it to him. Still, I could try and find him a lower price, I like solving problems for my patients. I asked him to wait for a moment. Maybe I could shave a a few dollars off, and that would be the difference.  After a bit of looking, I found the medication and the price, and felt disappointment. 

“Sorry, I can’t beat that price. I can order it, but it would cost you about $12 or $13 to get it from me.” I was a bit bummed. I like to help if I can. Still, maybe I could convince him to try it for a month or two, see if it would help. 

“That’s fine,” he said, “could you order it?”

I looked at him. Why would he want to pay be an additional 5 bucks for the the same medication he could get more cheaply from the pharmacy? He told me cost was the problem, but was willing to pay more to buy it from me? 

“Sure, but why don’t you get it from the pharmacy?”

He looked at me. “Doc. I  told you, they wanted eight seventeen for it. I can’t afford that.”

I frowned. $8.17 is cheaper than $12, $8.17 is cheaper than $13, this doesn’t make any sense. I mean, I can order it, but why pay more? You just told me, cost is the issue. Then, slowly, it sunk through my skull. 

“DO YOU MEAN TO TELL ME THEY WERE TRYING TO CHARGE YOU MORE THAN $800 FOR THIS?” I felt like my head was exploding. I couldn’t believe it. The pharmacy was trying to charge him with insurance, $817. Eight seventeen. Eight hundred and seventeen dollars. 

He looked at me and shook his head, “Yeah doc, that’s what I told you. They said it was eight seventeen. There’s no way I can pay for it. Go ahead and get it for me, maybe this one will work.”

I want to be clear: I don’t stock every medication. I can’t get every medication for less. But boy is it fun when I can save my patient $805 on a single prescription.

Cheaper Labs

I am always looking for ways to lower healthcare costs for my patients, and so am excited to announce I just implemented new prices for labs that are even cheaper than before. How cheap? Very. Like, 10-80% cheaper than the already cheap prices you’ve become accustomed to. Now, I’m not saying this so that suddenly I start ordering lots of labs for you, but it is pretty nice to know that when you need them, you can get them with a minimum of fuss. And expense.

Healthcare can be expensive, but there are lots of ways to lower the cost of labs, medications, and other things that you and your family need. Lower cost, high quality healthcare-- that's what we are after. 

I’m working on a few more projects that hopefully will help with this over the next few months as well, so stay tuned. 

Adventures in Healthcare Land (Part II)

Have you ever gone to to pick up a medication at the pharmacy, and been told, “its not covered by your insurance.” Its annoying, right? Its also annoying as doctor when this happens: I pick what I think is the best medication for a patient, and then am told by an insurance company if this is ok, or not. You know what is especially annoying? When we are arguing over pennies. 

I recently got a fax from a pharmacy. I had prescribed a medication to a patient, and before the insurance company would agree to pay for it, they needed additional justification as to why this was the right medication. Keep in mind, this was a medication to decrease stomach acid in a patient who was having heartburn. But before I spent 20 minutes filling out paperwork and faxing it back, I decided to check my inventory, and see how much it would cost the patient to get the medication from me. The answer?

$1.71. 

You read that right— about half the cost of your morning coffee. Oh, and that cost includes my mark-up. 

This is not an isolated incident, and is not the first time something like this has happened. I once had a patient wait 10 days to start a medication because the pharmacy had to get authorization for a medication for which I charge $1.53 per month (that is 5.1 pennies per day).

Now, I don’t think I can change the enormous healthcare system. I don’t think I will be able to change it even in California. But I do think I can change it for myself, and for my patients. Its a wonderful feeling; instead of getting angry about the absurdity of it, instead of trying to convince an insurance company to spend 5.1 pennies per day, instead of getting indignant because of the difficulties my patients are exposed to, build a solution that actually works. 

Adventures in Healthcare Land

I had to discuss a patient under my care with a colleague, who works as a major local healthcare system (name withheld to avoid embarrassment). I spoke with her nurse on Friday, and was told to call back on Monday. Ok. 

I called Monday. I got a phone tree. I dialed the phone tree. I got a message, “Thank you for remaining on the line. Your call will be answered by the next available representative.” This helpful message would repeat every 30 seconds. I waited for 20 minutes (that's 40 times I got to hear it). Then Next Available Representative picked up and asked me for the medical record number of the patient at this [major medical institution]. 

“I don’t have that information” 

“Ok” says the available representative. “One moment please.”

Click. 

I call back. I dial the phone tree.  I get the same helpful message, “Thank you for remaining on the line. Your call will be answered by the next available representative.” I wait. Again. For 10 minutes.

I again ask to speak with Dr. ______.

“Let me see if Dr. Is with a patient.”

“Ok”

Again, on hold. Wait 4 minutes.

Available representative comes back. “Dr. _______ is with a patient. Should I leave her a message?”

“I don’t know.” I respond. "I spoke with the nurse on Friday, and was told that to speak with Dr. _____, I dial this number, and ask to speak with her.” 

“Ok” says Available Representative. “Let me check with the nurse.” 

2 minutes later.

“Let me transfer you to a nurse”

Nurse, “Can you please verify the patient’s DOB?”

I give it to her.

“Can I put you on hold and see if Dr. _____ is available?”

“Sure” I say. 

On hold. 2 minutes. 

“Dr. _____ is finishing up with a patient, can I have her give you a call back?”

“Sure” I say. 

So, it took me 45 minutes to discover a) the doctor was busy and b) she would call me back. 

To be clear— this is a great doctor. I’d send a family member to her. She’s just trapped in a lousy system. 

Want to know what happens when you call Sequoia MD?

You call the office. One of three things will happen: someone (usually me) answers the phone. Or, Doris answers the phone, or you leave a voicemail. If it happens to go to voicemail, things get really complicated, and you have to make a decision:

You leave a message and I call you back, usually within a couple of hours, always same day. 

You try my cell. 

You send me a text message.

You send me an email. 

Don't believe me? Try it sometime, just to see what happens. 

Putting Leather on the World

Often, complex ideas are better explained with a story than with charts, graphs, or statistics. This story comes from Buddhism, and is one of my favorites. 

    There was once a man on a long journey. As he walked the path, he found he continued to cut his feet on the sharp rocks in the path he walked. His feet were painful and bloody, constantly being cut. Being a compassionate man, he realized if the sharp rocks were cutting his feet, they were probably cutting the feet of other travelers as well. Resolving to do something about this, so set about covering the sharp rocks with leather, so as to protect both his feet, and those of his fellow travelers. 

He resolved that this would be his great work-- covering the sharp rocks with leather, for himself and his fellow travelers. 

However, the more sharp rocks he covered with leather, the more sharp rocks he saw. No matter how many sharp rocks he covered, there always seemed to be more. He and others continued to have cuts on their feet. Despite his great exertions, and thousands of sharp rocks that were covered with leather, the cuts persisted. 

    One day, a monk was traveling the path, and stopped and asked what he was doing. The man explained, and showed the monk his progress, as well as the continued challenge he was facing. The monk replied, “Don’t you think it would be better to put leather on your feet, rather than putting leather on the world?”

Treating Substance Abuse Disorders in the Medical Model

Last post, I discussed how we can view substance abuse through the framework of a chronic relapsing-remitting disease. This post, we will explore what that means for treatment. 

First, the goal of treating any relapsing-remitting disease is to induce remission— make the flare-up, or the relapse, stop. This is often (though not always) achieved through medications. Once the disease is in remission, the goal is to keep it there. 

So, how do we keep diseases in remission? Well, it depends on the disease. Hopefully, we have medications that patients can take to keep the disease at bay. Often, the first question that comes up with this is, “Does that mean I have to be on medications for the rest of my life?” The answer is not simple, and involves weighing the risks of taking a medication (with its potential side effects) against its benefits (a higher likelihood the disease remains in remission). This is not a one-size-fits-all question, and really involves discussions about the risks and benefits. 

So, if remission is the goal, what about relapses?

Well, they happen. I wish they did not. I do not encourage them. The reality, however, is that they do happen, and when they do, its vital important that they are recognized as soon as possible, and addressed as soon as possible. This is true whether we care talking about Ulcerative Colitis or Opiate Abuse. The longer the relapse continues, the more damage is done; the sooner it is recognized, the faster we can intervene and get things back on track. 

The goal with relapses is to make them as short as possible (an hour is better than a day, a day is better than a week, a week is better than a month), as infrequent as possible (once a month is better than once a week, once a year is better than once a month) and as little destructive as possible, both in terms of health and in terms of damage to those around us. 

While this model is not perfect, it is helpful. And the good news, when it comes to treating opiate or alcohol dependency in particular, is that we have some very good medications that generally do not come with a lot of side effects. However, as with pretty much any chronic disease, the best outcomes are really achieved through a combination of medications and behavior change. Its not either/or, its both.

-Justin Altschuler, MD

The Medical Model for Substance Abuse

The statistician George box would say, “All models are wrong but some are useful.” Its a helpful phrase to remember when thinking about substance use disorders and addiction. There is not one right way to think about this problem, as every approach— medical, law enforcement, spiritual— contains both useful insights and significant flaws. However, I am a doctor, so my training teaches me to think about substance use disorders through the medical model. 

As doctors, we treat many conditions that are characterized as chronic, relapsing-remitting diseases. There are many diseases fit this mold, from Crohn’s disease to multiple sclerosis. Thinking about opiate use disorder, or any substance abuse disorder through this lens provides some useful insights: 

Chronic simply means it does not go away. It will always be there. It does not necessarily mean it will be a problem. I However, just because something is not bothersome at this moment does not mean it doesn’t exist. Other chronic illnesses include things like high blood pressure, diabetes, and heart disease. People with chronic illnesses do not necessarily feel bad all the time; often, the illness barely gets in the way of life. 

Relapsing-remitting means the disease goes through periods where it is bad and flared-up, is a problem, then goes through periods where it is not acting up, is not an issue, is in remission. The goal of treatment then becomes to induce remission, and keep the disease in remission for as long as possible. 

Viewed through this lens, the goals of treatment become much easier to understand: to induce remission, to maintain remission, and to ensure that any relapses are as short as possible, as infrequent as possible, and as little destructive as possible. This framework is true regardless of whether the disease is a substance use disorder, a neurological disorder, or a gastrointestinal disorder. However, given how loaded and stigmatized substance abuse disorders are, this framework also helps both patients and doctors approach the problem as a solvable issue, rather than an inherent failing in the patient. 

The question then becomes, how do we achieve this? That will be the topic of a future post.

Dishwasher Issues

Some of the patients I see  have challenges with relationships. Sometimes, these challenges grew from the substance abuse, sometimes these challenges were a big part of what started the substance abuse. Sometimes, they have nothing to do with substance abuse. 

It should not be controversial to say, but relationships come with disagreement— and that’s ok. In fact, it’s normal. But learning how to disagree with someone, particularly a romantic partner, can be a challenge.

In fact, most of us have probably been in a situation where we have had an enormous fight with someone over something trivial— like, for example, how to load the dishwasher. So, let’s focus on this for a moment. 

We all have an opinion about how to load a dishwasher. The plates go on the bottom, they face toward the silverware, the cutlery faces up, the glasses have to be on the edges… you get the idea. More importantly, exactly how we load the dishwasher is probably not too important; after all, worst case scenario, the dishes don’t come out sparkling. However, people can get into knock-dawn, drag out, screaming-at-the-top-of-my-lungs fights about… how to load the dishwasher. 

“Honey, I told you, the plates go on the back row.”

“NO, they go ON THE FRONT ROW.”

“They go on the BACK ROW.”

“NO. THEY. DON’T. FRONT ROW.”

Guess what…its not about the dishwasher. Its about the relationship, and the dishwasher is just a symptom. 

Here’s the same conversation, with what is said, compared with a hypothetical set of issues someone may be experiencing:

“Honey, I told you, the plates go on the back row.” Why don’t you ever listen to me?

“NO, they go ON THE FRONT ROW.” Why are you being overbearing. 

“They go on the BACK ROW.”  You don’t listen to me, my parents never listened to me, you ignoring what I think is important, just like I’ve always been ignored. 

“NO. THEY. DON’T. FRONT ROW.” My mother was overbearing all my life, and now you. All I want is the freedom to do things on my terms.”

The issues will vary, but, the problem of big fights over trivial things (like how to load the dishwasher) won’t go away until the underlying problem, or issue, is addressed directly. If you find yourself in this situation, take a step back, let everyone cool off, and try and address the actual problem… not how to load the dishwasher.

Upcoming Series

I am hoping to be a bit more consistent with the blog-- and to start publishing some of the more common themes and issues that come up when I am meeting with my patients. I plan for these to be fairly wide ranging-- from thoughts about substance abuse treatment to chronic pain to explanation of how the direct primary care practice works. 

First post will be coming out in a few days, and will be about dishwashers. 

Cheers,

Justin Altschuler, MD

Group Visits and Happy Holidays

Happy Holidays! For a lot of people, it is most decidedly NOT the most wonderful time of the year, but I hope your holidays have been good so far.

I will be out of the office quite a bit over the next couple of weeks visiting family. If you need anything, please get in touch on my cell phone. 

Group visits have been going well so far-- thank you to those who have attended. I think they have been helpful addressing some of the challenges patients with substance abuse disorders face. In fact, I am planning on adding an additional group on January 25 in the afternoon. Please let me know if you are interested in attending. 

I emailed a while ago as well regarding RubiconMD, a service I subscribe to that increases access to specialists. I am happy to report this has been a great addition to the care I am able to provide, and has allowed very rapid second opinions and guidance regarding tricky problems. 

Lastly, I would like to share my gratitude for you, my patients for being a part of the practice. It is off to a great start. Leaving work every day, I feel like I am able to do the right thing for every patient who have entrusted their care to me. It is a wonderful feeling. As Warren Buffett says, "I tap dance to work." 

I am looking forward to seeing you in the new year, and thank you for the privilege of being your doctor. 

Happy Holidays,

Justin Altschuler, MD

Introducing... the blog (and group visits)

We are always trying to innovate, and find better ways of doing things. So, as an experiment, I am planning on starting a small blog to update new happenings at SequoiaMD. In this first post, I am happy to introduce yet another new change to the practice-- group visits.

Many patients that I am seeing for substance abuse issues have expressed interested in meeting other people who facing similar challenges. This program is a direct response to conversations I have had with many of you, and I hope they are helpful!

The plan will be for a pilot program, initially limited only to people who I see for substance abuse. This is an opportunity to build community, friendship and fellowship with other people who have been there. Regardless of where you are on your journey, come connect with others who are walking the same road. 

Some specifics:

  • Group visits are optional. You are not required to attend
  • I will be present, and facilitating, every visit
  • This is included in your monthly membership— there is no extra fee
  • You may attend a group visit AND continue our regular appointments, you don’t have to give anything up to attend.
  • If there is enough interest, I will add additional groups.
  • These visits will not follow a traditional 12 step model. If you would like a 12-step style meeting, there are many available in the community. This is something different.
  • You MUST RSVP for these. You know how to get in touch with me.
  • Each visit will have a minimum of 3 people, and a maximum of 8. If there are less than three people Interested, I’ll cancel the appointment. 
  • To start, these will occur once per month, on the second Wednesday of the Month, at 9:30 AM. Currently scheduled November 8, December 13, and January 10. 

This is a pilot program, and will evolve with time. The goal is to be helpful, and so we learn what works and what doesn’t, the visits will likely change. If you would like to attend, please get in touch!

-Justin Altschuler, MD