Football's Metamorphosis

I was knocked out in a football game playing against Sevier County.  

It was November 1984, Harriman was the homecoming opponent at Sevier County, and it was unusually cold.  I was blocking downfield for Scott Mason’s long (took him forever) touchdown run and I was hit in the left temple.  I woke up looking at the sky and thinking “Wow, those sure are tall lights.”  

I admired the texture of the grass, came to understand I was cold and still somewhere in Sevier County, located my mouthpiece, and staggered to the sideline.  And I went back in on the next series.  

Under today’s rules, I would be out for likely a week or more.  But the only rule on concussions was if you could stand, you could play.  Toughen up, it’s football.  “Quit killin’ the grass.”

The focus on concussions in recent years has brought to the forefront the consequences of repeated blows to the head and “concussions” - even as we still do not understand the exact process occurring in the brain.  

A term commonly used now is traumatic brain injury (TBI). TBI describes the injury that occurs from repeated blows to the head resulting in impaired cognitive function and reasoning, memory loss, depression and other symptoms that profoundly reduce the quality of life for the players.  The physical evidence of this damage has been seen in the autopsies of players who have donated their brains to science - some at a heartbreaking young age.

An enormous challenge is measuring the level of injury a player has.  Some symptoms are observed, but most are self reported by the athlete.  If, however, the athlete does not report any symptoms, then he will continue to play.  

There are some tests now that can be given and compared to preseason performances, yet it seems as if measuring concussions is a lot like measuring how in love someone is - yep, they’re acting goofy and different, but how much of that is real?

It is probably easier to study the mysteries of the microscope and telescope than it is to measure a person’s thoughts, desires, motivation and pain.  The mind is more infinite than the finite infiniteness of space.   

Because of this evidence, recent high profile deaths and litigation, football will change.  (Soccer will soon follow.) It is inevitable.  Even the most ardent football fans and coaches I talk to will admit it privately under low hushed tones.  In ten years, football won’t look anything like it does now.  

But football has been there before.  In 1905 football was a brutal sport blamed for 19 player deaths.  President Teddy Roosevelt, a man who loved the outdoors and competition, weighed in threatening to kill the sport if it didn’t change.  Football modified the rules and was allowed to continue.  

The rules will now change again.  

In a recent opinion article in the Journal of the American Medical Association (JAMA), Dr. Paul Auerbach, and emergency physician, former football coach and collegiate football player, offered and assessment and proposed rules change for football.  He noted the recent trend in concussion research show that the cumulative total of hits, not necessarily that one big hit, is the underlying problem of TBI.  

He proposed six rule changes for all levels of football:  First, no “down linemen” for any play.  Linemen will stand and oppose each other without blows firing off on each play (it will look sort of like Baptists dancing.  I am Baptist so I can say that).  

Second, no tackling or striking an opponent with the top portion of the helmet.  First offense is a 15 year penalty and the second is an ejection.  That is a challenging for officials to call as real time football can be very fast.  

Third, no forearms to the head at the line of scrimmage or when tacking.  Same penalties.

Fourth, no more that two days of full contact practice for any player per week.  

Fifth, any player with suspected concussion is out a minimum of four weeks with a progressive return after that.

And sixth, any coach who allows an athlete to play in a game with concussion will be suspended for the next three games.  

He also stated there should be no tackling at any level prior to high school football.  

These changes face hurdles, the largest one being measuring concussions.  A new blood test seems to be emerging from research, but that is a long way from reality.  

Given that most everything we do now is measured digitally, I would suspect a type of motion sensor will eventually come to the market to measure the number and intensity of hits a player has during his entire career.  His “Impact Eligibility” will become another factor in playing time and years of playing. Not wearing it will be grounds for dismissal much like radiation badges in nuclear plants.  

Money, though, is the power that will prevail in this decision.  Pro-football, college, and now even high schools have advertising and sponsors for ads, equipment, stadiums and broadcasts who would resist change.  One major lawsuit could cause insurance rates to skyrocket and high schools and college would have no choice but to change.

So when you watch the college and high school football games this Thanksgiving weekend, keep in mind that the touch football game in the family’s backyard might be a foreshadowing of where football is metamorphosing.  The evidence simply can no longer be ignored.

Eric J. Littleton, M.D. (@DrEricLittleton) is a musician and Family Physician in Sevierville, TN.  Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com

(Insert Name Here) Wins the 2016 Presidential Election

The election is now over.  Unless there are hanging chads, clanging legal chatter, or a cataclysmic event that affected the voting, the results of the presidential election are now settled and (Insert Name Here) is the President Elect.  

(Insert Name Here) gave a memorable acceptance speech last night or early in the morning and called for a new beginning of healing, working together, and changing what is wrong with our country.  (Insert Name Here) claimed a clear mandate from the results and will push forward on campaign promises. (Insert Name Here) said they will be the president for all the people for the good of the country.   

(Insert the Other Name Here) also gave a speech thanking the supporters and vowing to fight on for all the things that were important during the campaign.  (Insert the Other Name Here) also noted the things wrong in America and asked supporters to keep putting the pressure on Washington, DC to make important changes or the country will suffer greatly.  (Insert the Other Name Here) vowed to be right there with supporters keeping up the fight but graciously acknowledged defeat and asked that (Insert Name Here) be given a fair chance to govern the country. 

(Insert the Other Name Here)’s supporters growled about voter fraud and media bias during the post election news shows.  

(Insert Name Here) and (Insert the Other Name Here) went to their respective homes and will be sleeping for the next two days from exhaustion.  Both will have bad hair when they wake up.

And America, in one large unified breath, will now sigh in relief.  The election is over.  

On October 13th the American Psychological Association released a survey of 3,511 adults from August 5 to August 31, 2016.  That actually was before many Americans had tuned into the election. 

The conclusion of the research was that the election is stressful to Americans.  More specifically, fifty-four percent of Democrats and fifty-nine percent of Republicans noted an increase in stress over the election.  Those who watched more television coverage and followed social media had a higher amount of stress.  

No, really?  Who knew? 

As a habit, I never ask a patient how they will vote, but instead I ask “What do you think the nation will do on Election Day?”

Without exception, the response I have heard the past two weeks is “I don’t know, but I can’t wait until it’s over.” 

The survey noted that the continuous news cycle, social media and the specific worries of the Millennials and “Matures” made this election more stressful.  Apparently Baby Boomers and Generation Xer’s weren’t quite as keyed up about it.  

Really?  It takes a survey to tell us we are stressed? Academically I understand, but the article really didn’t get to the meat of the matter of why.  

Why does the election of a president cause such stress?  

From documents drafted in debate we have been given by the sacrifice of others on the battlefield the freedom to choose our leaders.  Our President will likely choose two or three Supreme Court Justices who will serve for life.  Our President will set the agenda for political winds and whims, taxes and treaties, laws and losses, funding and fighting, friends and foes.  

Those are extremely important decisions.  And it is now out of our hands.  

But there is still power that we hold in our hands.  It is how we live.  

(Insert Name Here) cannot decide whether we sit on our couches or go walking/hiking.  Nor can (Insert Name Here) decide whether we decide to stop smoking.  Or to turn off the TV and read, write, think or pursue a hobby.   

(Insert Name Here) cannot decide whether I eat Funyuns dipped in peanut butter (a personal favorite) or a healthy smoothie (non-exploding).  

(Insert Name Here), regardless of whether a person supports them, cannot keep an individual from learning more about their faith, their personal beliefs, pursuing more deep and personal devotion to their  prayer life and serving their community.  

Some may argue that politicians and judges have wrongly removed prayer and religious symbols from the public arena.  I would argue that television, internet and social media have removed more prayer and religious sincerity from the home than any dislodged from the public square. 

I have seen internet usage destroy marriages and families.  I have seen cigarette smoking cause some agonizing deaths.   Those were choices that could have been made differently. 

Life is simply about those things we can control and those things we can’t.  

We can’t control how (Insert Name Here) will govern, but we can control how we choose to walk physically, spiritually and mentally with our attitude, discipline and devotion to our family, friends, and, yes, even our foes.  

We have been blessed in this country.  Richly so.  In the words of my former pastor, we can move forward either “humbly grateful or grumbly hateful.”   

And that attitude can be powerful medicine for a weary country.  

Eric J. Littleton, M.D. (@DrEricLittleton) is a musician and Family Physician in Sevierville, TN.  Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com 

The Smoothie Bomber

I set a bomb off in my office.  

No, not one of those spray can things that takes out insects.  

A real, internal pressure sudden explosion device from a metal container.  A wide mouthed aluminum bottle, to be specific.  In my personal office.  In our brand, spanking new, UT Regional Health Center building, no less.  

It has been eighteen months now so this story can be told.  It began in January 2015 with a desire for a healthy lunch smoothie made in my grind-up-a-brick blender.  Ice, spinach, apple, banana, blueberries, yogurt, soy protein and chocolate milk.  A dash of chia seeds to give it a punch.  Poured into the aluminum bottle with the wide plastic cap and carried to my office.  Placed in my small refrigerator next to my desk.  

And there it sat.  

For a month.  

An announcement came that the administrative hierarchy of UT Medical Center would be touring our new building on a Monday in February.  I decided to tidy up my office so as to not look like an ungrateful ogre in the newest building of the UT system.  This included trying to open the smoothie (I figured it was not longer edible for consumption after one month) and pour it out.  

The lid wouldn’t budge.  Not even a bit.  

Not a problem, I thought, just set it next to my leather bag to carry home and open tonight.  And there it sat - in the heat - for about seven hours.  

Fermentation is the process of turning sugar into alcohol and creating carbon dioxide gas as a byproduct.  Evidence shows that human beings have known of this process since nearly 7,000 BC.  Winemakers have this down to an artform and they also know that proper venting is necessary.  

That fact clearly didn’t cross my mind that morning.  Our dignitaries were to arrive at 2 PM.  

I was in an exam room with a patient about 1:30 when I heard a very loud sudden noise followed by something clearly falling.  My immediate response was stereotypical, “what are they doing out there….?”

After I finished with my patient I opened the door into my office (the staff said they had no idea what that noise was) and saw the entire back corner of my office, window shade and ceiling covered in apparent evidence of a sewer line rupture - wait- I am on the second floor and there is no sewer line above here - say, what is that plastic cap doing on the other side of the room?

I dawned on me what happened.  The entire liter contents of my smoothie had exploded up the wall, blown two ceiling tiles out of their frame and continued on up another ten feet to the roof of the building above my office.  My shelf was covered.  My bag was covered.  My desk looked like a kindergarten experiment.  And it smelled, too.  Sort of like a sweet green spinach apple wine. 

It was 1:45 and our guests were due in fifteen minutes.  I couldn’t contain myself after the sight of it all and started laughing.  I was laughing so hard my nurse came to look and stood there with bug eyes at the spectacle.  I couldn’t stop laughing.  The irony of being the newest physician on staff in the newest building at UT and exploding a smoothie bomb in my office was simply too funny.  And right before the tour.  What was there to do now? 

There was nothing to do.  It was beyond recoverable.  The only option I had was to stand in my new crisp white coat outside my office with the door closed - the only door closed on the tour, by the way.  I politely greeted our long line of guests as they strolled by in their suits with a smile and “thank you” for their support.  

A few asked about my piano in my office and if I could play a bit.  “No, I’m so sorry,” I explained, “I simply don’t play when patients are here so they don’t complain about waiting.”  It worked.  

My door stayed closed the rest of the day, too.  The staff was curious about the smell, but beyond my nurse, they never knew.  They just assumed it was another one of the smells of working in a medical building.  

I returned that night at nine o’clock with my step ladder, cleaning tools, and rags.  I scrubbed the walls, cleaned up into the attic above my office, soaked up the stains in the carpet, removed the stains from the shade, cleaned and replaced the ceiling tiles and restored my desk to professional status (sort of).  Occasionally I will still find a small stain on the far wall as a reminder.  

The next day I told my office manager and she gave it a quick inspection.  There really are no secrets for long in any office so I decided confession was best.  She ordered a new ceiling tile for the one that took the direct hit of the bottle cap.  She laughed, thankfully. 

I still enjoy making my smoothies (the chia seeds are key). BUT, I am now required to pour out my smoothies if not consumed within one week.  That’s fair.  

For a college chemistry major, that smoothie was humble pie.  

Eric J. Littleton, M.D. (@DrEricLittleton) is a musician and Family Physician in Sevierville, TN.  Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com

The Roller Coaster Stone Treatment

The days of freely choosing to ride roller coasters in this country may soon come to an end.  

Why? It all begins with a study on whether or not roller coasters can treat kidney stones.  In the latest issue of The Journal of the American Osteopathic Association, Urology Professor Dr. David Wartinger from Michigan State University College of Osteopathic Medicine states his research demonstrates riding a roller coaster can cause small kidney stones to pass.  

No. Really. He was investigating a report by an individual who claimed riding a roller coaster caused three stones to pass over three separate rides.  

The setup for his investigation involved creating a realistic model from a 3-D printer of a renal system and three different sized stones in the system.  Finding a patient with a kidney stone who is willing to ride a roller coaster while in pain is a tricky thing to do.  

Dr. Wartinger then obtained permission to ride Big Thunder Mountain Railroad roller coaster at Walt Disney World in Orlando for twenty trips per stone.  That would be sixty trips on a roller coaster at Disney World in the name of scientific research.  The 3-D model of the renal system, no doubt an odd site even at Disney, was cleverly concealed in a backpack. 

I don’t intend to question another man’s motives, but clearly Dr. Wartinger has obtained a new 3-D printer for his office and taken a nice trip to Disney World all paid for by someone else and in the name of science.  Clever.  Very clever.  

After sacrificing for the sake of medical research and riding sixty trips with the backpack, the research team found that regardless of the size of the stone, it passed 17% of the time in the front of the roller coaster and 64% of the time in the back of the roller coaster.  

A 64% chance of passing a stone riding in the back of a roller coaster?  Patients with kidney stones will line up for that.  

Anyone with kidney stones knows they are the great equalizer.  Women who have birthed babies and passed kidney stones almost always tell me childbirth is less painful.  Patients will have their own therapy routines when the pain starts.  Several cups of coffee and a beer.  Ride the lawn mower.  A liter of water and long walk.  Ride around in a British sports car (bad suspension) on streets with potholes.  They will do nearly anything to get a stone to pass.  

But now, thanks to this research,  Big Health Insurance Company (Big HIC) and government will get involved.  “You like your roller coaster? You’ll get to keep riding your roller coaster.”  Right.  

Since riding a roller coaster will be considered a form of treatment, the FDA will require each roller coaster to be certified as a “Renal Stone Extraction Device.”  This will require reams of documents on the data collected, protocols for how the patients will be treated, and a recertification process involving even more paperwork.  The FDA will need to personally inspect the ride, of course.  This increases costs. 

Big HIC will agree to contract for a very large amount of money per ride to treat their patients, but then begin denying any rides to their patients without a prior authorization (PA).  The PA will require a several pages document detailing what “conservative measures” the patient has tried to pass the stone first.  

Coffee?  Fluids?  A change in diet over several weeks?  Was a CT scan done to confirm at stone present?  Previous treatments used?  Any oral medications attempted?  More time.  More costs. 

Then, as part of the process, the Big HIC will insist that the patient first try the bumper cars, the kiddie roller coaster, and that interactive-moving-seat movie theater ride thing that can jar a tooth filling loose. No success?  Submit another form.  More time.  More costs.  

Finally, after an approval “within 72 hours of submission,” Big HIC will approve one trip around the coaster with a PA number.  Just one.  The appointment will be made and the patient will show up.  

The PA number will not have been forwarded to the ride operator who will then have to call and get the PA number to enter into the computer to authorize the ride.  Delays.  Increased costs.  Suffering patient.  

Because the roller coaster is now a “Renal Stone Extraction Device” individual privacy shells will need to be installed in the cars to maintain patient privacy while riding the coaster.  The patient will have to fill out several pages of forms prior to riding and get their little souvenir wrist ID bracelet.  They will be required to wear the little flimsy half gowns with the back side open revealing nearly as much of their buttocks as some of the teenage boys in line.  

After the ride the patient will be required to ride in a wheelchair back to their car to guarantee no falls.   Big HIC will have a team of inspectors who will show up at any time (demanding a ride, no doubt) to insure all policies are in place to their satisfaction.  More paperwork.  More costs.  

The roller coaster owners will then collect data on how successful their coasters are compared to the competition, how friendly their staff is to the patient, how few have complications during treatment, and how wonderfully beautiful their roller coasters are.  They will pay a consulting company to analyze the data and award them a “5-Star Rating” for excellence with their “Coaster Stone Treatment Team.”  Intense advertising will follow. 

More costs.  More paperwork.  

As a result, the kidney stone treatment ride will cost nearly $15,000 per ride, but the patient’s copay will only be an amount nearly the same as park admission before Big HIC got involved.

And the patient, who is the one suffering, has the least amount of voice in the entire process.  

That needs to change.   

Eric J. Littleton, M.D. (@DrEricLittleton) is a musician and Family Physician in Sevierville, TN.  Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com

EpiPens and EpiSpreadsheets

Michael Kaplan traveled from his home in Iowa to Clearwater, Florida to see his father.  It was August 2009 and his father, Sheldon Kaplan, had been diagnosed with a liver cancer.  

Sheldon Kaplan would live one more month before dying in his modest home where he and his wife lived out his unassuming retirement.  During their conversation his son shared that a friend’s child and his own mother in law’s life had been spared using an Epipen.  It probably brought a smile to the elder Kaplan’s face.  

Sheldon Kaplan was trained as an engineer at Northeastern University and worked at NASA in the 1960’s.  He then took a job working on a treatment for nerve agent poisonings with a military contractor and invented the ComboPen to be used in combat.  

He then had an idea to modify the ComboPen so that it could deliver a medicine that had been around for decades.  Epinephrine, or adrenaline, is naturally produced by the adrenal glands and triggers the “fight or flight” response humans feel when threatened or fearful.  It also is the life saving medication for allergic reactions to insect stings and certain foods. 

Epinephrine was discovered in 1901.  Placed in Sheldon Kaplan’s device, the Epipen was born and patent issued on June 28, 1977.  

As an employee of his company, he never made any financial gain from royalties for the EpiPen.  

But financial gain has been made in a very large way by the corporate owners of the patent.  

Recently Mylan, a pharmaceuticals company, announced that the EpiPen cost was increasing from $400 to $600.  This was a peculiar move by the company that owns 85% of the market for epinephrine pens in the United States.  Even more so given the fact that the EpiPen was $57 in 2007 when Mylan took over marketing of the product.  

It is estimated that the drug epinephrine in the EpiPen cost less than one dollar.  One dollar. 

Mylan quickly achieved something that is rare in our country nowadays.  They united Republicans, Democrats, Hillary Clinton, Donald Trump, Socialist pretending-to-be-Democrat Bernie Sanders, consumer watchdog groups, the American Medical Association, parent/actress Sarah Jessica Parker (ended a publicity campaign with Mylan) and angry parents who have ready access to social media.  

Mylan CEO Heather Bresch, the daughter of Democratic Senator Joe Manchin of West Virginia,  has tried to spin this media nightmare by saying it isn’t her company’s fault but simply the “broken system” of healthcare in America. Her company, just as I began to write this column, announced a very, very curious “generic version” of the EpiPen available for only $300.  It, the generic, is not different from the name brand EpiPen according to Mylan. 

Really?  You change the label on the same device and drop the price by half and yet still deliver a $1.00 drug in a device that costs $300?  Sounds like one of those “I’m sorry if I offended anybody” apologies that never really says “I was wrong.” 

This comes in the fortuitous timing of competitor Sanofi’s competing product recall in 2015 and Teva’s generic product approval denied by the FDA in March 2016.  Mylan’s 85% market share delivers 1.5 billion dollars and forty percent of their profit.  And that was before the competitors were conveniently eliminated.  

To be fair, Mylan has been generous with providing EpiPens for schools and athletic programs where students are involved.  That’s nice.  It looks good in the yearly corporate earnings report. 

The names Adrenalina WZF, Altellus, Anapen, Emerade, EpiPen, Fastjekt, FastPen, and Jext may be unfamiliar but are the competing epinephrine pen products in Europe.  One report lists a price of $75 for an over the counter device in France.  

I believe Heather Bresch is right.  It is the fault of the “broken system” of healthcare in America.  The “broken system” of healthcare seems to have its roots in one central axis and several supporting spokes:  a large, readily influenced by money, controlling governmental bureaucracy and the willing insurance, pharmaceutical, and hospital corporations who are eager to contribute to it.  

Physicians clearly are in that mix after sampling the taste of government money in the 1960’s and then becoming addicted to it.  Take government money, accept government control.  

But somewhere in America some man who was forced to purchase a health care insurance with a high deductible and no pharmacy benefits will need an EpiPen after multiple bee stings while he is working to support his family.  Or some child will have a food reaction while camping or at a friend’s house.  Both desperately will need the life saving one dollar’s worth of epinephrine.  Both may die because they didn’t have the $300 to get it nor the insurance to cover it. 

Sheldon Kaplan died shortly after his son traveled to see him.  His idea and work likely has saved hundreds of thousands of lives.  He died without making a dollar from it.  He died with the satisfaction that he had made a difference in this world.  

Now, on the other side of billions of dollars in sales, someone may die because access to an invention of a device, not the medicine, is limited by big government, big donors and big influence.  

The out of touch world of politicians, bureaucrats, lawyers and their ilk who have generous federal health insurance benefits in the Washington DC Beltway need to wake up to the reality of real America and worry about competition beyond their Nationals’ and Redskins’ teams.  

This country was made great on competition.  Competition, driven by the medical consumer, can fix a lot of the “broken healthcare” system.  

Rest in Peace, Mr. Kaplan. 

Eric J. Littleton, M.D. (@DrEricLittleton) is a musician and Family Physician in Sevierville, TN.  Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com

Roger Williams - Mr. Piano

I typed his name into the internet to see when he had died.  I hadn’t read much about him recently or heard of any new music.  Surely he must have passed. 

Not only was he not dead, but he was still touring.  He had five concerts that year.  Two in New York, two in Las Vegas, and one in Bristol, Tennessee.  Bristol, Tennessee?  In two days.  

It was April 2006.  My wife and son couldn’t go, so I ordered one ticket from the Paramount Theater’s website.  Downtown Bristol, on the Tennessee Side of Main Street.  

Roger Williams had been in the public eye playing the piano since his arrangement of “Autumn Leaves” grabbed the nation’s ear in 1955.  Born in 1924 in Omaha, Nebraska he served in the Navy in WWII, graduated Drake University and then Juilliard School of Music in New York.  

He had the classical training of a fine concert pianist, but he had more.  He had a way of hearing a song, processing the music, and then making it his own.  He mixed this with a quick wit and self-deprecating humor that made his concerts more than just a musical experience.  It was like you were in his living room.  

I found my way into downtown Bristol and into the the theater.  It was a full house and the only seats left were in the back.  A quick scan revealed I was likely the youngest person there. They, however, were a laughing and noisy group excited to be together to listen to one of their favorites.

The event was to celebrate a renovation of the the Paramount Theater and a new Baldwin Piano.  Roger Williams was a Steinway Artist, noted for playing twelve hour marathons at the Steinway Piano Store in New York for his birthdays.  He, however, had graciously agreed to play the new Baldwin for the event.  

The piano, resembling a small aircraft carrier, occupied most of the right of the stage.  His five piece band was on the left.  His bench was a plastic chair that was positioned exactly where his manager measured with a piece of wood for reference.  The tuner was finishing up his work.  

The house lights dimmed and Mr. Williams walked, actually shuffled, to the stage.  He smiled, waved, and sat down without moving the seat an inch.  He placed his hands to the piano in a most unorthodox and odd curve with his palms below the keys - and started to play.  

It was as if the new Baldwin had 176 keys instead of the standard 88.  As quick as lightning, but as light as a butterfly, his hands, still in the unorthodox position, went up and down the keyboard. The entire energy of the theater became focused on one stretch of black and white that he commanded, coerced, caressed and corralled.  It was breathtaking, and that was only the first few moments.  

Williams reputation began in Drake University where he was kicked out of a practice room for playing “Smoke Gets In Your Eyes.”  He could play the classics, but he found his love in playing more modern music from popular artists and movies.  Later on he played the classics Juilliard required, but that music became merely his tools for rearranging modern songs.  

The song he is most noted for, “Autumn Leaves,” has a particular right hand part that resembles, well, leaves falling.  It is exceedingly difficult to play, yet he made it look like a wave of the hand.  

He shared how he had played for every president since President Truman noting each one’s favorite (Ronald Reagan “The Impossible Dream”). He gave background history on “Born Free” and main theme music from “Star Wars” from his good friend John Williams (no relation). 

After intermission, he walked to the front of the stage to talk to the crowd about the songs they love.  Twenty-three songs were mentioned, a few followed with the comment “Oh, I haven’t played that in years.”  His band members, obviously old pros at this, wrote down the names of the songs.  Mr. Williams then took the listing of songs and played a medley of the twenty three pieces sewn together in a quilt of music.  

It was staggering.  I heard he had over ten thousand songs memorized, but to see it on display was just an unimaginable feat of memory.  He would search occasionally then pick up the scent of the song and the band would follow right along.  The crowd roared with approval.  I was nearly in tears.  

That was ten years ago.  It is still one of the most inspiring musical performances I have ever witnessed.  An eighty-one year old man mesmerizing a crowd with simply the music they grew up with played in his own style.  Some of it the notes, some of it the spaces between the notes, some of it a different velocity of the notes.  All of it - his.  

I have been graciously asked to play the piano for The Robert F. Thomas Foundation’s Evening of Elegance on August 13th at the Sevierville Event Center.  The Foundation supports many non-profit medical organizations and promotes better health for all of Sevier County residents.  I am honored, and humbled, to be asked to play and look forward to it with anticipation.  

I am not Roger Williams and wouldn’t even begin to pretend I can play one note like him.  But, I learned from him to take songs people know, internalize it, then try to make it my own.  That is the beauty of music.  It is the same notes on a page, but different music from the person.  

It will be two hours of complete musical relaxation for me, and I hope in some small way for the attendees of the event.  Nevertheless, if I can motivate, encourage, or interest a child to begin their own musical journey at the piano for a lifetime - that will be true success.  

Eric J. Littleton, M.D. (@DrEricLittleton) is a musician and Family Physician in Sevierville, TN.  Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com

Suing Mom

The television commercial will start off with a black screen and silence.  That alone will draw people to look up from their phones to see what happened to the mindless stream of noise that was previously coming from the digital sewer, sorry, television.  

“Has your immune system caused you unnecessary illnesses?” the deep voice similar to James Earl Jones will say as the string music in a minor key begins to waft in.  

“Well, maybe,” the viewer will say silently.    

Deep Voice:  “Have you noticed you seem to be more sensitive to things in your environment?”

“Well, now that I think about it.”

Deep Voice:  “Did you have to see a doctor, allergist, or be taken to the hospital for a reaction to something common around you?” the ad will continue.

“Hummmm, well, I do recall……”

Deep Voice:  “Did your MOTHER ever tell you to stop sucking your thumb or biting your nails?  Did she forcibly remove your thumb or other fingers from your mouth?  Did she embarrass you publicly in front of friends and family because of thumb sucking or nail biting?”

The phone has now been put down.  The viewer is all in.  

“Yeah! Yes, she did.  I still remember it in the middle of Big K in 1973.  Right in front of the other mothers she was talking to and my friends.  I was so embarrassed.  You know, she even put Bengay and tabasco sauce on my fingers to make me stop it!”

Deep Voice:  “You may be due compensation for your pain, suffering, public humiliation and emotional scarring from the actions of your mother.  Recent medical studies suggest that thumb sucking and nail biting may be potentially beneficial to your immune system. Yes, suing your mother may appear to be personal and harsh, but she can sue the pediatric societies for bad advice.  Tell her it’s nothing personal.  Call the law offices of Knott, Rich, Enuff and Associates at 1 (800) BAD-MOMS and speak to one of our client representatives to see if you qualify.  We make suing mom - easy.”

Is it really a stretch to think some law office will help people sue their mothers over child rearing?  Hardly, but neither is the thought that sucking the thumb and biting nails may actually be of benefit to the immune system.  

A study of over 1,000 children from New Zealand (Dunedin Multidisciplinary Health and Development Study) now in its fifth decade recently released information suggesting that sucking the thumb and biting the nails as a child may actually help by teaching the immune system to not be as sensitive to naturally occurring things in their environment.

Detailed questions about the participants were asked throughout the years and specifically included thumb sucking and nail biting questions at ages 5, 7, 9, and 11.  Skin testing for allergic responses was performed at ages 13 and 32.  The skin test looked for reactions to 40 substances.  

The results showed that children who either were thumb suckers or nail biters had 38 percent rate of reaction versus 49 percent for children without the habits.  

Furthermore, if the child was a thumb sucker and nail biter, the rate of reaction was even lower at 31 percent.  

So, should mothers now add another reason for feeling guilty about the failures of their life as a mother?  Mothers always worry about whether they raised their children well.  Telling them thumb sucking actually is good and battling with the child to stop it is bad - well, that might just cause some motherly consternation.  

Not quite.  A good rule of thumb (no pun intended) is to never jump all in for any new study.  If something is true, it will be so again and again.  That’s what truth does.  

Furthermore, positive allergy skin testing for these participants did not translate to definite hay fever, asthma or eczema which are commonly associated with allergies. In other words, just because the skin test was positive, did not mean their lives were impacted negatively as they matured. It was simply an observation of a test result.

It is another lovely example of everything measured isn’t everything real.  

Is it interesting?  Very much so.  We have begun seeing vast studies and research concerning the role of bacteria in our digestive system.  Everything from the risk of heart disease, depression, fatigue, muscle pain, and dementia are becoming a focus of study on the role of bacteria in our guts and how our diets, exposure, habits and antibiotic usage impacts it.  

So the bacteria under the nails and on the fingers isn’t bad?  Who knows?  There is a clear difference in the data, but what about the environment the child, and eventually adult, lives in?  What about choices of food?  Stress?  Antibiotic usage?  Probiotic (yogurt included) usage? Sports?  Pets and Animals?

The lawyers, of course, would love to make a case on this, as they frequently do with early suggestive data.  But suing mom?  Good luck with that.  

It’ll be a nail-biter of a case.  

Eric J. Littleton, M.D. (@DrEricLittleton) is a musician and Family Physician in Sevierville, TN.  Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com

Acupuncture and Other Things That Get Under the Skin

“I just don’t want to go to church anymore.”

That was the comment a young professional married woman said to me as she was discussing the details of her life during an office visit.  It surprised me as I knew she was active in her church.  

“It hurts so much.  They don’t mean to hurt, but they do.  They are just trying to make conversation.”

She went on to elaborate how others who know her, but aren’t her friends, ask on Sundays when “she is going to start having a family.”  

“They have no idea the roller coaster of emotions we have been through with fertility treatments, hopeful moments followed by anguishing tears of disappointment, and how all that can flood back when someone asks about it.  It just hurts too much and I don’t want to face it on Sundays.”

Her comments are very similar to other’s words and quiet battles of emotions, hormones, time tracking and near paranoia of anything that might impact the chance of conceiving.  It is a very stressful time for any couple and an innocent inquiry in a public place can nearly be unbearable.  

A study posted on ClinicalTrials.gov (a service of the U.S. National Institutes of Health) on June 30, 2016 reminded me of this conversation. Scientists and Physicians at Homerton University Hospital in the United Kingdom studied 127 women ages 23 to 43 on their initial or second round of in vitro fertilization (IVF) treatment.

IVF typically is the hormonal stimulation of eggs on the ovaries, the removal of the eggs, fertilization and then implantation back into the mother. The hormonal variations of the process are challenging enough even without the emotional overtones of the anticipation and apprehension.

The British study, however, added an interesting intervention into the process - acupuncture. Acupuncture is the insertion of small needles into the skin in very specific sites determined by centuries of Chinese (Eastern) practitioners.  It is commonly used to relieve pain and a variety of other ailments.  

Western medicine has warmed to the practice of acupuncture, but still doesn’t understand how it works.  How do you argue with someone who says their pain is better?

The women were divided into two groups, one group receiving four sessions of acupuncture during the IVF procedures and the other group receiving none.  

Keep in mind that these are British researchers and not some Acupuncture-R’-Us University in some lesser known Chinese city where acupuncture needles are made. The British don’t believe onions can make one cry until they have studied it.  They were, after all, the ones who decided to find out if salt was really as bad as we have believed for many years.  

The results were clearly interesting.  Of  the group treated with acupuncture there was a 46.2 percent success versus 21.7 percent for the untreated group.  Nevertheless, this must be viewed in its context.  

The researchers in critiquing their own work noted the study size is small and limited by the fact there is no placebo portion of the study.  How exactly to give a placebo acupuncture treatment isn’t clear.  

They also stated that “the additional attention paid to the acupuncture group as opposed to controls may have had a positive psychological influence.”  Translation - being able to spend time with the patient and show empathy and concern may have been the reason this group did better.  

Fascinating, isn’t it?  Two groups of women who desire to become pregnant undergo the same IVF treatments, but the group that is given more time and treatment with acupuncture has twice the success rate.  

Is this now a recommendation?  No, far from it.  The researchers suggested that acupuncture could be considered by treating physicians during IVF but that precautions of infection and bruising should be noted. “More studies are needed.”  Uh-huh.  Standard research closing line.  

Is it possible that the time spent listening to the hopeful mother enabled her to express things to a medical professional in a safe environment and not be worried about who would find out all her fears and worries?  Does our network of social media which wraps around us like a spider web in the yard cause some people going through deeply personal trials to feel even more lonely?  

Has the tap of simple "friending" reduced the sincere touch of friendship?  Do we have the ability to express our anxieties to each other without worrying if it will be digitally deployed an hour later?

Having a baby is terrifying enough.  I remember knowing a lot about pediatrics but had no clue about kids when my son was born (How do you wash this kid?).  Having anxiety about whether or not you can have a child, then the terror of how to feed, clothe, educate and discipline that child, is a great strain.  (That goes down significantly after the third child from what I have observed - “Where is that kid?”)

Maybe the acupuncture physically did something that is very challenging to measure by Western medicine machinery.  Fine - can’t argue with success.  But maybe it also hints at something deeper.  

Emotions.  Fears.  Thoughts.  Words.  Words we say to ourselves and words said to us.  They are powerful, powerful things and, yes, they impact us in ways we cannot measure on reported labs, but know in the real life.

We all fail at some point in this, but we all can try to remember to be kind tomorrow.  Every word kinder.  Everyday new.  

Eric J. Littleton, M.D. (@DrEricLittleton) is a musician and Family Physician in Sevierville, TN.  Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com

The Colors of Relaxation

I was in the very last class of Miss Ivy Hill’s kindergarten in Harriman.  She taught her classes for over thirty years in the upstairs classroom of her home.  The list of accomplishments of students who began their education under her tutelage is impressive.  She never married, but she had hundreds of “her children.”

Each graduate of her kindergarten has in some drawer, box or cedar chest, a large hard bound scrapbook as a reminder of Miss Ivy’s class.  She began each day with an assignment to color a picture from a nursery rhyme with specific instructions of which color to use, where to use that color, and which part to leave for her to complete.  Each week’s project occupies a single page. 

Some would listen to instructions and complete the task.  Others would learn that failure to listen resulted in a second chance to get it right.  The experienced Crayola Crayon artists knew the tricks to garner public praise - a heavy accented border then uniform coloring in the same direction while staying in the lines.  A whiff of a crayon can bring all of that back in an instant.  

It was an experienced educator’s way of teaching listening, focus, concentration, and achievement to a group of five year olds beginning their journey into education.  The scrapbook was an ingenious way to create a physical reminder of the class for the parents and student.  (Mine was better than my brother’s). 

I was reminded of this recently reading an article noting the recent major increase in the interest and sales of “adult coloring books.”  Thankfully that phrase simply means coloring books for adults and NOT coloring books NOT for children.  

The article noted sales of coloring books have increased in 2015 from 1 million to 12 million units.  Oddly, though, the writer took a negative opinion on the trend implying that, even though relaxing to many, coloring is a poor effort at therapy from stress, meditation and creativity.  

Really?  Poor example of creativity?  I just saw a painting of a solid color on canvas displayed in a prestigious museum as a work of brilliance.  Clearly I am not an art expert because it looks just like a single color painted on a canvas.  

The writer went on to say that the therapy, meditation and creativity were lacking because they did not involve professional counseling or guidance.  Really?  A person is not able to find something in life calming and relaxing without the aid of someone who guides it?  I disagree.  

Patients have brought their coloring books to my office delighted to show their work and glowing about how relaxing it is.  There is a sense of achievement with each page and a discussion about colors chosen and patterns created. 

It isn’t loud political arguments.  It isn’t heartbreaking news stories from around the world.  It isn’t a television pitchman wearing either the clothes of a minister or doctor trying to separate a person from their money for promises of a better life.  

It isn’t a digital screen with constantly moving banners.  It isn’t pop up ads rudely hijacking a screen.  It isn’t a low battery alert reminding one of a failure to properly charge last night.  

It isn’t the heartache of thinking, once again, about someone who isn’t there.  

It is just coloring.  Staying inside the lines.  The freedom to pick the color.  The choice of how to develop the pattern.  The uniqueness of the pencil or crayon.  The ability to focus on one thing, one thing only, and to allow everything of this world to be outside the brain and cease weighing down the heart.  

Is that not creativity?  The expression of one’s choices and decisions on a page in front of them?  The lines are there, but the choices are theirs.  

Is that not meditation?  Focusing on one thing, pushing aside the worries of the mind, and claiming a sense of peacefulness and achievement?  

Is that not art?  I’ve seen some harsh creations by artists making a religious statement. Surely the definition of art has already been broadened by now.  

I would even go one step further and suggest that it is an excellent exercise in maintaining cognitive function in older adults.  If I was a university medical professor seeing a leisurely five patients a week, I would propose a grant to study coloring and its effects on sustaining cognitive abilities and reducing memory decline in an aging population. It may actually measure the process.  

My mother began coloring last year.  The loss of my dad meant she had many decisions, adjustments, and changes in her life after sixty years years of having him to talk to about everything.  Now, with the close support of my older brother, she navigated the new life that widows have to learn on their own - rooted within their soul.  

Her coloring books provide a time of peacefulness when the brain seems to settle and focus on matters deeply within the mind.  Her completed pages are beautiful.  She even has one based on her favorite hymn and focuses on the peaceful reassurance of “It Is Well With My Soul” as she colors.  (Hymns - remember those? They are those wordy things in that book sitting in the pew in church)

It is an excellent trend and I hope it continues.  In a world of all things digital, the power of simple hand-eye coordination and expression of thought on a piece of paper is triumphing.  Again.  

Eric J. Littleton, M.D. (@DrEricLittleton) is a musician and Family Physician in Sevierville, TN.  Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com

Garlicked

My grandfather’s opinion of the kitchen in his house was quite simple. Everyone and everything should work in there except him.  

His concept of refilling his tea was to tap the rim of the nearly empty glass and say “Mary Ann!” My grandmother would then demonstrate moves that would make a linebacker going after a football proud, getting his glass, filling it and returning to her chair to continue her meal. 

So I was fascinated to find him sitting alone at the kitchen table one night actually preparing something to eat. Knife in hand, he was working on bulb looking thing I did not recognize. I was only twelve, not familiar with all the nuances of Western Tennessee cuisine, and was curious what would command such attention from my grandfather. 

(This was the same man who demonstrated the nuances of driving in West Tennessee - down the middle of the two lane road straddling the centerline until you see another driver.) 

“What’s that?” I asked. 

“Garlic.”

“Confused fellow,” I thought. “Garlic is a powder in a bottle that is used to make Funyuns (my favorite - dipped in peanut butter, of course) taste great.”

“It's called a clove,” he explained. “Ever had one?”

“No.”

“It's good for you. Good for your heart. You should try one,” he said as he peeled off a cashew shaped white portion of innocent looking garlic and laid it harmlessly in front of me on the table.

Not wanting to look cowardly to a man who seemed to have no fear, I sat down, took the subtle challenge to my history of finicky eating, and decided to try it. 

All of it. All at once. 

My first clue was the chuckling sound from my grandfather followed by the sound of the blood in my mouth and sinuses running for cover in the back of my skull. It seemed like someone had clamped a battery jumper cable to each of my nostrils, attached the other two clamps to a lightning generator in an old mad scientist movie, and then thrown the switch to the power. 

And the mad scientist was sitting there in front of me laughing like no man of his generation I had ever seen. Glad to make you laugh, Grandad, now how can I put this fire out?

He did this daily. A clove of raw garlic. It didn't even make him flinch. He lived another fifteen years after that with known heart disease and no statin cholesterol medications. 

I've often wondered where he got his information. Research seems to be agreeing with him now. 

A study in the Journal of Nutrition (Jan. 2016) performed at Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center revealed some very interesting findings about garlic.  

Matthew J. Budoff, MD, a lead researcher noted in his comments the benefits of garlic in reducing the accumulation of soft plaque and preventing the formation of new plaque in the arteries surrounding the heart.  

Atherosclerosis, or plaque, is the buildup of the lining of an artery which will slowly reduce the flow of blood over time.  In the coronary arteries this means a greater risk of heart attack. In the brain it means a greater risk of stroke (and dementia, some believe). 

The study consisted of 55 obese patients aged 45 to 70 who had high blood pressure, a poor lipid profile and elevated fasting sugar.  It measured plaque in the coronary arteries at the beginning.  The screening was conducted using Cardiac Computed Tomography Angiography (CCTA), a noninvasive imaging technology that accurately measures calcium deposits and plaque buildup in the arteries. Think of it as a very accurate CT scan. 

Part of the group was given placebo and the other portion of the group was given 2,400 mg of Aged Garlic Extract daily.  One year later a follow up scan was obtained.  The garlic had slowed total plaque accumulation by 80%,  reduced soft plaque, and showed regression for low-attenuation plaque.  

Regression means less blockage.  That means the one portion of the plaque actually improved over one year.  Improved is the key word. 

"We have completed four randomized studies, and they have led us to conclude that Aged Garlic Extract can help slow the progression of atherosclerosis and reverse the early stages of heart disease," said Dr. Budoff.  

This is significant in that the study actually demonstrated a change in the size of the build-up in the arteries and not simply improved some numbers on a blood test.  Niacin used to be a favorite supplement because in increased HDL (“good cholesterol”) numbers.  The American College of Cardiology stopped recommending niacin in 2013 as the improved numbers did not translate to improved heart conditions.  

There are other studies which have suggested the same outcome with garlic.  A few noted side effects of garlic are irritation of the stomach, stomach pain, possible bleeding disorders, and allergic reactions. 

Oh, and bad breath.  Even some of the “odorless” garlic pills still can have this.  

Will I recommend garlic to my patients?  Probably so.  This study has some very interesting results and is consistent with others prior to it.   

Will I take the garlic supplement myself?  Likely, as we all add plaque to our arteries as we age and my family clearly has a history of it.  

The problem for me will be the subtle sound of my grandfather’s laughter every time I open the bottle of garlic pills.  He never let me forget it.  

Eric J. Littleton, M.D. (@DrEricLittleton) is a Family Physician in Sevierville, TN.  His office is in the UT Regional Health Center Sevierville at 1130 Middle Creek Road. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com

Coming to a Mosquito Near You - Zika

My patient had a slight fever, muscle pains, red eyes and a very slight rash.  Nothing was exceedingly worrisome, until my next question. 

“Any recent travel?”

The answer was “yes” and revealed travel less than two days prior to one of the countries included in the CDC warning for the Zika virus.  That began a process that is now over four weeks old. 

I contacted the director of the regional health department who called her director in Nashville.  Within two hours we had the form and directions needed for collection of the blood and urine to test for the virus.  

The state has to authorize any testing for the Zika virus and limits the testing to a person with symptoms who has traveled, or had direct contact with someone who has traveled to a country in most of Latin America or the Caribbean.  The reason for this is there is one testing location available in the United States.  

One.  Only one. 

The advice given to me by the director was to advise my patient to stay away from areas with mosquitos.  As it was February and snowing a little outside, I assumed the mosquitos weren’t biting.  She told it would be a while before the test came back.  She wasn’t kidding. 

Most people with Zika have a very limited illness that quickly goes away.  The highly publicized concerns with this virus have been the strong, but not proven, suspected link to severe birth defects.  The infected mothers in the first two trimesters of pregnancy have a much greater chance of a baby born with microcephaly, a condition where the brain literally does not grow beyond the brainstem.  How, why, and how often this occurs is still unclear. 

The patient was kind and understanding and has recovered nicely.  It has been four weeks now and I just received the results of the test.  Four weeks.  The test was negative for Zika and positive for a paranoid doctor.  I’ll take that anyday. 

The other neurological condition seemingly associated with Zika is Guillain-Barré syndrome.  This occurs in a patient who has recently had the virus and their immune system turns against its own body attacking the neurological system.  Severe, temporary but potentially complete paralysis can occur lasting months and sometimes a lifetime.  

Imagine being completely healthy and within one week of a mild virus unable to walk, talk or possibly breath on your own all while completely able to think clearly.  That is Guillain-Barré. It is terrifying to ponder.  I saw this condition twice in Georgia and vividly remember both patients.  

The Zika virus is transmitted by mosquitos in Latin America and the Caribbean.  There have been 200 cases of Zika in the US all associated with a person who had traveled to the areas of concern.  There is a strong suspicion that Zika is sexually transmitted.  It is unclear how long that can be a concern after the infection.  

The virus is transmitted from an infected person to another by a mosquito biting the infected person then biting the next victim.  This is the same pattern of other tropical diseases such as yellow fever, dengue and malaria. 

Is Zika in tears, saliva and urine?  It has been detected, but it is unclear if that means it can be transmitted.  

How long is it possible to transmit Zika?  That is unclear.  

How big of a problem is this going to be this summer?  That, also, is unclear.  But from the sight of the mosquito bellying up to the buffet bar of my pasty white leg last weekend, we shall soon find out.  

Put yourself in the shoes of a young mother excited about her pregnancy in the first twenty-four weeks or so.  Then imagine Zika is being spread across your local region during the summer and that a simple mosquito bite might mean your baby is born with essentially no brain.  The potential for profound fear and worry is tremendous.  

Now imagine there is only one testing center in the United States and that is takes four weeks during the slow month of February to find out if a patient has Zika.  That is a very large problem that is being addressed currently, although no clear information on  how many centers will be available to test and who will perform it.  Eventually a rapid test could possibly be developed. 

We don’t have a treatment for Zika, yet, but it sure would be nice to know if it’s around.  

Potential areas of combating this virus will be vaccines (years), killing mosquitoes (spraying of communities and ridding of standing water) and a very controversial genetically engineered male mosquito which has shown success in Brazil already.  Genetically engineered anything is a controversial topic and the concern of unleashing a genetically altered mosquito versus the anxiety of having a child with a birth defect may make this a passionately debated topic in the news.

Well, at least passionately debated any other year when there isn’t a presidential election parade marching down the main street of the media coverage. 

If a person is traveling to Latin America or the Caribbean, it is advisable to read the CDC travel warnings.  Given the Summer Olympics are in Rio, Brazil this year, this could be a fascinating culmination of fear, freedom, public policy, personal independence, infection control, Olympic dreams, and genetic engineering all wrapped up into one summer story.  

Stay tuned.  There are many people from this region who travel regularly to areas of great need to perform wonderful ministries to people who love and appreciate it.  In less than twenty four hours, that traveler may be standing next to you in the store.  

(On a personal note, I want to wish a very fond farewell and express my deepest thanks to Jason Davis, Editor of The Mountain Press, who announced he is leaving the paper.  I spent many years with Jason on the sidelines of Sevier County’s football games always enjoying his quick smile, great eye for a picture, ready facts of the game and a flowing story to sum it up.  We had the unique privilege of being on the sidelines 11/11/2011 to witness the Herculean comeback win of Sevier County against Dobyns-Bennett from twenty eight points down in the second round of the playoffs.  That column was one of his very best among a collection of many great sports and news pieces.  Thank you, Jason, for giving me the opportunity to publish a column, something I never thought I would do.  It’s been a pleasure to work with you.)

Eric J. Littleton, M.D. (@DrEricLittleton) is a Family Physician in Sevierville, TN.  His office is in the UT Regional Health Center Sevierville at 1130 Middle Creek Road. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com

So Long, Dr. Burke

Dr. Curtis Burke is retiring from medicine. 

His letter was sent to his patients a few weeks ago.  Observing his past thirteen years of serving as a family physician in Sevierville he wrote “many things have changed in those years, including the very nature of the practice of medicine and my personal convictions about practicing medicine.”  

He continued. “I believe that the foundation of quality primary medical care is the unique, personal relationship between the patient and the physician.” 

Those words could not have been more accurately stated, nor backed with more credibility from the person who wrote them.  

Dr. Burke is in the same age range I am - circling 50 and wondering where the 40’s went.  He arrived in Sevierville a few years after I did in 2000.  He took the reigns of a full practice from Dr. Sonner and hit the ground running with thick charts and busy days. 

We shared many times in the hospital hallways, physician’s dictation room, and late nights making evening rounds.  We shared call which means he would care for my patients (and the other physicians in our group) during the night and on weekends.  

A lot is learned by observing how a physician writes his orders, thinks through problems, dictates a history and physical, and then a discharge summary.  My residency hammered this into us, no matter if it was 3 AM, the structure had to be good, assessment logical, and plan concise.  This is how you learn if a physician knows what he is doing.  

(I worked very hard in residency to craft my dictations so that they would be structured, numbered, indented, and full of pertinent facts.  This, of course, was a chore for the dear ladies in the transcription room in the belly of the hospital.  Therefore, I would occasionally dictate with a thick accent or with my best Elvis impersonation. They have not missed me.)

I quickly learned Dr. Burke was a great physician managing orders and paper charts, but came to appreciate that he has that hidden quality some physicians possess, and some don’t.  

When he looks at a patient he sees more than the problem.  He cares more than the moment.  He is there for the patient’s long term well-being.  

I saw him take nineteen admissions on one weekend (typical was six) and never say a negative word.  I have witnessed Dr. Burke serving the local hospital with countless hours on committees required to keep a hospital staff in order. He also served as Chief of Staff over all the physicians.  

It takes a physician to straighten out physician behaviour, and he did that, too.  With kindness.  

He was the quarterback on the physician team that beat the hospital team in a fund raising football game.  He was an automatic choice for the job, and rarely did a throw miss the mark.  His son, showing the same grit, made an interception for Sevier County in a high school game - while wearing a cast on his broken arm.  

But, according to his letter, he is leaving a profession he trained for the majority of his life, to now farm.  

What has happened to the practice of medicine that a solid, hard-working, talented and dedicated physician would walk away in the prime of his career? Who, or what, did this? 

Ironically, as I sat down to write my notes for this column, a five page letter from a Big Health Insurance Corporation (“Big HIC”) came across my desk.  Big HIC had determined that my patient needed a certain test and so they dispatched a technician and the machine to her house.  Oh, you her personal physician who has seen her for ten years, might like a copy of the result. Why, thank you, Big HIC.  

This was followed by another letter that has my “Report Card” in it.  Measurements of my average labs for diabetic patients, percentage of patients screened, percentage of patients getting colonoscopies, etc., for Big HIC were included.  

The data is always flawed.  Its collection is flawed.  Therefore, the results are flawed.  

I will show the Big HIC representative that a number of the patients on the list I have never even seen.  That is usually when the attractive female Big HIC representative will become uncomfortable and want to end the meeting.  I actually caused one to leave my office crying once.  My wife and my office manager made me apologize - which I did.  I did not apologize for standing on the facts, though.  

The relationship between a physician and patient has been irreparably wounded by the laws written by the government connected with the strings of money controlling puppet insurance companies.  We, the physicians, began allowing this to happen in the 1960’s.  There is enough blame to go around, but the laws create the field the game is played on.  

And so this community - already needing physicians - loses an excellent young one.  Dr. Burke’s ambition in life has been for the better health of his patients.  I am confident that his farm - neat rows, clean tools, vibrant plants - will provide healthy produce and, in a roundabout sort of way, continue contributing to the good health of those who consume it.  

Curtis, thank you for your devoted service to this community and your friendship to me.  I look forward to seeing your farm someday.  You will be missed. 

Eric J. Littleton, M.D. (@DrEricLittleton) is a musician and Family Physician in Sevierville, TN.  Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com

Coach Bell

“Coach Bell died today.”

Those were the words I shared with two of my best friends since childhood last week. 

Both friends are hard nosed football coaches who learned their craft in the backyard playing tackle football without helmets.  Both gave me my earliest lessons in concussion.  Both were moved to sadness and near tears as the sudden news swept their memories.  

Joel Fred Bell came to Harriman, Tennessee to be an assistant football coach after graduating from Carson Newman in the early 1980’s.  He was a man of unusual strength.  A strength not merely measured by weight lifting but of real strength from hard work, inner determination and faith.   

We were a pitiful team posting a 0-10 season when he arrived.  We made excuses.  We whined and complained.  We had a locker room full of mirrors and not enough sweat.  

He changed that.  He expanded our weight room.  He gave us individual workout schedules.  He held us accountable to being there or suffering the consequences:  answering to him and that look he could give.  

He never boasted about his football career.  He didn’t have to.  When Ricky Taylor became our first player to attempt 300 pounds on the bench press the team stood and watched as one of our greatest athletes nearly succeeded.  

When Ricky got up, Coach Bell slid in under the bar, took it in hand and - in a quick one, two, three, four, five, reps of the same 300 pounds - said more than we had ever heard from a coach.  

The clang of the weights was the only sound in the room until he quipped, “Back to work.”  We did.   

He taught us toughness.  His treatment plan for injuries in practice was “Get up and quit killin’ the grass.”  He thought we weren’t intense enough in one pre-game warm up so he got in the middle of the bull ring to call us out one by one.  I was called out first. I still have a scar on my chin from the forearm he gave me.  

We had great success my senior year from his determined motivation and intensity.  His defensive schemes had never been seen before at Harriman.  Our opponents were perplexed at the change of our usual garden variety defense into an intense swarm of players.  He had that effect on the field.  

That was over thirty years ago.  His greatest impact, though, still lives on.  

Young athletes, scholars and musicians begin to learn in their teens their natural gifts and talents.  It is the dedication and investment of coaches, teachers and parents that creates the environment where the young adult may develop those gifts by refining them with habits and determination.  Wasted talent breaks a mentor’s heart.  

Team first, me second.  Delayed gratification.  No complaining.  No excuses.  No whining.  Be accountable.  Be on time.  Be where you are supposed to be.  Do what you are supposed to do.  THINK!

The list of careers his players achieved is remarkable for a small town.  Nuclear engineer for the Navy.  Three football coaches, one of whom coached a state championship team.  US Marshall.  Award winning high school principal.  Engineer at Oak Ridge.  Accountant for the City of Atlanta. All good men and close friends.  

Great coaches build character before they ever build a team.  But great coaches must have character before they ever hope to build it in others.  

His love for us came from his love and devotion in his faith.  He left Harriman and to teach in his home of Cocke County and became a loving husband, father and grandfather.  His devotion to the Gideons, his church, family, friends and neighbors was demonstrated with a quick smile, genuine inquiry of interest, and a consistent “I’ll pray for you.”  

And you knew he didn’t just say it.  He did it.  

I will join my lifelong friends and fellow football players this Saturday to pay our respects to our coach and share our condolences to his family.  A coach who changed our view of ourselves, each other, and the world.  He showed us what it takes to overcome adversity, tough breaks, bad habits and bad attitude.  

A man who showed us how to not be afraid to express love.  A man who died far too young yet lived life fully.  

I have now witnessed the passing of my dad, father-in-law and coach in less than one year.  All three had great work ethic, character and deep faith.  I am trained by my profession to push back the inevitability of death as far as possible, but when it occurs, the memories, love and lessons must, and will, live on in my own life.   

Rest in peace, Coach.  

The Angry Voter

His blood pressure was up.  I soon found out why. 

It was a normal routine follow up visit for a chronic condition, but this time his blood pressure was higher than usual.  

“I’m angry,” he said.  “I’m upset and angry and I’m letting it get to me.”

I was preparing to ask more about the details when he spilled the whole story.  

“It’s just not fair.  Not fair at all.  It’s the dadgum presidential election and the people of Iowa, New Hampshire and South Carolina get to choose who we pick from.”

“Come again?” I asked.  

“The primaries!” he said emphatically.  “There were a blue million Republican candidates to start out with and now they are practically saying it is down to three.  That ain’t fair.  Not fair at all.  Who put them in charge of picking?”

He went on.  I wasn’t sure if this was helping or hurting his blood pressure.

“There’s a little over three hundred million people in this country.  There are three million people in Iowa, a little over a million in New Hampshire and nearly five million in South Carolina.  That’s nine million people getting to choose who the other two hundred ninety million vote for.”

“Furthermore,” he continued’ “Out of that, there were a hundred eighty-six thousand who voted, or caucused, whatever that it, in Iowa, five hundred thirty-eight thousand in New Hampshire, and seven hundred thirty-seven in South Carolina.  ‘Publicans, of course, I don’t care about the Democrats.”

“You memorized the numbers?” I asked.

“Yep, that’s how disgusted I am,” he replied.  

“How much are you watching this on TV?” 

“Too much, according to my wife.  I keep it on Fox News at night.  Their anchor ladies are much more attractive than CNN’s and certainly better looking than that liberal MSNBC.”

“Furthermore,” he continued, “why do we give these politicians and extra day to campaign, anyhow?  You know, Leap Year.  We give them an extra day of the year to campaign every four years.”

“So who do you wish was still in the race?” I asked.

“Christie.  Chris Christie.  Dadgum, I was really hoping he’d win.  I don’t know much about his politics, but he would have made it cool to be fat again. And Carly what’s-her-name, Ferrari, no, Fiorina, yeah, that’s it.  Loved her.  She looked just like Margaret Thatcher when she directly answered questions and always seemed to be the smart girl in a class of dumb boys.”

“Bush?” I asked.

“No, didn’t really get too excited about him.  Voting for him would be like ordering a bowl of oatmeal at the Shoney’s breakfast bar.  Maybe a good healthy choice, but not very exciting when you’re looking at the bacon, eggs, and ham.  You know, like Christie.”

“So, are you still going to vote?”

“Yes, I guess so,” he said. “You know I’d have voted for Dr. Carson if he was still in it.”

“He’s still in the race”

“He is?  Well he’s mighty quiet, then. I don’t know. You know physicians can be a moody, dictatorial, and hardly know a lick about finances.  No offense, of course.”

“None taken,” I replied.  

“So, I guess my choice is down to the U-Boys.”

“The what?” I asked.

“You know, they all have a ‘u’ in their names.  Trump, Cruz, or Rubio.  What is it with Republicans and having a ‘u’ in their name?  Poor old Kasich should change his name to Cusick so he can fit in. I don’t know if I can vote for Trump.  He sure has given the Republicans a good education, but his dang temper scares me.  If I could vote for Trump and Dr. Carson would carry the nuclear codes - I might could go for that.”

He went on.  “And those stupid debates.  You hardly learn anything about them.  They ought to sit the candidates down at a card table with a game of Monopoly, a banker, no moderator, then let them go at it.  We’d learn a lot more about the candidates through that than the stuffy debates.”

“You know you have a problem,” I said.

“Really?”

“Yes, it’s time for you to put down the remote.  Your blood pressure is up and your wife told me you are driving her crazy yelling at the TV,” I replied. “Maybe it’s time for you to watch Andy Griffith, or turn off the TV completely and read, get some exercise, and see if your blood pressure at home comes down.  If not, I’ll have to add another pill to your collection.”

“Okay.  You’re right.  I’ll turn it off.  Let’s give it a few months and I’ll follow my blood pressure at home.  I’ll miss Megan Kelly and even Judge Judy, but I don’t want another pill.”

“Alright,” I said.  “I’ll ask the ladies up front to make your appointment as you check out.”

“Great.  Just don’t make it the week of the Republican Convention.”

Eric J. Littleton, M.D. (@DrEricLittleton) is a Family Physician in Sevierville, TN.  His office is in the UT Regional Health Center Sevierville at 1130 Middle Creek Road. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com

The Digital Doctor Divide

There were stacks and stacks of old medical records from the 1950’s, 60’s and 70’s.  A seemingly endless commentary of the medical history of a small community in West Tennessee.  

All for perusing at my leisure. 

All of it a study in old school doctoring. 

There were one page hospital summaries. There were two line office visits (“S. Throat - Pen VK IM”) and an occasional dictated noted on adhesive paper placed in the chard.  A whopping five lines of dictation.  

There were a few bills.  Office visits were two to five dollars.  Hospital bills were less than a page and actually made sense of what was charged.  Insurance? It paid the nominal fee the doctor billed with no need of the levels and codes of today. 

Occasionally there was a smudge on the paper chart from the fountain pen ink.  The doctor’s fountain pens of that era were narrow and very firm so that the carbon paper in hospital charts could pick up the handwriting.  This would lead to smudges from the cuff of the shirt or coat.  

This was the kind of medicine where the doctor usually knew the patient since birth, had a schedule but it was only a rough estimate because anyone who walked in was seen and that usually meant forty to fifty patients a day (no quality surveys calling patients afterwards asking if the doctor was on time), the doctor would scribble or dictate a brief note to serve as a reminder for future reference, and nobody outside that medical office saw any patient’s medical record.  

See the patient, assess the patient, treat the patient, somehow without the aid of a cell phone, know when to go to the hospital for the patient.  

Move forward to current medicine. Seeing the patient has almost become an interruption to the data collection that is necessary for the billing, insurance and government.  (That’s until the insurance makes a decision to change coverage and the patient has to move on to a new physician.)

The focus, the thoughts, the line of thinking and listening must be constantly interrupted with a second thought process of entering it into a computer or being certain to collect enough data points to satisfy the chart auditor who will question the level of coding and billing sent to the insurance or government agency.  

It isn’t just chest pain.  In the language of ICD-10 coding it is R07.2 Precordial pain, however it could be R07.82 Intercostal pain, but could be R07.9 Chest pain, unspecified, but “that code is usually denied for lack of specificity so use R07.1.” Oh, okay, got it.  

Oh, wait, did I click on the right box for the test I was wanting…..?  Oh, I better look at the patient again so they think I’m not looking at the computer all the time while in the room with them.  I’ll get a bad review on the customer survey for not making eye contact and appearing engaged.

Is this having an impact on patient care?  In a recent survey of physicians published in 2015 in the Mayo Clinic Proceedings, physician burnout has clearly risen in the past year.  Overall the number of physicians reporting at least one symptom of burnout has risen from 45% to 54%.  

In a similar survey, Medscape, an online source of medical information, data and news for medical professionals, polled 15,800 physicians from 25 specialties.  Their data suggests that “physician burnout” (ICD-10 code Z73.0) has reached a critical level.  They defined burnout in the survey as “loss of enthusiasm for work, depersonalization, and a low sense of personal accomplishment.”

The top causes of burnout were noted by Medscape as bureaucratic tasks, working too many hours, and computerization.  However, in the 45-65 year old demographic, computerization was the leading cause of burnout, by far.  

The 45-65 year old physicians? They are the ones who usually have settled into a community and are the backbone of the medical system.  They don’t get too excited about new trends until they are dependable trends.  

Why is this?  First, I believe it is because physicians do not train to be data collectors or typists.  Sure, some level of documentation needs to be done to preserve continuity of care, reasoning for the treatment plan, discussion of risks and thoughts of alternative courses if needed, but that shouldn’t require a parallel thought process along with the medical thinking that is critical to getting a patient the best care.  

Do judges and lawyers do this? No, they have stenographers.  Do executive’s do this?  No, they have assistants.  

Second, most, but not all, electronic medical records are designed by computer programmers listening to physicians tell them what they need.  Some of the programs are better than others, but there is a world of difference in describing how to play a chord on the piano and actually playing it. The same goes in medicine. 

There is an enormous industry now based on the data collected on patients from vital signs (your insurance company knows if you are fat), to refill compliance (your insurance company knows if you are slack), and now even to the number of steps walked per day (your insurance company knows if you are lazy).  This isn’t going to change.

Always remember, politicians never give up power and companies never give up data.  They both crave more. 

Therefore, there is a vast and gaping canyon separating where we are in medicine and where we need to be with computerization.  Surprisingly, the solution for this is in its infancy, possibly pushed into the forefront by the Affordable Care Act’s requirement for Electronic Health Records.

First, physicians need to get back to being physicians.  They need to be able to listen, watch, look, interact, see subtle changes and think completely about the patient.  After all, it is about the patient. 

Second, scribes (assistants who accompany the doctor into the room) should be utilized to fluently know the computer system, know how to transcribe the doctor-patient encounter in real time and collect the data that is required in modern medicine. 

Third, it simply is time for better computerized medical records.  When I was in high school we would write programs in Basic Language on our sizzling fast Apple Macintosh computers.  I ventured into the visual programming of mathematical equations forming graphic designs.  It was cutting edge stuff to write for several days and see a colorful display of symmetrical lines as the result.  My friends caught on and I moved on to the Hi-Res graphic programming.  It took forever to write that code.  

Now, I can create graphic art on my iPad with a free app and moving a finger across the screen.  It is simple.  It is intuitive.  It allows me to focus on the art of design and not the netherworld of data architecture.  

Someone, somewhere, needs to design the same intuitive system for physicians to use in medical care.  Whoever that is deserves the financial windfall it will bring and the heartfelt appreciation of the physicians who might just not abandon their profession in their prime.

After all, it is the art of medicine, not the architecture of medicine.  

Eric J. Littleton, M.D. (@DrEricLittleton) is a Family Physician in Sevierville, TN.  His office is in the UT Regional Health Center Sevierville at 1130 Middle Creek Road. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com