Which is the greater good: to serve more people or to serve fewer ones better? To be more specific, in my current medical practice, I see a far greater number of patients than I did previously. Consequently, in a given day, I spend less time with each patient. I now can pretty much classify any new patient and their symptoms into one of a relatively small number of categories within the few couple of minutes of the encounter. Rapidly I can begin to triage their workup and select what diagnostic or therapeutic options I will employ. There is a limited number of clarifying questions I will ask. I try to do a little patient education regarding new drugs or unfamiliar diagnostic tests. If the patient has any questions I try to answer them. Then I speak some “transitioning” language so as to prepare the patient to be checked out by my staff. And I move on . . .

Many of our patients are poor or indigent. Many don’t have a lot of formal education. There’s a high incidence of smoking, obesity, diabetes, and sedentary lifestyles. It’s difficult to explain complex concepts of cardiac anatomy and disease pathophysiology to them. Usually if I try to engage them in the decision making process they just shrug and say “whatever you think, doc”. The most worrisome disorder - coronary artery disease - is highly prevalent and dangerous when undiagnosed. Yet the symptoms are often misleading or non-specific. The physical exam is nearly useless. But with a ten second CT scan that I might order, I can instantly see a “snapshot” of their cardiac risk that creates immediate direction for their therapy-or major reassurance when negative.

So what’s better? Should I spend more time establishing a relationship with these patients (most of whom, if new patients to the practice,are referred anyway by the primary providers for a consultation) or should I attempt to see a larger number so as to provide more of them with useful even potentially life-saving information and advice? I wonder . . .

Tags: obesity, technology, smoking

There are a lot of complications that result from obesity. Here are some that I observe on almost a daily basis:

• Obese people can’t exercise easily, which only compounds the difficulty in losing weight, since most studies have shown that exercise is a requisite for permanent successful weight control.
• It may prevent needed diagnostic studies--there are weight limits for the tables used in medical imaging, for example. Even if one is under the weight limit, the bigger the patient the worse the quality of the study--fat scatters X-rays and exacerbates artifacts.
• High blood pressure is difficult or impossible to control
• Diabetes is difficult or impossible to control
• Cholesterol levels are difficult or impossible to control
• Obese patients wind up taking lots of medicines, sometimes ten or fifteen or even twenty different agents-expensive!
• It promotes blood clots in the legs and lungs--potentially fatal
• Obesity increases the risk of heart disease independently of other risk factors
• It increases the risk of arthritis and early joint replacement
• Chronic low back pain and accelerated arthritis can lead to painkiller addiction

We live in a food toxic environment with many people never doing more than going from car to house and back to car--a recipe for ever-expanding waistlines and more of the above.

Tags: obesity