BYOG - bring your own greens

We discovered a way to eat healthy at our breakfast place, served by our friendly waitress, Bernie.  It’s a special resort-like feeling before a special work day!

How can a family physician promote wellness in our education system?

Questions:
How do we teach our children and youth in a way that also meet their true needs to be physically healthy, attentive and curious learners, social-emotionally aware and responsible citizens at home and at large?
How do I as a family physician facilitate a wellness conversation that might help us find some answers?
Possible solution I can provide:

To facilitate wellness groups for educators and parents to discuss topics such as:

What are the fundamental wellness messages?
How to teach wellness?
How to vaccinate against work burnout
What is addiction?
Understanding anxiety, depression, ADHD and autism spectrum.
How to teach our children to bring the wellness message home?

A cultural problem needs a cultural solution

Agree that we have a cultural problem – perhaps a real need for individual wellness mindset. Until the real need is met, a government is necessary to help promote that wellness mindset. I think this new mindset requires support from government, institutions, corporations and individual citizens.
Innovate ways to ensure self-management education that prevent as well as treat illnesses is part of every health care encounter.
Teach our children and youth in a way that also meet their true needs to be physically healthy, attentive and curious learners, social-emotionally aware and responsible citizens at home and at large.
Reach out to our private corporation to find ways to create an economy built on wellness rather than illness.
Use the power of marketing to profit responsibly from genuine solutions that meets the real needs rather than creating insatiable delusions and an endless stream of substitutes.
Celebrate disease preventing vegetables instead of disease-causing food-substitutes.
Make authentic conversations about the need for individual wellness a norm rather than a taboo.
Vote for individual wellness with every healthy meal eaten and every wellness conversation shared.
With gratitude.

I struggle to understand...

I struggle to understand the strong presence of marijuana producers at Family Medicine Forum.
I don’t pretend to know all the answer but suspect the following:
1. They paid someone to be present.
2. They hope to make that money back and then some by being present.

The implicit messages to our student and physician membership may be that:
They can be counted to provide fair and unbiased information. (In contrast to say tobacco or alcohol producers)
They are producing a sufficiently “safe” product and their strong presence at FMF do not need to be balanced with an equal representation from those who believe marijuana may be a public health hazard.

I also struggle to understand the breakfast choices of simple carbs at FMF for ~6000 of my esteemed fellow family physicians and leaders of wellness.

Again I have no certainty but suspect:

A breakfast in line with Canada Food Guide 2019 cost more and the FMF fee needed to be allocated to a more important function and was insufficient.

The implicit messages to our student and physician membership may be that:

1. Healthy breakfast is important but there are more important matters.
2. Healthy nutrition may prevent and improve chronic physical and mental conditions for patients and physicians alike but family physicians do not have to be a good role model; may eat poorly when there are more important things to do such as learning how to treat diseases caused largely by eating poorly.
I think there are many object of human addictions; but two prominent examples are to sugar and to narcotics.

My perspective on Cycle of Addiction

Sugar addiction:  Diabetes Type 2 Epidemic (30% of Ontarians are diabetic or prediabetic in 2016)

1. Real need: Whole Foods & appropriate physical activity
2. Craving from needs unmet: hunger
3. Easy substitute: simple carbohydrates
4. Brief relieve from hunger
5. Craving recurs from needs unmet: hunger
6. Go to 3.

I struggle to understand why in this days of Type 2 diabetes epidemic, such glucose beverages or a simple carbohydrate breakfasts still remain so popular;  and why as a society we don’t seem to be all that alarmed? We focus on treating A1C to target with medications to prevent organ damage; we provide even more phenomenal and technologically advanced care once the kidney fails; but seem so bored with issue of self-management that has the potential to prevent diabetes and potentially save the system $19500 per year per person ( times 3.9 million Ontarians).

Opioid addiction: Opioid Crisis (9000 opioid related death in Canada since 2016; 2066 apparent opioid death in 2018; most death in 30ish year olds; 17 people hospitalized for opioid poisonings in Canada each day  2017)

1. Real need: wholefood, appropriate physical activity, understanding role of pain and suffering, ability to pay attention to what is truly important and self-compassion
2. Craving from needs unmet: pain & suffering
3. Easy substitute: opioids
4. Brief relieve from pain & suffering
5. Craving recurs from needs unmet: pain & suffering
6. Go to 3.

Where does marijuana fit in for most users?  My present (please correct me if I am wrong) thinking is that absorbing it daily is not a true need like being nourished by 400 grams of non-starchy vegetables daily.

While I suspect there must be some studies by now demonstrating its safety and benefits eagerly and earnestly shared by producers of such a profitable product; I am hesitant to abandon all caution.  I read not all that long ago Valium was promoted as safe and a way to safeguard the virtues of college girls who might otherwise succumb to crumbling moral standards. More recently oxycodone was prophetically promoted as the “one to start with and the one to stay with”.
Certain glucose infused beverage also contained cocaine in the past; now it’s just effectively promoted as “the real thing”.

Three challenges of addictions are: 1. Suffering caused by a real need unmet. 2. Side effects of the substitutes.  3. Vulnerability to other harmful substitutes.
I believe much more conversations at an individual and system level about the true nature of addiction are needed.

My conversation with patients about addiction.

I am sometimes asked by patient to prescribe benzodiazepines, cannabis or opioids.

My approach is similar for all medications and substances with potential addiction properties.
1. I explain to them that no one (for emphasis of course, I point out the obvious) including myself is “immune” to addiction; that given the situation, anyone can become addicted. (They usually don’t believe me at this point)
2. I then explain to them the mechanism or cycle of addiction (fear of some suffering/ craving for end of it; seeking a quick relieve / a substitute solution; relieve from suffering; effect of quick solution begin to wear out; triggers the fear of suffer... then the cycle’s intensity compounds); I talk about some real life examples; and there is no lack of stories.  By now, they begin to see how addiction applies to them personally.
3. I then help them understand the lengthy list of other unintended and serious side effects of the substitute solution ( Eg.  Increased risk of falls in seniors; respiratory arrest, quality of life, etc.; I try to use examples most relevant to the individual.
4. I ask them and help them identify what it is their suffering the are hoping to alleviate.
5. I then offer them a real solution to their sufferings.  (Eg. my Basic Wellness Messages)
https://www.whatisharewithpatients.com/2019/02/a-family-physicians-basic-wellness.html?m=1
6. In my experience, above approach has resulted in various satisfactory outcomes; many embrace the knowledge and come to attend my wellness groups and learn more about the Basic Wellness Messages.

Some are disappointed but still respect the time spent and reasoning; none leaves with a quick fix or substitute solution without a clear understanding and an agreement on a solid plan to eliminate the substitute with the real solution.

In my opinion, the key ingredient of addiction management are:
1. That I take the time.
2. That I understand addiction is a common humanity. ( remove stigma and judgement of which self-judgement or shame is most intense)
3. That I explain the mechanism of addiction in a way that can be understood by the individual
4. That I help find a real solution to replace a substitute.
5. That a reasonable plan is agreed upon to safely wean off the substitutes and apply the real solution.
6. That I use the capacity and power of “self-management groups” to help patients begin personal transformations.

Thank you for reading!

Body Scan - A treatment for Insomnia

BODY SCAN FOR SLEEP
  • Begin by bringing your attention into your body, close your eyes.
  • Notice your body wherever you’re lying down, feeling the weight of your body on the floor.
  • Take a few deep breaths.
  • And as you take a deep breath, bring in more oxygen enlivening the body. And as you exhale, have a sense of relaxing more deeply.
  • You can notice your feet on the bed, notice the sensations of your feet touching the bed. The weight and pressure, vibration, heat.
  • You can notice your legs against the bed, pressure, pulsing, heaviness, lightness.
  • Notice your back against the bed.
  • Bring your attention into your stomach area. If your stomach is tense or tight, let it soften. Take a breath.
  • Notice your hands. Are your hands tense or tight. See if you can allow them to soften.
  • Notice your arms. Feel any sensation in your arms. Let your shoulders be soft.
  • Notice your neck and throat. Let them be soft. Relax.
  • Soften your jaw. Let your face and facial muscles be soft.
  • Then notice your whole body present.
  • Repeat.
(audio included in above link)

patient feedback

10 questions I’d like to ask each of my patient after each visit.

A score out of 100 may be informative of necessary changes to current interventions.

On scale of 1-10 please rate:

1. How good are you at paying attention to the present moment?
2. How much happiness in your life?
3. How well do you eat?
4. How well are you?
5. How responsible are you for the sufferings in your life?
6. How responsible are you for the happiness in your life?
7. How responsible are you for the wellness of your family?
8. How responsible are you for the wellness of your community?
9. How responsible are you for the wellness of the planet?
10. How much did you learn today?

What is synchronized care?

I recently read that there are four questions to address to create Synchronized Care.

So I thought I’ll give it a try and try to see how it might apply to my practice.

Of all the patients I could treat, which one should I treat now?

In my experience, patients that ask for help due to pain, suffering and illness are more open to new perspectives; there is no shortage of such patients.

Of all the processes that I could improve, which one should I improve first?

Maximize each engagement opportunity to treat presenting challenge as well as preventing future challenges through education. (I do that now)

What capacity do we need, where and when, now and in the future?
Educate patients in “physician-led self-management education groups” to increase capacity (just like in schools; I do that now.)

What is the impact of the “what if” scenarios on the quality, safety, accessibility and financial aspects of care?

What If there were a set of Basic Wellness Messages that everyone agreed on (Eg. Good posture, adequate fluid intake, adequate daily dose of disease preventing flavonoids from 400 grams of non-starchy vegetables, appropriate exercises and mindfulness training)
What if every youth leader, educator, healthcare provider, media CEO’s, celebrity, religious, corporate and government leaders were to be empowered and then commit to share these Basic Wellness Messages by role modeling?
What if every meal and each conversation reflect a new culture of wellness?

I think these are big asks.  I also don’t see why people won’t be interested for such a new culture. Wellness is what everyone wants. No one I know likes to suffer.  I think even if more opinion makers and leaders would decide to live and share a synchronized and common Basic Wellness Message; the impact on the healthcare system would be phenomenal.

How do I balance medicine and my personal life?

How do I balance medicine and my personal life?
Life is a series of moments.
Balanced life is a series of balanced moments.

A balanced moment is:

Balanced body with good posture, adequate fluids, nutrition(healthy daily dose of 8000 flavonoids from 400 grams of non-starchy vegetables) and exercises.

Balanced attention that is grounded to the moment  by moment experiences with gratitude, see things as they are with equanimity and put aside my own perspectives and make room for new ones with curiosity.

Balanced intention that addresses the needs of all of my oneness (my body, family, community, nature and all the rest) as informed by each moment.
Most of all just love life with all its messiness and be at some level totally ok with things just the way it is, how it is and where it is.

Why I look my patients in their eyes


I know that some patients ( in family practice or the ER ) present with concerns that may seem trivial to a medical provider and request for unnecessary investigations.  I think that is because they lack knowledge and are genuinely anxious or scared. I can’t see any other reason why anyone will wait in ER and watch CP24 for 5 hours straight on a Saturday evening in the company of a roomful of sick people; or demand to ingest some substances they don’t understand or go through the trouble to be irradiated.  I feel that one solution to our growing healthcare challenge is to seize every opportunity and educate. To share a simple message. To “share” with kindness rather than blame. To help patients see the personal relevance. To encourage them to share what they learn with their family.

Why I look my patients in the eyes:

I want them to know I care.
I want to hear what they say.
I want to feel what they don’t say
I want them to know and feel they are heard.
I want them to understand when I tell them the reason they catch colds so easily is due to their challenged immune system from poor nutrition (not getting the 8000 disease preventing flavonoids in the daily dose of 400 grams of non-starchy vegetables), chronic stress (inability to manage thought contents; to stay mostly in the present rather than in the past regrets/shame or future hope/fear ) and poor life balance (inability to prioritize what’s important in life)
I want them to understand when I tell them that their challenged immune system is the cause of a legion of pain, suffering and illness awaiting them: chronic physical conditions (Infections, allergies, autoimmune disorders, Inflammations, Intestinal conditions, Obesity, Diabetes, Hypertension, High cholesterol, Heart attacks, Strokes, Kidney failures, Arthritis, Neurological conditions, Eye conditions, Memory loss, etc. ) and chronic mental conditions (childhood attention deficit disorders, behaviour disorders, eating disorders, anxiety, depression, etc.)
I want them to understand that their poor life habits will not only hurt them personally but also the people they care about.
I want them to understand that most diseases can be managed if not prevented by a set of Basic Wellness Messages practiced diligently.
I want them to understand that pain, suffering and sickness are all way in which the body informs me when my mind is inattentive to the Basic Wellness Messages.
I want them to know that I can help them interpret the real cause of their pain, suffering or sickness and the real solutions.
I want them to understand the real solution is usually not a test.
I want them to understand the real solution is usually not a pill.
I want them to understand the real solution is usually not a device.
I want them to understand the real solution is usually not a book, a supplement or yet another “snake oil”
I want them to understand the real solution is usually not a therapist.
I want them to understand the real solution is mostly within their own control.
I want them to pay attention when I share with them the importance of a daily dose of 400 grams of non-starchy vegetables, daily Breath Awareness meditation as a way of training the mind and have authentic conversations to gain perspectives of gratitude and what is truly important in life.
I want them to understand that while there may seem to be a great many thing in the world that is out of their control; they do have higher degree of control over what they eat, think and prioritize in life. ( in that order :)
I want them to understand that they can vote for wellness in society with every meal they eat and every present moment lived and every wellness conversation enjoyed.
I want them to understand that they can be a powerful changemaker to bring about a blissful world for the future generations.

Letter to Honorable, Mr. Doug Ford and Ms. Elliot on personal and population wellness

Dear Honorable, Mr. Doug Ford and Minister Ms. Elliot,

On behalf of my patients and myself I am expressing gratitude for the arbitration result.  It means I can continue to enjoy the innovative opportunities the FHO model makes possible, to eliminate modifiable risk factors using “Physician-led self-management education and support groups” and to promote population health through collaboration with local community organizations.

In his book “The beautiful bailout - how a social innovations scale-up will solve government’s priciest problems”, Shaun Loney, an Ashoka fellow, shares his inspiring message of social enterprises.  He demonstrated his success of using one social need to meet another social need.

He got me thinking about the potential cost savings of running “physician-led self-management education group” on Type 2 diabetes alone!
According to Mr. Loney, the annual healthcare cost per Canadian = $6604
Annual health care cost per Canadian with diabetes = $26416
Difference per year = $19812

 In 2016, more than 1.6 million people in Ontario are living with diabetes, and another 2.3 million people have prediabetes.
Ontario population = 12,764,195
Prevalence of diabetes and prediabetes = 30%
In the case of Ajax Harwood Clinic:
Patient population = 6000
Ajax Harwood Clinic population with diabetes or prediabetes = 1800
Average household size in Ontario = 2.9
Cost saving per year  = 1800 x $19812 = $35,661,600
Downstream savings is 2.9 fold = $103,418,640
(assuming the changed dietary habit positively affects other member of each household)
The physician-led self-management education groups is paid by existing payment model and does not require any other investments.

The potential savings by empowering patients in my patient population to take action for wellness to prevent and manage type 2 diabetes alone is $103,418,640. (In a patient population 
of 6000; my apologies for making many assumptions for the sake of making a point.  Of course, I’d be grateful if someone with the know how would do the proper math and correct me.)

The collateral benefits of preventing and managing a chronic physical condition such as type 2 diabetes using an integrative approach will also include decreased chronic mental conditions, increased quality of life and increased economic productivity from a physically and mentally healthier workforce.
I would be grateful for a new culture of wellness.  A self-empowered and wellness mindset.  I believe this paradigm shift is achievable and just requires personal and population wellness conversations at every patient-encounter with healthcare providers, in every school classroom, in social media, in traditional media, inside private corporate boardrooms and government meetings.   In doing so, we can generate phenomenal cost savings that can pay for better access, better technology and most importantly an even more compassionate publically accessible and sustainable healthcare for future generations.
I have started doing my part as a citizen by making sure I eat 400 grams of non-starchy vegetables per day and learning to be truly grateful for the privilege of being a Canadian.  As a physician, I share these basic wellness messages at every single patient encounter and in groups.  I vote for Wellness with each and every meal I eat and every wellness conversation I partake.  


Thank you!

How to help seniors eliminate benzodiazepines, opioids and other medications

I read the “American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults” and thought it might be useful to share some perspectives that were helpful to my senior patients.

Gladys was referred to me by one of my other senior patient.  She had moved to Ajax and placed herself on another family doc’s waitlist.  She finally got a call to meet the new physician; and was told after their first meeting that she can’t be accepted due to her need for sleeping pills.
I remember in our first meeting, Gladys was wearing makeup, thin, slightly tremulous, anxious and earnest.
I think after I finally assured her that I will do my best to look after her; her attention switched from the fear of rejection to the fear of running out of her sleeping pills.
She explained to me that she has been on her sleeping pills for well over 20 years and can sleep only a little even with the meds; and that she must have them or she can’t sleep at all.  I explained to her the nature of addiction; that there is a real need, a substitute solution and a real solution.
I explained to her the real need is an increased ability to pay attention.  An increased ability to pay attention will allow her to redirect her attention from her incessant thoughts to other aspect of her moment by moment experience, such as tactile sensation. I explained that such increased ability will not only help her quiet her thoughts but also help her with day time anxiety.
I then explained to her that benzodiazepines, like all “depressive” substances (alcohol, cannabinoids, opioids, OTC sleep aids) are all substitutes.  I then explained to her the problems with substitutes are three fold; real needs unmet, mental suffering associated with the 4c’s of addiction, the host of side effects (relevant examples useful for illustration are plentiful) of the substitutes.
Finally I explained to her that I can show her mental exercises that will improve her attention.  She repeatedly expressed her doubts but when I pointed out to her that things weren’t really satisfactory even with the pills; she hesitantly agreed to listen and to give it a try.  I showed her how to BAM (Breath Awareness meditation).
Within 2 weeks, she was sleeping without benzodiazepines or any seditions.  I also encouraged her to increase non-starchy vegetable intake towards 400 grams per day.  In a short time, she quit her antidepressants and began volunteering at a nursing home. I should also mention that Gladys was 76 years old.
This strategy has worked in my practice over and over again. No patient leaves with a script for any habit forming substance without a “heart to heart” conversation on diet and addiction.  I have not had to start anyone on benzodiazepine for a long time.

One of my patient brought her elderly mom, Edith, to see me for the first time.  Edith was a 87 year old lady sitting in a wheelchair. Edith used to live in the city independently but had to move in with her daughter recently due to the loss of power in her left leg and intractable sciatica.  She had already seen the neurosurgeon and was told that there was no surgical solution. She had been to ER on several occasions. At her last ER visit, her hydromorphone dose was tittered up. She can no longer walk, lost her appetite, became constipated, continue to suffer intolerable pain, felt generally weaker and a sense of hopelessness.  She was placed on waitlist for bed in a chronic care facility.
I explained to her the importance of getting off the opioids; and for her to discover core muscle actions that restores sensations to her left leg.  I explained to her ways to use increased intra-abdominal pressures to stretch para-lumbar muscles and decompress the lumbar spine. I asked her to begin these exercises while laying in bed.  She was fortunate to have her dedicated daughter’s support. (Her daughter learnt to manage her own fibromyalgia using mindfulness-based practices and uses no analgesics.)
Within a month, by following those instructions, she stopped using her wheelchair, hydromorphone and laxatives.  Her appetite was restored and her pain managed with mindful posture core muscle engagements.

Then there is Anna, a friend’s elderly mother, who began living in a retirement home following her coronary bypass surgery.  I was asked to help. Post-op, she was unable to eat, losing weight, weak, unable to get out of bed, diapered and depressed and wanting to die.  Her sulphonyluria, DDP4 and metformin were eliminated and replaced with basal insulin and a diet containing 5 oz of non-starchy vegetables three times a day.  Now her am glucose is 7.2-8.4 based on glucose logs faxed weekly to my office. I can always tell when she is off her diet. Even though the nutritional order is in her chart, implementation by her retirement home is inconsistent.  I think I will give her director of home a call and share the “Effect of eating vegetables before carbohydrates on glucose excursions in patients with type 2 diabetes” - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3882489/

Anna is now waking with a walker.  She know to keep her back nice and straight, chest out and cores engaged.  She only uses the walker for balance.

She had some transient SVT post-CABG.  She is now off amiodarone, NOAC, furosemide, potassium and magnesium.

She is also off her quetiapine, mirtazapine and pantoprazole.  

She now no longer asking Jesus to take her;  instead she loves life, lives one moment at a time, says her rosaries every night and asks God to send an angel to sleep with her.  She now sleeps soundly every night till the morning. She tells me how much she enjoys her family and last night’s Valentine’s dinner at the retirement home.

Disclaimer:

To respect patient privacy, all names are changed.
These are specific examples which may or may not apply to you.  Please only change or discontinue medication under guidance of your own physician.





The use and misuse of medications

I read the following news about drug marketing.

“Boston – Employees at a drug company accused of bribing doctors rapped and danced around a person dressed as a bottle of the highly addictive fentanyl spray in a video meant to motivate sales reps to push the drug.”

I think selling, promotion, marketing are as old as civilization.
So in this case, I see there is the brilliant producer of a new product Fentanyl spray.  That has presumably been approved by some knowledgeable governing body for certain indications. Say for example, palliative pain control.
There is the very talented promoter who earns his salary for the sole purpose of directing the attention of the prescriber to the new product.
There is also the licensed and highly experienced prescriber whose job is to relieve pain and suffering and foremost of all do no harm.  This may be translated to prescribe as per approved indications or off label if necessary.
Finally there is the patient who trust the system, the prescriber, the product and the experience of being on the product.  The patient are at times known to become hyper-compliant with the product and persuade the prescriber to prescribe more.
Now things goes horribly wrong - Opioid crisis.
Who is really responsible?
1. The producer of a new product
2. The knowledgeable governing body
3. The talented promoter
4. The licensed and highly experienced prescriber
5. The patient
The takeaway for me is that perhaps not only the promoters need to bear some responsibility to be aware that every tool can be misused.  
I am grateful for innovations.
If I am dying from cancer I’d be grateful if my prescriber were sufficiently knowledgeable to help me with the best tools.  If I suffer back pain from being sedentary and poor nutrition and didn’t know better, I’d be grateful if my prescriber took the time to teach me self-management instead of giving me a way to avoid addressing the real cause of my pain and suffering by prescribing me a quick fix.

If I suffer pre-diabetes or type 2 diabetes (30% of Ontarians) due to my average Canadian diet and didn’t want to, or think I am just too busy to know better, I’d be grateful if my prescriber took lots of time to share with me that there are great many more pain, sufferings and illness that lays await for me unless I change my ways.
I’d be grateful to the producer, regulator and promoters of diabetic medications to direct some of their resources and creative energy to remind my prescriber of the importance patient self-management in the care of diabetes; and that in many cases by following well publicized dietary guidelines the need for medications can be decreased or sometimes eliminated.  Finally, I’d be grateful to the government elected by the people for the people to make it known to me and constantly remind me that it is foremost my duty as a citizen, a patient, a son, a brother, a father, a teacher and a leader to be be a role model of wellness for everyone around me.




What is happiness, complacency and oneness

I am grateful for my life and my life as a family physician. I tell my patients happiness are transient moments and so are sadness. T...