drmargaret

Medical doctors used to evaluate patients by using clinical medicine not laboratory medicine. They looked at people. They touched people. They asked them questions. They went to their homes. They talked to their family members. Moreover they lived in their communities and saw them on a day to day basis. Things were not sophisticated. The equipment was simple. There was a simple black bag that held most supplies. It could be taken from one house to another and back to the office.

Pharmaceutical drugs were created primarily from plants, and molds. They were also not sophisticated. There were a few medicines being worked on by creating small inert batches of bateria to stimulate the immune system to create antibodies to the infections. There were some other medicines being created by combining chemicals or compounding to form liquids or pastes.

This wasn’t so long ago. It was within my lifetime. I’m going to be 50 this year. I’m talking about this because it’s important to remember these practices. These are valuable and shouldn’t be lost over time.

I’ve worked with internists as a psychologist in my professional life. Few of the internists are trained in clinical medicine anymore. When I started in practice all were. My adoptive father was trained in compounding pharmacy and materia medica (the creation of medicine from plants) few are trained in that now, it’s a subspecialty in pharmacy. So over the years I’ve picked up clinical medicine information and information on plants used as medicine. I understand how medications are used and how they are to be used. I understand pharmacy labels. I can use this information to explain things to my patients and to the people I evaluate.

A young adult came into my office. Illness is written all over the body. It’s written on the face and hands. It shows up in the movements. It impacts psychological functioning. It impacts people differently if they are young or old. It impacts women differently if they are men or women. It impcts them differently if they are of different ethnicities. Science is just beginning to understand this, but clinical medicine has know this for decades.

This young adult was an African American woman. She was morbidly obese. She had problems sitting in the chair because it had arms. She has a bad diet. I don’t need her to tell me that I just need to look at her skin, hair, hands and finger nails. They all tell me. She has malnutrition and probable diabetes. She is 19. Her skin is pale at the lips, the eye lids and her gums are red. She has cuts in the corners of her mouth. Her nails have longitudinal beading like candle wax. Although she is overweight, she is starving of nutrients. She has massive signs of vitamin B complex deficiencies, signs of anemia, and signs of diabetes. She has had these for months if not years. Vegetables in her diet would improve these problems. She isn’t eating them or she has a substantial stomach problem. So I ask her what her medical problems are. She tells me she has diabetes. She is tired all the time. She is depressed. She can’t focus or concentrate. No one has diagnosed malnutrition. Her blood sugar is 250 on medication.

I’m not allowed to treat or advise when I evaluate. So I can only do it here. There are basic concepts of eating food and drinking water. Drinking water means consuming 6 to 8 glasses of fluid per day. To drink less means the body becomes dehydrated. The bowel and the kidneys do not work right. The body works harder. The heart pumps against a load causing a higher level of distolic pressure (the low blood pressure number when the heart rests between beats). Toxins build up and constipation can develop as a result of lack of fluid in the bowel. The skin becomes dry, cracks and infection can set in. Eyes become dry and vision blurs. Urine concentrates providing a haven for bacteria in the bladder and kidneys. The lungs become dry and fail to have adequate secretions increasing the risk of infection and pneumonia. Asthma or COPD, if present, worsens. As fluid continues to decrease the cells in the body dry out from fluids and clinical dehydration sets in. Subtle changes in mental status start to show up. Personality changes with increasing irritability, lethargy, hyperreflexia, progressing to seizures and eventually coma. Impaired thirst is often noted by people as they become increasingly dehydrated. Temperature may increase prior to seizures. Mortality can be quite high. It’s worsened by pharmaceuticals that add to dehydration or increase urinary output. In mildly dehydrated individuals (those drinking 2 to 3 glasses of water per day) it’s easy to go to a moderately dehydrated state and not have any realization. Laboratory medical doctors may miss the clinical signs of dehydration and simply add additional medications to combat the worsening medical illnesses secondary to dehydration.

In addition to drinking water it’s important to eat food. Food consists of fruit, vegetables, meat or some form of protein, and may include dairy products. There are people who do not eat food. They consume lots of calories from sugar or simple carbohydrates. But they fail to eat food over the course of a day. Rice, bread, tortillas, potatoes, carrots, corn, alcohol (even beer or wine), all convert to sugar and if you have problems with blood sugar (as in diabetes) you can’t eat them if your blood sugar is too high. Normal blood sugar runs between 90 and 120. There is no such thing as an individual blood sugar reading. I’ve had people tell me what “normal” is for them. There is just normal and abnormal. If you are over 120 you are too high. My mother was a diabetic. She died of complications of diabetes. Her complication was a heart attack. It is a common complication of diabetes. She would point to her diabeteic diet card and show me that it allowed her to eat bread. Yes it does. One slice. Not a loaf. Not when your blood sugar is 200. If your blood sugar is between 90 and 120 you can have a slice of bread. It’s better to have it when it’s 90 than when it’s 120. My blood sugar hasn’t seen 90 in 2 years. To lower my risk of a second heart attack I’m reducing my blood sugar and trying to keep it around 100. It runs 110. There is a strong family history of diabetes. The more I can control my blood sugar now the less risk I will have. I already have the lines in my fingers. I already have diabetic neuropathy and retinopathy. I just haven’t got diabetes. I just have all the clinical not the laboratory signs of diabetes. So I can recognize 8 to 10 years in advance that I am diabetic. It gives me lots of time to control the disease before I will ever need medication. Medication will be late in the disease process. That’s true with lots of clinical medicine. Clinical symptoms show up often before laboratory symptoms show up. The reason is because the criteria for the recognition of a disease in clinical medicine is different than for laboratory medicine.

Clinical medicine looks at people and notices details. Fine details. It’s used (or is supposed to be used) in the television program House. You shake hands with someone. You feel the hand. Is it warm or cold? Is it damp or dry? Is it soft or calloused? Is there a tremor? What does it look like? What do the nails look like? What does the palm look like? What is the color of their skin? Then you move to the face. Do they look at you? Do they make eye contact? Are their eyes clear? Are their eye lids open, not pale, even, not runny or reddened? Are their lips pale, made up, are their teeth in place, are their cuts in the corners of their mouth? Is their hair combed? Are they wearing a wig? Are they losing hair? Are there discolorations on their face or neck? How do they move? You get the idea. It’s details.

I met a woman with a large brown spot on her face. It was indented. I had asked her her medical history. She hadn’t mentioned it. It was basal cell cancer. Brown pigmented, pinkish, mottled in places. It would need a biopsy to confirm the diagnosis. It’s slow growing, so there is not a rush for a diagnosis. There were other things wrong with her that led me to suspect she had cancer besides the spot on her face. She had more problems besides cancer. I asked her if she had seen a skin doctor for her face. The skin thing was obvious. She had seen lots of specialists. She hadn’t mentioned it. She then told me it was cancer. She had had it removed a couple of years ago. It was basal cell. It had come back. She hadn’t returned to the doctor to have it removed again. Her doctor hadn’t noticed it. He doesn’t look at her when she comes in. She was surprised I had mentioned it. She wasn’t expecting me to actually “see” her.

Clinical medicine meant evaluating people in their community, often in their home, certainly in their language. Los Angeles is home to people who speak lots of languages. I no longer see people in their homes or at their bedsides. I see people with interpreters. I do attempt to communicate with people directly in their native language whenever possible. Even if it is one or two words it changes the evaluation. It changes it in one or two ways. It either means to the person being evaluated that I speak their langauge and that they should work with me that I am one of them not against them or it means that I know everything that has gone on between them and the interpreter and they must now tell the truth. I had a depressed Hatian woman who after asking me my name the third time I said “je suis Margarite.” She then said several sentences in French all happy. We talked about my trip to Paris and to the Carribean. She talked about missing her culture and speaking French. She was not depressed for 5 minutes out of an hour. It was a pleasure to see her like that. I had an Armenian woman I counted to four for in Armenian. Her jaw dropped open. She stared at me. She had been attempting to malinger up to that point. She asked where I was from. I said California. She asked about where my family was from and I said Ireland, from Cork. She then did very well continuing to look perplexed. She just wouldn’t fake badly for someone who spoke Armenian, even if it was just a few words. The same is true with Japanese, Vietnamese, Korean, Russian, even Gypsy sometimes. I’m fairly fluent in Spanish and in Los Angeles speaking Spanish is becoming expected. I have Spanish speaking relatives. I have an ethnically diverse family. That’s not expected. I have relatives that are Cuban, Portugese, Philipino, and African American. My immediate family is racially diverse as is my extended family. I was exposed to multiple languages and ethnic groups as a child.

When I was going to people’s homes to do evaluations I could see how they lived. I could see what they ate. I could see what they had in their refridgerators or freezers or on their counters. I could see how they prepared food. I could see how they kept their house. I could see how they kept their medications. I could see how they organized their lives. I could see how they interacted with their family or extended family and pets. I could see how they kept poisons, dangerous materials, or hazardous equipment. I could see where they lived.

I went to my brother’s house in Sonoma. He has had three heart attacks and a stroke. He is 18 months older than me. He has diabetes, neuropathy, asthma, and arthritis. He smokes. He doesn’t exercise all that much. He has a poor diet and uses insulin. Sonoma has some of the best food in the world. I cooked for him. I had him test his “uncontrollable” blood sugar before and after the meal. We had vegetables and fish. I made a desert out of yoghurt cheese and berries. His blood sugar at the start of dinner was 145. At the end of dinner it was 150. Within an hour it was 155 and within 2 hours it was back to 145. There were no sugars in the meal apart from a couple of berries. These were well managed by his medication. The food was great. He watched me cook it. I showed him his blood sugar was not “uncontrollable.” There was a lot of food. It was mainly vegetables. There was 3 ounces of fish per person. The next morning he wanted toast. I had him test his blood sugar before and after eating toast. One slice. He started at 130 before. 150 after. Within an hour it was at 200. after 2 hours it was at 220 and he didn’t feel well. He used insulin to bring his sugar down. The correlation was clear. Eating bread, even a single slice caused his blood sugar to skyrocket over several hours. Despite this, my sister in law tells me that he still decides to eat bread. That’s his choice. He still smokes. Despite asthma, despite heart disease. That’s also his choice. Both will shorten his life. He just can’t tell me he doesn’t know that.

Adults get to make bad decisions about their health. Clinical medicine allows psychologists to show people early the impact of their decisions. It doesn’t make people change their decisions. It may help influence them. People still can choose. Psychologists can provide information, motivation strategies, assistance in keeping to schedules or strategies, or help with compliance. We can lead people. We can’t force them.

Children watch adults and have a lot of their health care decisions made for them. Food choices and fluid intake are especially critical in developing children. As adults get lax about their own health they are also getting lax about the health of their children. We are seeing diseases in children which were formerly seen in middle aged adults. It’s not just obesity. It’s malnutrition coupled with obesity. It’s depression as a consequence of malnutrition. It’s inattention as a consequence of dehydration.

Psychotherapy will not fix lack of food or water.