Spending More Time Explaining and Less Time Examining.......

Somewhere, somehow my physical diagnosis instructor from my second year of medical school is cringing.

Today I saw a patient for a history and physical who was in good health.  He had no complaints and reported no medical problems, but when I asked what medicines he took and he answered me with 3 commonly used anti-hypertensive medicines I knew there was more to his story. 

Turns out this gentleman’s blood pressure was almost 170 as he sat and rested in my clinic.  Further questioning revealed him to be a pack-per-day smoker who while not obese rarely gets meaningful aerobic exercise.  Combine his poorly managed high blood pressure, his extensive smoking history, his male gender, his sedentary lifestyle and his age over 45 and he has 5 major risk factors for cardiovascular disease and is at relatively high risk for a cardiovascular event over the next ten years.

Faced with the constraints of time and a roster of waiting patients I had to make a tough choice.  My training told me to do an extensive physical exam in this situation but my common sense dictated a different approach.  Instead of spending a large chunk of our time together looking in his ears, percussing his abdomen and making him grab my fingers to test his strength I spent our time together talking about cardiovascular risk factors, nutrition, smoking cessation and exercise.

Turns out this smart gentleman hadn’t the first clue about cardiovascular health.  He had no understanding that our body metabolizes different carbohydrates different ways (the critical concept for all American’s to understand known as the “glycemic index”), knew little about the difference between saturated and unsaturated fats or the protective benefits of omega-3’s and had only a rudimentary understanding of the importance of smoking cessation and just why those nasty little fumes are so bad for his blood vessels. I explained all that and more to him today and I told him the truth that he was shaping up to be a high risk cardiovascular case as he aged and why I think he probably already had an element of sub clinical vascular disease right now. 

While perhaps I did not get a look at the cerumen building up in this guy’s ears I do think I did the right thing for my patient. That physical diagnosis instructor may not have approved but by spending my limited time talking to this patient instead of doing a bunch of pointless poking and prodding I laid the groundwork for this patient to have a greater understanding of his health and empower himself if he so chooses.  I did do some essentials like listen to his heart and lungs on exam and a few other basic things. 

He had been to dozens of doctors in his life but according to him no one had ever explained these critical concepts to him.  These are the people who five-ten years from now will be showing up in our clinics and emergency rooms with strokes, diabetes and heart attacks.   This particular gentleman was so appreciative that I took the time to tell him all this today and even paid me a great compliment at the end of our visit. 

Seau Tragedy Brings Light To Root Causes of America's Struggle With Mental Health

The recent tragedy of Junior Seau has the issues of suicide and depression at the forefront of American minds this week.  When someone who was as athletic, vibrant and famous as Seau takes his own life it garners attention.

While attention shifts to these issues this week in light of this tragedy,  America’s problem with mental health issues and especially depression and anxiety are severe and chronic and go beyond this one unfortunate incident.   America is a nation ravaged by mental health problems and there are some logical contributing factors.

Last week when a medical journal published an article on biochemical markers found more commonly in patients with a diagnosis of depression it received wide spread coverage in the mainstream media.   The idea that we could biochemically quantify depression appeals to the reductionist and materialist cultural paradigm about depression that mainstream psychiatry and drug companies propagate and make billions off of.

However this research was not as impressive as it seemed on the surface.  The research was done on an extremely small number of patients and none of the markers were really strongly predictive of depression but rather were just associated with it. The directionality of this association and many biasing factors that may have polluted it are unknown.

Furthermore, to proponents of mind body medicine, the concept that there are physiological elements of chronic stress associated with various psychological states is not news at all.

Research like this is useful to help quantify the psycho-physiology of various mood states.  However 40 years of research into depression has yielded little concrete information into the genetic or biochemical basis of mental health problems.

The real yield for fixing America’s mental health crisis lies in our social and physical environments.
There are 6 environmental reasons that America is struggling with mental health problems more than it needs to:

 Nutrition- Insulin dysregulation appears to have strong neurobehavioral effects.  Recently I learned something about insulin resistance that I had never learned before in 6 plus years of clinical training as a physician.  When your body eats a sugar load and your insulin spikes in response there is a subsequent cascade of stress hormones, including Adrenaline, released.  Indeed Insulin appears to have a profound effect on neuro-behavior in both human and animal studies.  The American diet remains loaded with processed foods, high glycemic carbohydrate and high fructose corn syrup that make surges in blood sugar and therefore insulin a regular part of most American’s physiology.  This is a big part of our nation’s struggles with mental health problems and mood in both adults in children.


Sedentary Lifestyle-  Nothing, not a pill, surgery, treatment or anything else, has as profound an affect on mood, stress relief, concentration, sleep and peace of mind as exercise does.  For hundreds of thousands of years human beings evolved living physically active lifestyles.  We are made to move and be active.   The evolution of post modern industrial life style of the past few generations is a relatively new experiment.   It creates a set of conditions that dictate a biological unnatural level of docility and this has created a whole host of physical and psychological manifestations.  America’s mental health crisis ties closely into it’s sedentary ways.

Social Environments-  Man evolved in social environments in which intimate relationships and community were critical.  We are social beings, and some research even validates the impact of empathetic and social relationships on our physiology.  One of the great tragedies is that in the last 50 years America has suffered an erosion of community and family.  Cultural conditions have favored the breakdown of extended family and community as a significant role in most people’s lives.  This is in stark contrast to the conditions that man lived in naturally for thousands of years, and one of the reasons why America struggles with mental health.  People need support.

Environmental Toxins-  The Neurobehavioral effect of many toxins and pollutants has been well established in animal and human studies.  As a physician studying environmental health at Harvard School of Public Health I can say definitively that we know dangerously little about the physiologic and neurobehavioral effects of many common pollutants.  What we do know is frightening and we currently release billions of pounds of heavy metals and pollution to the environment each year and this undoubtedly is contributing to mental health problems.

 Cultural Values-  Americans have no problem smoking,drinking or drugging themselves into a stupor, but there is a cultural value in place that discourages or stigmatizes emotional honesty.  The result is that many are raised in conditions where they don’t learn how to deal with or express natural feeling states and this ultimately affects mood and health profoundly.

Sleep-  Americans don’t sleep long enough or well enough and studies show this can profoundly affect mood.


On a population wide level our nation is struggling with mental health and behavior because of the food we eat and the way we live.   Pfizer or Merck will never make a billion dollars extolling the virtues of a natural lifestyle. I don’t believe many people are meant to be depressed (there may be a few), but some unfortunate people are just more vulnerable to how the abnormalities of the American lifestyle in addition to their life experiences (especially in childhood) interact with the genome.

The Seau tragedy is a horrible reminder of our nation’s ongoing struggles with mental health issues.  Like many with depression  Seau appears to have been a good and well loved person who was stricken  by a horrible illness.  Hopefully one good that will come from it is increased awareness of the root causes to prevent similar things from happening in the future.