I add my voice to the growing number of health care professionals and medical societies condemning the newest human rights violation by the Trump administration against our transgender community. The urgency of this issue is paramount! To deny health care rights during a global pandemic is both inhumane and absurd. Our trans patients and colleagues are already vulnerable due to the health disparities inherent in our system and biases from healthcare practitioners. Not only are out trans patients affected but all patients who fall under any part of our QUEER community in the past, present or future are at risk, making it even more difficult to be open and honest wit our health care providers.
Gender based and transphobic violence includes racism, murder and hate crime. It disproportionately affects black trans lives, especially black trans women. In the midst of the Black Lives Matter uprising and Covid19 the reversal of transgender health protections puts an immediate threat to black trans patients, and all trans BIPOC patients who identify as gender neutral or non-binary.
This recent action should be met with a call to arms from all medical professionals, including attending physicians, resident, medical students, nurses, APPs and staff. We must to do our best to provide trauma-based compassionate medicine and NEVER deny care for transgender patients nor any LGBTQ patients. The personal views of providers in any setting (outpatient, clinic, hospital or otherwise) must not be allowed to interfere with the right to health care. The recent COVID pop-up hospital in a Brooklyn park that denied transgender and LGBT care is an atrocious example of what the Trump administration is suggesting here.
There is a dearth of education for healthcare professionals from the earliest academic levels. Health disparities, intersectional oppression, and implicit biases of language, systems and structures have to be called out and addressed to stop this cycle of ignorance. Silence is clearly violence, and we cannot in good faith stay silent and allow conservative politicians to sacrifice health protection in the names of transphobia and racism – not now or ever again.
Kaiser Kabir OMS4 Lincoln Memorial
Masina Wright, DO PGY1 University of
New Mexico Hospital, Internal Medicine
Well, I bled for 16/30 days in April plus 5 in May. This is not my normal. This is pandemic menses. I don’t remember the relationships between cortisol, ovarian function and the reproductive cycle and frankly I haven’t had the energy to look it up again. I am also 46, so my ovarian reserves are low and having anovulatory/ short cycles could be the new normal until I get fully into bioidentical hormone replacement land. Still: Why such extended Abnormal Uterine Bleeding (AUB) ? And why this extended pain, expense and moodiness when I am already working long hours, alternating day and night shifts, and having to accept the global panic of COVID?
I have not changed much of my regular hormone regime. I have been taking bioidentical progesterone the second half of my cycle for the past 10ish years. Ovaries start decreasing progesterone production around 35yo often causing worsening PMS, cramps, and shorter lighter cycles. Taking progesterone lengthens my cycle from 21 to 26ish days and really helps with cyclic breast pain, bloating, cravings, PMDD and cramps. I had been on vacation when all this started and had not been taking it consistently 🙁
I also take testosterone as a subQ injection intermittently. It is prescribed as a weekly shot, but I tend to take it only every 2-3 weeks, mostly because I forget. Sometimes I forget to take it for months at a time. Cis female ovaries and adrenals produce small amounts of testosterone throughout the lifetime, and testosterone is the dominant cisfemale hormone of menopause! Endogenous production tends to decrease around age 40 as an average.
When I was working at Age Management Center, I tested dozens of women’s testosterone levels between ages 25-75 and it was extremely common to have very low levels: more common than normal levels! Optimization of this all-gender hormone brings a sense of vitality, physical and mental strength, increased muscle mass, heightened endurance, and improved orgasm strength (or orgasms, maybe for the first time!) It helps me have the energy to get to the gym and enjoy workouts. I also had an improvement in libido and sexual satisfaction. I have been taking this rx more frequently these days as internal medicine is *exhausting* so low T is not at the root of my hormonal shifts.
That leaves estrogen as the possible culprit, and this could certainly be the case.There are 3 different estrogens in the body that can be measured. Estradiol is the major circulating hormone that has all the beneficial effects – elasticizing bone, brain, blood vessels, and skin. Estrone is a metabolite of both testosterone and estradiol through aromatization and is theorized to have more inflammatory and proliferative effects. The ideal Estradiol: Estrone ratio is 2:1in the body. Estriol is the weakest estrogen and is localized to the uterus and vagina. This enhances vaginal lubrication and tissue health. It is also what is typically used for vaginal replacement in menopause or transmasculine health because it has less systemic effects. I am due to go get my hormone levels tested to see of I have had a big shift in estrogen levels. Lab work is ideal when done between days 19-21 of a cycle to catch all 3 hormone levels. I have not had any side effects of low estrogen yet, but as a 46yo, the decrease is coming.
I will likely transition to bioidentical hormone replacement when my ovaries retire fully. Humans used to go into menopause around 50-55 then die around 65. I do not think we were made to live an extra 40-50 years (90 yo) without any gonadal hormones. And as someone who will be in high productivity for many years head working in medicine, I will need these juicy, foundational, resilient, life giving hormones! Plus, I love the feeling of being strong physically, mentally, sexually and emotionally!
What about Breast Cancer you ask? Well, fortunately I do not have the gene that puts me at higher risk. I also eat lots of foods full of plant nutrients, antioxidants, fibers, and phytochemicals and good quality meats and fats. I exercise occasionally, especially out in nature where I can fill my lungs with fresh oxygen. I have a lot of stress in my life, but I do my best to counteract that with affection, loving kindness towards myself, sleep, mindfullness meditation, therapy, strong friendships and sunshine/water/flowers. Estradiol does increase proliferation of breast tissue; bioidentical progesterone counteracts that maintaining a balance of growth and suppression. Testosterone itself is also apoptotic meaning it is anti-cancer/ pro cellular health in nature. For me, in this body, having a well of hormones to draw from as I continue to function in the world is a source of inner vitality that I can give myself, even when my ovaries stop being able to produce it themselves. And, I will probably stop full bHRT after around 15 years, which is what evidence has shown is the time when long term hormone replacement therapy in ciswomen stops being as effective and starts to drift towards harmful. I may even just continue testosterone in those years which has less negative evidence as well as less links to breast pathology.
I have effectively convinced myself this was probably an estradiol dip in ovarian production resulting in a very short cycle partially due to low progesterone followed by an ovulatory but still low estrogen short cycle. Fingers crossed that this is not my new normal. I have also re-upped my commitment to taking my daily thyroid medication as well as adrenal herb supports, because the hormone systems all work in tandem and when one part is dysfunctional, others need to work extra hard. But the adrenal and thyroid systems are a whole other conversation for another day. And maybe I will read up more on the links between stress and hormones between now and then.
Meanwhile, This Gal needs to get ready for her night shift in the COVID ICU. Stress. Yup. Exhausting emotionally and physically. Yup. My ovaries can probably read the cortisol and adrenaline levels in my blood and there may be another month of AUB ahead as my body instinctively tries to preserve its resources for essential functioning only in these pandemic times. At least I know what to do for it! I also did book an appointment with a new gynecologist to have an expert on board in case I need something like imaging or a more extensive workup. A Doctor cant always heal herself!
I went to my local Co-op today, which is one of the only places that doesnt feel totally overwhelming to shop, and every single person had a mask on. This is the new norma I spent the week pretty anxious about the contagion and infectious side of COVID19. I had two of my patients get ruled out for the virus mid-treatment this week AND the contagion aspect seemed really important for those around me I come in contact with, not only myself. What do I need to do to not be a vector of spread? We now only wear scrubs to the hospital not work clothes, and I take my shoes off at my door. Are you freaked out about the contagious side of it? This is a real phobia for some people, and it at the root of many OCD compulsions. I feel for all the germ-phobes out there! My only advice is therapy therapy therapy. There are also one or two antidepressants that help with OCD if you are really noticing an uptick in this in your every day. Ask your PCP if they can help. If you dont have one, this is a great time to get one! Many health providers are accepting new patients, and their clinics or your local community center can help you get the health coverage you need.
Medicine really needs to start valuing mental health as equal to primary and specialty medical care in insurance reimbursements and coverage. SO much suffering comes from the mind. And teeth! Dental coverage too! I promised a blog on botanical medicine and viral illness. I am not up to date on the most current treatments and theories in the natural medicine world anymore. The Naturopathic News and Review publication is a great resource for cutting edge evidence from practicing ND’s.
Most of my botanical training is american traditional eclectic western botanicals, and the knowledge dates back to folk traditions, native medicine, midwifery, and turn of the century medicine. In this vein, there is a wealth of knowledge about foundational immune support and antivirals vs antibacterials and antifungals. If you are interested in this kind of care, most ND’s and herbalists are doing telephone and online appointments and shipping our medicine. Look under your Naturopathic Medicine State Association and see who is available in your area for personalized medicine.
Chinese botanical medicine also has a fantastic apothecary of immune supporting botanicals as well as support for basically every system. Their pharmacopeia is rich and complex with over 5000 herbs with specific indications and formulas. Many TCM Doctors and Acupuncturists are also herbalists and sell custom blended teas as part of their practice. Consider reaching out to someone locally for this as well with a phone or video appointment.
Herbal Medicine for COVID19 falls into prevention by strengthening and prevention by antimicrobial actions. Prevention by strengthening herbs are used when you are not sick. They tonify and strengthen the body, increasing reserves that can be called on if illness occurs. The following is a list of such herbs:
siberian and american ginsengs
cordyceps and other nourishing mushroooms (use sparingly)
Nettles are best made as a herbal tea and drank clear and often. They can also be eaten in soups, cakes, and stir fried although this is easier in some parts of the country than others.
Astragalus is a sweet root and is best as a broth, or a tablet taken 3 tablets in morning and night. This is a key ingredient in “change of season soup” from the TCM formulary for immune strengthening as well. Borage, Siberian and American ginsengs and ashwahaganda are adrenal tonics that boost immunity by decreasing inflammation and increasing resilience. I like borage tincture 1 tsp daily, ginsengs as tinctures or pills (they don’t taste great), and ashwganda as a standardized tablet or capsule. Ashwaganda means something close to “horse piss” Ive been told, and it is named after the strength and passion of a horse as this is what it embues. These should be discontinued at the first sign of a sniffle or other illness. Then switch to active antimicrobial prevention. Taking these while sick can sometimes strengthen the pathogen rather than the host.
Antimicrobials: These are divided by their functionality.
Use these herbs as a prevention; it is best to preserve the antibacterials for signs of actual infection. Like Rx antibiotics nature’s antibacterials have strong actions and their use needs to be preserved for proper indication
A selection of commonly used antivirals includes:
alium cepa (onion)
allium sativa (garlic)
echinacea – only in the first 24 hours of infection
euphrasia (eyebright) – for viral conjunctavitis and eye symptoms
A selection of my fave antibacterials include:
goldenseal – for inflamed mucus membranes and purulent discharges
berberis – for anything that looks or feels “infected” including GI issues
echinacea – one of the only botanicals proven against strep species. Use a glycerite form of the tincture and squirt it directly onto an inflamed throat. The glycerite is sweet and is safe for children and elders.
cats claw – used for Lyme infection
onion and garlic, oregano and thyme – in cooking! use liberally!
Antifungals are also important for chronic immune system depletion often manifested as thick brittle toenails or fingernails, frequent yeast infections, sinusitis and chronic belly issues. They are less relevent for this pandemic other than to sustain and support long term immune and lung health. My go-to antifungals include:
monolauren (from coconut oil) 300mg 2 times/ day
pau d’arco tincture or tea – 2 tsp or cups per day
tea tree oil – topical
caprylic acid – at least 2 caps daily
* a note on essential oils
I personally took a bottle of astragalus tablets 2 2twice-ish daily and now I am switching to Monolauren daily for 3 months with vitamin C and cats claw tincture daily for at least the next 3-4 weeks for intensive antiviral support. I am also taking ashwaganda as an energy tonic to support my stress levels during this unusual time to be working in medicine, and a probiotic. For my personalized medicine I have an herbal thyroid support formula alongside my Armor thyroid medication as I have Hashimotos thyroiditis. Finally, I drink homemade nettle tea or lavender/ chamomile tea and am doing the best I can to get cooked or fresh greens most days.
My training in essential oils is only for primarily olfactory/ inhaled, diffused in water or skin products. I was not trained in “by mouth” use of essential oils such as promoted by DoTerra or other EO companies so I cannot recommend tfor or against these by mouth. I do like topical and diffused use of these medicinal substances and find myself drawn to tee trea, eucalyptus and lavender, cypress, pine as my primary antimicrobial nature scents for baths, lotions, soaps and diffusion. Many flower essential oils have beneficial effects on the mind/ mental health as CN1 is a cranial nerve. There is a long tradition of use for cosmetic use as well.
Best of luck out there friendly readers. How we as humans conduct ourselves in these pandemic times can illustrate where we need to work on ourselves and where we shine bright. This is an excellent time for insight, awareness and evolution. Its also a perfect time for devolution and hopelessness. Reach out and find the resources you need or ask a friend to listen awhile: many providers are providing sliding scale or free servicesand telemedicine is blooming. The world is small with the internet. Kindness can be found in bugs on a sidewalk or a smiling eyes from 6 feet. If nothing else is true, it is that we are in this together.
When I went to San Francisco for holiday, the plan was not to get caught in a COVID19 community spread hotspot during my intern year in Internal Medicine. The plan was to get some heavy mist, ocean waves, redwood love and friend time. I got 2 out of the 4. What I received instead was some insight into my core values of medicine, health and healing and an increased horror of capitalism.
Having gone through a childhood living in a holistic health center outside of mainstream America, then Canada, then college and Naturopathic/ Acupuncture medical school in Canada I have a very left of center foundation of health and healing. And Yet I am an Internal Medicine doctor and successfully completed a fairly traditional, rural medicine based allopathic medical training. I rarely bring any of my foundational knowledge into my daily practice of medicine as we know it – even when I witness its applicability.
I consider myself at the bottom of the pyramid of medical training – a lowly intern- and always endeavor to learn and practice evidence based hospital based medical standards of care. There is so much I have to learn and I am truly a convert to the Church of Pharmacy. Yes, i prescribe vaccines and statins and birth control and antihypertensives with assurance and pride.
But in this situation, where there is no medicine other than the possible monoclonal antibody being engineered by Regeneron, I fall back on my original pillars of nutrition, botanical medicine and even prayer as medicines worth bowing to.
Ive been talking about the food parts alot lately on this blog. See Food Sensitivities as well as other Food as Medicine posts. I have been triggered and upset by the food hoarding and money spending on food that has been happening over the past two weeks as people collectively buy out shelves of food to stock their fridges. I mean, I love a full fridge and meal planning and I have love for the folks taking the time to cook vegetables and eat fruits and make special meals for themselves and family. I am sadenned by the scarcity mentality that has erupted like Pompeii and concerned about both restrictive food mentality and binge eating with or without purging in these uncontrollable times. Not to mention alcohol and pot and other substance use skyrocketing without the structures of work outside the house and mouting social and familial pressures…..
What is the medicine for this in these times? I do think its prayer and mindfulness. Cleaning house. Feng Shui. Emptying our skeletons from closets with literal and metaphorical help from therapists and friends and family across the globe using the internet. My daily quarantine schedule includes:
20 minutes of mindfullness meditation with the Insight App timer or guided visualization
20 minutes of stretching or calisthenics *(or more)
60 minutes of housework to beautify the space for work
at least 4 hours of academic work including reading, study
30 minutes of fresh air
time online with friends
‘I unexpectedly went to the Stella Maris church in San Fran 3 days in a row. It was in the neighborhood I stayed in, and had a welcoming open door I passed by often. I was drawn to the Marys, lightening candles and saying Hail Marys not only for myself, my lover and my friends but also the world. This is a global issues, not a first world only or American drama. There are decades (generations) of evidence for the power of prayer for long distance healing and miracles. I dont have the energy to research this right now to provide evidence based links; find them for yourself. In this time, more than ever, I believe in the power of prayer to lift us up from our selfishness and anxieties, our fears and projections, and to offer both solace and hopelessness in this wold wide moment we are sharing.
Pema Chodron says it best in her audiobook When Things Fall Apart which I could not recommend highly enough. Having a consciousness that we as healthy or strong humans can hold strength for those who are weaker or less privileged only in this very moment is a position of empowerment and capability that builds on itself. Prayer builds capability out of nothing. There is nothing to lose, and it does not need to be structured within a religion, a god or goddess, or a building. There is no wrong way to connect.
The other thing I have relied on heavily for prevention in these contagions viral times is herbal medicine. I have some knowledge of chinese herbs and some of western herbs. More to follow on pandemic herbal medicine in Part 2
My IG and twitter feeds keep sending me promoted ads for intermittent fasting and young thin women in my Internal Medicine residency program keep telling me they are doing it. As someone with a hair trigger red flag signal for anorexia and eating disorders, I am triggered. As someone with a 20 year nutrition degree and as a gal raised with a spiritual practice of fasting, I do understand the value behind the concept. The problems start when restriction/binging/restriction patterns are overlayed on the foundational evidence.
This is the best nutritional protocol and evidence I found to implement intermittent fasting into a food plan for weight loss or for longevity. There is good reasoning and practice behind the idea that the liver stores glycogen for storage, and that this “immediate use” supply needs to be used up before the body creates new glucose from adipose cells and muscle. This is reasonable: fasting uses up the supplies . Then fasting decreases fat or muscle from stores.
Some fasting articles I’ve read suggest 16 hours between eating every day. This sounds anlot like the “don’t eat food after 7” rule that has quite a few generations of folks sleep binging and waking up covered in cookies.
Some articles suggest 16 hours between meals twice a week. This seems more reasonable to me as it allows for some pre-planning to have restful, quiet time during the fasting period. Our human bodies are not designed to “run on empty.” I grew up in a spiritual yoga community where fasting was part of the practice towards enlightenment, but work was not done during the fast. One’s time in the fasting state is to be spent meditating, reflecting, and processing (like while we sleep.) Yoga is also an acceptable practice during this time as it stimulates glands and organs as well as the musculoskeletal body to return to homeostasis. Fasting is designed as a parasympathetic state to rebalance cyp liver enzymes and clear the intestines. Pushing through fasting into sympathetic, highly motivated activity like mental or physical labor requires the adrenal glands to overachieve and drive metabolism through adrenaline and sheer will aka cortisol.
The one place where hard work on a fasting belly IS indicated is for anyone looking to lower insulin resistance by using the biochemistry of exercise. This could be someone requiring huge doses of insulin for only moderate blood glucose control, or someone trying to beat type 2 diabetes in the pre-diabetic state. Exercising on an empty stomach is one of the few ways to upregulate the special cellular receptors called GLUT_4 for insulin to bring blood sugar into cells. I have tried this and its oddly satisfying. Nerd out on biochemistry and GLUT-4 here.
I don’t intermittent fast intentionally myself. Some weekend days I wont eat food until 2-3 in the afternoon, just based on my natural appetite; however, I do have black coffee and water and sometimes juice during that time. To be my best self, I need frequent and regular fuel to keep this brain and body going for the intense work weeks I do. Not allowing myself to eat when I am hungry in not helpful for my mental health either – not only do I get edgy or feel anxious, my own disordered eating and body dysmorphia can easily be motivated by restrictive eating patterns.
Aside from mental health, some people also have genetic metabolic imbalances if their lineage experienced a traumatic food restriction. This has been researched in Irish descendants as well as Jewish folks. Caloric restriction can actually trigger a survival metabolism where minimal resources are burned and every morsel of fat possible is stored. This is ancestral trauma that has caused permanent alterations in your genome that get triggered by environmental circumstances.
The science is compelling though: improved metabolism, destruction of cancer cells, immune regulation, cortisol balancing, cellular rejuvenation…. benefits are numerous!
Here is what I would do if I was either doing a period of cleansing/detox and intentionally working on restoring health or if I was committed to a defined period of intentional weight loss (8 months from this algorithm.)
Style 1: two mornings a week, fast until 12-1pm depending on your 16 hour window. On these mornings drink warm water, organic green tea or herbal tea, stretch and do yoga or go for a gentle walk, get into nature, rest/ meditate, write or reflect. Eat a Mediterranean style diet the remainder of the time.
Style 2: For a more intensive weight loss experience, follow the algorithm for 2 days a week of restricted caloric intake from the JAMA article referenced at the beginning of this post. I would not also follow the time restricted feeding patterns myself as I find this too rigid for modern life and overrides the natural appetite instincts which are essential. Eat a Mediterranean type diet or Paleo. Consider pairing this with the Whole 30 protocol or an elimination diet for true restorative food as medicine. Follow the above guidelines for your calorie restricted days with rest, nature, reflection, massage, acupuncture or other healing practices, whole organic foods, teas and water. Once you have completed month 4, return back up the protocol until you are back at full weekly caloric intake and reassess.
Insulin is a hormone that is produced by the pancreas that helps cells to absorb glucose in the blood. When we eat a lot of sugar or carbs, there is a rush of glucose (sugar) absorbed into the bloodstream and the pancreas responds by releasing insulin, signaling the cells to allow the sugar in. When blood sugars dip low from chronic hunger or lack of food, there is very little insulin produced.
A lifetime of sugar rushes and sugar deficits can lead to Type II Diabetes, a blood sugar disorder that is characterized by insulin resistance. Insulin resistance happens when your cells stop being able to efficiently respond to the presence of insulin. Imagine you live next to a train track, or by a fire station. Eventually the constant trains or sirens become background noise – we stop hearing them out of habituation. Insulin resistance is kind of like this – chronically elevated blood glucose results in cellular apathy. Each little cell stops posting the GLUT4 receptors in the presence of insulin and the glucose cannot be absorbed. This results in a starvation state for the cells with an overabundant state in the blood, with resulting nerve damage from high blood sugar and cellular aging from nutritional deficit. Can you imagine how this could be improved with nutritional regulation of blood glucose?
The good news is it is possible to improve insulin sensitivity at a cellular level, especially at the pre-diabetes stage. The first step is to adjust your eating habits and diet. The chronically elevated blood glucose needs to stop happening as it is the flooding of the system and causing the habitual “resistance.” This can be achieved with high protein and vegetable meals with abundant healthy fats eaten every 6 hours or so.
Our cells like a slow, steady amount of glucose and insulin in the blood. The logic is as follows: protiens and fats and high fiber carbs like vegetables and grains break down slowly in the digestion, giving a slow steady stream of nutrients and building blocks. Processed carbs, sugar and fruits are broken down quickly and result in a rush of glucose. Therefore, to slow the rush of blood sugar one needs fiber, fat and protien present with each meal. This makes sense – it is always easier to handle any situation in life when things come at us in a moderate, orderly fashion. The microcosm is the macrocosm.
The ginseng family including Panax Ginseng and American Ginseng are also used to lower blood sugar while increasing the ability to adapt to stress. This adaptogenic action exhibits effects across multiple endocrine organs including reproductive, adrenal and pancreas, making it a great herb for modern medicine. The ginsengs work at the plasma membrane level as well as improving steroid hormone receptor sites, which may explain their benefit and use in improving insulin resistance. http://www.ncbi.nlm.nih.gov/pubmed/10571242. There are many other botanicals that have a history of use in blood sugar management including bilberry, cinnamon, gymnemna and more.
Vitamin and mineral deficiency can also worsen existing
insulin resistance and exacerbate high blood sugar. The trace minerals chromium
and vanadium are both cofactors in the glucose-insulin complex and deficiencies
in either of these will worsen blood sugar issues. Chronic magnesium deficiency
is also commonly found in people with insulin resistance. This could be due to
a deficient dietary intake as magnesium is found in leafy green vegetables and
broccoli as well as fish, raw nuts and seeds, avocados, bananas and dark
Finally, high intensity, short-term exercise is essential for improving insulin resistance. This kind of exercise shifts metabolism into fuel-burning mode, instead of fuel saving mode. Being active multiple times a day is even better for shifting into glucose utilization mode and improving cell receptor activity. http://www.thebloodcode.com/type-2-diabetes-recovery-needs-daily-exercise/ . Exercise is the only thing that will independently stimulate individual cells to produce those Glut 4 insulin-regulated glucose transporters found primarily in fat and muscle cells, instantly improving insulin resistance and decreasing blood sugar.
In summary, insulin resistance is a complicated condition that is essential to address in the treatment of diabetes. Fundamental nutritional changes and lifestyle basics are essential starting points for anyone interested in improving blood sugar parameters and taking an empowered stance towards metabolic recovery.
Its been a long time since I have posted from the medical world of Dr Wright. I am now in Albuquerque New Mexico, Land of Enchantment and Liver Disease. So many dying ciswomen in their 30s suffering of liver failure here, and transwomen too. I have been pleased with the cultural competency for trans and non binary folk in this city so far! My hospital’s respect for the transfolk and their pronouns I have seen come through the door at UNMH has been heartwarming. The work is never done, but the foundations are in place thanks to those who have done this work before me.
There are so many things I could write about it feels overwhelming. Like
how does one deal with anxiety in a productive way that does not encourage substance use?
how much does good food really influence health
the value of death: vs life. what is a life well lived
what is a good death
As an internal medicine doctor I know part of my life is to facilitate death. This is the job of the warrior; and as a hospitalist I tend to those as they fight in their own particular battlefield . I have been privileged to sit with Death, and she is a mistress no one wants to see. And yet, often such a sweet gift.
I wish that hospital medicine could embrace healing meditations and buddhist lectures. Imagine folks watching these daily in their hospital beds instead of cooking shows and NCIS? These are a few of my faves:
Anything by Pema Chodron as well: I look for ones longer than 45 minutes
I certainly haven’t mastered the art of effectively handling my own stress without turning to food, or alcohol, or any thing that distracts me from the what-feels-like intolerable levels of emotion building up inside. So, I have empathy for my patients that use this coping mechanism to get through their life. What is the difference that has me as a privileged white woman in my 40s still strong and healthy foundationally, vs their 30 year old bodies that are broken down by alcohol? Genetics is certainly a piece of it. The Navajo, Zuni and Pueblo folks here have what must be a genetic succeptibility to liver failure secondary to alcohol use disorder. They are too sick, too young, and too many of them to have it be environment alone.
I cant help but feel these women are carrying the trauma of generations of dominance, trauma and oppression and it is manifesting as this alcohol sickness – a genetic trait passed from white rapists to their progeny and concentrated in generation after generation. Tie that to poverty, a lack of fresh fruits and vegetables, and ongoing systemic depression and it makes complete sense that we have these women dying, daily, in our hospital.
It is a helpless feeling, this system oppression and individual illness. This is certainly a piece of the burnout of becoming a physician. We do our best to hold together the pieces of survival for each person, holding the hope, while also titrating the reality of recovery.
As a person very new to this state I have very little working knowledge of the cultural climate of health care here and even what resources are available. As a new resident and hospital based physician, I have basically no time to investigate and advocate for this community at the ground level. All I can do is hold the space for the sickest of the sick and even in that I don’t have time to be present for their stories or their traumas.
Dandelion and Milk thistle, turmeric are not native botanicals to this part of the country, so I doubt they are used in traditional medicines? I wonder how much early liver protection with these herbs, as well as anger management, trauma based care, and other integrative therapies could be used to protect and heal the liver in the teens and twenties for these folks? My acupuncturist said New Mexico is the land of wind, and heat, both properties of the liver meridian. This would argue for an environmental component to the imbalance as well. Food, Water, Emotions, Genetics, Trauma, Environment, Substances – so many nuances to health and to disease. And I, as a doctor, am depressed with the minimal amount of time I have to explore these facets with each individual that may lend insight into prevention before these women end up in our hospital beds.
I just finished my final elective of medical school. I chose Rheumatology because I have such a strong genetic tendency towards this class of diseases, and because it was something I felt under-educated about heading into Internal Medicine.
Rheum itself means “a watery fluid that collects in or drips from the nose or eyes.” Whereas rheumatism is “any disease marked by inflammation and pain in the joints, muscles, or fibrous tissue, especially rheumatoid arthritis” according to online dictionaries. Clearly these two do not match up? Although perhaps one could argue it is the “watery fluid” of the joints that is attacked by immune system dysregulation in most of these conditions, resulting in pain, inflammation and joint destruction. Most of these conditions are also multisystemic, affecting the heart, lungs, kidneys, eyes, skin and more. The umbrella of rheumatology is large: conditions I saw in clinic included rheumatoid arthritis, lupus, scleroderma, psoriatic arthritis, polymyositis and dermatomyositis, pseudogout, gout, and polymyalgia rheumatica. There are of course more that I did not witness.
A large part of patient management involves managing and regulating pain. Opioids are now recognized as crutches inhibiting recovery for many people with long term pain rather than panaceas. Dr Clauw, a pain specialist from Michigan explains this way better than I could, and also addresses several prescription and over the counter medications as well as lifestyle management techniques for living your best life with chronic pain. Watch this YouTube video now, or listen to it while you drive: https://youtu.be/B0EhNajqkdU
One conversation that came up several times was the use of topicals for pain. Many folks cannot take ibuprofen for pain due to stomach or kidney disease, or are already on long term therapy with prescription strength NSAIDS and still have pain. Voltarin, a topical NSAID was prescribed regularly, specifically for osteoarthritic pain at the base of the thumb with good success.
Many patients use CBD preparations for consistent pain reduction. Some people call cannabiboids “opioid sparing medications” as people can reduce the amount of narcotics needed on a daily basis with the concurrent use of CBD products. The doctors I was working with did not specifically endorse nor did they advise against medical marijuana as Maine is a state where purchase and possession is legal with certification. However, they did support individuals trying topical marijuana preparations of their own initiative for pain management.
As aggressive autoimmune diseases, most of these conditions require sophisticated, high end medications to manage their progression. I saw many cases of men and women who had life changing benefits from DMARDS, or Disease Modifying AntiRheumatic Drugs. My main take home point from this rotation was if one of my patient is newly diagnosed with one of these conditions, REFER! to a rheumatologist as the medications are advanced and specific. My great-grandmother was bed-bound by 40yo with rheumatoid arthritis and she did not have the benefits of science to treat her disease progression. Even tho I am also a Naturopathic Doctor, I have respect for the powerful efficacy of these medications and do believe they improve and maintain quality of life in potentially destructive conditions like these.
On the other hand, medications alone are often not enough to manage and maintain the best health possible. The 2017 textbook I was given for the elective had a small section at the back for complementary and alternative therapies that have good evidence for rheumatology.
Vitamin C is an essential component of cartilage and collagen. Supplementation reduced progression of joint and cartilage destruction over time. My Note: Vitamin C is naturally occurring in high levels in many raw fruits and vegetables. This is a great reason to eat fresh raw foods as part of your every day diet with any kind of inflammation or joint disease.
Vitamin D is for more than strong bones; it is also a hormone that effects immune health. Countries that have less sunlight year round have higher occurrences of autoimmune disease. Get outside 20 minutes daily minimum all year round, and supplement vitamin D every winter. Have your blood levels tested every fall to ensure optimal levels of this hormone and nutrient.
Fish Oil has known anti-inflammatory properties in its EPA component and many brain benefits in its DHA. This rich omega 3 essential fat is best eaten as a meal at least 3 times per week – a tin of sardines, mackerel or herring has way more nutritional value than a couple of fish oil pills and costs so much less. Any seafood will contain fish oil – the littler the fish, the higher the benefit when it comes to these healthy oils. If you do go for the fish oil pills know that you get what you pay for. Evidence shows you need about 3000mg of fish oil via pills daily for benefit, or at least 450 mg DHA and 750mg EPA. I like Nordic Naturals Brand for best quality and efficacy if you are going to go the pill route. For tinned fish, there are lots of brands, but this is my fave and it’s easy to find in regular grocery stores.
Omega 3 oil is also available in vegetarian form as flax seed oil or marine algae oils.
The evidence for a specific kind of diet for autoimmune disease is variable. Dr Jackson referenced the Mediterranean Diet as the best foundational nutritional plan for Lupus specifically. This makes sense as it is a low inflammatory, high fruit, fiber and vegetable diet with known benefits for heart health and longevity.
Many people choose to go paleo, or follow the whole 30 autoimmune diet plan.Phoenix Helix is a podcast dedicated to autoimmune health and paleo nutrition. During my rotation I listened to a great episode with Dr. Aly Cohen, an integrative rheumatologist who spoke on scleroderma and integrative medical management. In addition to reviewing some specific suggestions for scleroderma, Dr. Cohen spoke on the importance of reducing processed food chemicals, pesticides and additives and choosing clean drinking water, not from plastic bottles. As she said, over 90,000 chemicals have been introduced to the ecosystem and therefore the human body in less than 100 years. Autoimmune disease is linked to this toxic burden and inability to process the chemicals. Find out more about her work @thesmarthuman on Twitter and Facebook.
Three weeks of rheumatology clinic was only enough to learn the basics of diagnosis and management, and gave me great respect for my fellow Rheumatologicial internists. Each of the conditions under the Rheumatology umbrella have advanced immune dysregulation and multisystemic consequences with potentially dire outcomes. Fortunately, pharmacology has a class of exceptional medications that work quite well, especially when paired with nutritional initiatives and long term pain management strategies that focus on quality of life. I am grateful to Dr. Stanhope and Dr. Jackson at Central Maine Medical Center Rheumatology Associates for letting me ask too many questions while they were trying to write notes during their busy clinic days – and for the freedom to enjoy afternoon sunshine on my last medical school rotation!
Ugh. New Years Resolutions. Worst idea ever! And yet – I had a tough end of 2018 personally so I decided to make some resolutions in an effort to bring structure and more wellness to my life.
Well, it is 13 days in and I have already failed all of my official resolutions. In fact I failed my first one in the first two days of the year:
1. spend less time on my phone, especially in the company of people I love
Excuses are bountiful. However, If you are in the same boat as me with lofty goals and a complex life, I encourage you to think about resolutions as a year long goal, not something to be abandonded by week 3. It could take even 3 years to build the structure that you need to support the foundation of your bigger dreams/resolutions like an art or writing studio and time to produce new work.
The Winter Solstice (12/21/18) is when we annually rekindle the spark of the year ahead. This tiny flame grows to a raging bonfire at Summer Solstice with our culling and tending and then dwindles down to the blue flames of Halloween and Nov-Embers. Then the cycle begins anew with the next Winter Solstice.
If you looked at your resolutions as a fire you were to tend for a 12-36 month duration, would that change your approach? Your commitment to your Self or Visions?
I have things about my lifestyle I need to adjust, and those are built on deeply entrenched habits that function as crutches that allow me to perform in my hugely challenging day to day life. I cannot just pull the supports from my foundational Activities of Daily Living; I CAN build new supports/habits to relieve the not-so-functional structures.
Building a new wellness foundation takes a team or at the very least a multifaceted approach. I failed my New Years Resolutions the first week because I did not have my new structures in place to support them. I now see who and what I could rely on to make this reality functional, and this second week of the year I was 50% more successful in my goals.
What are your NYR? What changes do you need to make this happen?